Complications following Gall Bladder Surgery

[mwl]

On Tuesday, April 1, my wife had laparoscopic gall bladder surgery. The surgery seemed to go well. After a morning operation we were back home about mid-afternoon. Later that evening her pain increased and kept increasing until about 1:00 AM Wednesday morning she could stand it no longer even with a dose of 2 Vicodin tablets. I took her to the hospital ER and they began trying to find out why. Later that day we were told that the clip on the bile duct had slipped and bile was leaking into her abdomen. Only large amounts of morphine could relieve her pain. Finally, late Thursday afternoon a stint (tube?) was placed into the bottom of her bile duct to drain the bile into the intestine. A doctor did this by going down through the mouth, throat, and stomach. Friday morning she felt somewhat better until about noon. She began to hurt again and the nurse gave her as much morphine as the doctor had ordered and the pain was not relieved. The doctor arrived, increased her morphine, and ordered blood tests. The blood tests revealed an irritated pancreas which the doctor agreed is very painful. My wife is now on an automatic morphine drip (push button, get drug) and the doctor states that a day or two will settle the pancreas down. So my wife remains in the hospital all doped up on morphine so she can stand the pain.

I've related this to the best of my layman's ability. Do you see anything wrong with the doctor's treatment? Why did the bile duct clip slip? The surgeon claims it just happens in a small percentage of cases and nothing can be done to prevent it. Was a mistake possibly made? My wife has been in serious pain and on morphine for the better part of 3 days now when we expected a simple out-patient procedure and a quick recovery. Was she just unlucky? I also have an issue with the delay in installing the stint about 36 hours after the problem was found. Supposedly, the doctor was "tied up". Should this have been given higher priority?

Your honest opinion would be sincerely appreciated. I am not looking for a law suit. I only wish to get a second opinion about this course of treatment and the problems my wife has encountered. She has had a very rough week.

[Kevin Pho, MD]

Hello - thanks for asking your question.

Unfortunately bile leak is one of the complications of cholecystectomy.  It is more common in laparoscopic procedures.  Studies suggest the incidence ranging from 0.6 to 2.2 percent.  Symptoms include abdominal pain such as your wife is experiencing.  

It sounds like an ERCP was performed to determine the source o the leak and placement of the stent.  In those without complications, stents can be removed after four to six weeks.  

Unfortunately it sounds like the irritated pancreas is possibly from the ERCP.  The incidence of this complication is approximately 5 percent.  Most cases of this complication can be treated with bowel rest and intravenous fluids.  If the pancreatitis is severe, then the hospital course may be lengthened.  If there continues to be irritation of the pancreas, then a repeat ERCP may need to be performed for further evaluation.  

It seems to me that your wife had an unlikely complication of the cholecystectomy (bile duct leak, approximately 0.6 to 2 percent), and to repair this, had an unlikely complication of ERCP (pancreatitis, approximately 5 percent).  These possible risks should have been explained prior to each procedure.

The current management (bowel rest and IV fluids) is reasonable.  As for the placement of the stent and ERCP, that was a reasonable procedure to do once the diganosis of bile duct leak was made.

Followup with a gastroenterologist is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[TazLady]

I had to write because your wifes problem sounds very familar.  I had extreme pain after my gallbladder operation too.  The surgeon droped my sac inside me and had to go "rooting" for the stones that escaped inside me and on the cutting room floor.  I was sent home that same day but the nurse in the recovery out patient room kept telling my husband due to what happened I should be in the hospital.  Of course the surgeon disagreed.

Well after 2 weeks of extreme pain I kept calling the surgeon telling him that the pain meds he gave me weren't doing a thing for me.  He told me I wasn't managing my pain well.  After 3 months, I was referred to a GI who assessed my situation and said to me that I was nothing more than bored lonely housewife looking for attention.  He even told me 1 time in the hospital after 3 days there, that was nothing wrong with me when I came in and nothing wrong with me now, other than the fact that I was "obeese".  I was 30 pounds over weight.  And since I didn't drink, wasn't losing weight for any unseen reason, I was under forty and fat....pancreatitis wasn't suspected or even looked for.  Even after 3 ER visits in which that ER doctor woke my PCP up at 4 in the morning to tell them I was having an acute pancreatic attack.  No one belived me.

Final after more than a year later I was diagnosed with Severe Chronic Pancreatitis.  I am now sick and will be for the rest of my life, all because some stupid doctors didn't care enough to listen to what I was telling them because I didn't fit a profile and didn't believe that I knew my body better than they did.

Your wife had gallbladder surgery followed by an ERCP for palcement of the stent.  The stent will have to come out and that will require another ERCP.  In my humble opinion she had an acute pancratic attack after gallbladder surgery and most likely another after the ERCP.  Pancreatic attacks like to happen after surgerys and especially after ERCP's.  I HOPE that she only had the 1 or 2 acute attacks, and will never have another one.  It is possible.  But you should see a SPECIALIST dealing with the pancreas and don't take no for an answer regarding a referral!  It is essential that she be evaluated and seen and treated if necessary.  Believe me, you DO NOT want to have chronic pancreatitis.  

And in case no one told her yet, even after having 1 pancreatic episode there are rules she must follow for the rest of her life to help prevent other attacks.  No alcohol of any kind.  Even in cough medicines, nyquil, non alcoholc wines and beers...etc.  Pancreatitis is about 80% caused by alcohol over abuse, but as in my case and it would seem your wifes, 20% of the time it is called idiopathic, which means it can't be determined how it was caused.   But mine was from surgery and it would seem hers was too, in my hum,ble opinion.  She should eat a low fat diet now.  No more than 25-30 grams of fat a day.  No fried foods.  And of course, everyone cheats on there diet in life, even pancreatic sufferers, but it just means you will have more pain after eating that meal than usual. She should see about getting pancreatic enzymes to help reduce the amount of work the pancreas has to do.  A Fecal Fat Test will help conclude it she has any problems digesting fats which is one of the symptoms of pancreatitis.

Morphine is the only thing that helps my pain when it is so bad that I need to be admitted to the hoispital or got the ER room.  Pancreatic attacks are worse than giving birth, your wife will attest to that.  There is nothing more painful out there than a pancreatic attack. Demerol doesn't do a thing for the pain.

I have gotten advise from an attorney about recourse from my own operation and because I signed a waiver, I was told nothing could be done.  Evidently the waiver has a clause in there that something could go wrong during the operation, such as a pancreatic attack.

If your wife is in the hospital they are not letting her eat because the pancreas needs to rest to get better.  And I will tell you that for every day she spends in the hospital, it will take a week before she fully recovers.  If she's there for 5 days, expect about a 5 week recovery time before she feels energenic and recooperated.

I say none of this to scare you but to warn you of the dangers of this disease.  I hope that all goes well for her and that makes a full recovery.  Some people with only a few pancratic attacks under there belt, never have another one again.  And her amylase or lipase level wasn't that extremly high to suggest that bad of an attack.  Mine have been as high as 2000 and 5000 during an especially bad attack that kept me in the hospital for 9 days. BUt it was elevated and that is a sign, besides the fact that she was diagnosed as having this attack.

If someone had given me advice about pancreatits before it got so bad for me, I'd have been more aggressive in finding a doctor to listen to me.  But after a year, I started believeing the doctors that there was nothing wrong with me and that it was all in my head.   So I say this all to you only as a warning of what can be.  If there is anyway to prevent pancreatitis from going from the acute to chronic stage, it must be taken.

Best of luck to you both,
TazLady
PS...If you have other questions you'd like to know from my experience, I will check back on this forum to see if you posted again.

[s.mcm]

I also had my gallbladder out last May.  I started having severe pain in the abdomin (abdomen) right where the rib cage meets. The pain travels to my back and sometimes my chest.  It feels like my back is breaking and a knife stuck in my abdomin (abdomen). The last two attacks in 3 weeks were so bad we had to call an ambulance.  As I am allergic to morphine they gave me demerol which helped a little.  One attack lasted 15 hours but the last one 5 hrs.  The hospital discovered my liver enzymes were really high .  Once the pain subsided enough to be controlled they sent  me home.  I am waiting for an ERCP through a specialist.  But with the SARS outbreak in Ontario all tests have been temp. cancelled.  Does anyone know what helps this pain?.  Can you describe the pain you have? I am sure that if it was my pancreas, they would have kept me in the hospital.
Good luck to your wife!

[surgeon]

No surgery is free of possible complications. Bile leaks occur after gallbladder surgery, and the one described was handled appropriately. Clips don't usually "fall off," and most people actually apply two. Even then, it can happen that bile leaks, and it's not always possible to find the exact reason. It's more likely  that the pancreatitis resulted from the ERCP. That's also a known complication; so yes, it sounds like your wife had lots of bad luck, but can be expected to recover fully. It's very unlikely to have recurrant pancreatitis when the cause is so specific and finite. As to the horror stories mentioned in the other posts, each seems to be a different situation. If I were you, I'd take advice and explanation and prognosis info from those who know the exact situation, rather than the experiences of others with similar but fundamentally different problems.

[leslie48]

I, too had a lap. choli the end of Feb. followed by ERCP two weeks later for a suspected stone.  There was no stone, but the Spincter of Odi was in spasm, so the "clipped" it.  After two weeks of ES Vicoden every 4-6 hours to deal with the unrelenting pain, I was continually brushed off with my continued complaints and given diet tips, etc. etc.   The last time I spoke with the doctor's nurse, she told me that the next step would be to start me on Amitriptylline 10mg, taken at bedtime for the pain.  Ok, I have taken this drug for nerve pain before and had some at home, although 50mg.  I took it that night and have every night since and the pain is gone.  Does it "fix the problem"? No, it masks the pain and fools your brain into not recognizing the pain messages, but I felt that "whatever it takes to stop the pain and get on with my life".  It is sad that the GI doctors are rare and in such demand that you cannot even get a post op appointment when they want you to be seen.  I have an appt. with the GI Dr. the end of April as that was as soon as they could "squeeze me in"...and I proceeded to see if I could get a 2nd opinion from another GI dr. and I could be seen in 2 months, if I wanted to wait that long.  So sad.  Why they do not explain things more clearly and give you information on what is normal and abnormal to expect after these procedures, is unclear to me, not to mention no consequences for same.  What are we to do?

[tessa0825]

Sometimes you PCP can help you get faster appts. with the GI Spec....I had an experience with this about a yr ago....We have one GI Assosciates office here that has (8) GI Specialists...When my Dr. suspected I had colon CANCER he told his nurse to make me an appt. with the GI Assos. She came back and told me I would receive my appt. in the mail within the next few days and I did...except it was for in 7 months...This was last May and I received a card with my appt on it for mid Dec....I thought it was a mistake and called them and they informed me it was NO mistake....They were booked full  (all 8 Drs.) and making appts that far ahead.....I had a return visit with my PCP in two weeks and when I got there he had assumed I already had seen the GI Spec.,he wanted to know how that visit went and why he didn't receive a report from the GI....I told him my appt. wasnt for another 7 months and he hit the roof...He called their office himself right then and talked to one of the specialists and I was seen in 4 days....Within 2 weeks I had my colonoscopy and my EGD and a week later my diagnosis.....My GI Spec. is wonderful and I can call anytime (if its important) and they make room for me.......Once you are an established Pt. I think it is alot easier to get in. Maybe if your PCP thinks you need to be seen sooner he can help.....Tessa

[Cally]

I had gall bladder surgery 9 weeks ago. It was a laproscopy.  The surgeon saw something on my pancreas and a CT has stated that it is likely an Anatomical Abnormality on the tail of the pancreas as the tissue closely resembles that of the pancreas.  I am to have another CT scan in September to see if there are any changes.  Since the surgery, I haven't felt that well.  Usually low to higher grade nausea perhaps made worse when I eat something with fat or a bit spicy, aching of lower back, particularly on the left and left SI joint [which has been a problem for several years], discomfort in the upper left and to the left of the belly button, nerve in my left butt quickly irritated by sitting and radiates sensations on the left side of my body. Over the last 2 years I have lost 13 pounds and in the last 2 weeks have gone down another 3 to l06 pounds. I am a small frame of 5'2", non smoker, non coffee or tea drinker, only drink 2 to 3 glasses of wine a month, and am very focused on eating a well-balanced diet. Am concerned and wonder if these concerns are related to the surgery or if an MRI could be more explicit about the pancreas.  I'm sure my anxiety over this is not helping the situation.  Thanks for your time.  Cally

[imurhucklbery]

my situation is rather unusual compaired to the posts i have read
so far. I am a 28 year old male with no family history of gallbladder disease. however 3 months ago i started having problems that became increasingly painful as this disease progressed. after being turned away by almost every emergency room Dr. in town, finally someone took me serious enough, and had enough insight and compassion to investigate my symptoms.
i had been running a fever for over two months, after a ultrasound, i was admitted to the hospital. the surgeon advised me that i had to have surgery the following day, or risk a ruptured gallbladder. it was considered life threatening. the next day i had the surgery, it took almost 2 and 1/2 hrs, and my gallbladder was the size of an orange. it contained 3 large stones the size of quarters, various other smaller sizes. after the operation i remained in the hospital for 3 days, i still had a fever of 101.7 when discharged, still had severe pain. it has been 7 weeks since my surgery, and i am still running a fever, i can eat about once every 3 days, then i have nauseau, vomiting, followed by two solid days of green/yellow stagnat liquid stool w/out any fecal matter. i am on reglan and prevacid, and have been removed from all pain meds for over 3 weeks. following the Dr.s orders, i have attempted to modify my diet and lifestyle in an attempt to cope with the complications i am having now.
however i feel once again my situation is hopeless and have no idea where to turn for answers.

[imurhucklbery]

my situation is rather unusual compaired to the posts i have read
so far. I am a 28 year old male with no family history of gallbladder disease. however 3 months ago i started having problems that became increasingly painful as this disease progressed. after being turned away by almost every emergency room Dr. in town, finally someone took me serious enough, and had enough insight and compassion to investigate my symptoms.
i had been running a fever for over two months, after a ultrasound, i was admitted to the hospital. the surgeon advised me that i had to have surgery the following day, or risk a ruptured gallbladder. it was considered life threatening. the next day i had the surgery, it took almost 2 and 1/2 hrs, and my gallbladder was the size of an orange. it contained 3 large stones the size of quarters, various other smaller sizes. after the operation i remained in the hospital for 3 days, i still had a fever of 101.7 when discharged, still had severe pain. it has been 7 weeks since my surgery, and i am still running a fever, i can eat about once every 3 days, then i have nauseau, vomiting, followed by two solid days of green/yellow stagnat liquid stool w/out any fecal matter. i am on reglan and prevacid, and have been removed from all pain meds for over 3 weeks. following the Dr.s orders, i have attempted to modify my diet and lifestyle in an attempt to cope with the complications i am having now.
however i feel once again my situation is hopeless and have no idea where to turn for answers.

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