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Complications of Operations upon the Biliary Tract
Complications of Operations upon the Biliary Tract JOHN T. REYNOLDS, M.D. *
COMPLICATIONS of operations upon the gallbladder and biliary tree usually may be traced to diagnostic misunderstanding or to one of many technical problems associated with the operation itself. Since most of these complications are either preventable or curable, the premise must be that patients in whom the diagnosis is correct, who are operated upon correctly and whose postoperative course is carefully managed will be symptom-free. Furthermore, the operation should carry less than 0.5 per cent mortality. By discussing the diagnostic pitfalls and the technical maneuvers required to solve biliary duct problems, it will be possible to detect how errors occur which lead to complications. DIAGNOSTIC ERRORS
In order that diagnosis will not be in error, we must have a clear-cut idea of the pathogenesis of the symptoms of biliary tract disease. In general, we operate upon patients with biliary tract disease because of the symptoms caused by stones or because of the complications of stones. Congenital anomalies or neoplasms constitute a minor group of cases. Asymptomatic stones are recognized on x-ray by their calcification or bya filling defect in the gallbladder shadow. Operations to remove such stones prophylactically may be done, but to make such recommendations saJe;there.mtist be nO preoperativecontraindications and there must be no complications. -:-When gallstones-cause s..ymptoms, theyusualJy do so in their attempt t6 escape the.-.gaUbladder ~ In this- process, they enter the cystic duct and if successful:escape-through:it-into the common duct and duodenum. Their-passage- is almost: alw.a:Ysassociated with severe pain .. This pain statt$ rather suddenly, is colic-like in--nature and is characteristically violent.Jt is usually the most severe pain the patient has ever experienced. *Clinical Associate Professor of Surgery, University of Illinois College of Medicine, Chicago.
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It often reaches its zenith in a fairly short time. Located in the right upper quadrant, it tends to radiate through to the back and to the tip of the scapula. It frequently is precipitated by the combination of a fairly large meal, in which cholagogues are abundant, followed by a period of rest in the horizontal position. (Figs. 36 and 37). During the pain, bodily position does not exaggerate nor relieve it but the patient usually tries many positions in an attempt to obtain relief. Few patients can tolerate the pain without seeking medical help. Morphine sulfate
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Fig. 36. This drawing illustrates the normal position of stones in the gallbladder when the patient is in the upright position.
or atropine sulfate usually relieves the pain and when the patient awakens only local soreness remains. The duration of the colic depends on the fate of the stone. When the stone is so large that it does not escape the cystic duct it may fall back into the gallbladder. This terminates the colic. Such colics are short in duration, last but a few minutes or less than an hour, and may be impossible to diagnose. The pain is most often "colic-like" in the early stages when a relatively undiseased gallbladder wall still has enough of its musculature to contract and so help to expel the stone. In advanced cases there may be loss of some of the characteristic pain. The cystic duct shortens and dilates, there is less resistance to the passage of stones, and colics are correspondingly less severe.
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When the stone neither drops back into the gallbladder, nor escapes into the common duct, it may become impacted in the neck of the cystic duct. Then the colicky pain tends to disappear and is replaced by a constant pain. It is rapidly associated with local tenderness. This is in part a result of the inflammation which develops in the cystic duct about the impacted stone, and in part a result of the retention of bile and mucus. Should the gallbladder be nearly empty at the time the cystic duct becomes occluded, mucus is secreted and a hydrops is formed.
Fig. 37. This drawing illustrates how a horizontal position may encourage stones in the gallbladder to enter the neck and start down the cystic duct, thus initiating an attack of colic.
If the gallbladder has been largely replaced by scar tissue, there is little or no secretion of mucus and no distention. Here the gallbladder never becomes palpable, for it is tightly scarred over its contained stones, and only vague tenderness is present deep under the liver. If a stone becomes impacted in the cystic duct when the gallbladder is full of bile, a different course of events takes place. As absorption proceeds, the concentration of the bile continues, and the increased concentration of cholesterol irritates the gallbladder, giving rise to a chemical cholecystitis with pus formation. This pus, which is sterile, becomes gradually diluted with the mucus and plasma which the gallbladder wall continues to produce, and an empyema of the gallbladder results. Without bacterial infection, this empyema may remain for many weeks,
John T. Reynolds
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Fig. 38. This chart illustrates the intensity of the pain of a biliary colic, the almost imperceptible rise in temperature and tenderness, and the prolonged duration of the pathological changes in the gallbladder.
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Fig. 39. This chart illustrates the effect of stone impaction in the cystic duct. Note the prolonged curve for pain, the much more marked elevation in temperature, the presence of tenderness for a period of days.
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Complications of Operations on Biliary Tract
causing no more than mild distress. It is usually palpable. If bacteria add to the inflammation, gangrene and/or perforation may occur. This is rare, but may take place either in the first few hours or much later, depending upon the virulence of the bacterial infection. It can usually be anticipated by the fact that fever may develop-which is not likely to occur with simple empyema. (See Fig. 40.) Without adhesions, a generalized peritonitis will develop, but should adhesions have developed previously, a pericholecystic abscess with phlegmon will be formed. The latter gives rise to a vague, exquisitely tender mass, which helps to differentiate it from the distinct globular mass of hydrops or empyema
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Fig. 40. Chart illustrating the changes which take place when empyema develops. It emphasizes well that perforation occurs in a patient who has an elevated temperature, and that it is accompanied by an increase in the intensity of the pain.
Passage of a stone out of the gallbladder wall into an adjacent viscus gives rise to a cholecystenteric fistula. While the pericholecystic abscess may resolve spontaneously, the patient with generalized biliary peritonitis requires immediate laparotomy and usually cholecystectomy. Simple cholecystostomy, avoiding the free peritoneal cavity, and if possible removal of the stone from the neck of the cystic duct may suffice. If it is technically reasonable, cholecystectomy may be preferred. The latter is sometimes surprisingly simple to perform, and because in so doing all of the complete disease entity is removed, it is of definite value. Occasionally, spontaneous internal drainage of a pericholecystic abscess gives rise to an internal biliary fistula and relief of the symptoms.
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In arteriosclerosis, spontaneous thrombosis of the cystic artery may lead to gangrene of the gallbladder and to perforation. Here, of course, the disease is rapid, with the development of peritonitis. The true nature of the disease is detected at laparotomy. Cholecystectomy is indicated. The history is the most important single factor in the diagnosis of gallbladder colic. In ordinary gallbladder colic, there is no temperature or pulse elevation, although they will both be elevated when complications set in. Physical examination usually is positive, but dependable only in the acute stage where right upper quadrant tenderness is present. When a hydrops or empyema develops, the gallbladder becomes palpable; when an acute cholecystitis perforates, either an abscess or generalized peritonitis will appear. Figures 38, 39 and 40 illustrate the relationship of pain to findings. On cholecystography, the gallbladder fails to visualize when significantly diseased. However, it must be emphasized that the failure to visualize is not necessarily an indication for surgery. In other words, one must have a history suggestive of biliary colic plus a nonfunctioning gallbladder to justify operation. Failure to observe such dictum has resulted in many unnecessary cholecystectomies. The newer dyes may change the dependability of this dictum. Other causes of pain in the right upper quadrant must be eliminated. Since other conditions may cause pain in the presence of a nonvisualizing gallbladder, the removal of the gallbladder will obviously not relieve such pain. Hyperacidity, peptic ulcer, irritable colon, arthritis of the thoracic spine, right· renal colic, angina pectoris, coronary thrombosis and porphyria are among the conditions for which cholecystectomy has been ill-advisedly carried out. The exclusion of these conditions is obligatory. It is mandatory that a typical biliary history be obtained, or at least history characteristic of one or more of the other conditions be eliminated. For example, a patient with an irritable colon may have a nonvisualizing gallbladder, but dietary indiscretion, rather than precipitating biliary colic, precipitates colicky attacks associated with diarrhea and mucus in the stools. Similarly, after repeated pains of angina pectoris, one would expect some progressive changes in the electrocardiogram. If these are not present, the patient must be re-evaluated. A nonvisualizing gallbladder may then suggest that the biliary tract was the source of the pain. Roentgenograms o(the thoracic spine may show the presence of arthritic changes in a patient whose atttacks are brought on by movement. The development of herpetic lesions may be noted in a patient with unusual cutaneous hypersensitivity. Relief of pain by careful antacid regimen and rest should suggest hyperacidity and/or peptic ulceration. Since gallbladder colic is rarely an emergency, operation must not be done until a diagnosis can be established without any doubt. Once the stone has passed out of the cystic duct and has entered the
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common duct, jaundice may appear. When it does, it is usually fluctuant and intermittent; rarely is it constant and progressive. It is often quite transient, and there are many cases of so-called "silent" common duct stones. The addition of jaundice to the history of colic strengthens the indication for operative intervention (see Fig. 41) . Occasionally, jaundice without pain constitutes the indication for operation. Here the diagnosis of "silent" common duct stones must be differentiated from such causes of jaundice as hepatitis, hemolytic icterus (both may be contraindications to operation), carcinoma of the liver,' chronic pancreatitis, postoperative common duct strictures, or carcinoma obstructing the common duct. Except in the rare case of gangrene of the gallbladder, chills and fever are not part of the clinical picture of gallbladder disease. If chills and fever occur with the jaundice, suppurative cholangitIs must be diagnosed. Unless relieved spontaneously, liver abscess or septicemia may result. Therefore, surgical relief must be provided. This implies a choledochostomy. Such so-called conservative procedures as "drainage cholecystotomies" have no place in the treatment of jaundice or of suppurative cholangitis, because they usually do not and cannot be depended upon to drain the common duct. As mentioned, failure to establish drainage of the common duct may result in liver abscesses and in death. CONTRAINDICATIONS TO OPERATION IN NONJAUNDICED PATIENTS
If there is any likelihood that disease other than cholecystitis is the cause of the patient's pain, operation should not be performed until the diagnosis is clarified. Similarly, if there is any contraindication because of the patient's general condition, it should not be done. Although, in general, cardiac conditions constitute a contraindication to operation, there are certain cases in which cholecystectomy seems specifically indicated. Local changes which make the dissection hazardous may occur. Since many of these are acute and tend to disappear with time, it may be wise to wait. When a stone passes the cystic duct, the duct becomes inflamed and the inflammation may involve the other structures of the liver hilus. These changes make dissection difficult, not only because of the oozing likely to occur, but because the now friable structures in the hilus tear readily, and do not hold sutures well if repair is attempted. These changes begin within 36 hours after the onset of the attack, and may last for many weeks after the colic has passed. It is wise to operate early, before the inflammation has occurred, or to wait for several weeks or even months, until the effects of inflammation have resolved. Since gallbladder colic is an emergency only in the presence of gangrene or perforation of the gallbladder (which are readily diagnosed-see Fig. 40), such a "waitand-watch" policy may be followed with safety.
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Another contraindication to operation is the presence of acute pancreatitis. Patients suffering from acute pancreatitis should be given antispasmodics and sedatives, or a splanchnic nerve block to relieve their pain. They should also receive intensive supportive therapy, in the form of blood and plasma, to replace the fluid lost into the peritoneal cavity, which occurs as a part of the reaction to fat necrosis. This is particularly essential in patients who have severe shock in the fulminating form of the disease. Operation can offer no relief from their condition and the shock of an operation may deprive them of any chance to recover. Since mortality of operation may reach 60 per cent in the ill patients, and may be kept to below 15 per cent by nonoperative means, this approach is generally accepted. If the abdomen is opened by mistake, and acute pancreatitis is discovered, it is probably best that the abdomen be closed with nothing more being done than to place a drain down to the head of the pancreas. If there is positive evidence of increased pressure in the common duct, as evidenced by dilatation of the common duct and jaundice, a choledochostomy may be done. Supportive care should be vigorous. CONTRAINDICATIONS TO OPERATION IN JAUNDICED PATIENTS
Since jaundice itself does not create an emergency, all jaundiced patients should have a careful liver function study. Operation should not be performed on patients with hepatitis. If there is (vidence of of liver disease, such as the presence of a positive cephalin flocculation test, increased thymol turbidity, and reduction in the level of the serum proteins, in the presence of jaundice, hepatitis should be suspected. Only when obstructive jaundice seems reasonable should operation be done. If the patient's prothrombin time is prolonged and does not respond to the administration of vitamin K, he should not be operated upon because of the hazard of hemorrhage. A careful hematological work-up will reveal the presence of hemolytic icterus, for which splenectomy may be indicated. Failure to remove the spleen will result in persistence of the jaundice. TECHNICAL DETAILS OF THE OPERATION
Once operation is decided upon, its execution must be technically correct in order to avoid complications. This implies not only that the biliary tree be properly handled, but that the other structures encountered be respected. Adequate relaxation and adequate incision must be obtained, and delicate instruments and tubes must be available. The cystic duct is frequently long and parallel to the common duct, at times even traversing the' pancreas to enter the common duct at the ampulla It should be carefully dissected in each patient, its junction with
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the common duct seen and proven free of stones, both by palpation and by the fact that when the stump is unclamped, bile flows freely back from the common duct. If there is too much cystic duct left, so that actual gallbladder tissue is present, this may function and result in the development of a new gallbladder, which may cause symptoms. The cystic duct. should be suture-ligated about ~~ inch distal to the junction with the ('ommon duct. If placed too near the common duct, suture may result in "tenting" of the common duct, with partial occlusion thereof, and resultant stricture of the common duct. A second gallbladder, possibly intrahepatic, should be looked for. The gallbladder should be opened by the surgeon at the operating table as soon as it has been removed. Particular attention should be paid to the relationship of the diameter of the cystic duct to the size of the stones. If the gallstones are so large that they could not pass out of the cystic duct, it is equally unlikely that there would be stones in the ('ommon duct. However, if the cystic duct is large and the smallest stones in the gallbladder could readily have passed through it, stones must be presumed to be present in the common duct. In such cases, the common duct is usually dilated. If stones are not removed from the common duct, they may pass spontaneously, but this cannot be depended upon. If left in place, they will usually cause symptoms. Pain, similar to previous attacks but less severe, occasional jaundice, and, in the presence of infection, chills and fever may be expected. Furthermore, such stones when left in place may be associated with elevation of the ductal pressure and so contribute to the tendency of the cystic duct ligature to slip off. In almost all such cases, the common duct will be found to be dilated. Since stones in the common duct are rarely palpable, other means of detecting their presence must be used. Jaundice, in the course of biliary colic, is considered pathognomonic. Common duct compression, however, may occur from a stone impacted in the cystic duct. In such instances it may be forced against the common duct by increasing pressure in the hydrops of the gallbladder and by the inflammation which often surrounds the stone. Such diagnosis, referred to by the French as "the cystic duct syndrome," is recognized when a single large impacted stone is found above a tiny cystic duct in a patient who gives a history of jaundice. In addition to dilatation of the cystic duct, dilatation of the common duct and/or palpable stones are indications for common duct exploration. In order to avoid damage to a very small common duct, it should be pointed out that only rarely will stones be present in a small common duct. Small common ducts (below 6 to 7 mm. in diameter) should not be opened. Occasionally, there may be rare instances of jaundice in which
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both hepatitis and obstruction seem to play a part, in which it may be important to determine the patency of the common duct, and the presence or absence of tiny stones or "sludge." Then, and only then, may it be necessary to disregard the small size of the common duct as a contraindication to choledochostomy. Such procedures as common duct pressure readings, to study the tone of the sphincter muscle, operating room cholangiograms have been developed. Both procedures require great experience to avoid technical errors which make their execution and interpretation difficult. The common duct should be opened longitudinally, the incision being long enough to permit a stone forceps and scoop to be manipulated within it easily, and without tearing or traumatizing the duct. This means an incision at least 1.5 cm. in length. The stone forceps and scoop should be passed up into the hepatic ducts and down into the distal common duct. All stones found should be removed, and when no more are present, or when no stones are found, the patency of the ampulla should be established. A probe should pass with ease out of the common duct and into the duodenum. It may be recognized by the metallic appearance of the tip of the probe which seems to be coming out through the serosa of the anterior duodenal wall. If there has been little evidence of common duct stones, and no jaundice, the fact that a probe does not pass readily out of the ampulla may be ignored. However, if the patient has had recurrent bouts of jaundice, if the common duct is distended, particularly if the bile in the common duct is full of sediment, gravel or "sludge," or if the patient has had symptoms referable to the left side of the abdomen and to the back, suggesting pancreatitis, the patency of the ampulla must be established. In such cases, the duodenum must be opened, the ampulla found and the condition of the ampulla investigated. It may be difficult to see the ampulla, and it may be necessary to wait until either bile or pancreatic juice pours out to identify the opening. A stone may be seen, pouting out of its end, or a stone may be palpated between the duodenal wall and the end of the probe in the common duct. A Keith needle may be passed up a tiny ampullary opening until it touches the tip of the probe, or until a stone is encountered. The stone should be removed. If the bile has been cloudy, or filled with sediment, the lower end of the common duct may be filled with sediment--even a cast of the lower several centimeters may be found. In such instances, drainage of the common duct into the duodenum has been inadequate, and an ampullotomy should be performed. Primary common duct stone may require ampullotomy if the ampulla is tight. It is our preference to make a long incision into the ampulla, 2 or 3 cm. in length, and if possible to sew it open by approximating the mucosa of the common duct to the mucosa of the duodenum. When such a metic-
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Complications of Operations on Biliary Tract
ulous mucosa-to-mucosa suture is possible, it seems likely that the common duct mucosa will heal to that of the duodenum and no stricture will . form. A simple T-tube placed above in the choledochostomy incision, will splint the ampulla sufficiently. If the opening in the pancreatic duct is such that its occlusion seems likely, a small polyethylene tube may well be left in place to splint it. It is our feeling that attempted dilatation of the ampulla and the use of a long-arm T-tube are contraindicated. The ampulla is likely to return to its preoperative size, and if the pancreatic duct drains into the ampulla just at the duodenal margin, a long-arm tube will block the pancreatic duct and may give rise to a fulminating and fatal acute pancreatitis.
Stone Blocking Common Duct: Suppurative Cholangitis
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Fig. 41. Chart illustrating the temperature curve in a patient with suppurative cholangitis. Note the almost complete relief obtained by choledochostomy. Note that this is not cholecystectomy.
N onabsorbable sutures are probably best avoided in closing the cystic duct and common duct, because many cases have been reported in which silk or cotton sutures have worked their way into the common duct, become covered with inspissated bile and caused common duct symptoms. If a patient is allergic to catgut, on the other hand, rapid separation of the wound in the duct can occur with biliary fistula formation. T-tubes should be left in the common duct after all common duct explorations, because the ampulla frequently swells shut temporarily after the manipulation of common duct probing. They should be so much smaller than the lumen of the duct that they do not rub on the lining of the duct. They should be so nicked, opposite the long arm, that they will collapse readily on pulling, and the short arms should not exceed 1 to 1.5 cm. in length. A choledochogram should be done on the
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operating table just before closing in order to determine that no stone has been left in the duct. If a stone is found, it should be removed. In order to avoid confusing the shadow of an air bubbJe with a shadow due to a stone, an additional cholangiogram may be taken the next morn-
Fig. 42. Drawing illustrating the relative position of the ampulla of Vater in the curve of the duodenum. The duodenum is open and the ampulla is much more readily seen in the drawing than in the operating room. It may be so small that the area must be watched to see whence either bile or pancreatic juice makes its appearance. The dotted line up the common duct outlines the area into which the incision for ampullotomy should be made.
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ing. If a stone is found, immediate choledochotomy is simple, while the wound is fresh. The tube should be left in place until it can be clamped off, thereby forcing the bile to escape from the liver into the duodenum. If clamping off the T-tube causes pain, the ampulla is still closed. If the T-tube is taken out at this time, a biliary fistula will develop.
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Fig. 43. In this drawing the ampulla has been opened and the mucosa of the common duct has been sutured to the mucosa of the duodenum. Note that within the common duct the opening of the pancreatic duct is indicated. In the inset, the possible use of a polyethylene tube to assure drainage of the pancreatic duct is indicated.
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Once the T-tube can be kept clamped several hours a day, it may be pulled out. In the course of dissection necessary to establish the above findings, such diseases as chronic pancreatitis, common duct malignancy and pancreatic carcinoma will also be encountered, if present. When encountered, they should be treated. Chronic pancreatitis, which may have been suggested by the presence of left-sided pain and pain referred to the back, may be recognized by the presence of edema and induration of the pancreas, and occasionally by the presence of areas of fat necrosis both in the pancreas and in the fat tissue about the pancreas. Chronic pancreatitis not only requires cholecystectomy, but if there is any diffieulty in passing the probe from the common duct into the duodenum, a transduodenal exploration of the ampulla should be carried out. The ampulla, in such cases, is often found to be very small-admitting only a very fine probe or fine needle. Whether or not all cases of pancreatitis should be subjected to ampullotomy is not yet known, but if there is evidence that the ampulla is very tight and especially where repeated attacks of acute pancreatitis have been present clinically, it should be done. When chronic pancreatitis is found, it is important to make every effort to eliminate or establish a diagnosis of associated carcinoma. This is difficult, because a small tumor near the head of the pancreas may occlude the pancreatic duct and produce diffuse chronic pancreatitis throughout the rest of the organ. Biopsies taken through the areas of pancreatitis will reveal not only this, but the tumor may be missed. If not palpable, retrograde probing of the pancreatic duct from the ampulla may allow one to determine whether or not there is a block. If such a block is encountered, a mass may be felt at that level, and a biopsy can be taken properly there. A Penrose drain should be sutured with very fine catgut to the areas of pancreatic biopsy so that any pancreatic juice may have egress, from the peritoneal cavity. Needless to say, if a removable carcinoma is found at either the lower end of the common duct, in the pancreas or in the duodenum, a pancreaticoduodenectomy should be done. Such a diagnosis is usually readily made by the palpation of the small but stony-hard carcinoma of the common duct or the pancreas, or the presence in the duodenum of the papillary and usually fungating carcinoma of the ampulla. Because of the technical difficulties of its execution, and the rather considerable mortality associated with it, pancreaticoduodenectomy should not be carried out unless a positive diagnosis can be established. This may . necessitate frozen sections and the pathologist's opinion of the gross tumor at the operating table. Bimanual palpation of both liver lobes may detect the presence of a deep-lying primary carcinoma of the liver itself. (Injection of nitrogen
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mustard directly into the hepatic artery may be of some palliative value in these cases.) TECHNICAL ERRORS
In addition to the problem of proper disposition of the biliary tree itself, there are the problems of a technical nature which affect the vascular systems. Vascular anomalies are infinite, and injuries to the blood vessels may occur. The area in which dissection is necessarily carried out is limited, and the hilar structures are often confused and distorted by edema secondary to the passing of a stone. All structures which could be veE;isels must be ligated. Since there is no standard vascular pattern, each dissection must be individualized. The cystic artery or arteries must be recognized as such, separated from the hepatic arteries and ligated. It is not uncommon to find the hepatic artery coursing from the hilus along the bed of the gallbladder, or even anterior to and parallel with the cc:lurse of the common duct. Here dissection must be done so that all of the details of their anatomical pattern are recognized, and so that trauma to the hepatic artery is avoided. When, in the course of dissection, brisk bleeding is encountered, it should be controlled, not by hemostat, but by digital compression either directly over the bleeding site, or by compression of the hepatic artery. If this is not done, the surgeon, wishing to stop the bleeding rapidly, is likely to grasp blindly into a rapidly increasing pool of blood and clamp not only a bleeder, but a portion of the tissue of the hilus, which may mean common duct, hepatic artery, or portal vein. This accident has occurred repeatedly. When bleeding occurs during dissection, if the hepatic artery is controlled by digital compression, the blood can be sucked out, the field rendered visible, and the point of bleeding accurately grasped when the hepatic artery is released. It is obvious that in some cases ligation of the hepatic artery may cause death, and the ligation of the common duct may lead to death, or, at best, to a stricture of the common duct. If this same ligature cuts through the common duct, delayed biliary peritonitis may occur. Oozing which is difficult to control frequently arises from the liver bed. Temporary hemostasis may be encouraged by absorbable sponge, but this should not be left in place on closing the patient's abdomen. After hemostasis has been secured through the use of the absorbable sponge it should be removed cautiously. Any remaining bleeding spots may be covered with small bits of muscle placed over them. When a fistula develops between the gallbladder and the intestinal tract, it is possible that taking it down will result in leakage. This should be anticipated, if possible, by previous intestinal antisepsis. Unless there is obstruction in the common bile duct, this complication rarely causes
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septic phenomena. When a large acute fistula is found between the duodenum and the gallbladder, it may be wise to leave it, since these almost always close spontaneously. If a large stone is found half way between the duodenum and the gallbladder, and particularly if there is so much inflammation in the duodenum that it would be impossible to close the hole made in removing the stone, it may be better to remove the stone and restore continuity between the gallbladder and the duodenum. Although such a procedure preserves the cholecystoduodenal fistula, it prevents a duodenal fistula. SPECIFIC COMPLICATIONS
Although all of the complications which may follow major operations may affect these patients, there are some which seem to occur more commonly after biliary operations. Of these, paralytic ileus seems to be the most common, followed by atelectasis, phlebitis and evisceration. Perhaps because of the depth of the dissection and the proximity to major nerve reflex areas, paralytic ileus seems particularly disturbing to patients who have had biliary tract operations. It is of course best prevented by the use of a gastric drainage tube and careful avoidance of oral intake until the passage of flatus and return of hunger indicate that peristaltic function has returned. Of especial interest, however, are those complications which are peculiar to operations upon the biliary tract itself. Immediate and late complications are discussed separately because the immediate ones are more likely to be life-threatening and require urgent and definite care. These may be listed as: biliary peritonitis, biliary fistula, hemorrhage and wound sepsis. IlDlDediate COlDplications
Biliary Peritonitis. When jaundice develops early in the postoperative period and is associated with distention, hiccoughs, elevation of temperature, rapid pulse with rebound tenderness and spreading pain, it is usually an indication of peritonitis due to bile leakage and is recognizable as biliary peritonitis. There is free drainage of bile into the peritoneal cavity. If a drain has been placed in the wound, bile is likely to"be seen ... draining from the wound. This bile drainage may be slight or it may be profuse. If profuse, it is particularly treacherous because one is likely to feel that with such profuse bile drainage there could be no accumulation within the peritoneal cavity. This is rarely true. Separation of the wound edges down to the peritoneum reveals the presence of bile which escapes as soon as the peritoneum is opened. Such an escape of bile must indicate that: (1) it is impossible to be certain as to the quan-
Complications of Operations on Biliary Tract
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tity of bile escaping; (2) more bile is escaping from the biliary tree than escapes the ahdominal cavity; and (3) the inevitable conclusion that laparotomy is indicated. Because of the tremendous loss of plasma into the peritoneal cavity as a result of the irritation caused by this large amount of bile, such patients should be given transfusions before and during the exploration. When the abdomen is opened, the peritoneal cavity is usually found to be full of bile. The bile should be sucked out and the source must be found. If the cystic duct ligature has slipped (this is impossible when a suture ligature is used) the defect in the duct must be closed. If the escape of bile is from fine bile ducts in the gallbladder bed (which should have been seen at the time of cholecystectomy) they should be ligated or the area in the liver from which the bile escapes should be over-sewn. Penrose drains, left down to this area, will usually encourage whatever bile drainage has not been adequately stopped, to make its egress from the peritoneal cavity along their course. Occasionally, a leak occurs from the common duct where it has been either traumatized, incised, crushed or excised. (This is quite unlikely if adequate vision has been secured at the time of the original operation.) If the patient is in poor condition, it is simplest and quickest to introduce a catheter into the hepatic end of the duct and bring it out the abdominal wall. This creates a total biliary fistula, but it stops the biliary leak into the peritoneal cavity. Such a patient will then be able to recover, and after convalescence is satisfactory and he is gaining weight, at an elective time, the biliary tract can be implanted into the intestine. Should the diagnosis be established when the patient is still in relatively good condition, the re-establishment of bile drainage into the gastrointestinal tract may be carried out at once. This may be done by whatever maneuver seems most reasonable at the time. Reconstruction is best done by the end-to-end technique if the second operation follows the first by only a day or two, if there is plenty of duct both proximally and distally, if it is not too friable and if the duct is sufficiently large to allow a splinting internal tube to be placed into it. Such a tube should be introduced either above or below the level at which the duct is divided, and one arm of the T-tube should splint the repair site. When there has been loss of duct, or where there is increased friability, the author favors the use of the defunctionalized loop of jejunum to receive the proximal (hepatic) duct. In such instances, the distal duct, not being used, is disregarded. Biliary Fistula. Occasionally, external leakage of bile occurs without any indication of bile peritonitis. Here, because of the lack of peritonitis, the danger is much less. The origin of such bile is presumably from either the fine bile ducts which occasionally pass unseen from the bed of the gallbladder to the liver, or from a ligature which has slipped from the
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cystic duct. As a general rule, such biliary fistulas will close spontaneously in a few days and need occasion no special care. When they remain open for a long period of time, they presumably originate from a defect in an obstructed common duct and will be discussed under late complications. Rarely the bile drainage is so voluminous that it presents a serious threat to fluid and electrolyte stability. Internal drainage must then be provided. Wound Sepsis. When patients develop signs of sepsis early after biliary tract operations, it may mean wound infection, common duct infection with suppurative cholangitis, or it may be associated with retained spORge. Wound infection itself is uncommon, but due to the presence of bacteria unusually resistant to the usual antibiotics, especially Staphylococcus aureus and anaerobic streptococci, such infections do occur. Intense wound pain, redness and edema will be noted on inspecting the wound, and separation of the wound will reveal the presence of small amounts of pus. Bacterial smears will reveal the nature of the organism. Should the wound give the appearance of an anaerobic wound, with extensive fat necrosis, and perhaps a suggestion of gas, the possibility that this is an acute skin gangrene should be thought of, and if the smear reveals an anaerobic bacterium, the wound should be opened as widely as needed to expose the bacteria to the air. In very ill patients, if the infection is limited to the skin, zinc peroxide paste will expedite the elimination of these organisms. If the causative organism is Staphylococcus aureus, it will require specific antibiotic therapy with whatever agent is most effective. Usually erythromycin will be most effective, but sensitivity tests will be necessary. With common duct infection, the febrile course will be septic with chills and fever. Such a course almost without exception indicates that obstruction has been overlooked in the common duct. If the chills and fever abate spontaneously within a few days time, well and good; if the peak of the fever keeps mounting, choledochostomy with removal of the stones must be done. The retention of a sponge is rare because of careful sponge counts, but an absorbable sponge which will supposedly completely disappear has been used. Here low grade fever, undue pain in the gallbladder region, the development of a palpable area of induration in the operative area -all suggest chronic infection. When drained, or when spontaneously discharged, the contained sponge, a gummy residue with much old blood, will be found. In the event it is impossible to control bleeding, either gauze or an absorbable sponge may be used. The gauze may be removed in a few days. If absorbable sponge is employed, as few layers of the material as possible should be used. Usually one or two layers will be effective as a larger amount of tbis material. Hemorrhage. When hemorrhage of serious amount occurs, shock may
Complications of Operations on Biliary Tract
177
be the first symptom. Rarely does the escape of bright blood from the operative field, along the drain, require any more drastic care than the replacement of the blood as it escapes. The bleeding usually stops and there is no more problem. Serious internal bleeding may occur, either from the cystic artery or from a similar vessel (an anomaly, for instance), so deep in the field that it does not escape to the surface. (The drain, if left in place, is likely to be surrounded by fibrin which blocks external drainage.) Such patients may have deep pain in the pit of the stomach, which is likely to be regarded as normal postoperative pain, and it is not until they are in profound shock that it is suspected that the cause of the trouble might be hemorrhage. Unfortunately, the location of the pain, the advanced age of the patient, the shocklike picture, may also suggest that a coronary thrombosis may have taken place. Comparison of pre- and postoperative electrocardiograms may help in the differentiation, as will repeated blood counts, hemoglobin and hematocrit determinations. The rapidity with which the symptoms advance may make the diagnosis difficult or impossible. Since it is as imperative not to operate upon a patient whose heart has recently sustained an acute infarction as it is imperative not to fail to stop a hemorrhage, the diagnosis must be established before it is too late. The author, who has had two deaths from such a cause, hopes that in the future the flooding of the operating field with procaine may release an arterial spasm and thereby encourage bleeding while the abdomen is still open. Late COInplications
These include biliary fistulas, chills and fever, jaundice and finally, persistence or return of the pain for which the patient was operated upon originally. Biliary fistulas, as discussed under the heading of ac~te complications, as a rule disappear without much difficulty provided there has been no obstruction present in the common duct distal to the point at which the bile leaves it. When a fistula fails to close, there can be little doubt that ohstruction of some nature is present and this can rarely be treated other than by laparotomy. Some idea as to the nature of the obstruction may be obtained by the use of lipiodol injection of the fistulous tract. Chills and fever almost always develop when a fistula closes in the face of an obstruction. Such chills and fever always indicate an infection of the bile in the common duct. The occurrence of jaundice, provided such hemolytic factors as arise from transfusion reaction or hepatitis can be ruled out, also indicates that there is obstruction to the outflow of bile. Acoholic stools and dark urine with some itching may be present. Again it is seen that these complications all require a secondary operation to find the obstruction.
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John T. Reynolds
In the presence of a fistula, the common duct is easily traced by following the fistulous tract. The complication of chills and fever indicates that the patient is likely to be less satisfactory as a surgical risk. In the patient with jaundice, there is one technical advantage. Usually with obstruction the proximal common duct has dilated considerably and is, therefore, much more easily managed from a technical point of view. The problem of the cause of the obstruction has been covered in the preliminary discussion. Now the added factor of postoperative edema and adhesions merely add to the technical difficulties. Obviously, a retained stone would be the most favorable, and is also the most common cause of any or all of these symptoms. If found, it can be removed, the patency of the common duct re-proven by cholangiogram or probe, and the common duct treated with a T-tube, as previously discussed. Should chronic pancreatitis be encountered, it may be necessary to carry out an ampullotomy. When the obliterated portion of the duct is much higher than the ampulla, a reconstruction operation may be necessary, as discussed under the problem of biliary peritonitis. If the obstructing lesion happened to be carcinoma, such lesion must be handled in accordance with the findings. In the preoperative preparation of these jaundiced patients, and those with biliary fistulas, attention must be given to the clotting mechanisms. Their prothrombin time must be brought up to normal by adequate diets, replacement of bile if possible, and vitamin K orally or parenterally. Furthermore, these patients should be on this regimen, with a high protein diet, long enough for them to show evidence of positive nitrogen balance. In the absence of such metabolic studies, the evidence of gain in weight without obvious gain in body water suggests a positive nitrogen balance. Furthermore, since the gastrointestinal tract is likely to be entered, some sort of intestinal antiseptic should be provided-sulfasuxidine or sulfathalidine, 2 grams four times a day for at least five days. Only in the event that suppurative cholangitis of mounting intensity cannot be controlled should operation be done, in spite of the poor condition of the patient. Surgical trauma to the common duct may have occurred. Here the problem is that of exposure of the point of obstruction, or fistula, in· a field of previous operation. Distortion is common, and scar formation may be heavy, particularly if the obstruction was the result of healing of a pericholedochal abscess, hematoma or fistula. Since such scars may distort the hilus and bring the hepatic artery and portal vein uncom~ fortably near the operative field, it is best to approach the hilus from the right (lateral) side, since by so doing one tends to encounter the common duct before the vessels. It is usually wise, in such cases, to free up the peritoneal cavity completely, so that the liver, stomach and colon are not immobilized by adhesions to the abdominal parietes.
Complications of Operations on Biliary Tract
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Dissection carried up into the hilus of the liver usually will finally disclose the distended hepatic end of the hepatic duct. Its identity must be proved by aspiration lest in error the right branch of the portal vein be erroneously incised. When the common duct, or the hepatic duct, cannot be found after repeated aspiration and fairly deep dissection, it is probably wise to isolate the hepatic artery and trace it into the liver; then the portal vein. Usually, somewhere between the ramifications of these vessels, a tuft of heavy connective tissue will be found in the depths of which the bile ducts will be encountered. This at times may have to be traced through liver parenchyma before actual bile duct can be found. It is a common experience to find that in these cases the entire common duct has become obliterated up to the point at which the two hepatic ducts join. Thus the junction may be well below the hilus, or very deep within the liver substance. Difficult and time consuming as the dissection may be, it should be pursued with care, because once the common duct is found, repair may be done and permanent relief may be anticipated in as high as 80 to 85 per cent of the cases. I favor the use of the Roux-Y defunctionalized loop of jejunum. It is divided at a point as near the ligament of Treitz as possible, and yet at a level where it may be brought up to the hilus of the liver without tension. This latter is of great import. This distal cut end of jejunum is then anastomosed to the open end of the common duct, end-to-end. If possible, a two layer technique is used, with nonabsorbable serosal sutures, and as many fine catgut mucosa-to-mucosa stitches as is technicallypossible. This means that frequently no more than 5 to 6 stitches may be placed, mucosa-to-mucosa. The result is that the common duct, anastomosed end-to-end to the mucosa, is also practically engulfed by the larger jejunum when the serosa stitches are placed. This prevents separation of the structures. Re-establishment of the gastrointestinal continuity is accomplished by implanting the proximal cut end of the jejunum into the side of the distal jejunum about 18 inches caudad to the site of the choledochojejunostomy. The resultant new common duct now carries no food. Postoperatively, all of these patients leak bile. Since the leakage of a mild amount of bile is well tolerated if it escapes in toto, adequate drainage with several Penrose drains about the choledochojejunostomy anastomosis must be practiced. Intraluminal tubes may be placed, but they should be brought out to the skin through the distal loop so that they may be controlled and removed at the surgeon's wish. I have had a tube which was anchored in the common duct by a silk thread, which passed out the duct to the abdominal wall. It was cut free at the end of six weeks according to McArthur's technique. It did not pass, but remained, becoming covered with bile incrustations, caused obstruction and had to be removed surgically. The duct was found closed at the site of allaS-
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tomosis. In view of such experiences, and experiments showing that indwelling tubes may irritate the bile ducts, such indwelling tubes have lately been completely eliminated in the management of these strictures. Persistence or Recurrence of Pain. When the same pain for which the patient was orginally operated upon persists, when pain recurs, or when the patient suffers from recurrent acute pancreatitis, it must be concluded that, provided no diagnostic errors were committed prior to the original operation, some local disease is still present. It is, of course, essential that the diagnosis be reviewed in order that the other causes of right upper quadrant pain again be eliminated. Such syndromes as fits of pain due to thalamic discharge should be eliminated by electroencephalographic study, as should the possibility of porphyria be eliminated by searching for porphobilinogen and uroporphyrin in the urine. Such local conditions as a stone left in the cystic duct stump, too much cystic duct stump, the remainder of what was originally a double gallbladder, neuroma in the region of the cystic duct, and common duct stone, may be present. In any event, unless a strong contraindication for re-exploration exists, these patients must be re-explored and the steps detailed in the first portion of the paper repeated. Certainly the entire field should be well and completely explored. The simple presence of a long cystic duct stump should not exclude the importance of being certain that there is no neuroma in the field, nor that a common duct stone or chronic pancreatitis is also present. Chronic and Recurrent Acute Pancreatitis. Because of the peculiar importance of chronic pancreatitis with recurrent episodes, this subject is dealt with separately. As mentioned earlier, patients who suffer from acute pancreatitis should not be operated upon during the acute episode, because of the occasional overwhelming shock which accompanies the fulminating types of the disease. However, their intimate relationship to biliary tract disease has always led to eventual cholecystectomy. Investigation of the condition of the common duct should be done. Frequently patients have been seen in whom recurrent attacks of pancreatitis have been investigated surgically, and in whom there were no recurrent attacks as long as T-tube drainage of the common duct was maintained. Return to the preoperative state of repeated episodes follows the removal of the T -tube. These patients sometimes have more or less chronic pancreatitis in the form of distress to the left, and to the backthe areas into which pain is referred during the acute attacks. It is probable that bile has regurgitated up into the pancreatic duct to initiate these attacks. This premise is supported not only by the original work of Opie, but by the details of the anatomical peculiarities of the ampulla of Vater in many of these cases seen at operation. Here the common finding is the fact that the pancreatic duct empties into the common bile duct. Sometimes this occurs just at t.he junction with the
Complications of Operations on Biliary Tract
181
duodenal mucosa, sometimes higher up. This may be seen in cholangiography, or it may be noted at operations on the ampulla. The demonstration of this condition requires patience, and often only the blunt end of a Keith needle will readily enter the ampulla itself, the pancreatic duct, or occasionally even the lowermost portion of the common duct. A small opening of the ampulla, an opening of the pancreatic duct within the common duct, and the fact that occasionally there seems to be a mechanical block of the pancreatic duct by a long septum between the common duct and the pancreatic duct may be found. Frequently the intramural portion of the common duct is narrowed. The ampulla should be opened as discussed earlier in the paper, and should be sutured open if at all possible. Cases in which recurrent pains, recurrent attacks of acute pancreatitis, and recurrent low-grade jaundice often associated with mild fever have been due to inadequate drainage of bile and/or pancreatic fluid from the ampulla are completely relieved by this operation. SUMMARY
Complications of operations on the biliary tract are almost always the result of failure to follow the correct method of treating the patient. Either a patient was operated upon under a mistaken diagnosis; the operation was done at a time unfavorable for complete solution of the problem under discussion; or some misunderstanding of the condition found at operation existed. Careful dissection and complete investigation of each portion of the biliary tract must be meticulously carried out in order to obtain maximal response to the operation. The majority of the postoperative complications may be remedied if their nature is suspected at the onset, and if the proper attack is made on the offending area. 612 N. Michigan Avenue Chicago 11, Illinois
COMPLICATIONS of operations upon the gallbladder and biliary tree usually may be traced to diagnostic misunderstanding or to one of many technical problems associated with the operation itself. Since most of these complications are either preventable or curable, the premise must be that patients in whom the diagnosis is correct, who are operated upon correctly and whose postoperative course is carefully managed will be symptom-free. Furthermore, the operation should carry less than 0.5 per cent mortality. By discussing the diagnostic pitfalls and the technical maneuvers required to solve biliary duct problems, it will be possible to detect how errors occur which lead to complications. DIAGNOSTIC ERRORS
In order that diagnosis will not be in error, we must have a clear-cut idea of the pathogenesis of the symptoms of biliary tract disease. In general, we operate upon patients with biliary tract disease because of the symptoms caused by stones or because of the complications of stones. Congenital anomalies or neoplasms constitute a minor group of cases. Asymptomatic stones are recognized on x-ray by their calcification or bya filling defect in the gallbladder shadow. Operations to remove such stones prophylactically may be done, but to make such recommendations saJe;there.mtist be nO preoperativecontraindications and there must be no complications. -:-When gallstones-cause s..ymptoms, theyusualJy do so in their attempt t6 escape the.-.gaUbladder ~ In this- process, they enter the cystic duct and if successful:escape-through:it-into the common duct and duodenum. Their-passage- is almost: alw.a:Ysassociated with severe pain .. This pain statt$ rather suddenly, is colic-like in--nature and is characteristically violent.Jt is usually the most severe pain the patient has ever experienced. *Clinical Associate Professor of Surgery, University of Illinois College of Medicine, Chicago.
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160
It often reaches its zenith in a fairly short time. Located in the right upper quadrant, it tends to radiate through to the back and to the tip of the scapula. It frequently is precipitated by the combination of a fairly large meal, in which cholagogues are abundant, followed by a period of rest in the horizontal position. (Figs. 36 and 37). During the pain, bodily position does not exaggerate nor relieve it but the patient usually tries many positions in an attempt to obtain relief. Few patients can tolerate the pain without seeking medical help. Morphine sulfate
GRI\VITY
holds
it') fundus of ,9..oltbladder 5tones
PATIENT IN UPRIGHT
POSTURE
Fig. 36. This drawing illustrates the normal position of stones in the gallbladder when the patient is in the upright position.
or atropine sulfate usually relieves the pain and when the patient awakens only local soreness remains. The duration of the colic depends on the fate of the stone. When the stone is so large that it does not escape the cystic duct it may fall back into the gallbladder. This terminates the colic. Such colics are short in duration, last but a few minutes or less than an hour, and may be impossible to diagnose. The pain is most often "colic-like" in the early stages when a relatively undiseased gallbladder wall still has enough of its musculature to contract and so help to expel the stone. In advanced cases there may be loss of some of the characteristic pain. The cystic duct shortens and dilates, there is less resistance to the passage of stones, and colics are correspondingly less severe.
Complications of Operations on Biliary Tract
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When the stone neither drops back into the gallbladder, nor escapes into the common duct, it may become impacted in the neck of the cystic duct. Then the colicky pain tends to disappear and is replaced by a constant pain. It is rapidly associated with local tenderness. This is in part a result of the inflammation which develops in the cystic duct about the impacted stone, and in part a result of the retention of bile and mucus. Should the gallbladder be nearly empty at the time the cystic duct becomes occluded, mucus is secreted and a hydrops is formed.
Fig. 37. This drawing illustrates how a horizontal position may encourage stones in the gallbladder to enter the neck and start down the cystic duct, thus initiating an attack of colic.
If the gallbladder has been largely replaced by scar tissue, there is little or no secretion of mucus and no distention. Here the gallbladder never becomes palpable, for it is tightly scarred over its contained stones, and only vague tenderness is present deep under the liver. If a stone becomes impacted in the cystic duct when the gallbladder is full of bile, a different course of events takes place. As absorption proceeds, the concentration of the bile continues, and the increased concentration of cholesterol irritates the gallbladder, giving rise to a chemical cholecystitis with pus formation. This pus, which is sterile, becomes gradually diluted with the mucus and plasma which the gallbladder wall continues to produce, and an empyema of the gallbladder results. Without bacterial infection, this empyema may remain for many weeks,
John T. Reynolds
162
.>t!
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Stone Passes CystiC Duct No Infection
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-Height of pain
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Fig. 38. This chart illustrates the intensity of the pain of a biliary colic, the almost imperceptible rise in temperature and tenderness, and the prolonged duration of the pathological changes in the gallbladder.
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Fig. 39. This chart illustrates the effect of stone impaction in the cystic duct. Note the prolonged curve for pain, the much more marked elevation in temperature, the presence of tenderness for a period of days.
163
Complications of Operations on Biliary Tract
causing no more than mild distress. It is usually palpable. If bacteria add to the inflammation, gangrene and/or perforation may occur. This is rare, but may take place either in the first few hours or much later, depending upon the virulence of the bacterial infection. It can usually be anticipated by the fact that fever may develop-which is not likely to occur with simple empyema. (See Fig. 40.) Without adhesions, a generalized peritonitis will develop, but should adhesions have developed previously, a pericholecystic abscess with phlegmon will be formed. The latter gives rise to a vague, exquisitely tender mass, which helps to differentiate it from the distinct globular mass of hydrops or empyema
Empyema and Free Perforation
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Fig. 40. Chart illustrating the changes which take place when empyema develops. It emphasizes well that perforation occurs in a patient who has an elevated temperature, and that it is accompanied by an increase in the intensity of the pain.
Passage of a stone out of the gallbladder wall into an adjacent viscus gives rise to a cholecystenteric fistula. While the pericholecystic abscess may resolve spontaneously, the patient with generalized biliary peritonitis requires immediate laparotomy and usually cholecystectomy. Simple cholecystostomy, avoiding the free peritoneal cavity, and if possible removal of the stone from the neck of the cystic duct may suffice. If it is technically reasonable, cholecystectomy may be preferred. The latter is sometimes surprisingly simple to perform, and because in so doing all of the complete disease entity is removed, it is of definite value. Occasionally, spontaneous internal drainage of a pericholecystic abscess gives rise to an internal biliary fistula and relief of the symptoms.
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John T. Reynolds
In arteriosclerosis, spontaneous thrombosis of the cystic artery may lead to gangrene of the gallbladder and to perforation. Here, of course, the disease is rapid, with the development of peritonitis. The true nature of the disease is detected at laparotomy. Cholecystectomy is indicated. The history is the most important single factor in the diagnosis of gallbladder colic. In ordinary gallbladder colic, there is no temperature or pulse elevation, although they will both be elevated when complications set in. Physical examination usually is positive, but dependable only in the acute stage where right upper quadrant tenderness is present. When a hydrops or empyema develops, the gallbladder becomes palpable; when an acute cholecystitis perforates, either an abscess or generalized peritonitis will appear. Figures 38, 39 and 40 illustrate the relationship of pain to findings. On cholecystography, the gallbladder fails to visualize when significantly diseased. However, it must be emphasized that the failure to visualize is not necessarily an indication for surgery. In other words, one must have a history suggestive of biliary colic plus a nonfunctioning gallbladder to justify operation. Failure to observe such dictum has resulted in many unnecessary cholecystectomies. The newer dyes may change the dependability of this dictum. Other causes of pain in the right upper quadrant must be eliminated. Since other conditions may cause pain in the presence of a nonvisualizing gallbladder, the removal of the gallbladder will obviously not relieve such pain. Hyperacidity, peptic ulcer, irritable colon, arthritis of the thoracic spine, right· renal colic, angina pectoris, coronary thrombosis and porphyria are among the conditions for which cholecystectomy has been ill-advisedly carried out. The exclusion of these conditions is obligatory. It is mandatory that a typical biliary history be obtained, or at least history characteristic of one or more of the other conditions be eliminated. For example, a patient with an irritable colon may have a nonvisualizing gallbladder, but dietary indiscretion, rather than precipitating biliary colic, precipitates colicky attacks associated with diarrhea and mucus in the stools. Similarly, after repeated pains of angina pectoris, one would expect some progressive changes in the electrocardiogram. If these are not present, the patient must be re-evaluated. A nonvisualizing gallbladder may then suggest that the biliary tract was the source of the pain. Roentgenograms o(the thoracic spine may show the presence of arthritic changes in a patient whose atttacks are brought on by movement. The development of herpetic lesions may be noted in a patient with unusual cutaneous hypersensitivity. Relief of pain by careful antacid regimen and rest should suggest hyperacidity and/or peptic ulceration. Since gallbladder colic is rarely an emergency, operation must not be done until a diagnosis can be established without any doubt. Once the stone has passed out of the cystic duct and has entered the
Complications of Operations on Biliary Tract
165
common duct, jaundice may appear. When it does, it is usually fluctuant and intermittent; rarely is it constant and progressive. It is often quite transient, and there are many cases of so-called "silent" common duct stones. The addition of jaundice to the history of colic strengthens the indication for operative intervention (see Fig. 41) . Occasionally, jaundice without pain constitutes the indication for operation. Here the diagnosis of "silent" common duct stones must be differentiated from such causes of jaundice as hepatitis, hemolytic icterus (both may be contraindications to operation), carcinoma of the liver,' chronic pancreatitis, postoperative common duct strictures, or carcinoma obstructing the common duct. Except in the rare case of gangrene of the gallbladder, chills and fever are not part of the clinical picture of gallbladder disease. If chills and fever occur with the jaundice, suppurative cholangitIs must be diagnosed. Unless relieved spontaneously, liver abscess or septicemia may result. Therefore, surgical relief must be provided. This implies a choledochostomy. Such so-called conservative procedures as "drainage cholecystotomies" have no place in the treatment of jaundice or of suppurative cholangitis, because they usually do not and cannot be depended upon to drain the common duct. As mentioned, failure to establish drainage of the common duct may result in liver abscesses and in death. CONTRAINDICATIONS TO OPERATION IN NONJAUNDICED PATIENTS
If there is any likelihood that disease other than cholecystitis is the cause of the patient's pain, operation should not be performed until the diagnosis is clarified. Similarly, if there is any contraindication because of the patient's general condition, it should not be done. Although, in general, cardiac conditions constitute a contraindication to operation, there are certain cases in which cholecystectomy seems specifically indicated. Local changes which make the dissection hazardous may occur. Since many of these are acute and tend to disappear with time, it may be wise to wait. When a stone passes the cystic duct, the duct becomes inflamed and the inflammation may involve the other structures of the liver hilus. These changes make dissection difficult, not only because of the oozing likely to occur, but because the now friable structures in the hilus tear readily, and do not hold sutures well if repair is attempted. These changes begin within 36 hours after the onset of the attack, and may last for many weeks after the colic has passed. It is wise to operate early, before the inflammation has occurred, or to wait for several weeks or even months, until the effects of inflammation have resolved. Since gallbladder colic is an emergency only in the presence of gangrene or perforation of the gallbladder (which are readily diagnosed-see Fig. 40), such a "waitand-watch" policy may be followed with safety.
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John T. Reynolds
Another contraindication to operation is the presence of acute pancreatitis. Patients suffering from acute pancreatitis should be given antispasmodics and sedatives, or a splanchnic nerve block to relieve their pain. They should also receive intensive supportive therapy, in the form of blood and plasma, to replace the fluid lost into the peritoneal cavity, which occurs as a part of the reaction to fat necrosis. This is particularly essential in patients who have severe shock in the fulminating form of the disease. Operation can offer no relief from their condition and the shock of an operation may deprive them of any chance to recover. Since mortality of operation may reach 60 per cent in the ill patients, and may be kept to below 15 per cent by nonoperative means, this approach is generally accepted. If the abdomen is opened by mistake, and acute pancreatitis is discovered, it is probably best that the abdomen be closed with nothing more being done than to place a drain down to the head of the pancreas. If there is positive evidence of increased pressure in the common duct, as evidenced by dilatation of the common duct and jaundice, a choledochostomy may be done. Supportive care should be vigorous. CONTRAINDICATIONS TO OPERATION IN JAUNDICED PATIENTS
Since jaundice itself does not create an emergency, all jaundiced patients should have a careful liver function study. Operation should not be performed on patients with hepatitis. If there is (vidence of of liver disease, such as the presence of a positive cephalin flocculation test, increased thymol turbidity, and reduction in the level of the serum proteins, in the presence of jaundice, hepatitis should be suspected. Only when obstructive jaundice seems reasonable should operation be done. If the patient's prothrombin time is prolonged and does not respond to the administration of vitamin K, he should not be operated upon because of the hazard of hemorrhage. A careful hematological work-up will reveal the presence of hemolytic icterus, for which splenectomy may be indicated. Failure to remove the spleen will result in persistence of the jaundice. TECHNICAL DETAILS OF THE OPERATION
Once operation is decided upon, its execution must be technically correct in order to avoid complications. This implies not only that the biliary tree be properly handled, but that the other structures encountered be respected. Adequate relaxation and adequate incision must be obtained, and delicate instruments and tubes must be available. The cystic duct is frequently long and parallel to the common duct, at times even traversing the' pancreas to enter the common duct at the ampulla It should be carefully dissected in each patient, its junction with
Complications of Operations on Biliary Tract
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the common duct seen and proven free of stones, both by palpation and by the fact that when the stump is unclamped, bile flows freely back from the common duct. If there is too much cystic duct left, so that actual gallbladder tissue is present, this may function and result in the development of a new gallbladder, which may cause symptoms. The cystic duct. should be suture-ligated about ~~ inch distal to the junction with the ('ommon duct. If placed too near the common duct, suture may result in "tenting" of the common duct, with partial occlusion thereof, and resultant stricture of the common duct. A second gallbladder, possibly intrahepatic, should be looked for. The gallbladder should be opened by the surgeon at the operating table as soon as it has been removed. Particular attention should be paid to the relationship of the diameter of the cystic duct to the size of the stones. If the gallstones are so large that they could not pass out of the cystic duct, it is equally unlikely that there would be stones in the ('ommon duct. However, if the cystic duct is large and the smallest stones in the gallbladder could readily have passed through it, stones must be presumed to be present in the common duct. In such cases, the common duct is usually dilated. If stones are not removed from the common duct, they may pass spontaneously, but this cannot be depended upon. If left in place, they will usually cause symptoms. Pain, similar to previous attacks but less severe, occasional jaundice, and, in the presence of infection, chills and fever may be expected. Furthermore, such stones when left in place may be associated with elevation of the ductal pressure and so contribute to the tendency of the cystic duct ligature to slip off. In almost all such cases, the common duct will be found to be dilated. Since stones in the common duct are rarely palpable, other means of detecting their presence must be used. Jaundice, in the course of biliary colic, is considered pathognomonic. Common duct compression, however, may occur from a stone impacted in the cystic duct. In such instances it may be forced against the common duct by increasing pressure in the hydrops of the gallbladder and by the inflammation which often surrounds the stone. Such diagnosis, referred to by the French as "the cystic duct syndrome," is recognized when a single large impacted stone is found above a tiny cystic duct in a patient who gives a history of jaundice. In addition to dilatation of the cystic duct, dilatation of the common duct and/or palpable stones are indications for common duct exploration. In order to avoid damage to a very small common duct, it should be pointed out that only rarely will stones be present in a small common duct. Small common ducts (below 6 to 7 mm. in diameter) should not be opened. Occasionally, there may be rare instances of jaundice in which
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both hepatitis and obstruction seem to play a part, in which it may be important to determine the patency of the common duct, and the presence or absence of tiny stones or "sludge." Then, and only then, may it be necessary to disregard the small size of the common duct as a contraindication to choledochostomy. Such procedures as common duct pressure readings, to study the tone of the sphincter muscle, operating room cholangiograms have been developed. Both procedures require great experience to avoid technical errors which make their execution and interpretation difficult. The common duct should be opened longitudinally, the incision being long enough to permit a stone forceps and scoop to be manipulated within it easily, and without tearing or traumatizing the duct. This means an incision at least 1.5 cm. in length. The stone forceps and scoop should be passed up into the hepatic ducts and down into the distal common duct. All stones found should be removed, and when no more are present, or when no stones are found, the patency of the ampulla should be established. A probe should pass with ease out of the common duct and into the duodenum. It may be recognized by the metallic appearance of the tip of the probe which seems to be coming out through the serosa of the anterior duodenal wall. If there has been little evidence of common duct stones, and no jaundice, the fact that a probe does not pass readily out of the ampulla may be ignored. However, if the patient has had recurrent bouts of jaundice, if the common duct is distended, particularly if the bile in the common duct is full of sediment, gravel or "sludge," or if the patient has had symptoms referable to the left side of the abdomen and to the back, suggesting pancreatitis, the patency of the ampulla must be established. In such cases, the duodenum must be opened, the ampulla found and the condition of the ampulla investigated. It may be difficult to see the ampulla, and it may be necessary to wait until either bile or pancreatic juice pours out to identify the opening. A stone may be seen, pouting out of its end, or a stone may be palpated between the duodenal wall and the end of the probe in the common duct. A Keith needle may be passed up a tiny ampullary opening until it touches the tip of the probe, or until a stone is encountered. The stone should be removed. If the bile has been cloudy, or filled with sediment, the lower end of the common duct may be filled with sediment--even a cast of the lower several centimeters may be found. In such instances, drainage of the common duct into the duodenum has been inadequate, and an ampullotomy should be performed. Primary common duct stone may require ampullotomy if the ampulla is tight. It is our preference to make a long incision into the ampulla, 2 or 3 cm. in length, and if possible to sew it open by approximating the mucosa of the common duct to the mucosa of the duodenum. When such a metic-
169
Complications of Operations on Biliary Tract
ulous mucosa-to-mucosa suture is possible, it seems likely that the common duct mucosa will heal to that of the duodenum and no stricture will . form. A simple T-tube placed above in the choledochostomy incision, will splint the ampulla sufficiently. If the opening in the pancreatic duct is such that its occlusion seems likely, a small polyethylene tube may well be left in place to splint it. It is our feeling that attempted dilatation of the ampulla and the use of a long-arm T-tube are contraindicated. The ampulla is likely to return to its preoperative size, and if the pancreatic duct drains into the ampulla just at the duodenal margin, a long-arm tube will block the pancreatic duct and may give rise to a fulminating and fatal acute pancreatitis.
Stone Blocking Common Duct: Suppurative Cholangitis
~I~
Choledochostomy
l
......
o
I
2
4
5
6
7
8
9
DAY 5
Fig. 41. Chart illustrating the temperature curve in a patient with suppurative cholangitis. Note the almost complete relief obtained by choledochostomy. Note that this is not cholecystectomy.
N onabsorbable sutures are probably best avoided in closing the cystic duct and common duct, because many cases have been reported in which silk or cotton sutures have worked their way into the common duct, become covered with inspissated bile and caused common duct symptoms. If a patient is allergic to catgut, on the other hand, rapid separation of the wound in the duct can occur with biliary fistula formation. T-tubes should be left in the common duct after all common duct explorations, because the ampulla frequently swells shut temporarily after the manipulation of common duct probing. They should be so much smaller than the lumen of the duct that they do not rub on the lining of the duct. They should be so nicked, opposite the long arm, that they will collapse readily on pulling, and the short arms should not exceed 1 to 1.5 cm. in length. A choledochogram should be done on the
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operating table just before closing in order to determine that no stone has been left in the duct. If a stone is found, it should be removed. In order to avoid confusing the shadow of an air bubbJe with a shadow due to a stone, an additional cholangiogram may be taken the next morn-
Fig. 42. Drawing illustrating the relative position of the ampulla of Vater in the curve of the duodenum. The duodenum is open and the ampulla is much more readily seen in the drawing than in the operating room. It may be so small that the area must be watched to see whence either bile or pancreatic juice makes its appearance. The dotted line up the common duct outlines the area into which the incision for ampullotomy should be made.
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ing. If a stone is found, immediate choledochotomy is simple, while the wound is fresh. The tube should be left in place until it can be clamped off, thereby forcing the bile to escape from the liver into the duodenum. If clamping off the T-tube causes pain, the ampulla is still closed. If the T-tube is taken out at this time, a biliary fistula will develop.
~f~mysctd(1lttJre at
:ofindsion . ... ..withinte&upted
$~tures
.
Fig. 43. In this drawing the ampulla has been opened and the mucosa of the common duct has been sutured to the mucosa of the duodenum. Note that within the common duct the opening of the pancreatic duct is indicated. In the inset, the possible use of a polyethylene tube to assure drainage of the pancreatic duct is indicated.
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Once the T-tube can be kept clamped several hours a day, it may be pulled out. In the course of dissection necessary to establish the above findings, such diseases as chronic pancreatitis, common duct malignancy and pancreatic carcinoma will also be encountered, if present. When encountered, they should be treated. Chronic pancreatitis, which may have been suggested by the presence of left-sided pain and pain referred to the back, may be recognized by the presence of edema and induration of the pancreas, and occasionally by the presence of areas of fat necrosis both in the pancreas and in the fat tissue about the pancreas. Chronic pancreatitis not only requires cholecystectomy, but if there is any diffieulty in passing the probe from the common duct into the duodenum, a transduodenal exploration of the ampulla should be carried out. The ampulla, in such cases, is often found to be very small-admitting only a very fine probe or fine needle. Whether or not all cases of pancreatitis should be subjected to ampullotomy is not yet known, but if there is evidence that the ampulla is very tight and especially where repeated attacks of acute pancreatitis have been present clinically, it should be done. When chronic pancreatitis is found, it is important to make every effort to eliminate or establish a diagnosis of associated carcinoma. This is difficult, because a small tumor near the head of the pancreas may occlude the pancreatic duct and produce diffuse chronic pancreatitis throughout the rest of the organ. Biopsies taken through the areas of pancreatitis will reveal not only this, but the tumor may be missed. If not palpable, retrograde probing of the pancreatic duct from the ampulla may allow one to determine whether or not there is a block. If such a block is encountered, a mass may be felt at that level, and a biopsy can be taken properly there. A Penrose drain should be sutured with very fine catgut to the areas of pancreatic biopsy so that any pancreatic juice may have egress, from the peritoneal cavity. Needless to say, if a removable carcinoma is found at either the lower end of the common duct, in the pancreas or in the duodenum, a pancreaticoduodenectomy should be done. Such a diagnosis is usually readily made by the palpation of the small but stony-hard carcinoma of the common duct or the pancreas, or the presence in the duodenum of the papillary and usually fungating carcinoma of the ampulla. Because of the technical difficulties of its execution, and the rather considerable mortality associated with it, pancreaticoduodenectomy should not be carried out unless a positive diagnosis can be established. This may . necessitate frozen sections and the pathologist's opinion of the gross tumor at the operating table. Bimanual palpation of both liver lobes may detect the presence of a deep-lying primary carcinoma of the liver itself. (Injection of nitrogen
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mustard directly into the hepatic artery may be of some palliative value in these cases.) TECHNICAL ERRORS
In addition to the problem of proper disposition of the biliary tree itself, there are the problems of a technical nature which affect the vascular systems. Vascular anomalies are infinite, and injuries to the blood vessels may occur. The area in which dissection is necessarily carried out is limited, and the hilar structures are often confused and distorted by edema secondary to the passing of a stone. All structures which could be veE;isels must be ligated. Since there is no standard vascular pattern, each dissection must be individualized. The cystic artery or arteries must be recognized as such, separated from the hepatic arteries and ligated. It is not uncommon to find the hepatic artery coursing from the hilus along the bed of the gallbladder, or even anterior to and parallel with the cc:lurse of the common duct. Here dissection must be done so that all of the details of their anatomical pattern are recognized, and so that trauma to the hepatic artery is avoided. When, in the course of dissection, brisk bleeding is encountered, it should be controlled, not by hemostat, but by digital compression either directly over the bleeding site, or by compression of the hepatic artery. If this is not done, the surgeon, wishing to stop the bleeding rapidly, is likely to grasp blindly into a rapidly increasing pool of blood and clamp not only a bleeder, but a portion of the tissue of the hilus, which may mean common duct, hepatic artery, or portal vein. This accident has occurred repeatedly. When bleeding occurs during dissection, if the hepatic artery is controlled by digital compression, the blood can be sucked out, the field rendered visible, and the point of bleeding accurately grasped when the hepatic artery is released. It is obvious that in some cases ligation of the hepatic artery may cause death, and the ligation of the common duct may lead to death, or, at best, to a stricture of the common duct. If this same ligature cuts through the common duct, delayed biliary peritonitis may occur. Oozing which is difficult to control frequently arises from the liver bed. Temporary hemostasis may be encouraged by absorbable sponge, but this should not be left in place on closing the patient's abdomen. After hemostasis has been secured through the use of the absorbable sponge it should be removed cautiously. Any remaining bleeding spots may be covered with small bits of muscle placed over them. When a fistula develops between the gallbladder and the intestinal tract, it is possible that taking it down will result in leakage. This should be anticipated, if possible, by previous intestinal antisepsis. Unless there is obstruction in the common bile duct, this complication rarely causes
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septic phenomena. When a large acute fistula is found between the duodenum and the gallbladder, it may be wise to leave it, since these almost always close spontaneously. If a large stone is found half way between the duodenum and the gallbladder, and particularly if there is so much inflammation in the duodenum that it would be impossible to close the hole made in removing the stone, it may be better to remove the stone and restore continuity between the gallbladder and the duodenum. Although such a procedure preserves the cholecystoduodenal fistula, it prevents a duodenal fistula. SPECIFIC COMPLICATIONS
Although all of the complications which may follow major operations may affect these patients, there are some which seem to occur more commonly after biliary operations. Of these, paralytic ileus seems to be the most common, followed by atelectasis, phlebitis and evisceration. Perhaps because of the depth of the dissection and the proximity to major nerve reflex areas, paralytic ileus seems particularly disturbing to patients who have had biliary tract operations. It is of course best prevented by the use of a gastric drainage tube and careful avoidance of oral intake until the passage of flatus and return of hunger indicate that peristaltic function has returned. Of especial interest, however, are those complications which are peculiar to operations upon the biliary tract itself. Immediate and late complications are discussed separately because the immediate ones are more likely to be life-threatening and require urgent and definite care. These may be listed as: biliary peritonitis, biliary fistula, hemorrhage and wound sepsis. IlDlDediate COlDplications
Biliary Peritonitis. When jaundice develops early in the postoperative period and is associated with distention, hiccoughs, elevation of temperature, rapid pulse with rebound tenderness and spreading pain, it is usually an indication of peritonitis due to bile leakage and is recognizable as biliary peritonitis. There is free drainage of bile into the peritoneal cavity. If a drain has been placed in the wound, bile is likely to"be seen ... draining from the wound. This bile drainage may be slight or it may be profuse. If profuse, it is particularly treacherous because one is likely to feel that with such profuse bile drainage there could be no accumulation within the peritoneal cavity. This is rarely true. Separation of the wound edges down to the peritoneum reveals the presence of bile which escapes as soon as the peritoneum is opened. Such an escape of bile must indicate that: (1) it is impossible to be certain as to the quan-
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tity of bile escaping; (2) more bile is escaping from the biliary tree than escapes the ahdominal cavity; and (3) the inevitable conclusion that laparotomy is indicated. Because of the tremendous loss of plasma into the peritoneal cavity as a result of the irritation caused by this large amount of bile, such patients should be given transfusions before and during the exploration. When the abdomen is opened, the peritoneal cavity is usually found to be full of bile. The bile should be sucked out and the source must be found. If the cystic duct ligature has slipped (this is impossible when a suture ligature is used) the defect in the duct must be closed. If the escape of bile is from fine bile ducts in the gallbladder bed (which should have been seen at the time of cholecystectomy) they should be ligated or the area in the liver from which the bile escapes should be over-sewn. Penrose drains, left down to this area, will usually encourage whatever bile drainage has not been adequately stopped, to make its egress from the peritoneal cavity along their course. Occasionally, a leak occurs from the common duct where it has been either traumatized, incised, crushed or excised. (This is quite unlikely if adequate vision has been secured at the time of the original operation.) If the patient is in poor condition, it is simplest and quickest to introduce a catheter into the hepatic end of the duct and bring it out the abdominal wall. This creates a total biliary fistula, but it stops the biliary leak into the peritoneal cavity. Such a patient will then be able to recover, and after convalescence is satisfactory and he is gaining weight, at an elective time, the biliary tract can be implanted into the intestine. Should the diagnosis be established when the patient is still in relatively good condition, the re-establishment of bile drainage into the gastrointestinal tract may be carried out at once. This may be done by whatever maneuver seems most reasonable at the time. Reconstruction is best done by the end-to-end technique if the second operation follows the first by only a day or two, if there is plenty of duct both proximally and distally, if it is not too friable and if the duct is sufficiently large to allow a splinting internal tube to be placed into it. Such a tube should be introduced either above or below the level at which the duct is divided, and one arm of the T-tube should splint the repair site. When there has been loss of duct, or where there is increased friability, the author favors the use of the defunctionalized loop of jejunum to receive the proximal (hepatic) duct. In such instances, the distal duct, not being used, is disregarded. Biliary Fistula. Occasionally, external leakage of bile occurs without any indication of bile peritonitis. Here, because of the lack of peritonitis, the danger is much less. The origin of such bile is presumably from either the fine bile ducts which occasionally pass unseen from the bed of the gallbladder to the liver, or from a ligature which has slipped from the
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cystic duct. As a general rule, such biliary fistulas will close spontaneously in a few days and need occasion no special care. When they remain open for a long period of time, they presumably originate from a defect in an obstructed common duct and will be discussed under late complications. Rarely the bile drainage is so voluminous that it presents a serious threat to fluid and electrolyte stability. Internal drainage must then be provided. Wound Sepsis. When patients develop signs of sepsis early after biliary tract operations, it may mean wound infection, common duct infection with suppurative cholangitis, or it may be associated with retained spORge. Wound infection itself is uncommon, but due to the presence of bacteria unusually resistant to the usual antibiotics, especially Staphylococcus aureus and anaerobic streptococci, such infections do occur. Intense wound pain, redness and edema will be noted on inspecting the wound, and separation of the wound will reveal the presence of small amounts of pus. Bacterial smears will reveal the nature of the organism. Should the wound give the appearance of an anaerobic wound, with extensive fat necrosis, and perhaps a suggestion of gas, the possibility that this is an acute skin gangrene should be thought of, and if the smear reveals an anaerobic bacterium, the wound should be opened as widely as needed to expose the bacteria to the air. In very ill patients, if the infection is limited to the skin, zinc peroxide paste will expedite the elimination of these organisms. If the causative organism is Staphylococcus aureus, it will require specific antibiotic therapy with whatever agent is most effective. Usually erythromycin will be most effective, but sensitivity tests will be necessary. With common duct infection, the febrile course will be septic with chills and fever. Such a course almost without exception indicates that obstruction has been overlooked in the common duct. If the chills and fever abate spontaneously within a few days time, well and good; if the peak of the fever keeps mounting, choledochostomy with removal of the stones must be done. The retention of a sponge is rare because of careful sponge counts, but an absorbable sponge which will supposedly completely disappear has been used. Here low grade fever, undue pain in the gallbladder region, the development of a palpable area of induration in the operative area -all suggest chronic infection. When drained, or when spontaneously discharged, the contained sponge, a gummy residue with much old blood, will be found. In the event it is impossible to control bleeding, either gauze or an absorbable sponge may be used. The gauze may be removed in a few days. If absorbable sponge is employed, as few layers of the material as possible should be used. Usually one or two layers will be effective as a larger amount of tbis material. Hemorrhage. When hemorrhage of serious amount occurs, shock may
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be the first symptom. Rarely does the escape of bright blood from the operative field, along the drain, require any more drastic care than the replacement of the blood as it escapes. The bleeding usually stops and there is no more problem. Serious internal bleeding may occur, either from the cystic artery or from a similar vessel (an anomaly, for instance), so deep in the field that it does not escape to the surface. (The drain, if left in place, is likely to be surrounded by fibrin which blocks external drainage.) Such patients may have deep pain in the pit of the stomach, which is likely to be regarded as normal postoperative pain, and it is not until they are in profound shock that it is suspected that the cause of the trouble might be hemorrhage. Unfortunately, the location of the pain, the advanced age of the patient, the shocklike picture, may also suggest that a coronary thrombosis may have taken place. Comparison of pre- and postoperative electrocardiograms may help in the differentiation, as will repeated blood counts, hemoglobin and hematocrit determinations. The rapidity with which the symptoms advance may make the diagnosis difficult or impossible. Since it is as imperative not to operate upon a patient whose heart has recently sustained an acute infarction as it is imperative not to fail to stop a hemorrhage, the diagnosis must be established before it is too late. The author, who has had two deaths from such a cause, hopes that in the future the flooding of the operating field with procaine may release an arterial spasm and thereby encourage bleeding while the abdomen is still open. Late COInplications
These include biliary fistulas, chills and fever, jaundice and finally, persistence or return of the pain for which the patient was operated upon originally. Biliary fistulas, as discussed under the heading of ac~te complications, as a rule disappear without much difficulty provided there has been no obstruction present in the common duct distal to the point at which the bile leaves it. When a fistula fails to close, there can be little doubt that ohstruction of some nature is present and this can rarely be treated other than by laparotomy. Some idea as to the nature of the obstruction may be obtained by the use of lipiodol injection of the fistulous tract. Chills and fever almost always develop when a fistula closes in the face of an obstruction. Such chills and fever always indicate an infection of the bile in the common duct. The occurrence of jaundice, provided such hemolytic factors as arise from transfusion reaction or hepatitis can be ruled out, also indicates that there is obstruction to the outflow of bile. Acoholic stools and dark urine with some itching may be present. Again it is seen that these complications all require a secondary operation to find the obstruction.
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In the presence of a fistula, the common duct is easily traced by following the fistulous tract. The complication of chills and fever indicates that the patient is likely to be less satisfactory as a surgical risk. In the patient with jaundice, there is one technical advantage. Usually with obstruction the proximal common duct has dilated considerably and is, therefore, much more easily managed from a technical point of view. The problem of the cause of the obstruction has been covered in the preliminary discussion. Now the added factor of postoperative edema and adhesions merely add to the technical difficulties. Obviously, a retained stone would be the most favorable, and is also the most common cause of any or all of these symptoms. If found, it can be removed, the patency of the common duct re-proven by cholangiogram or probe, and the common duct treated with a T-tube, as previously discussed. Should chronic pancreatitis be encountered, it may be necessary to carry out an ampullotomy. When the obliterated portion of the duct is much higher than the ampulla, a reconstruction operation may be necessary, as discussed under the problem of biliary peritonitis. If the obstructing lesion happened to be carcinoma, such lesion must be handled in accordance with the findings. In the preoperative preparation of these jaundiced patients, and those with biliary fistulas, attention must be given to the clotting mechanisms. Their prothrombin time must be brought up to normal by adequate diets, replacement of bile if possible, and vitamin K orally or parenterally. Furthermore, these patients should be on this regimen, with a high protein diet, long enough for them to show evidence of positive nitrogen balance. In the absence of such metabolic studies, the evidence of gain in weight without obvious gain in body water suggests a positive nitrogen balance. Furthermore, since the gastrointestinal tract is likely to be entered, some sort of intestinal antiseptic should be provided-sulfasuxidine or sulfathalidine, 2 grams four times a day for at least five days. Only in the event that suppurative cholangitis of mounting intensity cannot be controlled should operation be done, in spite of the poor condition of the patient. Surgical trauma to the common duct may have occurred. Here the problem is that of exposure of the point of obstruction, or fistula, in· a field of previous operation. Distortion is common, and scar formation may be heavy, particularly if the obstruction was the result of healing of a pericholedochal abscess, hematoma or fistula. Since such scars may distort the hilus and bring the hepatic artery and portal vein uncom~ fortably near the operative field, it is best to approach the hilus from the right (lateral) side, since by so doing one tends to encounter the common duct before the vessels. It is usually wise, in such cases, to free up the peritoneal cavity completely, so that the liver, stomach and colon are not immobilized by adhesions to the abdominal parietes.
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Dissection carried up into the hilus of the liver usually will finally disclose the distended hepatic end of the hepatic duct. Its identity must be proved by aspiration lest in error the right branch of the portal vein be erroneously incised. When the common duct, or the hepatic duct, cannot be found after repeated aspiration and fairly deep dissection, it is probably wise to isolate the hepatic artery and trace it into the liver; then the portal vein. Usually, somewhere between the ramifications of these vessels, a tuft of heavy connective tissue will be found in the depths of which the bile ducts will be encountered. This at times may have to be traced through liver parenchyma before actual bile duct can be found. It is a common experience to find that in these cases the entire common duct has become obliterated up to the point at which the two hepatic ducts join. Thus the junction may be well below the hilus, or very deep within the liver substance. Difficult and time consuming as the dissection may be, it should be pursued with care, because once the common duct is found, repair may be done and permanent relief may be anticipated in as high as 80 to 85 per cent of the cases. I favor the use of the Roux-Y defunctionalized loop of jejunum. It is divided at a point as near the ligament of Treitz as possible, and yet at a level where it may be brought up to the hilus of the liver without tension. This latter is of great import. This distal cut end of jejunum is then anastomosed to the open end of the common duct, end-to-end. If possible, a two layer technique is used, with nonabsorbable serosal sutures, and as many fine catgut mucosa-to-mucosa stitches as is technicallypossible. This means that frequently no more than 5 to 6 stitches may be placed, mucosa-to-mucosa. The result is that the common duct, anastomosed end-to-end to the mucosa, is also practically engulfed by the larger jejunum when the serosa stitches are placed. This prevents separation of the structures. Re-establishment of the gastrointestinal continuity is accomplished by implanting the proximal cut end of the jejunum into the side of the distal jejunum about 18 inches caudad to the site of the choledochojejunostomy. The resultant new common duct now carries no food. Postoperatively, all of these patients leak bile. Since the leakage of a mild amount of bile is well tolerated if it escapes in toto, adequate drainage with several Penrose drains about the choledochojejunostomy anastomosis must be practiced. Intraluminal tubes may be placed, but they should be brought out to the skin through the distal loop so that they may be controlled and removed at the surgeon's wish. I have had a tube which was anchored in the common duct by a silk thread, which passed out the duct to the abdominal wall. It was cut free at the end of six weeks according to McArthur's technique. It did not pass, but remained, becoming covered with bile incrustations, caused obstruction and had to be removed surgically. The duct was found closed at the site of allaS-
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tomosis. In view of such experiences, and experiments showing that indwelling tubes may irritate the bile ducts, such indwelling tubes have lately been completely eliminated in the management of these strictures. Persistence or Recurrence of Pain. When the same pain for which the patient was orginally operated upon persists, when pain recurs, or when the patient suffers from recurrent acute pancreatitis, it must be concluded that, provided no diagnostic errors were committed prior to the original operation, some local disease is still present. It is, of course, essential that the diagnosis be reviewed in order that the other causes of right upper quadrant pain again be eliminated. Such syndromes as fits of pain due to thalamic discharge should be eliminated by electroencephalographic study, as should the possibility of porphyria be eliminated by searching for porphobilinogen and uroporphyrin in the urine. Such local conditions as a stone left in the cystic duct stump, too much cystic duct stump, the remainder of what was originally a double gallbladder, neuroma in the region of the cystic duct, and common duct stone, may be present. In any event, unless a strong contraindication for re-exploration exists, these patients must be re-explored and the steps detailed in the first portion of the paper repeated. Certainly the entire field should be well and completely explored. The simple presence of a long cystic duct stump should not exclude the importance of being certain that there is no neuroma in the field, nor that a common duct stone or chronic pancreatitis is also present. Chronic and Recurrent Acute Pancreatitis. Because of the peculiar importance of chronic pancreatitis with recurrent episodes, this subject is dealt with separately. As mentioned earlier, patients who suffer from acute pancreatitis should not be operated upon during the acute episode, because of the occasional overwhelming shock which accompanies the fulminating types of the disease. However, their intimate relationship to biliary tract disease has always led to eventual cholecystectomy. Investigation of the condition of the common duct should be done. Frequently patients have been seen in whom recurrent attacks of pancreatitis have been investigated surgically, and in whom there were no recurrent attacks as long as T-tube drainage of the common duct was maintained. Return to the preoperative state of repeated episodes follows the removal of the T -tube. These patients sometimes have more or less chronic pancreatitis in the form of distress to the left, and to the backthe areas into which pain is referred during the acute attacks. It is probable that bile has regurgitated up into the pancreatic duct to initiate these attacks. This premise is supported not only by the original work of Opie, but by the details of the anatomical peculiarities of the ampulla of Vater in many of these cases seen at operation. Here the common finding is the fact that the pancreatic duct empties into the common bile duct. Sometimes this occurs just at t.he junction with the
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duodenal mucosa, sometimes higher up. This may be seen in cholangiography, or it may be noted at operations on the ampulla. The demonstration of this condition requires patience, and often only the blunt end of a Keith needle will readily enter the ampulla itself, the pancreatic duct, or occasionally even the lowermost portion of the common duct. A small opening of the ampulla, an opening of the pancreatic duct within the common duct, and the fact that occasionally there seems to be a mechanical block of the pancreatic duct by a long septum between the common duct and the pancreatic duct may be found. Frequently the intramural portion of the common duct is narrowed. The ampulla should be opened as discussed earlier in the paper, and should be sutured open if at all possible. Cases in which recurrent pains, recurrent attacks of acute pancreatitis, and recurrent low-grade jaundice often associated with mild fever have been due to inadequate drainage of bile and/or pancreatic fluid from the ampulla are completely relieved by this operation. SUMMARY
Complications of operations on the biliary tract are almost always the result of failure to follow the correct method of treating the patient. Either a patient was operated upon under a mistaken diagnosis; the operation was done at a time unfavorable for complete solution of the problem under discussion; or some misunderstanding of the condition found at operation existed. Careful dissection and complete investigation of each portion of the biliary tract must be meticulously carried out in order to obtain maximal response to the operation. The majority of the postoperative complications may be remedied if their nature is suspected at the onset, and if the proper attack is made on the offending area. 612 N. Michigan Avenue Chicago 11, Illinois