CONDITIONS OF THE BILIARY TRACT REQUIRING

URGENT SURGERY*

FRANK GLENN, M.D.

Associate Professor of ClinicaI Surgery, Cornet1 University MedicaI College

NEW YORK, NEW YORK

T HERE are no methods or pIans of treatment empIoyed by the medica profession that cannot be improved

upon. Our knowIedge at the present time does not incIude a compIete understanding of the processes invoIved in tissue damage and repair. UntiI it does, our best criteria for guidance are to be found in the studies of results, not from a single method or pIan, but from many, adding new ones as newIy found facts justify them. The treatment of diseases of the biIiary tract is no exception to these genera1 statements. This subject is an important one. Warren CoIe’ estimates that 15 per cent of the aduIt popuIation have symptoms of nonmaIignant disease of the biliary tract. Throughout the United States it is one of the four conditions most frequentIy treated surgicaIIy.

It is my purpose to caI1 attention to those conditions occurring in the Iiver and biIiary tract which require urgent surgery for the optimum therapeutic resuIt. They are acute ChoIecystitis, intestina1 obstruc- tion due to gaIIstones and associated biIiary fistuIa, common duct obstruction, trauma of the Iiver, and a few rare condi- tions that may prove more common if kept in mind by the cIinician.

Acute choIecystitis and its surgica1 treatment is a controversia1 subject. The experience of the surgica1 department of the New York HospitaI and CorneII Uni-

versity is reported Iisting a few cases of the type that are said to occur rareIy, as, for exampIe, a free perforation of the gaIIbIad- der ending in a fataIity, and another in a recovery; then a rare compIication indeed -thrombosis of the right hepatic artery.

IntestinaI obstruction due to a gaIIstone is invariabIy associated with a biliary fistuIa into the intestina1 tract. It occurs frequentIy enough to necessitate its being considered in the diagnosis of intestina1 obstruction in those patients with histories of Iong-standing gaIIbIadder disease. Im- mediate operation for the reIief of intestina1 obstruction foIIowed by a Iater operative repair of the fistuIa and remova of the infected gaIIbIadder attains the best end resuIt.

Throughout the Iiterature, it is repeat- edIy stated that operation for jaundice due to caIcuIi in the common duct shouId be postponed unti1 the degree of icterus has reached a pIateau. Patients with jaundice are admittedIy major surgica1 problems, and adequate preoperative preparation shouId not be Iacking before any operation is undertaken. There is increasing evidence, however, that additiona Iiver damage resuIts from waiting in obstructive jaun- dice, and that patients who are adequateIy prepared, do we11 after operation.

The increasing speed of transportation empIoyed by our civilian popuIation has

* From the Department of Surgery of the New York Hospital and Cornell University Medical CoIlege, New York, New York.

160

NEW SERIES VOL. LVIII, No. a GIenn-BiIiary Tract Surgery American JournaI of Surgery 161

pIaced major Iiver trauma, such as rupture, in a more important r6Ie as a cause of death in accidents. The oId methods of treatment for this condition are no Ionger tenabIe because of their associated high mortaIity. There are now appearing reports that indicate that immediate and coura- geous action on the part of the surgeon may reduce the present mortaIity rate.

Then, finaIIy, there are a few rare condi- tions encountered in biIiary tract surgery which wiI1 be diagnosed onIy if continuaIIy kept in mind. By consideration which Ieads to diagnosis and proper treatment, addi- tiona1 patients may be saved. They are, for exampIe, (a) torsion of the gaIIbIadder, (6) biliary peritonitis due to spontaneous rupture of diIated biIiary ducts, and (c) cysts of the common duct.

There is perhaps no more controversia1 subject in surgery today than the treat- ment of a patient with acute choIecystitis. The vast Iiterature devoted to this subject aIone indicates that there is evidence for and against earIy operation. The data to be presented are in favor of earIy surgica1 treatment. Let us begin with those patients who have been diagnosed correctIy as suffering from acute choIecystitis. Over a period of sIightIy more than nine years, 350 patients with acute ChoIecystitis have been treated in the New York HospitaI. A poIicy of earIy or immediate operation after preoperative preparation was em- pIoyed. Our resuIts are shown in TabIe I.

TABLE I

RESULTS IN 350 PATIENTS WITH ACUTE CHOLECYSTITIS

OPERATED UPON EARLY OR IMMEDIATELY

Patients. 350 Deaths........................ 6 Mortality. I 7 To

These patients were representative of aI- most a11 the phases encountered in acute ChoIecystitis; Iikewise, they were of a11 ages from nine years to eighty-one, and with associated conditions found in such a wide age distribution. The mortaIity rate may be Iooked upon as being within a reasonabIe Iimit; however, any mortaIity rate, the resuIt of therapy, shouId be

improved upon. Four of the six deaths mentioned might have been avoided had surgica1 treatment been instituted before gangrene and perforation took pIace. There are those2 who contend that gangrene of the gaIIbIadder rareIy occurs and that perfora- tion, if it takes pIace, does not resuIt in a free escape of the gaIIbIadder contents into the peritonea1 cavity. Nevertheless, it does happen, and early in the history of biIiary tract surgery, to be exact in 1844, James Duncan,3 Surgeon, RoyaI Infirmary, Edin- burgh, reported an instance of gangrene of the gaIIbIadder which had ruptured, pro- ducing a peritonitis, folIowed by death. The diagnosis was made at autopsy. Doctor SamueI A. Vest, Jr.,4 of BaItimore, in 1933, coIIected the reported cases of gangrenous choIecystitis; a tota of seventy-one cases were gIeaned from the Iiterature and nine were reported as new. Twenty-three of the eighty patients died as a resuIt of the condi- tion, a mortaIity rate of 37 per cent.

The morbidity of compIications in the series of 350 patients operated upon bears cIose anaIysis, for out of these comes the mortaIity rate. Eighty-four had gangrene of the waI1 of the gaIIbIadder; and of these, twenty-two had perforation with a IocaI- ized peritonitis or abscess; three had free perforation into the peritonea1 cavity. One of these recovered and two died. Gangrene of a portion or of the entire gaIIbIadder waI1 is a sequeIa of acute choIecystitis and fre- quentIy Ieads to perforation.

Case I is an instance of a patient with a free perforation of the gaIIbIadder who was operated upon earIy, and who recovered:

CASE I. H. A., N. Y. H. No. 169394. A maIe, age forty-three, was admitted to the hospital complaining of severe abdominal pain. Twenty-four hours before admission he began to have abdominal cramps which castor oil had not reheved. The pain continued and became more severe, Iocalizing in the right upper quadrant. Radiation of pain from the right upper quadrant to the right shouIder was present.

PhysicaI examination reveaIed a weII de- veloped, we11 nourished forty-three year old

162 American Journal of Surgery Glenn-BiIiary Tract Surgery NOVEMBER, I+V

male, obviousry suffering from acute abdomina1 pain. The head was negative and eyes, ears and nose were not remarkabIe. The teeth were dirty with moderate dental caries; the neck aIso was negative. The chest expanded weII. There was some suppression of breath sounds at the right base posteriorly; no riles or rhonci were present. The heart was not enlarged; the sounds were of good quaIity and there were no mur- murs. BIood pressure was 12g/80.

The abdomen showed generahzed muscIe re- sistance, most marked in the right upper quadrant where exquisite tenderness was present. No peristaIsis was heard. Genitalia showed a heaIed incisiona scar on the dorsaI surface and the base of penis. A second in- cisionaI scar was present on the posterior sur- face of the scrotum; otherwise it was negative. Extremities were negative, reff exes physio- IogicaI and rectum negative.

Laboratory Findings. Urine was negative; the white bIood count 16,400; 86 per cent poIy- morphonucIears. KIine test was repeated three times before a negative resuIt was obtained. The Wassermann test was negative on two occasions. BIood urea nitrogen was 8.

A diagnosis of acute choIecystitis with pos- sibIe perforation was made. He was immedi- ateIy operated upon. A Iarge amount of biIe was found in the peritoneal cavity. BiIe was escaping from a perforation in an area of gangrene in the waI1 of the fundus of an acuteIy inflamed gaIIbIadder. A choIecystec- tomy was performed. The patient made an un- eventfu1 recovery save for a postoperative ateIectasis.

Pathologic Examination. Gross: The gaII- bladder measured 6 cm. in Iength and exhibited a thick waI1 which was markedIy congested throughout. The fundus was perforated with escape of gaIIstones. Upon opening the organ, this perforated area was found surrounded by sIough and congested mucosa which was other- wise rather smooth, pinkish and coated with inspissated yeIIowish materia1. There were nu- merous extensive fragmented muIberry stones in the Iumen, the Iargest of which measured I

cm. in diameter. The waI1 of the organ, on section, showed a heavy deposit of a creamy material which might represent intramuraI choIestero1 or might aIso represent necrotic connective tissue. It was so yeIIow that it was thought to be IargeIy choIestero1 and biIe saIts.

The following is an instance of free per- foration of the galIbIadder Ieading to a fatal peritonitis :

CASE II. N. M., N. Y. H. No. 51896. A femaIe, age sixty-six, was admitted to the hospita1 after having been under observation for severa days elsewhere for severe right upper quadrant pain. A diagnosis of exoph- thaImic goiter had been made two years before and she had had treatment incIuding iodine, with improvement. No history beyond eight years couId be obtained in reIation to the biIiary tract. However, for that period she had had recurrent attacks of right upper quadrant pain associated with nausea and vomiting and occasionaIIy jaundice. The present attack began three days before admission. There was a sudden onset of severe right upper quadrant pain radiating to the back and to the region of the right shouIder. There were nausea and vomiting. The pain became worse. On ad- mission to the hospita1 the patient appeared extremeIy iI1. Her temperature was 38.4’~. puIse, 94. There was exopthaImos and an en- larged, paIpabIe thyroid gland. The heart was definiteIy enIarged. BIood pressure was 160/60. The periphera1 vesseIs were definiteIy thickened and tortuous. The abdomen was somewhat distended. There was muscle spasm over the entire abdomen with marked tenderness over the right upper quadrant. There was a pal- pabIe, tender gaIIbIadder. Rebound tenderness was referred to the right upper quadrant.

Laboratory Findings. Urine showed I pIus aIbumin, 2 pIus sugar, occasiona red bIood ceIIs, many white bIood ceIIs, occasional casts, 2 plus acetone, and I plus biIe; white bIood count; 18, 800; bIood urea nitrogen 14; icteric index 14; sugar I 12.

It was thought that the patient was suffering from a generaIized peritonitis, probably due to perforation of the gaIIbIadder. The patient was given ffuids and digitaIization was begun. Five hours after admission, under IocaI anesthesia, the abdomen was opened through a right pericosta1 incision. Dark biIe was found free in the peritonea1 cavity. There was a perforation of the acuteIy inffamed gaIIbIadder near the fundus. Because of the patient’s precarious con- dition, the gaIIbIadder and the peritoneal cavity were drained. In spite of supportive measures the patient died two days after oper- ation of a generalized fibrinous peritonitis. The

NEW SERIES VOL. LVIII, No. I GIenn-BiIiary Tract Surgery American Journal of Surgery ‘63

liver, on microscopic examination, reveaIed been frequent recurrent episodes of right upper moderate fatty vacuolization. BacilIus coIi was quadrant pain for seven weeks prior to admis- the predominating organism obtained from the sion. On physical examination, the patient was peritonea1 cavity. acutely i11, deepIy jaundiced, and compIained

FIG. I. Schematic drawing of acute cholecystitis. Common duct obstruction believed to have resuked in thrombosis of the right hepatic artery and accompanying ischemia of the liver.

Discussion. A sixty-six-year-oId woman, suffering from poorIy controIIed hyperthyroidism, deveIoped an acute choIe- cystitis with a known history of at Ieast eight years of biIiary tract disease. The acuteIy inflamed gaIIbIadder perforated through a congenital saccuIation, Ieading to a termina1 peritonitis. Had the patient been operated upon before perforation occurred, the outcome might have been averted.

The folIowing is an exampIe of an acute cholecystitis which was not treated surgi- caIIy unti1 amost ten days after the onset. The attack of acute ChoIecystitis was a complication in a Iong-standing biIiary tract disease (about twenty years). This was accompanied by another rare and fata complication, thrombosis of the right hepatic artery.

CASE III. E. B., N. Y. H. No. 221902. A female, age fifty, multipara, was admitted to the hospita1 because of right upper quadrant pain, chiIIs, fever and jaundice of ten days’ duration. There was a history of biIiary tract disease of more than twenty years. There had

of pain in the right upper quadrant. Blood pressure was 132/60. A mass couId be paIpated in the region of the gallbradder, which was tender. The Iiver edge was beIow the Costa1 margin and was tender also. There was general- ized abdomina1 tenderness throughout the abdomen.

Laboratory Findings. Urine: 2 plus aIbumin, with casts and occasiona white bIood cells. It was aIso positive for biIe; red bIood count 3,000,000; hemoglobin .$? per cent; white blood count 21,300; icteric index 25; choIes- tero1 286.

After three days of preoperative preparation, incIuding A uids, gIucose, transfusions, and vitamin K, she was transferred to the Surgical Service. Under IocaI anesthesia, a choIecystos- tomy was performed, with the remova of severa choIestero1 stones from the gaIIbIadder, with apparentIy free drainage of normaI biIe Iater. Thereafter, the patient continued to re- ceive daiIy transfusions, intravenous gIucose, vitamin K and other supportive measures. In spite of this, she ran a protracted course with marked eIevation of temperature daily. The bIood cuIture revealed BaciIIus lactis aerogenes. The patient was given sulfanilamide. The in- fection, however, persisted. The jaundice in-

164 American Journd of Surgery GIenn-BiIiary Tract Surgery NOVEMBER, 1941

creased, reaching an icteric index of 125. Twenty-three days after operation the right Iarge toe became gangrenous, and one day before death numerous petechiae were ob- served over the chest wall. Throughout her hospita1 course, she had marked elevation of respiratory rate, yet nothing couId be demon- strated of a pathoIogic nature in the region of the right diaphragm.

The patient died twenty-six days after oper- ation. At autopsy, there was found an acute choIecystitis, stones inspected in the common duct, choIangitis, and a thrombosis in the right hepatic artery with infarcation of the liver. (Fig. I.) There were multiple infarcts throughout the arterial tree.

Discussion. The patient, a multiparous woman of fifty, was known to have had a history of biliary tract disease of at least twenty years. At the time of admission to the SurgicaI Service of the hospita1 the patient had an acute choIecystitis and ob- struction of the common duct. She also had a bIood stream infection (BaciIIus Iactis aerogenes). Because she was extremely iII, a minima1 type of operation was carried out under IocaI anesthesia-a choIecystos- tomy. This permitted decompression of the biIiary tract but, because of the overwheIm- ing bIoodstream infection, the patient, in spite of a11 supportive measures, continued a downhi course, and died twenty-six days Iater. It is reasonabIe to assume that the extension of the infection from the acuteIy inhamed gaIIbIadder and the debiIitated condition, the result of the extensive infec- tion, Ied to a thrombosis of the right hepatic artery, the eventua1 cause of her death.

IntestinaI obstruction, due to gaIIstones and choIecysto-intestina1 fistuIas, is one of the Iess frequent compIications encountered in biIiary tract disease. However, intestina1 obstruction of the smaI1 bowe1 in particular requires urgent surgery regardIess of the cause. It fohows the perforation of the gaII- bIadder into some part of the gastro- intestina1 tract. As pointed out long ago by RoIIeston,5 this is usuaIIy the resuIt of acute inffammation and a stone. EvidentIy

the stone is extruded from the gaIIbIadder into the intestine, stomach, or whatever viscera is cIosest at hand. If the gallstone is smaI1, it wiI1 be passed by rectum, or there might be, as has been reported, vomiting of a gaIIstone if the communication is between the gaIIbIadder and the stomach. The common site of the IistuIa is in the second part of the duodenum. If the stone is suffrcientIy Iarge, it may resuIt in intesti- naI obstruction in the lower portion of the iIeum or at the iIeoceca1 junction.

The fistulas that remain probably cIose in many instances, but they may remain patent. In this event, there foIIows an as- cending river infection (choIangitis) which provokes continua1 Iiver damage. In addi- tion, there is frequentIy partia1 to compIete occlusion of that portion of the common duct dista1 to the cystic duct.

Most important in the diagnosis of smaII intestina1 obstruction due to gahstones is a history of Iong-standing biIiary tract dis- ease and of one or more acute attacks. The symptoms of intestinal obstruction are not unIike those due to other causes, but there are certain findings on roentgenoIogic examination which, if present, confirm the diagnosis. They are: (I) distended Ioops of smaI1 bowe1, (2) a gaIIstone in the termina1 iIeum and (3) air in the biIiary tract. The foIIowing patient is an exampIe:

CASE IV. M. C., N. Y. H. No. 290940. A white femaIe, age sixty-one, was admitted because of vomiting and epigastric pain of two and one-half days’ duration. There was a definite history of Iong-standing indigestion which had been much more marked during the past year, consisting of considerabIe beIching after eating. Two and one-haIf days before admission the patient experienced cramping pains throughout her entire abdomen, most marked in the epigastrium. About two hours after their onset she became nauseated and vomited. The cramps persisted, as did the nausea and vomiting. She vomited tweIve times during two days.

Physical Examination. Temperature was 38”c., pulse 84, respirations 24, bIood pressure 132/go. The patient was a we11 deveIoped,

NEW SERIES VOL. LVIII,,No. 3 GIenn-BiIiary Tract Surgery American Journal of Surgery 165

sIightIy obese female, obviousIy ill. There was trace of aIbumin with 2 to 4 white bIood ceIIs xanthaIasma on the Ieft eyelid. The fundi showed sIight attenuation of the arterioles.

per h.p.f. on admission. Subsequent specimens were negative. HemogIobin was 15.5, red bIood

FIG. 2. Roentgenogram showing (I) air in the biliary tract; (2) dis- tended smaI1 bowe1; and (3) gallstone, probably in the termina1 iIeum.

Ears and nose were unremarkabIe. The Iips were dry and there was complete adentia. The tongue was coated and moderateIy dry. The tons& were atrophic and the posterior pharynx clean. The neck was negative and the breasts showed no tenderness or masses. There were scattered rales at both bases of the Iungs posteriorIy, which tended to clear on coughing and deep breathing. The heart was norma in size, rate and rhythm; sounds were distant and there were no murmurs. A~ was greater than PZ. The abdomen was rounded and sIightIy tym- panitic. There was moderate pennicuIus; a large, very tympanitic area in the epigastrium extended down beIow the umbilicus. There was diffuse superficia1 muscle soreness. Pelvic and recta1 examinations were noncontributory.

Laboratory Findings. Urine: There was a

count 4,500,000; white bIood count 13,700; 76 per cent polymorphonucIears; bIood urea nitrogen, 24-18-28-6; bIood sugar 102 and 103;

serum chIoride 660; serum protein 6.2, 5.5, and 5.6; carbon dioxide combining power 65 volumes per cent. Stools: guaiac negative on two occasions.

Roentgenologic Examination. This revealed distended loops of smaI1 intestine with obstruc- tion in the termina1 portion and questionable air in the biliary tract. (Fig. 2.) The patient was treated with a MiIIer-Abbott tube for twenty-four hours, with partia1 rehef of the intestinal distention. She was then operated upon for smaI1 bowel intestina1 obstruction. A large gaIIstone, measuring 4 cm. in Iength and 2.5 cm. in diameter, was found impacted in the ileum. It was composed of two stones tightIy

166 American Journal of Surgery GIenn-BiIiary Tract Surgery NOVEMBER, x9.+2

joined together. The patient made an unevent- surgical treatment of obstructive jaundice ful postoperative recovery. (Fig. 3.) due to caIcuIi, is the improved preoperative

Discussion. This is an example of a preparation of the patients during which

patient with a history of Iong-standing water, serum protein, and chIoride em- baIances are corrected, glucose reserves estabIished and vitamin therapy instituted. In spite of this advance, however, there persists a genera1 reructance to operate upon the jaundiced patient. This attitude has recently been reiterated from three of the leading surgical chnics in the country. Ravdin” states : “We have come to beIieve that earIy operation, once occIusion has occurred, is not aIways to be desired. It has been our poIicy to withhoId operation when the biIirubin concentration is increasing or decreasing. If it is increasing or decreasing we wait unti1 the concentration reaches a pIateau. During this period the patient is being prepared for operation. Except when suppuration is suspected, the operation is safer when hepatic function has stabilized itseIf against a high or Iow serum-bile pigment concentration and an adequate

FIG. 3. Schematic drawing showing the cholecystoduo- program of therapy has been carried out.” denal fistuIa, and dilated Ioops of smaI1 intestine due to Waiters and SneIP adhere to a simiIar gaIIstone in the terminal ileim. Roentgenologic exam- ination of such a condition usually shows air in the biliary tract.

biIiary tract disease. For many years she was without symptoms; then for a period of one year prior to her hospita1 admission she had evidence of renewed activity in a pathoIogic gaIIbIadder. There is no history of an attack suggesting perforation of the gallbladder into the intestine, and her first episode was acute obstruction due to impaction of the stone in the iIeum.

SurgicaI procedures for obstructive jaun- dice due to stones as we11 as other causes have been associated with a mortaIity rate much higher than that for operations upon the biIiary tract without jaundice. One of the outstanding factors accounting for the mortahty figure has been the tendency to hemorrhage. The use of vitamin K to cor- rect a Iowered pIasma prothrombin IeveI in these patients has reduced the mortaIity in aImost every cIinic reporting its experi- ence. Contributing to better results in the

poIicy. They state that operation shouId be withheld in jaundiced patients with the hope of a gradual decrease in the icteric index. SpecificaIIy, in intermittent biIiary obstruction, a faI1 in the concentration of the serum biIirubin indicates a favorabIe time for operation. They advise against operation upon a patient with a rising jaundice or biIirubin. Having made these genera1 statements, they go on to say that sometimes the rise in biIirubin may be Iong and continuous, and that vaIuabIe time may be lost before operation is undertaken. FinaIIy, they conclude that operation shouId be undertaken in jaundiced patients only by the surgeon of wide experience who reIies on his judgment.

Cole8 suggests the advisabirity of earlier operation in certain instances. He writes: “The diff&Ity in determining the oppor- tune time for operation and the frequency of hepatic insuffIciency and other diseases require an unusua1 amount of care and judgment in taking care of this condition.

NEW SERIES VOL. LVIII, No. 2 GIenn-BiIiary

Not infrequentIy infection of a type such as suppurative choIangitis deveIops in such a fulminating way that emergency opera- tions are necessary.”

A summary of the general practice, expressed by many writers in the current Iiterature, reflects an attitude which is Iess straightIaced than it was ten years ago; nevertheIess, it stiI1 justifies procrastina- tion which permits Iiver damage.

The effect of obstructing the flow of biIe in dogs by Iigation of the biIe ducts upon the IeveI of pIasma prothrombin has been demonstrated by Lord, Andrus, and Moore.g The IeveI of plasma prothrombin graduaIIy feI1 over a period of one hundred days to a vaIue of less than 20, and the anima1 died. (Chart I.) When these same investigators diverted the biIe from the duodenum by means of a cholecysto- nephrostomy, the plasma prothrombin feI1 more sIowIy and the animaI survived 165 days. (Chart 2.) Obstructive jaundice in animals at Ieast hastens Iiver dysfunction which, we believe, is best measured today by the plasma prothrombin level.

Tract Surgery AmericanJournalofSurgery 167

with its metaboIism of fat so that fat infiltration takes pIace. If infection is already present, obstruction to the bile flow is even more detrimental.

20-

D&O 20 40 1 60 1 80 I 100 1 120 Sept. 14.1938 Jan. I?,1939

CHART I. Effect of ligation of the common bile duct on the IeveI of the pIasma prothrombin in a dog. (Lord, Andrus and Moore. 9)

The deIay in surgery is not alone the fauIt of the surgeon. CertainIy, the fact that diagnosis in jaundice cases is not always accurate does deter one from prompt operation, because a genera1 anes- thesia and an operative procedure upon the

I Days”0

I I I I I 1 I I I 20 40 60 60 100 120 140 160 180

Sept. 8.1938 'F&15,1939

CHART II. Effect of an internal biIiary fistuIa on the IeveI of the plasma prothrombin. (Lord, Andrus and Moore.9)

It is we11 to remember that the increase in ducta pressure which foIIows common duct occIusion causes a retardation of the porta bIood which may be foIIowed by IocaI hepatic anoxia. The Iiver ceIIs are known to be extremeIy sensitive to oxygen want, and further Iiver damage foIIows. This renders the liver ceI1 Iess capabIe of hoIding and storing the gIycogen, it reduces its store of mobiIe protein and interferes

abdomen should be avoided in nonobstruc- tive jaundice. Thus, what has been said is directed toward the patient upon whom there has been made the diagnosis of jaundice due to a stone in the common duct.

Jaundice, in such instances, is an indica- tion for surgery in an attempt to prevent further damage to the Iiver; as long as jaundice persists, there wiI1 be further Iiver

168 American Journal of Surgery GIenn-BiIiary Tract Surgery NOVEMFIER. 1942

damage. It may be contended that an operative procedure which will relieve the jaundice without removing the cause is sometimes justifiable; and if we draw con- clusions from simple experiments on ani- maIs as noted above, a biIiary fistula is preferable to persistent obstructive jaun- dice. Indeed, if repIacement therapy, such as feeding whoIe bile or using biIe-fractions as substitutes, is empIoyed, the patient wiI1 be benefited. For those patients, who are over fifty, and come under care markedly jaundiced because of stone or stones in the bile ducts, such a compromising procedure may sometimes avert a fatality. Jaundice in the aged patient, with a scarred liver,’ may be a serious probIem with onIy a smaI1 margin of safety. These patients, in par- ticular, shouId be spared Iiver damage insofar as it is possible to do so.

LIVER TRAUMA

Injuries to the liver have recently come into greater prominence because of the increasing frequency of the major trauma in war casualties in Europe, and the ever increasing number of automobiIe accidents in this country. Liver injuries previousIy were more often inflicted by knife or gun- shot in contrast to the subcutaneous or contusion wounds of today. In war areas impacts due to explosions, and, in civiIian Iife, to rapid means of transportation, account for the increase in injuries to the Iiver.lO These may be grouped as foI1ows: (a) rupture; capsuIe and liver parenchyma are ruptured; (b) subscapular rupture; rupture of parenchyma, capsule intact; (c) deep or centraI ruptures; without injury to the capsuIe or periphery of the parenchyma.

The immediate danger from Iiver rupture is the exsanguinating hemorrhage produced and the accompanying shock. These pa- tients who died within twelve hours probabiy do so because of Ioss of blood. Furtwaengler” believes that damaged liver causes vascular spasm and renaI ischemia which is foIIowed by kidney shut-down. Orr and HeIwig l2 hold a simiIar view in

that they beheve that a toxin Iiberated from the Iiver compIetely nullifies the detoxifying function of the kidney. Boyce13 contends that there is liver faiIure throwing a greater burden on the kidney which has been rendered less efficient by the toxic materia1 Iiberated by the damaged liver.

Diagnosis. Th ese patients are to be found among the major trauma accidents. A history of injuries of sudden impact, be it from a means of transit, a fall, or forces of compression, as in explosions from bombings, shouId be sufficient grounds for seriously considering Iiver injury. The true rupture of the liver, in&ding capsule and parenchyma, leads to hemorrhage and shock. Shock is the first symptom, foIIowed by severe anemia. External injury may be lacking, but there is evidence of intra- abdomina1 bIeeding, particuIarly in the flanks and cul-de-sac. Pain in the right upper quadrant is frequent, as weII as pain referred to the right shoulder.

Treatment. RepIacement of blood loss should be instituted before operation is begun and continued until the hemorrhage is controIIed and the patient’s condition improved. Ruptures and large tears are probably best treated by a Iight tamponade of gauze. PIacing omentum in the defect will sometimes diminish the hemorrhage. Suture of the liver by massive mattress sutures has been successful. However, care must be exercised not to add further damage to the liver. Attempts at suture were first suggested by Postempski,14 in 1884, and very little encouragement has appeared in the Iiterature since. RecentIy, in our experimental laboratory, Andrus and McSwain have used a ribbon-gut car- ried by a wide, blunt needIe in the liver of dogs with quite satisfactory resuIts. We wouId, on indication, attempt it in a patient. Resection of most of the Ieft Iobe has been accompIished successfuIIy. Drain- age of the peritonea1 cavity in an attempt to avert a bile peritonitis is a we11 estab- Iished practice. (Fig. 4.)

In the examination of the suspected Iiver injury, the posterior and inferior

NEW SERIES VOL. LVIII, No. 2 GIenn-BiIiary Tract Surgery American Journal of Surgery

aspec Iookc is on

of the Iiver shouId not be over- properIy with other intra-abdomin la1 [, for it has been pointed out that this juries. Frequently, injury to the I of the most common sites of unob- occurs with other intra-abdomina1 ca

FIG. 4. Drawing indicating nonperitonealized area of liver, a common site of liver rupture sometimes overIooked.

I69

in- Iver tas-

FIG. 5. Torsion of the gaIIbladder. On section of the organ a bIack coIor is found to involve the mucosa and the greatly thickened waI1 of the organ. (From Hun.lg)

FIG. 6. Choledochus cyst. (From Bod- Iey.*l)

trophes such as a perforated viscus or rupture of the spleen.

served injury. (Fig. 4.) The remova of the Prognosis. Th e various case series re- damaged, devitaIized, or necrotic Iiver ported are evidence of the seriousness of shouId be stressed; one of the outstanding major Iiver trauma. Krieg,‘j of Detroit, results was reported by Branch of Boston, reports sixty cases, with a total mortality who removed 345 Gm. from the left Iobe of 61.6 per cent, and an operative mortaIity of the Iiver in a chiId of seven. Important as of 56.6 per cent. Seventy-three per cent of it is to Iocate and treat the Iiver injury, one the deaths occurred within seventy-two shouId not fai1 to search fof and dea1 hours. 0’NeiII16 coIIected one hundred

170 American Journal of Surgery GIenn-BiIiary

cases from the Los AngeIes General Hospi- tal over a ten-year period. Thirty-two of these patients were operated upon, with a mortality rate of 40 per cent. The remain- ing sixty-eight were from the autopsy records. From these cases it may be con- cIuded that most of the “ruptures” of the liver were aIong the posterior and inferior surface. The nature and extent of the injury play an important r8Ie in the prognosis.

If the patient survives the immediate shock with hemorrhage, signs of peritonitis appear and increase with the escape of biIe into the peritonea1 cavity. If the patient survives the first few hours and recovers from the blood Ioss and shock, there is next a period during which there may be death due to Iiver failure or complete renaI shut- down. Nor does surviva1 of these two periods insure recovery, because infection and resuIting peritonitis, IocaI or generaI- ized, may foIIow. When a CIostridium weIchii peritonitis occurs, the end resuIt is aImost invariabIy death.

0’NeiII16 has constructed the foIlowing tabIe (TabIe II) which is probabIy quite representative for our urban areas, and accounts for the manner in which the acci- dents occur in a civiIian popuIation:

TABLE II

TYPES OF VIOLENCE IN 100 CASES OF RUPTURED L,“ER

Pedestrian versus automobite.. 46

AutomobiIe versus automobile. 20

BicycIe versus automobiIe.. . 4 Blow in epigastrium during light. 4 FaIIing from a height.. 3 Thrown against a steering whee1. 3 Miscellaneous 20

The present war is producing, and wiI1 probabIy continue to produce, many Iiver injuries. DetaiIed case reports are now beginning to appear. Roscoe CIark,17 from the British Post-Graduate SchooI, reports a case of subcutaneous rupture of the Iiver treated surgicaIIy, with recovery, and comphcated by a Iiver sequestrum which was removed thirty-seven days after the first operation. Fragmentation of the liver is often foIIowed by autoIysis and death. This experience, together with Branch’s18

Tract Surgery NOVEMBER. rg~

two cases, one in which aImost half the liver of a child was removed, and another in which a portion was removed and an- other portion Ieft behind, suggests that compIete remova of Iiver fragments in Iiver trauma is imperative for compIete re- covery. These new probIems may be soIved in part in the experimenta Iaboratory.

Rare Conditions. FinaIIy, in our con- sideration, are those conditions that are rare and seldom encountered in even Iarge series of patients with biIiary tract disease. These, unfortunately, are not often diag- nosed before operation or autopsy. There are three to be briefly deaIt with: (I) torsion of the gaIIbIadder, (2) choIedochus cyst and (3) biIe peritonitis due to idio- pathic rupture of a biIe duct.

Torsion of the Gallbladder. Since the origina description of torsion of the gaII- bIadder, by WendeI,*O in 1898, Iess than sixty cases have been reported. For torsion to take pIace, the gaIIbIadder must be abnormaIIy free so it may rotate, and thus twist its supporting pedicIe which is made up of the cystic duct and vesseIs. Over half of the reported cases have been in patients over sixty years of age. The onset of pain in the abdomen is sudden, becomes severe and is persistent, usuaIIy accompanied by vomiting. A mass is often paIpabIe in the gaIIbIadder region, with varying degrees of tenderness and rigidity of the abdomina1 waI1. It is doubtfu1 if one couId distinguish it from a straightforward choIecystitis.

At operation, the gaIIbIadder is large, discoIored and tense; its bIood suppry is occIuded, and if this has persisted for Iong, the organ wiI1 show areas of gangrene. (Fig. ,5.) Less than haIf the patients have had stones. Operation is simpIe and the end resuIts satisfactory. Cases coming to au- topsy show a rupture of the gaIlbIadder and generaIized peritonitis. We have encoun- tered one instance in a series of 1,550 patients.

Choledochus Cyst. Over 130 cases have been reported. AImost al1 the patients had symptoms dating back to chiIdhood, aI- though they presented themseIves for

NEW SERIES VOL. LVIII, No. z GIenn-Bihary Tract Surgery American Journal of Surgery 171

treatment at a11 ages. BodIey2l and Gross22 (Fig. 6) have written extensiveIy on the subject. They beheve that a congenita1 defect in the duct such as a narrowing of the Iumen or a Iack of the norma structures in the waI1 constitute the primary defect. The cystic diIatation resuIts in jaundice and Iiver damage. As it enIarges, encroachment on surrounding structures may produce a variety of symptoms. Traumatic rupture of such a cyst has been reported by BIocker, WiIIiams and WiIIiams,24 of Texas. Short- circuiting operations and decompression have been empIoyed with discouraging resuIts. ChoIedoco-enterostomy and anas- tomosing of the cyst to the intestine has been empIoyed with some success. It may be comforting to know that Judd and Green23 encountered it onIy once in 17,381 operations; we have not had a singIe case in our series of patients. The case reported herewith is from Presbyterian HospitaI, and is contributed by Dr. BeverIy Smith:

CASE v. M. D., Presbyterian HospitaI No. 62 1745. A single femaIe, age twenty, was admitted to the Presbyterian HospitaI, Septem- ber 23, 1940, compIaining of a mass in her right upper abdomen which had steadily en- larged to its present size during the past five weeks, jaundice for three weeks, itching, Ioss of appetite, Ioss of weight, and discomfort in the region of the abdominal mass. Her past health had been exceIIent except for an attack of painIess jaundice Iasting one month, in 1932, at the age of twelve. She was deepIy jaundiced at that time, her skin itched, but she couId not recaI1 having had cIay-coIored stooIs. Other than this she had aIways been heaIthy, active and engaged in strenuous outdoor exercise.

About August 16, 1940, she noticed a hard nontender mass in her right upper quadrant, measuring about 2 by 2 inches, just beIow the Costa1 margin. In a week’s time it doubIed in size. In two more weeks it fiIIed the right haIf of the abdomen. During the second week that she noticed the mass she became jaundiced. Her skin itched and the jaundice steadiIy deepened. Three weeks after she noticed the mass and one week after onset of the jaundice, she noted cIay-coIored stooIs. She had never been reaIIy acutely iI1, and was nauseated and vomited onIy after taking certain fatty foods.

When she first noted the mass she feIt a duI1 aching abdomina1 pain in this region, but this subsided and had not recurred. She had been constipated, Iost thirty pounds, and her appetite had failed. There had been no tarry stooIs.

Physical Examination. The patient was thin, deepIy jaundiced and chronicaIIy iI1. There were many scratch marks over the whoIe of her body. A nontender, firm, sIightly irreg- uIar mass, measuring 25.5 by 30.5 cm., which gave the sensation of containing fI uid, extended from the right Costa1 margin to the right anterior superior iliac spine, beyond the umbilicus, and couId be baIIoted in the right flank. A diagnosis of a cyst of the right upper quadrant was made, and was considered to be either pancreatic, hepatic, choIedocha1 or mesenteric.

Laboratory Findings. Red f)Iood count ~,OOO,OOO; hemogIobin 55 per cent; white bIood count I 1,900; polymorphonuclears 55 per cent; lymphocytes 34 per cent; KIine negative. Proth- rombin was within norma limits. Roentgeno- Iogic examination showed that the abdominal mass displaced the stomach and duodenum for- ward and to the left, and the transverse coIon downward. The mass couId be separated from the Iiver. The patient was given bile saIts, vitamin K and a transfusion, and because of her rising serum biIirubin was operated upon September 27, 1940, at which time a cystic mass was encountered which was too Iarge to be de: limited. It was aspirated. The first fluid was white mucoid and was foIIowed by dark brown fluid without odor. The section aspirated 5,200 cc. of simiIar fluid. The duodenum Iay anterior on and to the Ieft of the cyst wall, the smaI1 intestines were pushed to the Ieft into the peIvis, the transverse coIon was below it and also in the peIvis, the stomach was upward and to the left, the gaIIbIadder was in its norma position. It was edematous and about twice the norma size. The Iiver was not apparentIy cirrhotic. Its lobes were normaI. About IOO cc. of biIe-stained, cIear, nonodorous fluid was evacuated from the peritonea1 cavity.

The patient’s immediate postoperative course was satisfactory, and thirty-seven days after the first operation a second procedure was undertaken. This time the cyst was anasto- mosed to the duodenum, and its opening to the exterior cIosed. The patient was discharged forty-two days after her second operation. markedIy improved.

172 American JournaI of Surgery GIenn-BiIiary Tract Surgery NOVEMBER, rg@

Discussion. This patient reached adult Iife before a cyst of the common duct became suffIcientIy Iarge to produce symp- toms. The treatment, consisting of decom- pression by drainage of the cyst and Iater anastomosing the cyst to the duodenum, has given a very satisfactory resuIt.

Bile Peritonitis. The presence of biIe in the peritonea1 cavity, not originating from the gaIIbIadder, is perhaps not as rare as the infrequent reports in the Iiterature might indicate. Escape of biIe from the biIe ducts may resuIt from their rupture due to trauma, infection, or back pressure, or a combination of these. One can readiIy see how trauma may produce this picture, or back pressure, due to progressive obstruc- tion as caused by neopIasm, or common duct stone, especiaIIy in the debiIitated; but it is diffIcuIt to understand in patients without a history of trauma and without demonstrabIe common duct obstruction.

The folIowing is a case report of a pa- tient of Dr. RaIph Bowers at the New York HospitaI :

CASE VI. A. A., N. Y. H. No. 301032. A white femaIe, age seventy-five, was admitted compIaining of severe generalized abdomina1 pain for tweIve hours. Her past history was significant in that she had had indigestion for many years. Four months before she had re- covered from bronchopneumonia. Her present iIIness dated back to the day before admission when, about one hour after breakfast, she had sudden, severe generalized abdomina1 pain. When seen by her IocaI doctor she presented a clinical picture of shock. She vomited during the day, remained acuteIy iII, with only a sIight eIevation in temperature. She was then brought to the hospita1. On admission, her temperature was 3&2”c., puIse I IO, bIood pressure 168/90. The abnormal findings were Iimited to the abdomen. This was fuI1 but not distended. There was generaIized abdomina1 tenderness with some muscuIar resistance, most marked in the epigastrium and in the right Iower quad- rant. Rebound tenderness was referred to this area. The remainder of the examination was noncontributory.

Laboratory Findings. UrinaIysis showed a very faint tract of albumin, a trace of sugar;

hemogIobin 16.5 per cent; red bIood count

5,5oo,ooo; white bIood count I 1,900; poly- morphonucIears 88; urea nitrogen 9; serum protein 4.8 per cent; chIorides 660; prothrombin 53 per cent. CuIture of fluid from the gaII- bladder wound showed StaphyIococcus aureus nonhemoIytic.

Because the patient presented a picture of an acute condition of the abdomen, suggesting an acute ChoIecystitis with possibIe perforation, she was subjected to a ceIiotomy. A biIe peri- tonitis was found, with a pancreatitis. The gaII- bIadder was edematous, the wall thickened, and the organ dilated. A cholecystostomy was performed, after making a carefu1 search for the source of the escape of biIe. This was not found. Her postoperative course was rather stormy and she died four days after the operation. At autopsy, a defect was found in the junction of the cystic and common duct. It was concluded, by the pathologist, that there had been a rupture of the cystic duct and that this was the source of a Iarge amount of biIe found free in the peritonea1 cavity. In addition there was found a pancreatic fat necrosis and acute ChoIecystitis.

Discussion. This seventy-five-year-oId patient presented the symptoms of an acute condition of the abdomen necessitat- ing surgica1 expIoration. The biIe peritonitis which was found was the resuIt of a spon- taneous rupture in the biIiary tract.

CONCLUSION

There are several conditions encountered in the surgery of the biIiary tract that may be better treated if a poIicy of earIy.opera- tion is foIIowed. In the successfu1 em- pIoyment of such a poIicy preoperative preparation must always be adequate and the contraindications to surgica1 therapy recognized. Each patient is an individual and requires attention pecuIiar to his needs. If these facts are kept in mind, earIier surgery in acute choIecystitis, intes- tina obstruction due to gaIIstones and associated biIiary surgery, common duct obstruction, trauma of the Iiver, torsion of the gaIIbIadder, biIiary peritonitis and cysts of the common duct may further reduce our present morbidity and mortality figures.

NEV

COLE, W. H. Factors in the prognosis and mortaI- it-v of gaIlbladder disease. Internat. Abst. Surg., 6;: @-&, 1939.

2. GRAHAM. E. A.. COLE. W. H.. COPHER. G. H. and

3.

4.

5.

6.

IO.

II.

v SERIES VOL. LVIII, No. 1 GIenn-BiIiary Tract Surgery American Journal of Surgery 173

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