SOME CAUSES OF FAILURE OF OPERATION TO CURE GALLSTONE DISEASE.

WILLIAM J. MAYO, A.M., M.D., ROCHESTER.

Surgery of the gall bladder and bile passages is one of the most satisfactory branches of our art. The relief is perfect and rapid, leaving little to be desired. The death rate, taking the cases as they come, is hardly more than 3 or 4 per cent., and in uncomplicated cases less than 1 per cent., depending to a large extent on the condition of the patient. Including all causes of failure to cure, either complete or partial, and such late sequelæ as adhesions and hernia, the number of such instances is small. In 580 operations on the gall bladder and bile passages, we had but 17 cases, or 3 per cent., which required a secondary operation. During this period, however, we have on a number of occasions operated a second time for symptoms arising after an operation performed elsewhere. It is fair, therefore, to presume that some of our cases have, unknown to us, been operated on at a later period by other surgeons, and that failures to establish a complete cure have been more numerous than this percentage would seem to indicate. It must be taken into consideration also that many patients have symptoms referable to uncured lesions, which are not sufficiently serious to demand operation, and these may be accounted as partial or temporary failure; but looked at even in this light, gallstone surgery is wonderfully successful and practically all of the patients are benefited and few would exchange their post-operative for their previous condition.

Poor results usually occurred in our earlier work, and meeting with such cases has gradually enabled us to overcome the causes which lead to the subsequent troubles. Of course, in rare instances, the condition of the patient may not warrant a complete procedure at one sitting, and a second operation is

deliberately elected. With a single exception, to be referred to later, all of the cases in which results were less perfect than were desirable, occurred in complicated cases, and it can be laid down as an axiom that delay in seeking surgical relief is the direct cause of the complications. It is the general experience that complicated cases have usually had symptoms during a period sufficiently prolonged to have made a diagnosis possible before the development of serious lesions, and that an operation at that time would have been safer and cure more certain.

I would here refer to the clinical fact that a small number of patients who have had a cholecystostomy performed will have a colic or two following operation, and sometimes accompanied by transient jaundice. We have seen this most often during the first month or two after discharge from the hospital. In the large majority of instances the colics do not recur and the patient remains well. The temporary trouble is probably due to a crippled gall bladder becoming filled, and by reason of recent adhesions, not emptying properly, so that based on a single spell of pain shortly after closure of the fistula, a second operation may not be necessary unless there are other evidences of trouble.

The most common cause of future symptoms is incomplete removal of stones. In the original work of Tait he advocated cholecystostomy and drainage based on the frequency of overlooking stones, as it enabled spontaneous discharge. In our early experience we had in one case 55 calculi work out of the fistula during the first two weeks. There is, however, little excuse for leaving stones in the gall bladder, as by using the finger as a guide it will be rare that even a small calculus will be overlooked.

Stones in the cystic duct frequently escape attention, and it was only after several such misfortunes that we began to exercise greater care in exploring the cystic duct. The parts are deeply situated, and as these patients are often obese it is not easy to locate such a calculus previous to the development of the Robson technic, that is, the sand bag under the back, the

high incision and dislocation of the liver downward and outward, which exposes the cystic and common ducts perfectly. In most of these cases cholecystectomy is indicated. If the stone completely obstructs the cystic duct the duct and cystic vessels are caught with curved forceps just beneath the impacted stone. The duct is then cut across and the gall bladder and duct with the stone quickly removed from below upward, almost by traction alone, with an occasional division of some more firm adhesions to the liver. Twice we have reoperated on cases in which the gall bladder had been removed distal to the stone, leaving it in the duct to cause future trouble. This is more apt to be the case when the gall bladder is dissected out from above downward. The deep field is obscured by the blood running downward and the same vessels are cut over and over again. Stones are often overlooked in the common duct, as they may lie quiescent for years. The jaundice may be very slight and in some cases not noticeable. The gall bladder in the meantime may become obstructed at the cystic duct so that this organ may be enlarged and cystic with calculus at the neck and nothing to call attention to the common duct stone. This is so contrary to the usual condition of contracted gall bladder and open cystic duct in common duct stone as to lead to error. The ducts should be explored with the fingers before opening the gall bladder in every case. After opening the gall bladder, the relief of tension prevents moving the stone in the dilated duct and escape of the cystic contents is apt to soil the field. If the gall bladder is distended, it is well to explore a second time after tapping; but before opening the gall bladder with the attendant possibility of infecting the deep parts. If stones are found in the common duct it will usually be sufficiently dilated to introduce the finger into the duct for exploration. In many cases in no other way can we be sure the common and hepatic ducts are clear.

One source of failure of cholecystostomy to cure is from secondary obstruction of the cystic duct, preventing free drainage of the gall bladder down through the passages. This may

eventuate in a mucous fistula or repeated attacks of colics as the gall-bladder secretions are periodically forced through the strictured duct. In some cases the gall bladder will distend and finally rupture through the scar, discharging bile and mucus. In practically all of these cases the cystic duct has been obstructed by stone, causing ulceration, the healing of which induces a stricture, or kinking of the channel may occur. Other things being equal, it is better to excise the gall bladder in all cases in which the cystic duct is involved. In this way we have of late eliminated this, the most common cause of secondary trouble.

In septic cases drainage is necessary for a long period of time, and if the fistula be allowed to close too quickly, severe symptoms may ensue. We have twice had to reopen and reestablish drainage in septic cholecystitis; both cases were colon infections. This is less liable to happen in ordinary empyema of the gall bladder in which a fistula will usually remain until sterilization has been accomplished by natural processes. In colon infections tubage should be continued until the bile becomes sterile.

Cancer can also be said to be secondary to stone formation and may take place after cholecystostomy or, being present, may be mistaken for inflammatory disease. All thick-walled gall bladders should be looked on as suspicious, and as they are functionally useless, cholecystectomy should be done rather than cholecystostomy, and in this way many early cancers will be cured.

Chronic pancreatitis may exist at the time of operation and to obtain a good result drainage must be long continued. We have twice allowed the fistula after cholecystostomy to heal too quickly. The secondary symptoms were marked by attacks of slight jaundice and occasionally fever and chills and rather persistent stomach trouble. At the second operation the only cause for the condition found lay in a chronic pancreatitis, and both cases were cured by cholecystenterostomy. We must in every case examine as to the condition of the pancreas at the same time we explore the ducts, and if this disease is

present, either drain the gall bladder for a long time or do a cholecystenterostomy with the Murphy button in addition to removing the stones. Early in this paper I spoke of having seen only one uncomplicated case which required a secondary operation. This was a cholecystostomy with a very large gall bladder, the stones were easily removed and the ducts were free. For weeks after operation there was occasional escape of bile from the fistula, not much, but troublesome. On dissecting out the gall bladder it was found that by a low attachment to the abdominal incision this viscus had formed a channel along which in certain positions of the body bile would gravitate outward. After cholecystostomy the gall bladder should be attached as high up in the incision as is convenient. Persistent biliary fistula usually means obstruction of the common duct. I take it that every one understands the importance of not attaching the gall bladder to the skin. In the early days persistent bile fistula was usually due to a muco-cutaneous suture, the evils of which obsolete practice I do not need to point out.

The turning in of the margins of the incision in the gall bladder and drawing a purse-string suture closely about the drainage tube in a similar manner to a Kader gastrostomy enables healing of the fistula to take place most promptly. There are two rather common causes of failure to effect a perfect cure that may not always be avoided. Post-operative adhesions are liable to cripple the movements of the viscera in this neighborhood. Adhesions to the stomach and duodenum are the most annoying. Secondary separation may be necessary with the use of Cargile's membrane. As a rule like the pain of old pleuritic adhesions in time relief comes as bands stretch out. We make a rule not to allow gauze drains to come in contact with the stomach and duodenum on account of the development of adhesions. We always interpose a piece of rubber tissue and leave it from 6 to 8 days until the adhesive film surrounding the drains becomes organized. Hernia following operations for gallstone disease is not usually troublesome, but long incisions in obese people may give rise