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Preoperative and Postoperative Management of Patients Having Biliary Tract Operations
Preoperative and Postoperative Management of Patients Having Biliary Tract Operations ALLEN M. BOYDEN, M.S. (SURG.), M.D., F.A.C.S.*
DISEASES of the biliary tract are in general more amenable to correct surgical care than are those of most other systems or organs of the body. Properly planned and executed operative treatment combined with intelligent preoperative preparation and postoperative management will yield a high percentage of permanently successful results with a minimal surgical mortality. This, of course, presumes careful segregation of patients for operation as well as experienced selection of the proper procedure once the operation is undertaken. The improved end results and the significant reduction in postoperative mortality in recent years are due to many factors. Of great importance is improvement in the understanding of liver function. This has made possible more accurate diagnosis as well as greater protection of the liver from further damage by suitable supplemental therapy, choice of safer anesthetic agents, and proper timing of surgical intervention. Blood transfusions and antibiotic therapy have played a lesser role in these improved results than is commonly believed. The great increase in highly trained and qualified surgeons is resulting in reduction in the number of tragic injuries to the bile ducts and hepatic arteries. More scientific anesthesiology and better qualified anesthetists are added factors. However, in my opinion, of greatest importance in the improved results is the strict attention given to all of the minutiae of care during the pre- and postoperative periods. Too often in discussions of this subject there is no mention of many of these details which together contribute so much to safe and uncomplicated convalescence. At the risk of seeming obvious and meticulous these details will be fully outlined in the discussion which follows.
Associate Clinical ProJessot· oj Surgery, University oj Oregon Medical School; Head, General Surgery Department, The Portland Clinic; Attending Surgeon, St. Vincent's Hospital and Multnomah County Hospital, Portland, Oregon.
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1376 PREOPERATIVE MANAGEMENT
Psychologic Preparation for Operation
It is of primary importance that the patient should have some understanding of what he may expect from the operation as well as what is expected of him in the immediate postoperative period. Unfortunately, improper selection of patients in addition to inadequate or incomplete operations are common enough to yield a large number of unsatisfactory results. Examples are familiar to all physicians interested in this field. Cholecystectomy performed for the stoneless gallbladder, stones in the common duct after cholecystectomy, and partial cholecystectomy, not to mention duct strictures resulting from operative trauma, are some of the more important causes of surgical failures. When advised that biliary tract surgery is necessary, many patients express doubt of its value and are fearful lest they join other surgical failures known to them. It is important, therefore, for the surgeon to give the patient not only a reasonable explanation of the intent of the operation planned and its effect on digestive function, but also assurance that he may expect improved health following operation. This psychologic preparation must in most cases consist of more than a beneficent smile and an admonition not to worry. Peace of mind is a most welcome attribute in the preoperative period and in most patients can best be achieved by intelligible though brief explanation. Certain things are required of the patient in the immediate postoperative hours and the first few days following operation. Explanation prior to operation of the importance of raising phlegm and secretions from the throat and bronchial tree will pay real dividends in reduction of postoperative atelectasis. If one fails to make such an explanation until the postoperative visit and then tries to breach the haze of premedication, residual anesthesia and, perhaps, postoperative opiate, it is no wonder that the resulting attempts at coughing against a painful wound are feeble and ineffectual. Heavy smokers with attendant bronchorrhea and irritative tracheitis and bronchitis should be advised to discontinue tobacco several days prior to operation. If the relationship of increased bronchial secretions and spasmodic and uncontrolled coughing to the development of pulmonary complications and wound dehiscence is made clear, few patients will fail to cooperate in this regard. Similarly, the importance of frequent forced dorsi and plantar flexion of the feet, leg exercises, and early ambulation in preventing or reducing thromboembolic phenomenon and in shortening the convalescent period are more easily explained in advance of operation. Furthermore, the patient's cooperation and interest in carrying out these orders despite attendant discomfort are more certainly obtained by such foresight. If the patient is not forewarned, fear and incredulity are the obvious reac-
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tions to a demand to stand beside the bed or walk in the early postoperative period. The discomforts of a nasogastric tube are more readily accepted if the patient is advised beforehand of its importance. Preoperative clarification of these and other aspects of the surgical problem not only reduces the fears and hazards of the postoperative period but leads to a rapport between patient and surgeon which is most conducive to rapid convalescence. Should complications develop it will be easier to institute proper therapeutic measures without causing undue worry or concern on the part of the patient. Hospitalization and bnmediate Preoperative Care
Patients with uncomplicated chronic cholecystitis and cholelithiasis require few specific measures in the preoperative period. It is usually sufficient to admit such a patient to the hospital on the afternoon preceding operation. Aged and debilitated patients, those with jaundice, liver damage, cardiac disease, or diabetes mellitus will, of course, require careful hospital control for a longer period. The afternoon and evening before operation will give adequate time for completion of the preliminary hospital record, shaving and preparation of the operative field as well as detection of acute respiratory infection, fever, or skin infections which might necessitate postponement of the operation. Supper should consist of light, easily digestible food. Barbiturates, such as Seconal or Nembutal 50 to 100 mg. (% to 1Yz grains) will usually assure a good night's sleep. It is wise to cleanse the large bowel by enema the evening prior to operation. This will usually be effective in avoiding a full colon which is an impediment to the surgeon at operation and a source of discomfort to the patient in the early postoperative period. A full colon at operation commonly results in fecal impaction, the presence and elimination of which is annoyingly uncomfortable and often painful. The introduction of an intranasal gastric suction tube is most important in all operations in the upper abdomen. It eliminates gastric distention, thus facilitating the operation by aiding exposure. It is available for emptying the stomach of air or anesthetic gases which may occasionally be forced into it in considerable volume by positive pressure bag breathing methods. In the absence of the nasal gastric tube manipulation of the stomach during exploration, or pressure upon it by packing, may lead to regurgitation of gastric material into the pharynx and inhalation of this material into the bronchial tree with dire consequences. This accident is not infrequent in the early recovery phase of anesthesia, and is largely avoided by the Levin tube. The tube should be inserted in the morning, shortly before operation, rather than at night since its presence is not conducive to restful sleep.
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It should be relatively small to nummlze irritation of the nose and pharynx. Since manipulation of the tube may be necessary under anesthesia, a relatively new tube will be found more satisfactory than an older pliable soft one. In this regard, care should be taken to insert the tube well into the stomach, and its position should be checked by the anesthetist prior to induction of anesthesia. If the tip barely reaches the cardia it will be ineffective in emptying the stomach. To insert it more deeply in the anesthetized patient is often difficult or impossible. General Considerations in COlllplicated Biliary Tract Disease
Patients with long-standing and severe symptoms of biliary tract disease commonly postpone operation until serious complications develop. Common duct stone, internal biliary fistula, obstructive jaundice, impaired liver function and acute cholecystitis by and large are the result of neglected disease of the gallbladder. Many patients seek medical aid for symptomatic gallbladder disease only to be given ineffectual advice regarding diet and antispasmodic medicaments. Unfortunately, both patient and physician may, therefore, be at fault in permitting years to elapse before agreeing to or advising surgical treatment despite the knowledge that operation offers the only curative therapy. Some of these patients, on the advice of either a physician or wellmeaning friends, will have limited their diets to such a degree that nutritional deficiencies occur. The gradual elimination of one food after another leads to inadequate intake of various essentials, lack of which may increase the risk of operation. Anemia must be corrected. If medication fails or if a complicated problem precludes delay, transfusion may be indicated preoperatively. The prothrombin time may be elevated in the absence of jaundice because of inadequate intake of vitamin K. Extreme weight loss is associated with contraction of blood volume. If this is uncorrected preoperatively, shock may supervene with even the slightest operative manipulation. Patients with such nutritional deficiencies will require a diet high in calories, protein, minerals and vitamins for weeks or months prior to definitive surgery. If it is impossible to maintain such a regimen because of severe dyspepsia or frequent vomiting then multiple transfusions and intravenous vitamins, particularly K and C, will be mandatory prior to operative intervention. In such instances operation should not be postponed longer than necessary to accomplish this therapy since delay will augment the seriousness of the situation. Jaundice
Intensive preoperative preparation is required in the jaundiced patient. Jaundice, fortunately, is not a surgical emergency. Conversely, operation should not be postponed for long periods when it is obviously
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indicated. Enough time can always be taken for adequate study in an effort to establish the diagnosis and to prepare the patient for operation. However, despite careful clinical evaluation, including the many diagnostic tests, exploratory laparotomy for diagnosis may on occasion be necessary. If under such circumstances exploration is undertaken in patients with primary hepatocellular disease, liver function may be further reduced by cellular damage resulting from hepatotoxic anesthetic agents and transient episodes of shock or anoxia during operation. Mortality of the disease is thereby seriously increased. By the same token, long-standing obstructive jaundice due to stone or stricture may cause serious liver injury, particularly when associated with infection. Operation withheld in such cases may, therefore, be equally disastrous. The differential diagnosis of jaundice and the interpretation of the various liver function tests are beyond the scope of this discussion. Suffice it to say that operation is hazardous when the cholesterol esters are low, when prothrombin time fails to respond to intravenous administration of vitamin K, and when the serum albumin is below normal. The prognosis in such situations is extremely serious. In obstructive jaundice due to stone the depth of icterus may fluctuate and even intermittently clear. It is safer to operate during the free interval if observation indicates that the jaundice is clearing. Obviously, operation should not be postponed indefinitely in an attempt to achieve this optimum. Every effort should be made to protect the liver in the jaundiced patient. A high protein, high caloric diet rich in vitamins is most effective in improving liver function. Bed rest is of great importance. Since vitamin K is not absorbed from the intestine in the absence of bile salts, both of these substances should be supplemented in the preparation of the jaundiced patient. Vitamin K may be given intramuscularly or intravenously but is more expensive in this form·and unless rapid restoration of prothrombin levels to normal is necessary is no more effective than by the oral route. In the debilitated patient with long-standing biliary tract disease reduction of liver function may be present in the absence of jaundice. The index of suspicion toward liver disease must be high in such patients if effective therapy is to be instituted and mortality kept to a minimum. All jaundiced and debilitated patients must be typed and cross matched for transfusion preoperatively. Particular care must be given in the use of blood and plasma in patients with impaired liver function for fear of increasing cellular damage by transfusion reaction or homologous serum jaundice. Nevertheless, transfusion is commonly necessary in these patients and the surgeon must not forego the use of blood because of these dangers. Ideal therapy in the jaundiced patient is best accomplished by the close collaboration of internist and surgeon. Such cooperation has proved
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of infinite value in treating other conditions, such as acute upper gastrointestinal hemorrhage, and should certainly pertain to the treatment of jaundice as well. Too often the surgeon is asked to see the patient for the first time after a long period of observation by the internist. Satisfactory evaluation of the over-all situation is often difficult under these circumstances. The clinical impression will have a more solid basis, and decision as to therapy will be less hurried if longer observation is possible. Patients and relatives soon realize the value of such consultation and react with greater confidence to changes in therapy. Acute Cholecystitis
The method of treatment of patients with acute cholecystitis is still debated. Opinions vary from those who believe that all such patients should be considered surgical emergencies to those who feel that operation should be deferred either until the acute process has subsided or until it becomes apparent that it is not subsiding but progressing and that perforation is imminent. A middle ground has been the choice of many surgeons who advise immediate operation only if the patient is seen within the first 48 to 72 hours of the onset of the acute attack. Edema, inflammation and induration around the porta hepatis and duodenohepatic ligament will commonly not have become so advanced as to preclude safe definitive cholecystectomy and choledochostomy if indicated. However, if patients are seen later than 72 hours after the onset of acute cholecystitis, conservative observation is recommended. The acute process will subside in a high percentage of patients, permitting definitive surgery at an interval of 4 to 6 weeks. If the acute process advances, exploration will commonly expose a situation in which cholecystectomy would be hazardous, leaving cholecystostomy as the safest alternative. In most instances in which this latter course has been followed, cholecystectomy is recommended after a 6 to 8 week interval. One definite exception to conservative observation has been stressed by Buxton, Ray and Coller.! They pointed out that patients with diabetes mellitus do poorly on such a regimen. Therefore they recommend immediate operation when these conditions coexist. It is not within the realm of this paper to enter into or continue this debate. The summary given simply serves as a basis for discussing preoperative care for this complication of chronic gallbladder disease, whatever course of treatment may be chosen. If immediate operation is decided upon, it is necessary to restore fluids and electrolytes to a status as near normal as possible prior to operation. Patients arriving at the hospital may have lost large volumes of fluid from vomiting. Amounts lost should be estimated and restored
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as rapidly as possible with Ringer's or glucose and saline solutions intravenously. Insensible losses for the period of acute illness shQuld also be replaced by glucose in water intravenously. This replacement may consume 6 to 12 hours, a period that may well be utilized to complete diagnostic tests, such as serum amylase determinations, blood sugar estimations in patients with diabetes, and blood urea nitrogen or nonprotein nitrogen studies if kidney disease is suspected. Since many of these patients are elderly, evaluation of the cardiac status is of paramount importance. When necessary, rapid digitalization may be accomplished during this interval. Continuous nasogastric suction should be started at once and fluids by mouth restricted completely. Demerol or morphine should be used to reduce pain during this interval of preparation, but in dosage which will avoid respiratory depression with its attendant anesthetic difficulties. When conservative management is chosen, close observation is necessary. Absolute bed rest and continuous gastric suction are the rule. Small doses of opiates are given to minimize pain, but not in amounts to dull the sensorium. Fluid and electrolyte replacement and continued maintenance of fluid balance are essential. Antibiotic therapy is started immediately. Penicillin is probably the drug of choice in the absence of idiosyncrasy and should be given in doses of 600,000 to 800,000 units every 12 hours. It is wise to give this medication for 7 to 10 days, continuing well after the temperature has returned to normal and other inflammatory signs have subsided. Since the particular germ producing the inflammation is not known at this stage it seems unsound to give shotgun mixtures of two or more antibiotics. One must not change from one drug to another in the event of progression of the disease. Infection in acute cholecystitis is secondary to obstruction of the cystic duct in the great majority of cases, and if the process fails to subside it indicates gangrene or impending rupture secondary to this obstruction. Operation, not alteration of antibiotic therapy, is necessary. Daily white blood cell and differential counts will aid in evaluation of regression or progression of the acute process. In the severe case, it may be wise to have such counts every 12 hours during the first 2 days of observation. The sedimentation rate may also be of value in determining the status of the inflammatory process, but this test is not so sensi~ tive as the white blood count and may remain elevated for a prolonged period. Repeated abdominal examinations are most important. Reduction or increase in tenderness and muscle guarding is of great significance. A rounded, tender mass beneath the right costal margin is of well known diagnostic importance. Increase in its size or degree of tenderness may be an early indication of perforation or abscess. On such a regimen the majority of patients will improve. Pain rapidly
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subsides. Right upper quadrant tenderness and muscle spasm are reduced. Fever and leukocytosis gradually disappear. Oral feedings may be slowly resumed as the acute signs and symptoms subside. Ideally, such a patient should remain on a bland low fat diet while awaiting interval cholecystectomy. The indications that the acute disease is not subsiding include: continuing or increasing pain; exacerbation of pain; increasing tenderness or rigidity; increased size of right upper abdominal mass; continuing or increasing fever, particularly if associated with chills; and increasing leukocytosis with shift to the left in the differential granulocyte count. Under such circumstances one must assume that perforation has occurred or is impending. Operation is immediately indicated. CHOICE OF ANESTHESIA
In general the anesthetic problems in operations on the biliary tract are those common to other upper abdominal operations. However, the additional risks encountered as a result of impaired liver function add greatly to the responsibility of both surgeon and anesthesiologist. A detailed discussion of the various agents and methods is not indicated here, but certain factors bear consideration and need emphasis. Premedication should consist of Demerol 75 to 100 mg., or morphine 8 to 10 mg. (~ to 76 grain), combined with atropine or scopolamine 0.3 to 0.4 mg. (Yzoo to 7150 grain). Most barbiturates are broken down in the liver and their effect will be greatly enhanced in patients with impaired liver function. They must be used in small doses or preferably not at all. Perfect relaxation is of paramount importance in an area deep and often difficult to expose because of associated obesity. Anatomical anomalies are so frequent that the surgeon can never depend on a "normal" relationship. Hemorrhage from a slipped or broken ligature will so obscure the field that disastrous accidents may result. Such problems arise more frequently when relaxation is inadequate. Cholecystectomy, common duct exploration, duodenotomy, repair of duct injuries and strictures require perfect exposure and a quiet abdomen. In the patient with impaired liver function, anoxia or hypoxia may greatly increase hepatocellular damage. Shock and hypotension, with their associated hypoxia, should be prevented if possible and rapidly corrected if they occur. Several of the inhalation anesthetic agents are hepatotoxic, particularly chloroform and trichloroethylene. Deep ether anesthesia is also toxic to the liver and must be avoided. Pentothal sodium must be used sparingly in this instance since its action may be greatly prolonged because of the fact that a damaged liver cannot eliminate it effectively. It will be seen that no single anesthetic drug or combination of agents is entirely safe. Spinal anesthesia is most satisfactory provided hypo-
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tension is avoided by the use of vasopressor drugs. In skilled hands it approaches the ideal. Its greatest disadvantage is that its duration cannot be controlled except by the continuous method which few are qualified to use. General anesthesia is more commonly chosen, intratracheal administration being preferable. Induction may be accomplished by cyclopropane, nitrous oxide or ethylene followed by ether, using the closed method. If supplemented with curare or other muscle relaxants in moderate amounts ether administration need not be excessive. Intercostal block combined with local infiltration is often preferable when cholecystostomy is done for acute cholecystitis. If used for more major and definitive surgery it will usually require supplemental inhalation anesthesia. POSTOPERATIVE MANAGEMENT
General Considerations
The surgeon's chief responsibilities in the postoperative period are to maintain physiologic equilibrium until normal functions are restored; to relieve pain; to care for the wound; to prevent, so far as possible, the development of postoperative complications; and to recognize and treat such complications as early as possible should they occur. To accomplish these ends he must write explicit and comprehensive orders for after-care and insist that they be accurately carried out. He must be constantly alert to even minor changes in the patient's condition which may indicate the beginning of various complications. Careful perusal of the nurses' notes may yield valuable information. It is surprising how often they are disregarded. . Careful observation during the early postoperative hours is of greatest importance. Frequent pulse and blood pressure readings will reveal the early signs of postoperative hemorrhage or surgical shock. The dressing should, of course, be observed for bleeding. Anoxia due to respiratory depression or obstruction should be promptly treated. This is the golden period in which to avoid pulmonary atelectasis by clearing the tracheobronchial tree of excessive secretions or vomitus with tracheal catheter suction. The control of pain is of primary concern. Morphine, Demerol, Pantopon and Dilaudid are most commonly used. Sensitivities to one or more of these drugs are quite common, the chief one of any concern resulting in nausea and vomiting. It is helpful to inquire of such possibilities prior to operation. In the event of nausea continuing well beyond the postanesthetic period it will be wise to change the opiate medication. Small doses of these drugs are usually adequate and will minimize depression of the respiratory center. If the first hypodermic can be given before pain is severe it will reduce the total amount necessary. After vertical upper abdominal incisions, particularly when stay sutures are necessary,
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pain is severe and opiates will be required longer and more frequently than is usually the case after transverse incisions. The nasogastric tube may usually be removed the evening of biliary tract operations unless duodenotomy or anastomotic procedures have been necessary. It serves no useful purpose otherwise after the postanesthetic period and is a source of discomfort to the patient as well as an unnecessary addition to the nursing problem. Maintenance of fluid balance is accomplished during the first postoperative days by solutions administered intravenously. In the absence of gastrointestinal fluid loss this should be in the form of 5 per cent glucose in water, and no more than 2000 cc. daily is necessary. As a result of water retention following the stress of operation it is probable that less than this amount is required on the day of operation. It will replace insensible losses and provide an adequate volume for normal kidney function. Saline solutions should not be used unless salt is lost either from the gastrointestinal tract or from excessive sweating. Losses of fluids by vomiting, gastrointestinal suction, bile drainage, or intestinal fistulas must be accurately recorded and replaced by appropriate electrolyte solutions. If such losses are in large amounts and continue for more than a few days, potassium chloride must also be supplemented. In most patients having biliary tract operations gastrointestinal activity rapidly returns to normal. However; one should not insist on early feeding against the patient's desire. Ordinarily, water and clear liquids (broth and tea) will be tolerated in small amounts the day after operation and a soft diet may be resumed on the third or fourth postoperative day. Patients should later be encouraged to try foods which have previously been discontinued because of biliary dyspepsia. If severe disease has pre-existed and is now corrected they will sooner realize that they may expect more normal digestive function. In patients with liver damage the early resumption of a high caloric and high protein diet is imperative. With careful surgical technique, avoidance of excessive opiates postoperatively, and in the absence of air swallowing, abdominal distention after biliary tract surgery should be minimal. Efforts to relieve distention by rectal or colonic manipulations are meddlesome and usually ineffectual. It is unusual for the bowels to move before the third postoperative day after any major abdominal operation. It is customary to stimulate this act on the third or fourth day after operation by the use of a suppository or low enema. Early ambulation is conducive to rapid return of the previous bowel habit. One of the bulky laxative preparations, such as Metamucil, may be helpful in effecting a more normal bowel habit in the previously constipated patient. Most patients subjected to upper abdominal operations will have little trouble voiding in the early postoperative period. It is unusual to see large urinary volumes during the first 24 hours following operation be-
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cause kidney function is reduced as a result of the stress mechanism. Often patients will not void for 12 to 18 hours after operation. If the patient complains of bladder discomfort yet cannot void while lying in bed, or if bladder distention is evident, he may be assisted to stand to encourage evacuation of the bladder. Catheterization should be avoided if possible since it may increase the incidence of postoperative urinary tract infection. Frequent small voidings indicate urinary retention, and demand inlying catheter drainage until the bladder is again compensated. In elderly men this may initiate a train of circumstances which will require prostatectomy for correction. Early ambulation will greatly aid rapid return of bowel and bladder function, reduce the total use of opiates, help in preventing pulmonary and thromboembolic complications and, in general, shorten convalescence. It helps to maintain or restore the patient's morale. In most cases it should be started 12 to 24 hours after operation and should be encouraged several times daily. However, seriously ill patients should not be forced out of bed because of a routine. Few elective operations on the biliary tract will require the use of antibiotics. These drugs are indicated in the presence of acute cholecystitis pre- or postoperatively, and for pulmonary or urinary complications. When contamination of the operative field occurs, during duodenotomy or anastomotic procedures, for example, the prophylactic use of antibiotics probably reduces localized peritoneal and wound infections. Penicillin is the drug of choice except when cultures of infected material reveal lack of sensitivity and indicate more effectual substitutes. Certainly, lack of response of an infection to one antibiotic indicates a change when sensitivity studies are not available except as previously mentioned in the preoperative treatment of acute cholecystitis. Care of the Wound
The Drain. Most surgeons agree that drainage should be instituted after all operations on the biliary tree. Certainly this should include every cholecystectomy, choledochostomy, cholecystostomy, anastomotic duct operation, resection of the pancreatic head or sphincterotomy. Anastomoses between gallbladder and stomach, duodenum or jejunum may not require drainage. It is customary to place a Penrose drain in Morison's pouch. When drainage is minimal this drain is loosened on the third or fourth day and removed a day or two later. If drainage is profuse it must remain longer. The value of drainage is exemplified by the following case reports: CASE I. Mrs. L. A., aged 44, was first seen 4 months following cholecystectomy. The surgeon reported that at the conclusion of the operation the field was completely dry and drainage was therefore considered unnecessary. The postoperative course was stormy, but she was finally discharged from the hospital
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after 2 months in an extremely debilitated condition. An internist consultant discovered an abnormally high right diaphragm and at 7 to 10 day intervals aspirated 1000 to 3000 cc. of bile through the right side of the chest posteriorly. This history, plus the presence of bile in the stools and the absence of jaundice, suggested that an accessory bile duct was draining into the subphrenic space. At operation the common and hepatic ducts were normal. The mouth of a leaking accessory duct was closed with a fine silk suture and a huge subphrenic bile collection was drained. Although the subdiaphragmatic drain was not removed for 3 weeks, a residual chronic subphrenic abscess was later drained. Full recovery followed. CASE II. Mrs. F. B. F., aged 52, underwent cholecystectomy which was followed 12 hours later by profuse drainage of bile from the drainage site. On the tenth postoperative day a left subhepatic bile collection was drained and the operative area was re-explored. The common and hepatic ducts were intact and the cystic duct ligature had not slipped. The source of bile leak was not discovered despite observation of the gallbladder bed for 20 minutes. Penrose drains were placed in Morison's pouch as well as in the left subhepatic space and the wound was closed. Bile continued to drain profusely. Convalescence was otherwise uneventful. The stools were normal. Drainage of bile persisted for 9 months, when it gradually ceased. The patient has remained in excellent health for 4 years.
These two examples of accessory bile ducts give ample evidence of the necessity of placing drains after cholecystectomy. In the first, bile fortunately localized in the subphrenic space; otherwise, bile peritonitis would have been inevitable. The drain undoubtedly prevented death in the second patient. The Sutures. Skin sutures may be removed on the seventh to the ninth day after operation in the uncomplicated wound. Retention sutures should remain 12 to 14 days or even longer in debilitated patients. Care of the T-Tube. After exploration of the common duct, drainage of the duct must be instituted. Failure to do so may result in serious complications. Most surgeons prefer to use a T-tube, the duct being closed snugly around its long arm. At the conclusion of the operation it should be sutured to the skin and its end placed loosely in a small bottle which is tied to the dressing. This should be completed in the operating room since an uninformed assistant or nurse might temporarily clamp it to prevent soiling the dressings or blankets and thus cause a leak at the line of common duct closure. The tube should never be connected with rubber tubing to a bottle since any traction might dislodge it from the common duct and bile peritonitis result. Provided there is no bile leakage around the tube it may be clamped on the seventh or eighth day for an hour three times a day. If pain does not result it should then be clamped for 24 hours. In the uncomplicated choledochostomy, when no disease of the duct itself is present, a cholangiogram should now be taken. In the absence of residual stone or obstruction the tube may be removed on the ninth or tenth day. In the absence of obstruction nothing is to be gained by permitting it to remain longer. Drainage of bile will seldom occur after its removal.
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Long-arm T -tubes, suggested by Cattell,2 are occasionally used when mild stricture of the pancreatic portion of the duct is present, or following sphincterotomy or the creation of a false passage during exploration. Under such circumstances the tube should remain in place for much longer intervals. It is usually not possible to obtain a cholangiogram with this type of tube. In strictures or injuries of the common duct when it is possible to perform duct-to-duct anastomosis the procedure is often done over aT-tube, the tube emerging from the duct through an opening above or below the suture line. It is customary in such situations to leave the tube 6 to 12 months in the hope that scar contracture at the suture line will have reached its maximum during this interval. Failure to leave a tube in the common duct after exploration, or its removal before the formation of a drainage tract, may result in bile peritonitis or bile accumulation in the subphrenic space, as in the following case. CASE III. Mrs. R. U., aged 70, was first seen 6 weeks following cholecystectomy and choledochostomy. Since no abnormality had been noted in the duct at exploration the drain and T-tube were removed on the second postoperative day. A stormy period ensued. A few days before I was asked to see her a small catheter had been inserted through a right lower intercostal space, posteriorly, to drain an "empyema." The peculiar yellow color of the drainage led to request for consultation. Drainage of large posterior and anterior right subphrenic abscesses containing large amounts of bile resulted in gradual recovery.
Care of the Cholecystostomy Tube. This tube also should be loosely placed in a small bottle tied to the dressing or binder. Leakage around it usually develops in 8 to 10 days. By this time it is well walled off from the general peritoneal cavity and may usually be removed. If the obstructing stone in the cystic duct was not removed at operation a mucous fistula will persist. If the cystic duct is free from obstruction the site of drainage will promptly close unless stones obstruct the common bile duct or the ampulla of Vater, in which case a biliary fistula will persist. Prior to removal of the tube, cholangiogram should be attempted and may yield valuable information. Complications and Their Treatment
The prevention, recognition and treatment of pulmonary complications, thrombosis, embolism and urinary tract infections are being fully discussed by other authors in this symposium and will not be further considered here. Bile peritonitis and subphrenic bile collections have been mentioned previously and examples of the latter presented. These complications may result from rupture of the acute gallbladder, slipped ligature of the cystic duct, accessory ducts inadvertently divided at the time of cholecystectomy, or leakage around the T-tube. They may be prevented post-
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operatively in most instances by proper drainage. Should they occur, re-exploration is indicated. Subphrenic abscess may occasionally result from biliary tract operations in the absence of bile leak. Failure to complete the toilet of the operative field and its environs prior to closure of the wound may be the cause of such abscesses. During operation blood and at times bile or contaminated material from the gallbladder, stomach or intestine may drain to dependent areas which are not effectively walled off. Stones may escape from the common duct during exploration or from the inadvertently opened gallbladder and become lost. At the conclusion of the operation it takes but a moment to wipe out the subphrenic and subhepatic spaces and the right peritoneal gutter. This will avoid leaving a nidus for future infection. Acute pancreatitis may result from operation on the biliary tract. Three fatal cases of hemorrhagic pancreatitis following sphincterotomy have recently been reported by Pattison and Blatherwick. 3 In the discussion of this paper the long-arm T -tube was implicated as a possible cause of postoperative pancreatitis. I have encountered 2 instances of severe pancreatitis after choledochostomy, in neither of which was a Cattell tube used. These are as follows: CASE IV. Mrs. M. J. McD., aged 57, had a cholecystectomy on November 3, 1949. At that time small common duct stones were removed a.nd the sphincter was dilated to 6 mm. with Bake's dilators. Three weeks later, when a lesser omental abscess was drained, portions of necrotic pancreas were removed. Pancreatic drainage persisted for several months. CASE V. Mrs. W. H. H., aged 45, was first seen on September 14, 1953. Following cholecystectomy and choledochostomy in July, 1949 she had remained well until 1 month prior to admission. Three attacks of colic, chills and fever, and jaundice indicated common duct stone. At operation a widely dilated common duct was found and a patulous sphincter admitted the 9 cm. dilator without pressure, the ampulla being palpated over the dilator. Stones were not recovered. The pancreas was normal to palpation. High fever, abdominal rigidity, back pain and distention developed rapidly and suggested acute pancreatitis. Marked elevation of serum amylase confirmed the diagnosis.
Fortunately, both patients recovered after a prolonged convalescence. It is probable that manipulation of, or trauma to, the ampulla or pancreas rather than any particular operation or apparatus is responsible for this uncommon complication. Postoperative hemorrhage may result from slipping of the cystic artery ligature, from a raw gallbladder bed, or from failure to ligate veins coursing between the gallbladder margin and the serous coat of the liver. Massive hemorrhage may occur before signs of it appear from the drain. The diagnosis will depend primarily on frequent postoperative observations of pulse and blood pressure which should be routine.
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Operative injuries of the common duct are all too frequent. That such injury has been done is often not recognized at operation, the first sign of trouble being massive bile drainage or rapidly developing jaundice in the first few days after cholecystectomy. Both are indications for early re-exploration if the patient's condition will permit. As previously mentioned, biliary fistula may be due to leakage through the cystic duct, accessory ducts, hepatic ducts or common duct. Whatever its cause, early surgical correction is indicated. I Jaundice resulting from ligature of the common hepatic or common bile duct develops benignly, the postoperative course being otherwise uneventful. This is in sharp contrast to the fulminating course of the patient with so-called hepatorenal failure. This latter condition may result from accidental ligature of the right hepatic or main hepatic artery. Jaundice in such an instance is associated with fever, impending shock, semicoma, increasing renal failure and a rapidly fatal course. Many common duct strictures develop weeks or months after operation and are the result of partial occlusion of the duct by a ligature or tenting of the duct with partial excision of the wall or some other trauma to the duct short of complete ligature. Details of their diagnosis and surgical correction is beyond the scope of this discussion. SUMMARY
Factors responsible for poor end results in biliary tract surgery are: (1) improper selection of patients; (2) inaccurate and inadequate operations; (3) disregard of the advances in the understanding of liver function; (4) inferior anesthesia; and (5) failure to recognize the importance of the minutiae of care during the pre- and postoperative periods. Preoperative management must include psychologic preparation of the patient by explaining not only the benefits which he may reasonably expect, but also the part he must play in aiding convalescence. The necessity for coughing, the importance of nasal suction, the benefits of early ambulation should be explained if maximum cooperation is expected. The specific problems before and after operations on the biliary tract include jaundice, impaired liver function and, occasionally, chronic debility from long-standing disease or dietary limitation. Acute cholecystitis presents problems in management differing from other complications of chronic gallbladder disease. Jaundice is never an emergency. But time should not be wasted when operation is indicated after diagnosis is made or when it cannot be made without exploration. Jaundice itself, particularly when associated with cholangitis, may increase hepatocellular disease. When severe liver damage is present operation is hazardous. High protein, high caloric diet and vitamin K are the most important measures in therapy before and after operation. In debilitated patients with or without jaundice, impaired
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liver function as well as secondary anemia and chronic blood volume reduction may be present. In acute cholecystitis rapid restoration of fluid balance plus careful evaluation of associated diseases is essential before operation is undertaken. If conservative treatment is chosen, constant observation of changes in symptoms, signs, and the simple laboratory guides will give warning of impending perforation. Acute cholecystitis will usually subside, ~ermitting safe definitive operation at an interval. Anesthesia for biliary tract disease must yield perfect relaxation yet avoid hypotension, hypoxia, and the hepatotoxic effects of various anesthetic agents. Scientific anesthesiology is therefore of great importance. Explicit written orders carried out by an alert nursing staff often prevent many of the common postoperative complications and permit early recognition of those that may develop. Specific complications of biliary tract surgery include bile peritonitis and subphrenic bile collections, subphrenic abscess, injuries of the biliary duct or arterial systems, and acute pancreatitis. All but the latter may be avoided by careful surgical technique and proper drainage of the operative site and of the common duct in case it is explored. The cause of acute pancreatitis as a complication following common duct operations apparently relates to manipulation of the ampulla or the pancreas. Early recognition of these complications and institution of proper therapy is mandatory if mortality is to be reduced. REFERENCES 1. Buxton, R. W., Ray, D. K. and Coller, F. A.: Acute Cholecystitis. J.A.M.A. 146: 301-307 (May 26) 1951. 2. Cattell, R. B.: A New Type of T Tube for Surgery of the Biliary Tract. Lahey Clinic Bull. 4: 197-204 (Jan.) 1946. 3. Pattison, A. C. and Blatherwick, N. H.: Fatal Acute Pancreatitis Following Choledochal Ampullary Sphincterotomy. In publication. (Read before the Pacific Coast Surgical Association, Santa Barbara, California, February 8 to 11, 1954) 1216 S. W. Yamhill Street Portland 5, Oregon
DISEASES of the biliary tract are in general more amenable to correct surgical care than are those of most other systems or organs of the body. Properly planned and executed operative treatment combined with intelligent preoperative preparation and postoperative management will yield a high percentage of permanently successful results with a minimal surgical mortality. This, of course, presumes careful segregation of patients for operation as well as experienced selection of the proper procedure once the operation is undertaken. The improved end results and the significant reduction in postoperative mortality in recent years are due to many factors. Of great importance is improvement in the understanding of liver function. This has made possible more accurate diagnosis as well as greater protection of the liver from further damage by suitable supplemental therapy, choice of safer anesthetic agents, and proper timing of surgical intervention. Blood transfusions and antibiotic therapy have played a lesser role in these improved results than is commonly believed. The great increase in highly trained and qualified surgeons is resulting in reduction in the number of tragic injuries to the bile ducts and hepatic arteries. More scientific anesthesiology and better qualified anesthetists are added factors. However, in my opinion, of greatest importance in the improved results is the strict attention given to all of the minutiae of care during the pre- and postoperative periods. Too often in discussions of this subject there is no mention of many of these details which together contribute so much to safe and uncomplicated convalescence. At the risk of seeming obvious and meticulous these details will be fully outlined in the discussion which follows.
Associate Clinical ProJessot· oj Surgery, University oj Oregon Medical School; Head, General Surgery Department, The Portland Clinic; Attending Surgeon, St. Vincent's Hospital and Multnomah County Hospital, Portland, Oregon.
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1376 PREOPERATIVE MANAGEMENT
Psychologic Preparation for Operation
It is of primary importance that the patient should have some understanding of what he may expect from the operation as well as what is expected of him in the immediate postoperative period. Unfortunately, improper selection of patients in addition to inadequate or incomplete operations are common enough to yield a large number of unsatisfactory results. Examples are familiar to all physicians interested in this field. Cholecystectomy performed for the stoneless gallbladder, stones in the common duct after cholecystectomy, and partial cholecystectomy, not to mention duct strictures resulting from operative trauma, are some of the more important causes of surgical failures. When advised that biliary tract surgery is necessary, many patients express doubt of its value and are fearful lest they join other surgical failures known to them. It is important, therefore, for the surgeon to give the patient not only a reasonable explanation of the intent of the operation planned and its effect on digestive function, but also assurance that he may expect improved health following operation. This psychologic preparation must in most cases consist of more than a beneficent smile and an admonition not to worry. Peace of mind is a most welcome attribute in the preoperative period and in most patients can best be achieved by intelligible though brief explanation. Certain things are required of the patient in the immediate postoperative hours and the first few days following operation. Explanation prior to operation of the importance of raising phlegm and secretions from the throat and bronchial tree will pay real dividends in reduction of postoperative atelectasis. If one fails to make such an explanation until the postoperative visit and then tries to breach the haze of premedication, residual anesthesia and, perhaps, postoperative opiate, it is no wonder that the resulting attempts at coughing against a painful wound are feeble and ineffectual. Heavy smokers with attendant bronchorrhea and irritative tracheitis and bronchitis should be advised to discontinue tobacco several days prior to operation. If the relationship of increased bronchial secretions and spasmodic and uncontrolled coughing to the development of pulmonary complications and wound dehiscence is made clear, few patients will fail to cooperate in this regard. Similarly, the importance of frequent forced dorsi and plantar flexion of the feet, leg exercises, and early ambulation in preventing or reducing thromboembolic phenomenon and in shortening the convalescent period are more easily explained in advance of operation. Furthermore, the patient's cooperation and interest in carrying out these orders despite attendant discomfort are more certainly obtained by such foresight. If the patient is not forewarned, fear and incredulity are the obvious reac-
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tions to a demand to stand beside the bed or walk in the early postoperative period. The discomforts of a nasogastric tube are more readily accepted if the patient is advised beforehand of its importance. Preoperative clarification of these and other aspects of the surgical problem not only reduces the fears and hazards of the postoperative period but leads to a rapport between patient and surgeon which is most conducive to rapid convalescence. Should complications develop it will be easier to institute proper therapeutic measures without causing undue worry or concern on the part of the patient. Hospitalization and bnmediate Preoperative Care
Patients with uncomplicated chronic cholecystitis and cholelithiasis require few specific measures in the preoperative period. It is usually sufficient to admit such a patient to the hospital on the afternoon preceding operation. Aged and debilitated patients, those with jaundice, liver damage, cardiac disease, or diabetes mellitus will, of course, require careful hospital control for a longer period. The afternoon and evening before operation will give adequate time for completion of the preliminary hospital record, shaving and preparation of the operative field as well as detection of acute respiratory infection, fever, or skin infections which might necessitate postponement of the operation. Supper should consist of light, easily digestible food. Barbiturates, such as Seconal or Nembutal 50 to 100 mg. (% to 1Yz grains) will usually assure a good night's sleep. It is wise to cleanse the large bowel by enema the evening prior to operation. This will usually be effective in avoiding a full colon which is an impediment to the surgeon at operation and a source of discomfort to the patient in the early postoperative period. A full colon at operation commonly results in fecal impaction, the presence and elimination of which is annoyingly uncomfortable and often painful. The introduction of an intranasal gastric suction tube is most important in all operations in the upper abdomen. It eliminates gastric distention, thus facilitating the operation by aiding exposure. It is available for emptying the stomach of air or anesthetic gases which may occasionally be forced into it in considerable volume by positive pressure bag breathing methods. In the absence of the nasal gastric tube manipulation of the stomach during exploration, or pressure upon it by packing, may lead to regurgitation of gastric material into the pharynx and inhalation of this material into the bronchial tree with dire consequences. This accident is not infrequent in the early recovery phase of anesthesia, and is largely avoided by the Levin tube. The tube should be inserted in the morning, shortly before operation, rather than at night since its presence is not conducive to restful sleep.
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It should be relatively small to nummlze irritation of the nose and pharynx. Since manipulation of the tube may be necessary under anesthesia, a relatively new tube will be found more satisfactory than an older pliable soft one. In this regard, care should be taken to insert the tube well into the stomach, and its position should be checked by the anesthetist prior to induction of anesthesia. If the tip barely reaches the cardia it will be ineffective in emptying the stomach. To insert it more deeply in the anesthetized patient is often difficult or impossible. General Considerations in COlllplicated Biliary Tract Disease
Patients with long-standing and severe symptoms of biliary tract disease commonly postpone operation until serious complications develop. Common duct stone, internal biliary fistula, obstructive jaundice, impaired liver function and acute cholecystitis by and large are the result of neglected disease of the gallbladder. Many patients seek medical aid for symptomatic gallbladder disease only to be given ineffectual advice regarding diet and antispasmodic medicaments. Unfortunately, both patient and physician may, therefore, be at fault in permitting years to elapse before agreeing to or advising surgical treatment despite the knowledge that operation offers the only curative therapy. Some of these patients, on the advice of either a physician or wellmeaning friends, will have limited their diets to such a degree that nutritional deficiencies occur. The gradual elimination of one food after another leads to inadequate intake of various essentials, lack of which may increase the risk of operation. Anemia must be corrected. If medication fails or if a complicated problem precludes delay, transfusion may be indicated preoperatively. The prothrombin time may be elevated in the absence of jaundice because of inadequate intake of vitamin K. Extreme weight loss is associated with contraction of blood volume. If this is uncorrected preoperatively, shock may supervene with even the slightest operative manipulation. Patients with such nutritional deficiencies will require a diet high in calories, protein, minerals and vitamins for weeks or months prior to definitive surgery. If it is impossible to maintain such a regimen because of severe dyspepsia or frequent vomiting then multiple transfusions and intravenous vitamins, particularly K and C, will be mandatory prior to operative intervention. In such instances operation should not be postponed longer than necessary to accomplish this therapy since delay will augment the seriousness of the situation. Jaundice
Intensive preoperative preparation is required in the jaundiced patient. Jaundice, fortunately, is not a surgical emergency. Conversely, operation should not be postponed for long periods when it is obviously
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indicated. Enough time can always be taken for adequate study in an effort to establish the diagnosis and to prepare the patient for operation. However, despite careful clinical evaluation, including the many diagnostic tests, exploratory laparotomy for diagnosis may on occasion be necessary. If under such circumstances exploration is undertaken in patients with primary hepatocellular disease, liver function may be further reduced by cellular damage resulting from hepatotoxic anesthetic agents and transient episodes of shock or anoxia during operation. Mortality of the disease is thereby seriously increased. By the same token, long-standing obstructive jaundice due to stone or stricture may cause serious liver injury, particularly when associated with infection. Operation withheld in such cases may, therefore, be equally disastrous. The differential diagnosis of jaundice and the interpretation of the various liver function tests are beyond the scope of this discussion. Suffice it to say that operation is hazardous when the cholesterol esters are low, when prothrombin time fails to respond to intravenous administration of vitamin K, and when the serum albumin is below normal. The prognosis in such situations is extremely serious. In obstructive jaundice due to stone the depth of icterus may fluctuate and even intermittently clear. It is safer to operate during the free interval if observation indicates that the jaundice is clearing. Obviously, operation should not be postponed indefinitely in an attempt to achieve this optimum. Every effort should be made to protect the liver in the jaundiced patient. A high protein, high caloric diet rich in vitamins is most effective in improving liver function. Bed rest is of great importance. Since vitamin K is not absorbed from the intestine in the absence of bile salts, both of these substances should be supplemented in the preparation of the jaundiced patient. Vitamin K may be given intramuscularly or intravenously but is more expensive in this form·and unless rapid restoration of prothrombin levels to normal is necessary is no more effective than by the oral route. In the debilitated patient with long-standing biliary tract disease reduction of liver function may be present in the absence of jaundice. The index of suspicion toward liver disease must be high in such patients if effective therapy is to be instituted and mortality kept to a minimum. All jaundiced and debilitated patients must be typed and cross matched for transfusion preoperatively. Particular care must be given in the use of blood and plasma in patients with impaired liver function for fear of increasing cellular damage by transfusion reaction or homologous serum jaundice. Nevertheless, transfusion is commonly necessary in these patients and the surgeon must not forego the use of blood because of these dangers. Ideal therapy in the jaundiced patient is best accomplished by the close collaboration of internist and surgeon. Such cooperation has proved
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of infinite value in treating other conditions, such as acute upper gastrointestinal hemorrhage, and should certainly pertain to the treatment of jaundice as well. Too often the surgeon is asked to see the patient for the first time after a long period of observation by the internist. Satisfactory evaluation of the over-all situation is often difficult under these circumstances. The clinical impression will have a more solid basis, and decision as to therapy will be less hurried if longer observation is possible. Patients and relatives soon realize the value of such consultation and react with greater confidence to changes in therapy. Acute Cholecystitis
The method of treatment of patients with acute cholecystitis is still debated. Opinions vary from those who believe that all such patients should be considered surgical emergencies to those who feel that operation should be deferred either until the acute process has subsided or until it becomes apparent that it is not subsiding but progressing and that perforation is imminent. A middle ground has been the choice of many surgeons who advise immediate operation only if the patient is seen within the first 48 to 72 hours of the onset of the acute attack. Edema, inflammation and induration around the porta hepatis and duodenohepatic ligament will commonly not have become so advanced as to preclude safe definitive cholecystectomy and choledochostomy if indicated. However, if patients are seen later than 72 hours after the onset of acute cholecystitis, conservative observation is recommended. The acute process will subside in a high percentage of patients, permitting definitive surgery at an interval of 4 to 6 weeks. If the acute process advances, exploration will commonly expose a situation in which cholecystectomy would be hazardous, leaving cholecystostomy as the safest alternative. In most instances in which this latter course has been followed, cholecystectomy is recommended after a 6 to 8 week interval. One definite exception to conservative observation has been stressed by Buxton, Ray and Coller.! They pointed out that patients with diabetes mellitus do poorly on such a regimen. Therefore they recommend immediate operation when these conditions coexist. It is not within the realm of this paper to enter into or continue this debate. The summary given simply serves as a basis for discussing preoperative care for this complication of chronic gallbladder disease, whatever course of treatment may be chosen. If immediate operation is decided upon, it is necessary to restore fluids and electrolytes to a status as near normal as possible prior to operation. Patients arriving at the hospital may have lost large volumes of fluid from vomiting. Amounts lost should be estimated and restored
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as rapidly as possible with Ringer's or glucose and saline solutions intravenously. Insensible losses for the period of acute illness shQuld also be replaced by glucose in water intravenously. This replacement may consume 6 to 12 hours, a period that may well be utilized to complete diagnostic tests, such as serum amylase determinations, blood sugar estimations in patients with diabetes, and blood urea nitrogen or nonprotein nitrogen studies if kidney disease is suspected. Since many of these patients are elderly, evaluation of the cardiac status is of paramount importance. When necessary, rapid digitalization may be accomplished during this interval. Continuous nasogastric suction should be started at once and fluids by mouth restricted completely. Demerol or morphine should be used to reduce pain during this interval of preparation, but in dosage which will avoid respiratory depression with its attendant anesthetic difficulties. When conservative management is chosen, close observation is necessary. Absolute bed rest and continuous gastric suction are the rule. Small doses of opiates are given to minimize pain, but not in amounts to dull the sensorium. Fluid and electrolyte replacement and continued maintenance of fluid balance are essential. Antibiotic therapy is started immediately. Penicillin is probably the drug of choice in the absence of idiosyncrasy and should be given in doses of 600,000 to 800,000 units every 12 hours. It is wise to give this medication for 7 to 10 days, continuing well after the temperature has returned to normal and other inflammatory signs have subsided. Since the particular germ producing the inflammation is not known at this stage it seems unsound to give shotgun mixtures of two or more antibiotics. One must not change from one drug to another in the event of progression of the disease. Infection in acute cholecystitis is secondary to obstruction of the cystic duct in the great majority of cases, and if the process fails to subside it indicates gangrene or impending rupture secondary to this obstruction. Operation, not alteration of antibiotic therapy, is necessary. Daily white blood cell and differential counts will aid in evaluation of regression or progression of the acute process. In the severe case, it may be wise to have such counts every 12 hours during the first 2 days of observation. The sedimentation rate may also be of value in determining the status of the inflammatory process, but this test is not so sensi~ tive as the white blood count and may remain elevated for a prolonged period. Repeated abdominal examinations are most important. Reduction or increase in tenderness and muscle guarding is of great significance. A rounded, tender mass beneath the right costal margin is of well known diagnostic importance. Increase in its size or degree of tenderness may be an early indication of perforation or abscess. On such a regimen the majority of patients will improve. Pain rapidly
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subsides. Right upper quadrant tenderness and muscle spasm are reduced. Fever and leukocytosis gradually disappear. Oral feedings may be slowly resumed as the acute signs and symptoms subside. Ideally, such a patient should remain on a bland low fat diet while awaiting interval cholecystectomy. The indications that the acute disease is not subsiding include: continuing or increasing pain; exacerbation of pain; increasing tenderness or rigidity; increased size of right upper abdominal mass; continuing or increasing fever, particularly if associated with chills; and increasing leukocytosis with shift to the left in the differential granulocyte count. Under such circumstances one must assume that perforation has occurred or is impending. Operation is immediately indicated. CHOICE OF ANESTHESIA
In general the anesthetic problems in operations on the biliary tract are those common to other upper abdominal operations. However, the additional risks encountered as a result of impaired liver function add greatly to the responsibility of both surgeon and anesthesiologist. A detailed discussion of the various agents and methods is not indicated here, but certain factors bear consideration and need emphasis. Premedication should consist of Demerol 75 to 100 mg., or morphine 8 to 10 mg. (~ to 76 grain), combined with atropine or scopolamine 0.3 to 0.4 mg. (Yzoo to 7150 grain). Most barbiturates are broken down in the liver and their effect will be greatly enhanced in patients with impaired liver function. They must be used in small doses or preferably not at all. Perfect relaxation is of paramount importance in an area deep and often difficult to expose because of associated obesity. Anatomical anomalies are so frequent that the surgeon can never depend on a "normal" relationship. Hemorrhage from a slipped or broken ligature will so obscure the field that disastrous accidents may result. Such problems arise more frequently when relaxation is inadequate. Cholecystectomy, common duct exploration, duodenotomy, repair of duct injuries and strictures require perfect exposure and a quiet abdomen. In the patient with impaired liver function, anoxia or hypoxia may greatly increase hepatocellular damage. Shock and hypotension, with their associated hypoxia, should be prevented if possible and rapidly corrected if they occur. Several of the inhalation anesthetic agents are hepatotoxic, particularly chloroform and trichloroethylene. Deep ether anesthesia is also toxic to the liver and must be avoided. Pentothal sodium must be used sparingly in this instance since its action may be greatly prolonged because of the fact that a damaged liver cannot eliminate it effectively. It will be seen that no single anesthetic drug or combination of agents is entirely safe. Spinal anesthesia is most satisfactory provided hypo-
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tension is avoided by the use of vasopressor drugs. In skilled hands it approaches the ideal. Its greatest disadvantage is that its duration cannot be controlled except by the continuous method which few are qualified to use. General anesthesia is more commonly chosen, intratracheal administration being preferable. Induction may be accomplished by cyclopropane, nitrous oxide or ethylene followed by ether, using the closed method. If supplemented with curare or other muscle relaxants in moderate amounts ether administration need not be excessive. Intercostal block combined with local infiltration is often preferable when cholecystostomy is done for acute cholecystitis. If used for more major and definitive surgery it will usually require supplemental inhalation anesthesia. POSTOPERATIVE MANAGEMENT
General Considerations
The surgeon's chief responsibilities in the postoperative period are to maintain physiologic equilibrium until normal functions are restored; to relieve pain; to care for the wound; to prevent, so far as possible, the development of postoperative complications; and to recognize and treat such complications as early as possible should they occur. To accomplish these ends he must write explicit and comprehensive orders for after-care and insist that they be accurately carried out. He must be constantly alert to even minor changes in the patient's condition which may indicate the beginning of various complications. Careful perusal of the nurses' notes may yield valuable information. It is surprising how often they are disregarded. . Careful observation during the early postoperative hours is of greatest importance. Frequent pulse and blood pressure readings will reveal the early signs of postoperative hemorrhage or surgical shock. The dressing should, of course, be observed for bleeding. Anoxia due to respiratory depression or obstruction should be promptly treated. This is the golden period in which to avoid pulmonary atelectasis by clearing the tracheobronchial tree of excessive secretions or vomitus with tracheal catheter suction. The control of pain is of primary concern. Morphine, Demerol, Pantopon and Dilaudid are most commonly used. Sensitivities to one or more of these drugs are quite common, the chief one of any concern resulting in nausea and vomiting. It is helpful to inquire of such possibilities prior to operation. In the event of nausea continuing well beyond the postanesthetic period it will be wise to change the opiate medication. Small doses of these drugs are usually adequate and will minimize depression of the respiratory center. If the first hypodermic can be given before pain is severe it will reduce the total amount necessary. After vertical upper abdominal incisions, particularly when stay sutures are necessary,
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pain is severe and opiates will be required longer and more frequently than is usually the case after transverse incisions. The nasogastric tube may usually be removed the evening of biliary tract operations unless duodenotomy or anastomotic procedures have been necessary. It serves no useful purpose otherwise after the postanesthetic period and is a source of discomfort to the patient as well as an unnecessary addition to the nursing problem. Maintenance of fluid balance is accomplished during the first postoperative days by solutions administered intravenously. In the absence of gastrointestinal fluid loss this should be in the form of 5 per cent glucose in water, and no more than 2000 cc. daily is necessary. As a result of water retention following the stress of operation it is probable that less than this amount is required on the day of operation. It will replace insensible losses and provide an adequate volume for normal kidney function. Saline solutions should not be used unless salt is lost either from the gastrointestinal tract or from excessive sweating. Losses of fluids by vomiting, gastrointestinal suction, bile drainage, or intestinal fistulas must be accurately recorded and replaced by appropriate electrolyte solutions. If such losses are in large amounts and continue for more than a few days, potassium chloride must also be supplemented. In most patients having biliary tract operations gastrointestinal activity rapidly returns to normal. However; one should not insist on early feeding against the patient's desire. Ordinarily, water and clear liquids (broth and tea) will be tolerated in small amounts the day after operation and a soft diet may be resumed on the third or fourth postoperative day. Patients should later be encouraged to try foods which have previously been discontinued because of biliary dyspepsia. If severe disease has pre-existed and is now corrected they will sooner realize that they may expect more normal digestive function. In patients with liver damage the early resumption of a high caloric and high protein diet is imperative. With careful surgical technique, avoidance of excessive opiates postoperatively, and in the absence of air swallowing, abdominal distention after biliary tract surgery should be minimal. Efforts to relieve distention by rectal or colonic manipulations are meddlesome and usually ineffectual. It is unusual for the bowels to move before the third postoperative day after any major abdominal operation. It is customary to stimulate this act on the third or fourth day after operation by the use of a suppository or low enema. Early ambulation is conducive to rapid return of the previous bowel habit. One of the bulky laxative preparations, such as Metamucil, may be helpful in effecting a more normal bowel habit in the previously constipated patient. Most patients subjected to upper abdominal operations will have little trouble voiding in the early postoperative period. It is unusual to see large urinary volumes during the first 24 hours following operation be-
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cause kidney function is reduced as a result of the stress mechanism. Often patients will not void for 12 to 18 hours after operation. If the patient complains of bladder discomfort yet cannot void while lying in bed, or if bladder distention is evident, he may be assisted to stand to encourage evacuation of the bladder. Catheterization should be avoided if possible since it may increase the incidence of postoperative urinary tract infection. Frequent small voidings indicate urinary retention, and demand inlying catheter drainage until the bladder is again compensated. In elderly men this may initiate a train of circumstances which will require prostatectomy for correction. Early ambulation will greatly aid rapid return of bowel and bladder function, reduce the total use of opiates, help in preventing pulmonary and thromboembolic complications and, in general, shorten convalescence. It helps to maintain or restore the patient's morale. In most cases it should be started 12 to 24 hours after operation and should be encouraged several times daily. However, seriously ill patients should not be forced out of bed because of a routine. Few elective operations on the biliary tract will require the use of antibiotics. These drugs are indicated in the presence of acute cholecystitis pre- or postoperatively, and for pulmonary or urinary complications. When contamination of the operative field occurs, during duodenotomy or anastomotic procedures, for example, the prophylactic use of antibiotics probably reduces localized peritoneal and wound infections. Penicillin is the drug of choice except when cultures of infected material reveal lack of sensitivity and indicate more effectual substitutes. Certainly, lack of response of an infection to one antibiotic indicates a change when sensitivity studies are not available except as previously mentioned in the preoperative treatment of acute cholecystitis. Care of the Wound
The Drain. Most surgeons agree that drainage should be instituted after all operations on the biliary tree. Certainly this should include every cholecystectomy, choledochostomy, cholecystostomy, anastomotic duct operation, resection of the pancreatic head or sphincterotomy. Anastomoses between gallbladder and stomach, duodenum or jejunum may not require drainage. It is customary to place a Penrose drain in Morison's pouch. When drainage is minimal this drain is loosened on the third or fourth day and removed a day or two later. If drainage is profuse it must remain longer. The value of drainage is exemplified by the following case reports: CASE I. Mrs. L. A., aged 44, was first seen 4 months following cholecystectomy. The surgeon reported that at the conclusion of the operation the field was completely dry and drainage was therefore considered unnecessary. The postoperative course was stormy, but she was finally discharged from the hospital
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after 2 months in an extremely debilitated condition. An internist consultant discovered an abnormally high right diaphragm and at 7 to 10 day intervals aspirated 1000 to 3000 cc. of bile through the right side of the chest posteriorly. This history, plus the presence of bile in the stools and the absence of jaundice, suggested that an accessory bile duct was draining into the subphrenic space. At operation the common and hepatic ducts were normal. The mouth of a leaking accessory duct was closed with a fine silk suture and a huge subphrenic bile collection was drained. Although the subdiaphragmatic drain was not removed for 3 weeks, a residual chronic subphrenic abscess was later drained. Full recovery followed. CASE II. Mrs. F. B. F., aged 52, underwent cholecystectomy which was followed 12 hours later by profuse drainage of bile from the drainage site. On the tenth postoperative day a left subhepatic bile collection was drained and the operative area was re-explored. The common and hepatic ducts were intact and the cystic duct ligature had not slipped. The source of bile leak was not discovered despite observation of the gallbladder bed for 20 minutes. Penrose drains were placed in Morison's pouch as well as in the left subhepatic space and the wound was closed. Bile continued to drain profusely. Convalescence was otherwise uneventful. The stools were normal. Drainage of bile persisted for 9 months, when it gradually ceased. The patient has remained in excellent health for 4 years.
These two examples of accessory bile ducts give ample evidence of the necessity of placing drains after cholecystectomy. In the first, bile fortunately localized in the subphrenic space; otherwise, bile peritonitis would have been inevitable. The drain undoubtedly prevented death in the second patient. The Sutures. Skin sutures may be removed on the seventh to the ninth day after operation in the uncomplicated wound. Retention sutures should remain 12 to 14 days or even longer in debilitated patients. Care of the T-Tube. After exploration of the common duct, drainage of the duct must be instituted. Failure to do so may result in serious complications. Most surgeons prefer to use a T-tube, the duct being closed snugly around its long arm. At the conclusion of the operation it should be sutured to the skin and its end placed loosely in a small bottle which is tied to the dressing. This should be completed in the operating room since an uninformed assistant or nurse might temporarily clamp it to prevent soiling the dressings or blankets and thus cause a leak at the line of common duct closure. The tube should never be connected with rubber tubing to a bottle since any traction might dislodge it from the common duct and bile peritonitis result. Provided there is no bile leakage around the tube it may be clamped on the seventh or eighth day for an hour three times a day. If pain does not result it should then be clamped for 24 hours. In the uncomplicated choledochostomy, when no disease of the duct itself is present, a cholangiogram should now be taken. In the absence of residual stone or obstruction the tube may be removed on the ninth or tenth day. In the absence of obstruction nothing is to be gained by permitting it to remain longer. Drainage of bile will seldom occur after its removal.
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Long-arm T -tubes, suggested by Cattell,2 are occasionally used when mild stricture of the pancreatic portion of the duct is present, or following sphincterotomy or the creation of a false passage during exploration. Under such circumstances the tube should remain in place for much longer intervals. It is usually not possible to obtain a cholangiogram with this type of tube. In strictures or injuries of the common duct when it is possible to perform duct-to-duct anastomosis the procedure is often done over aT-tube, the tube emerging from the duct through an opening above or below the suture line. It is customary in such situations to leave the tube 6 to 12 months in the hope that scar contracture at the suture line will have reached its maximum during this interval. Failure to leave a tube in the common duct after exploration, or its removal before the formation of a drainage tract, may result in bile peritonitis or bile accumulation in the subphrenic space, as in the following case. CASE III. Mrs. R. U., aged 70, was first seen 6 weeks following cholecystectomy and choledochostomy. Since no abnormality had been noted in the duct at exploration the drain and T-tube were removed on the second postoperative day. A stormy period ensued. A few days before I was asked to see her a small catheter had been inserted through a right lower intercostal space, posteriorly, to drain an "empyema." The peculiar yellow color of the drainage led to request for consultation. Drainage of large posterior and anterior right subphrenic abscesses containing large amounts of bile resulted in gradual recovery.
Care of the Cholecystostomy Tube. This tube also should be loosely placed in a small bottle tied to the dressing or binder. Leakage around it usually develops in 8 to 10 days. By this time it is well walled off from the general peritoneal cavity and may usually be removed. If the obstructing stone in the cystic duct was not removed at operation a mucous fistula will persist. If the cystic duct is free from obstruction the site of drainage will promptly close unless stones obstruct the common bile duct or the ampulla of Vater, in which case a biliary fistula will persist. Prior to removal of the tube, cholangiogram should be attempted and may yield valuable information. Complications and Their Treatment
The prevention, recognition and treatment of pulmonary complications, thrombosis, embolism and urinary tract infections are being fully discussed by other authors in this symposium and will not be further considered here. Bile peritonitis and subphrenic bile collections have been mentioned previously and examples of the latter presented. These complications may result from rupture of the acute gallbladder, slipped ligature of the cystic duct, accessory ducts inadvertently divided at the time of cholecystectomy, or leakage around the T-tube. They may be prevented post-
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operatively in most instances by proper drainage. Should they occur, re-exploration is indicated. Subphrenic abscess may occasionally result from biliary tract operations in the absence of bile leak. Failure to complete the toilet of the operative field and its environs prior to closure of the wound may be the cause of such abscesses. During operation blood and at times bile or contaminated material from the gallbladder, stomach or intestine may drain to dependent areas which are not effectively walled off. Stones may escape from the common duct during exploration or from the inadvertently opened gallbladder and become lost. At the conclusion of the operation it takes but a moment to wipe out the subphrenic and subhepatic spaces and the right peritoneal gutter. This will avoid leaving a nidus for future infection. Acute pancreatitis may result from operation on the biliary tract. Three fatal cases of hemorrhagic pancreatitis following sphincterotomy have recently been reported by Pattison and Blatherwick. 3 In the discussion of this paper the long-arm T -tube was implicated as a possible cause of postoperative pancreatitis. I have encountered 2 instances of severe pancreatitis after choledochostomy, in neither of which was a Cattell tube used. These are as follows: CASE IV. Mrs. M. J. McD., aged 57, had a cholecystectomy on November 3, 1949. At that time small common duct stones were removed a.nd the sphincter was dilated to 6 mm. with Bake's dilators. Three weeks later, when a lesser omental abscess was drained, portions of necrotic pancreas were removed. Pancreatic drainage persisted for several months. CASE V. Mrs. W. H. H., aged 45, was first seen on September 14, 1953. Following cholecystectomy and choledochostomy in July, 1949 she had remained well until 1 month prior to admission. Three attacks of colic, chills and fever, and jaundice indicated common duct stone. At operation a widely dilated common duct was found and a patulous sphincter admitted the 9 cm. dilator without pressure, the ampulla being palpated over the dilator. Stones were not recovered. The pancreas was normal to palpation. High fever, abdominal rigidity, back pain and distention developed rapidly and suggested acute pancreatitis. Marked elevation of serum amylase confirmed the diagnosis.
Fortunately, both patients recovered after a prolonged convalescence. It is probable that manipulation of, or trauma to, the ampulla or pancreas rather than any particular operation or apparatus is responsible for this uncommon complication. Postoperative hemorrhage may result from slipping of the cystic artery ligature, from a raw gallbladder bed, or from failure to ligate veins coursing between the gallbladder margin and the serous coat of the liver. Massive hemorrhage may occur before signs of it appear from the drain. The diagnosis will depend primarily on frequent postoperative observations of pulse and blood pressure which should be routine.
Management of Patients Having Biliary Tract Operations
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Operative injuries of the common duct are all too frequent. That such injury has been done is often not recognized at operation, the first sign of trouble being massive bile drainage or rapidly developing jaundice in the first few days after cholecystectomy. Both are indications for early re-exploration if the patient's condition will permit. As previously mentioned, biliary fistula may be due to leakage through the cystic duct, accessory ducts, hepatic ducts or common duct. Whatever its cause, early surgical correction is indicated. I Jaundice resulting from ligature of the common hepatic or common bile duct develops benignly, the postoperative course being otherwise uneventful. This is in sharp contrast to the fulminating course of the patient with so-called hepatorenal failure. This latter condition may result from accidental ligature of the right hepatic or main hepatic artery. Jaundice in such an instance is associated with fever, impending shock, semicoma, increasing renal failure and a rapidly fatal course. Many common duct strictures develop weeks or months after operation and are the result of partial occlusion of the duct by a ligature or tenting of the duct with partial excision of the wall or some other trauma to the duct short of complete ligature. Details of their diagnosis and surgical correction is beyond the scope of this discussion. SUMMARY
Factors responsible for poor end results in biliary tract surgery are: (1) improper selection of patients; (2) inaccurate and inadequate operations; (3) disregard of the advances in the understanding of liver function; (4) inferior anesthesia; and (5) failure to recognize the importance of the minutiae of care during the pre- and postoperative periods. Preoperative management must include psychologic preparation of the patient by explaining not only the benefits which he may reasonably expect, but also the part he must play in aiding convalescence. The necessity for coughing, the importance of nasal suction, the benefits of early ambulation should be explained if maximum cooperation is expected. The specific problems before and after operations on the biliary tract include jaundice, impaired liver function and, occasionally, chronic debility from long-standing disease or dietary limitation. Acute cholecystitis presents problems in management differing from other complications of chronic gallbladder disease. Jaundice is never an emergency. But time should not be wasted when operation is indicated after diagnosis is made or when it cannot be made without exploration. Jaundice itself, particularly when associated with cholangitis, may increase hepatocellular disease. When severe liver damage is present operation is hazardous. High protein, high caloric diet and vitamin K are the most important measures in therapy before and after operation. In debilitated patients with or without jaundice, impaired
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liver function as well as secondary anemia and chronic blood volume reduction may be present. In acute cholecystitis rapid restoration of fluid balance plus careful evaluation of associated diseases is essential before operation is undertaken. If conservative treatment is chosen, constant observation of changes in symptoms, signs, and the simple laboratory guides will give warning of impending perforation. Acute cholecystitis will usually subside, ~ermitting safe definitive operation at an interval. Anesthesia for biliary tract disease must yield perfect relaxation yet avoid hypotension, hypoxia, and the hepatotoxic effects of various anesthetic agents. Scientific anesthesiology is therefore of great importance. Explicit written orders carried out by an alert nursing staff often prevent many of the common postoperative complications and permit early recognition of those that may develop. Specific complications of biliary tract surgery include bile peritonitis and subphrenic bile collections, subphrenic abscess, injuries of the biliary duct or arterial systems, and acute pancreatitis. All but the latter may be avoided by careful surgical technique and proper drainage of the operative site and of the common duct in case it is explored. The cause of acute pancreatitis as a complication following common duct operations apparently relates to manipulation of the ampulla or the pancreas. Early recognition of these complications and institution of proper therapy is mandatory if mortality is to be reduced. REFERENCES 1. Buxton, R. W., Ray, D. K. and Coller, F. A.: Acute Cholecystitis. J.A.M.A. 146: 301-307 (May 26) 1951. 2. Cattell, R. B.: A New Type of T Tube for Surgery of the Biliary Tract. Lahey Clinic Bull. 4: 197-204 (Jan.) 1946. 3. Pattison, A. C. and Blatherwick, N. H.: Fatal Acute Pancreatitis Following Choledochal Ampullary Sphincterotomy. In publication. (Read before the Pacific Coast Surgical Association, Santa Barbara, California, February 8 to 11, 1954) 1216 S. W. Yamhill Street Portland 5, Oregon