Category Archives: cholecystectomy

Gallbladder Surgery? It’s Not That Simple In Your Case

My second outpatient trip to London in a week and, unlike Wednesday, a beautiful clear morning without a cloud in the sky. I needed to be at St.Thomas’ by 9:00 to see a surgeon about having my gallbladder removed. It was an early start and my first waking thought was to wonder if eating a complete can of baked beans for dinner the night before had been such a good preparation for a journey on public transport. Hopefully a couple of extra Loperamide would do the trick.

It wasn’t until I parked my car near the station that I remembered where my mobile ‘phone was – on the dining room table. Was this going to be a liberating or frustrating experience? How was I going to let my wife know what the surgeon had said? How was I going to let my brunch companion know where and when we should meet? (At least I had my camera with me).

Having spent the train journey pondering this dilemma I arrived at St.Thomas’ outpatients’ department without having reviewed my list of questions or the copies of the ultrasound scans and follow-up letters I took with me. After a few minutes my name appeared on the laser display board and I made my way to the room indicated.

St.Thomas’ Hospital – opposite the Houses of Parliament

I had been expecting to meet the surgeon himself but was met by his registrar. I explained to her that I really wanted to see the surgeon and she said she would ensure I could spend a few minutes with him before I left. She started to go through my medical history. To speed up the process I produced a copy of the diagram I had drawn showing the key points in 40 years of Crohn’s and its companions. She was very impressed and no doubt I started beaming like a Cheshire cat. That soon stopped with the next set of questions.

40 Years of Medical History – on a page

I thought I was there to discuss whether surgery was a good idea, or not, and the possible complications. She was clearly running through the standard pre-operative assessment checklist – “Are you mobile? Can you wash and dress yourself? Can you manage household chores on your own?” I answered “Yes” to all the above but of course the answer to the last one was “No, I can’t. That’s why I got married”. (I’m joking!). I told her that my preferred option was no surgery until absolutely necessary as it would be too disruptive at present.

We then started to discuss my medical history in detail. She examined my abdomen and complimanted me on the quality of my scars. At this point it was obvious that surgery wasn’t going to be simple. She went off to see if the surgeon was available, taking the diagram with her. I think they must have then discussed its contents as about 10 minutes later they both returned and the surgeon introduced himself. He also liked my diagram and quickly ran through the key points.

He asked me to describe the circumstances that led up to me being there. I recounted the incident of violent shivering and turning yellow that occured at the end of January. He asked if I felt any pain (everyone has asked that one) and I was able to say I felt nothing at all. From that he concluded that a small gallstone must have temporarily lodged in my bile duct, long enough to cause the symptoms, and then quickly passed through before the pain started.

I went through the discussions I had had at my local hospital (East Surrey) and their suggestion that I needed to be seen by a specialist liver unit. I wondered why one of their concerns was liver cirrhosis? He replied that whenever a patient appears with esophageal varices / portal hypertension / portal vein thrombosis then it would be assumed that liver cirrhosis was the most likely cause. My latest Fibroscan result was 7.8 suggesting that cirrhosis was at a low level. I explained the hepatologist’s theory that the PVT had been caused by peritonitis following perforated bowel surgery in 1979. He thought this was very feasible.

Usually gallbladder removal is a same day operation using keyhole surgery. In my case it would be a lot more complicated. He noted my wish to delay surgery for as long as possible and was minded to agree with me. He wanted to present my case to their departmental review meeting to get other opinions. In the meantime they would arrange for me to have an MRCP scan (magnetic resonance cholangiopancreatography), a targetted MRI scan that looks at the biliary and pancreatic ducts. This would determine if any other gallstones were lodged in the bile duct. He asked me to book a further appointment for 6 weeks time so we could discuss the results and the meeting’s conclusions.

I had some final questions :

Will a cholecystectomy make my bile acid malabsorption worse? “We simply don’t know”.

Am I likely to suffer from post operative ileus (lockdown)? “Possibly”.

If we leave surgery until it is absolutely necessary what could the consequences be? “Anything from pain to having to prepare one’s relatives for bad news”.

Timescales for elective surgery? “Surgery would be carried out in the specialist Liver Unit at Kings College Hospital so the timescales would depend on their waiting list”.

I left any further surgical questions for our next meeting. His final action was to introduce me to their senior nurse co-ordinator who acted as a single point of contact for their patients. If I had any questions or concerns then I should call or email him.

….and my ‘phone predicament? Don’t bother with BT public telephone boxes – they take your money and then don’t work. When I arrived at St.Thomas’ I explained my problem to a very helpful guy behind the Patient Transport desk who allowed me to use his extension to make the necessary calls after my appointment.

….and so to brunch and a discussion on topics for the next #IBDHour Tweetchat.

Next appointment – Friday 10th November. Watch this space….

It’s in the blood

As a precursor to seeing a surgeon this Friday I booked an appointment with Haematology. It was only after making the booking that I read their last follow-up letter which said they had discharged me from their care. So it was with a certain amount of doubt that I approached today’s trip to London. Would I be wasting their time?

The waiting room at Guy’s was very quiet. Ominously quiet. Half a dozen patients at most. I had never seen it that deserted. The phlebotomist took blood samples and after a short wait, once the results were available, I was called in by one of the haematologists. I had not met her before and so as the consultation proceeded I needed to fill in some of the details.
I explained that since being discharged a new medical issue had arisen – a bout of jaundice. As a result I would be going to St.Thomas’ to see an upper GI surgeon to discuss having my gallbladder removed. She noted that gallbladder removal, by keyhole surgery, is a fairly simple operation on the surgery scale so I explained there were other complications and that my local hospital felt unable to cope with them, hence my referral to GSTT.
We went through the complications and their history :
Keyhole surgery unlikely to be an option due to previous adhesions/scar tissue
Portal Vein Thrombosis/portal hypertension
Low Platelets – would need to be over 80 or might need infusion
Liver cirrhosis
Co-ordinating consultants across two hospitals and four departments
As we covered each topic she used their eNote system to record her recommendations and these would be available for the surgeon to read. The follow-up letter itself would take a while to be issued.
The conclusion was that they would need to write up a plan for the surgery and would also refer me to their thrombosis unit to review my case. I came away feeling justified in requesting the appointment. I wanted to be better informed for Friday’s appointment and now felt armed with additional questions to ask. It can sometimes be a danger sounding quite well informed and having picked up some of the medical terms (the consultants version of polari) as you may get the answers back at a level higher than your actual knowledge! Never be afraid to ask if you don’t understand something.
Yes, I could have left all the above to chance but if I can help the process along, make sure the various parties are communicating and minimise risks then I’ll do whatever it takes. Roll on Friday…
I spent the rest of my time wandering along the banks of the River Thames, taking in the sights and ended up at Tate Modern.
Tower Bridge, HMS Belfast and a new berthing partner
Tate Modern – Installation by Magdelena Abakanowicz

Elective or Emergency?

I’ve often mentioned that I find blogging a great way of keeping objective about the various medical issues I encounter, hence this post which is a prelude to a meeting with a new Upper GI surgeon in London next Friday.

Why?

At the end of January I had a bout of jaundice. Whilst I turned yellow there was never any of the pain that usually accompanies it. I was in two minds whether to go to our local A&E but eventually gave in and made my way down there. To cut a long story short, a few weeks later I had a follow-up appointment with Upper GI consultant who suggested cholecystectomy (gallbladder removal). He was, however, concerned about some possible complications and for this reason recommended the surgery be carried out in a hospital with a specialist liver unit.

I exercised my patient’s right to choose which NHS hospital to be referred to and in my case the choice was simple – Kings College Hospital. I asked around and was given the name of an Upper GI surgeon who is highly recommended and has the added bonus of also working at St.Thomas’ and therefore access to my notes.

(There was a similar situation in 2009 when I found out I needed an ileostomy. The colorectal surgeon did not consider East Surrey Hospital had the facilities to cope with recovery from such a complex operation and so was sent to St.Thomas’ . I moved my outpatient care there in 2011.)

Preparing to meet the surgeon for the first time

The appointmet is set for 9:00am next Friday (22nd September). Before then I need to have a list of questions and any relevant documents. I am expecting to meet the named surgeon.

Just to complicate matters I will be seeing Haematology at Guy’s Hospital on the preceeding Wednesday. Will my medical file make it back to St.Thomas’ for Friday?

I have printed out the relevant documents from East Surrey Hospital- 2 x ultrasound reports + 2 x follow-up letters + last blood trest results.

I’ve also included my “jigsaw” diagram which shows the various conditions we need to consider and the dates they were diagnosed or last tested – Crohn’s, PVT. BAM, thrombocytopenia, potential PSC + last blood test showed borderline thyroid.

What Shall We Talk About?

Reason for referral – the consultant at East Surrey was concerned that, in my case, cholecystectomy ran the risk of liver damage due to cirrhosis. He also noted my low platelet count and thought that keyhole surgery may not be feasible due to the scarring/adhesions from two previous laparotomies.

Latest test results – Fibroscan (testing for liver cirrhosis) – 2012 was 7.2; currently 7.8. Platelets – 96 (but have been as low as 56). Ultrasound scan showed one large gallstone but made up from many small ones. Weight – 78kg

Risks and Benefits of Surgery

Type of surgery – Keyhole or laparotomy? What factors will decide

Timescales – waiting time for operation; how long for surgery and recovery for either keyhole or laparotomy

Likelihood of liver damage?

WIll bile acid malabsorption become worse if gallbladder removed? (SeHCAT in 2015 showed severe BAM. I keep it under control with just Loperamide but have Colesevelam ready should it be required).

Likelihood of post-operative ileus? After two previous operations I experienced it badly?

Do I need to have reached a particular weight prior to surgery? (Prior to my ileostomy I was given 3 x Fortisip/day to reach a target weight of 85kg)

My Preferred Way Forward

To have surgery when it becomes necessary not as pre-emptive measure. “Emergency rather than elective”. Maybe that’s over dramatic and should read “Just-in-time rather than elective?” What are the risks of this approach? What signs will indicate that an operation is needed? How soon does action need to be taken once the signs appear?

The consultant at East Surrey Hospital said if I get jaundice again I should go to their A&E and then they will decide whether to  transport me to London by ambulance.

Anything Else?

Next upper GI endoscopy/variceal banding due December 2017

Bloating – have been like this since ileostomy/reversal. Any thoughts on likely cause? One or more of the 5 F’s?

…..should be an interesting meeting

Should It Stay or Should It Go?

At the end of April I recorded a visit to London to see my gastro consultant (see post “50 Shades of Grey”). We discussed the “blip” last February  when I turned yellow. The keywords being – local A&E, jaundice, gallstones. There was the added complication that my local hospital was taking care of this issue. Split responsibilities and patient records tend to slow the treatment process down.

Back in November 2016, at my annual Upper GI endoscopy, I had asked if it would be a good idea to have another Fibroscan, a specialist ultrasound scan that measures liver stiffness (cirrhosis). The last one had been in November 2012 and it would be nice to know if there had been further deterioration. It was agreed that it would be a good idea but the request form was never issued.

The need to know about worsening cirrhosis had now become more urgent. My gastro filled in the request form as I watched. A few days later the appointment came through – 4th September. That long? Four months just for a very simple 5 minute test?

Friday 7th July 2017 – East Surrey Hospital Outpatients

When the “blip” happened I had gone down to our local A&E and spent the night there being monitored. Afterwards there was a follow-up appointment with an upper GI consultant locally (see post called “Time Bomb No.2, please” – April 2017). A further ultrasound scan was ordered and he said he would be happy to see me again to discuss the results. The scan took place on 12th May, the day NHS IT systems were hit by a virus. Usually I would expect to take a copy of the report away with me but not this time. I let a month go by then asked my GP surgery if they had seen the missing report. No, but a day later they had obtained a copy and rang me to let me know. (They provide an exceptional service)

The report stated “could suggest chronic cholecystitis” (inflammation of the gallbladder). Dr. Google was divided upon this condition. Some sites declared it serious and in need of treatment straight away; others said that if the patient was asymptomatic then it could be left alone. I rang the consultant’s secretary and she organised the follow-up appointment for 7th July.

(I had been under the impression, after the first appointment, that the consultant was going to discuss the case with my “doctor” (gastro consultant at GSTT) and would make a direct referral to Kings College Hospital Liver Unit. Wrong on both counts. The “doctor” he meant was my GP and the referral would be made via the GP after the follow-up scan. Doh! I had assumed that the process was already under way.)

I asked him specifically what concerns he had that would require surgery to be carried out in a specialist liver unit. He replied that they were : liver cirrhosis, low platelets, the adhesions from previous laparatomies and a possible bleed. No arguing with that. He also said that if I had a recurrence of the jaundice or pain in a specific area then I should go to our local A&E and they would take the decision on whether to treat me or transport me to London. We left it that a letter would be sent to my GP asking him to make the necessary arrangements. I thought it might be best to discuss it with my GP rather than just let the process take its course.

In the meantime I wanted to find out if there were any other hospitals I should consider along with KCH so I posted a question on FB in the PSC and BAM support forums. A number of other units were suggested but KCH came out well and it would be easier for me to get to.  Then I was recommended a consultant who works between St.Thomas’ and KCH. This would be the best of both worlds as they would have access to all my medical notes. I now had a name and contact details for the doctor I want to be referred to.

Tuesday 19th July 2017

My GP rang  this afternoon and we agreed that he would put the referral process in motion. He was of the opinion that this could have been done hospital to hospital.

Whilst I’m feeling fit and in no pain then I’m quite happy to leave the gallbladder well alone but I want to be prepared in case it all starts to go wrong.  It should be an interesting conversation with the consultant/surgeon as to his recommended way forward, especially when we start to discuss complicating factors – the minor annoyances of PVT, PSC, Splenomagely, thrombocytopenia and BAM.  I’m sure he would be interested in the results of the Fibroscan.

(That’s quite a list of complicating factors. As I’ve mentioned before it could well be a winning hand in “chronic condition top trumps”)

 

Time Bomb No.2, please

Monday – 13th March 2017 – off to see my GP to get a prescription for Colesevelam, a bile acid sequestrant. He greeted me with “bloody hell, you look well!”  I didn’t understand the reason for his comment until later. We agreed on the new drug and he also reviewed my existing medications. So far so good.

He had been reading my medical record, the last entry of which was a trip to A&E with jaundice.  He had assumed that I was back to see him with a recurrence of the  problem, hence his comment. He asked me what the plan was following discharge back at the beginning of February. As far as I was concerned I had undergone a follow-up ultrasound scan and it was now matter closed. Clearly he thought there should have been some follow-up. He was rather miffed that I had heard nothing and said that he would chase it up.

We then had a fairly lengthy discussion on gallstones and surgery to have my gallbladder removed. That was a bit of a shock. I had gone in to get a prescription and come away with a referral to see a surgeon. Not what I was expecting. I managed to book the referral for 3 weeks time

Wednesday 5th April 2017 – East Surrey Hospital

This was going to be another one of those “interesting” appointments. I hadn’t been to see a surgeon since 2011. It would be with someone I hadn’t met before and I knew from experience that much of a first appointment would be taken up with the new doctor rapidly trying to assimilate my medical history. I thought I might help this process by producing the diagram below.

Unfortunately the doctor had already read my notes before he called us in so my diagram did not have its intended benefit.

My wife accompanied me as surgery and recuperation obviously affects all the family, not just the patient.  We were greeted by the new consultant who turned out to be a professor. I had produced a list of questions based on the BARN principle – Benefits, Alternatives, Risk or do Nothing (or what’s Next?). Our discussion  covered many aspects of gallbladders and the biliary system. I’ll use my list to organise them into subjects.

BENEFITS

What would be the advantage of having galbladder removed? No more gallstones and therefore no more risks associated with them.

Would the operation be laparoscopic cholecystectomy (keyhole) or open surgery? What are the deciding factors? Due to my previous surgery and the likelihood of extensive adhesions it might not be possible to use keyhole techniques. The only way of seeing what adhesions are present would be by inserting a camera into the abdominal cavity.

What are hospital and recovery period for open surgery? Usually two days in hospital and two weeks recuperation.

BAM currently well controlled by 2 capsules of Loperamide/day, would losing my gallbladder mean starting on Colosevelam? No. It should not affect the current situation

ALTERNATIVES

Is there an alternative to surgery ie. ERCP? ERCP only suitable for removing stones from ducts once they have left the gallbladder.

We could do nothing – see below

RISKS

Any risks specific to gallbladder removal? There would be the usual risks of surgery but given my other conditions :

Portal Vein Thrombosis
Cirrhosis
Crohn’s DIsease
Bile Acid Malabsorption
Thrombocytopenia

They could cause additional complications. He was specifically concerned about thrombocytopenia (low platelets) and the chance of losing a large amount of blood during the procedure. He was also concerned about potential liver damage and noted that I already had the start of cirrhosis.

(As an aside – BAM could actually be helping my condition as there is less bile for recycling)

Given my past experience could surgery lead to post operative ileus? With keyhole surgery it is unlikely but there is a possibility with open surgery.

do NOTHING

What happens if we do nothing? It was finely balanced as to which course of action would be best. As I was asympytomatic and feeling well then maybe this was the option to choose. Ultimately it would be a joint decision between the consultant and myself.

Can “do nothing” cause long term damage to other organs? If another gallstone escaped from the gallbladder then the amount of potential damage  would depend where it came to rest. He drew a simple diagram to illustrate his point. If the stone lodged just below the gallbladder then it could cause it to expand. If it lodged further down the system at the sphincter where the stomach joins the duodenum then it could cause cholangitis (inflammation of the biliary ducts) and/or pancreatitis (inflammation of the pancreas). Both are very serious conditions.

What would the warning signs be? Pain in the right side, maybe stretching up to the shoulder. Skin and whites of eyes turning yellow. Usually the pain would be severe which is why it was strange that I felt nothing during my recent episode of jaundice.

NEXT steps

He put in a request for a further ultrasound scan (locally) but would be recommending that I was referred to a hospital with a dedicated, specialist liver unit due to his concerns about the potential risks of an operation ie.  needing a liver transplant if things went badly wrong!!!! I asked him to discuss this with my gastro consultant at St. Thomas’ Hospital.

In future I must try and avoid fatty or spicy foods as these could cause the gallbladder to contract which might, in turn, expel a stone into the ducts.

When I returned home I emailed my consultant at St. Thomas’ to give him an update on my situation and explain about being referred to a dedicated liver unit. I also asked if the results of the recent biopsies (taken during a colonoscopy) were available and whether my liver stiffness should be the subject of ongoing monitoring.

Time Bomb No.2

Maybe it’s being slightly over dramatic but it does seem that I am now carrying another time bomb around with me. No.1 – the esophageal varices – have now been joined by No.2 – gallstones. If the varices burst, again, or another gallstone gets stuck then they will needing emergency hospital admission…. but the sun has been shining all day so let’s not get too hung up about it.