Bile duct stones combined with cholangitis clinical pathway standard inpatient procedure
(A) Applicable objects.
The first diagnosis of bile duct stones combined with cholangitis (ICD-10: K80.3).
Common bile duct exploration and lithotomy + common bile duct T-tube drainage was performed (ICD-9-CM-3: 51.41).
(II) Diagnostic basis.
According to the Clinical Diagnosis and Treatment Guide-General Surgery Sub-volume (People’s Health Publishing House, 2006, 1st edition), and the textbook of the National Higher Education Institution, Surgery (People’s Health Publishing House, 2008, 7th edition).
1.Symptoms: abdominal pain, chills and high fever, jaundice.
2.Signs: sclera may have yellow staining, deep pressure pain under the saber and right upper abdomen and local signs of peritonitis, and percussion pain in the liver area.
3.Auxiliary examination: ultrasound, CT, MR or MRCP suspect or suggest common bile duct stones.
4. Laboratory tests: routine blood tests show elevated total white blood cell count, elevated neutrophil percentage, increased serum total bilirubin and conjugated bilirubin, elevated serum transaminases and alkaline phosphatase.
(C) Selection of treatment plan.
According to the Clinical Diagnosis and Treatment Guide-General Surgery Branch (People’s Health Publishing House, 2006, 1st edition), and the textbook of the National Higher Education Institution, Surgery (People’s Health Publishing House, 2008, 7th edition).
1, cholecystectomy + choledochotomy for stone extraction (including choledochoscopy and lithotripsy and stone extraction) + choledochotomy with T-tube drainage (as the basic procedure), applicable to.
(1) Emergency and severe cases;
(2) intrahepatic bile duct stones without significant liver parenchymal fibrosis and atrophy;
(3) with biliary cirrhosis and portal hypertension but liver function is in compensatory phase.
2, cholecystectomy + bile duct exploration and stone extraction (including choledochoscopy and lithotripsy, stone extraction) + repair and reconstruction of bile duct strictures in the hilar region (such as bile duct stricture formation + jejunal Roux-Y anastomosis, bile duct stricture formation + free jejunal segment anastomosis, bile duct stricture formation + tissue patch repair, etc.), for stones distributed along the intrahepatic bile duct tree confined in one or two hepatic segments or in bilateral hepatic lobe bile ducts. It is only associated with regional parenchymal fibrosis and atrophy, as well as stenosis of the main hepatic ducts in the affected liver segments, or severe stenosis of the left and right hepatic ducts or bile ducts below the confluence.
3. Cholecystectomy + choledochotomy for stone extraction (including choledochoscopy and lithotripsy and stone extraction) + partial hepatectomy (in the form of regular resection of liver segments or lobes), for atrophic lobes or segments, multiple stones that are difficult to remove, and intrahepatic cholangiocarcinoma of the hepatic duct with uncorrectable stenosis or cystic dilatation, or/and chronic liver abscess, or/and lobar segments.
(iv) The standard hospital day is 10-13 days.
(v) Entry pathway criteria.
1. The first diagnosis must meet the ICD-10: K80.3 bile duct stones combined with cholangitis disease code.
2. The patient himself/herself has the will for surgical treatment and meets the following conditions.
(1) The stones are confined to one or two hepatic segments along the intrahepatic biliary tree, often combined with stenosis of the hepatic duct in the lesioned segment and atrophy of the affected segment;
(2) Multiple stones in intrahepatic bile ducts (including: without significant parenchymal fibrosis and atrophy; or with regional parenchymal fibrosis and atrophy, combined with stenosis of the main hepatic duct in the atrophic liver segment; or with biliary cirrhosis and portal hypertension, combined with severe stenosis of the right and left hepatic ducts or bile ducts below the confluence, but with liver function in the compensated phase);
(3) Combined with extrahepatic bile duct stones.
(3) When the patient is combined with other diseases, but no special treatment is needed during hospitalization nor does it affect the implementation of the clinical pathway process of the first diagnosis, the pathway can be entered.
(F) Preoperative preparation 1-3 days (referring to working days).
1. Required examination items.
(1)Routine blood + blood group, routine urine, routine stool + occult blood;
(2)Liver and kidney function, electrolytes, coagulation function, infectious disease screening;
(3)Abdominal ultrasound;
(4) Electrocardiogram, chest X-ray.
2.Checkup items that can be selected according to the patient’s condition.
(1) Tumor marker examination (including CA19-9, CEA);
(2) Echocardiography, pulmonary function test and blood gas analysis (for patients with underlying cardiopulmonary disease or elderly and frail patients);
(3) ERCP, CT of the upper abdomen or MRCP/MRA.
(vii) Selection of medication.
1. Antibacterial drugs: follow the Guidelines for Clinical Application of Antibacterial Drugs (Health Medical Development [2004] No. 285). Second-generation cephalosporins are recommended, and ceftriaxone or cefoperazone or cefoperazone/sulbactam can be selected for those with a history of recurrent infections; for patients with definite infections, antimicrobial drugs can be adjusted according to the results of drug sensitivity tests.
2. Before giving antimicrobial drug treatment, relevant specimens should be taken and sent for culture as far as possible, and drug sensitivity test should be conducted after obtaining pathogenic bacteria as the basis for adjusting drug use. Those with surgical indications should undergo surgical treatment, and bile should be collected during surgery for bacterial culture and drug sensitivity testing.
3.Start the empirical treatment of antibacterial drugs as early as possible. Empirical treatment should be used to cover the intestinal Gram-negative bacilli, Enterococcus spp. and other aerobic bacteria and anaerobic bacteria such as Bacteroides fragilis. It is generally advisable to use until 72-96 hours after the body temperature is normal and the symptoms have subsided.
4. Contrast agent selection: for those with negative iodine allergy test, choose pancystic glucosamine; for those with positive iodine allergy test, choose organic iodine contrast agent.
(H) The operation day is the 3rd-4th day of admission.
1.Anesthesia mode: general anesthesia by endotracheal intubation or epidural anesthesia.
2.Surgical method (including open surgery or laparoscopic surgery): the basic operation is choledochotomy for stone extraction (including choledochoscopy and lithotripsy, stone extraction), or T-tube drainage of common bile duct, or repair and reconstruction of hepatoportal bile duct stenosis (such as bile duct stenosis formation + jejunal Roux-Y anastomosis, bile duct stenosis formation + free jejunal segment anastomosis, bile duct stenosis formation + tissue patch repair, etc.), or partial hepatic resection (regular resection by liver segment or lobe).
The indications for bile duct-jejunum Roux-en-Y anastomosis and bile duct-free jejunal segment anastomosis (combined with sphincter of Oddi relaxation or stenosis) should be strictly controlled, and in principle, bile duct-duodenal anastomosis cannot be performed.
3.Intraoperative medication: routine medication for anesthesia, supplemental blood volume medication (crystal, colloid), and vasoactive drugs.
4.Blood transfusion: according to the preoperative hemoglobin status and intraoperative bleeding.
(ix) 7-9 days of postoperative hospital recovery.
1.Checkup items that must be reviewed: blood routine, blood electrolytes, liver and kidney function.
2.Choose according to the patient’s condition: trans-T-tubular cholangiography, abdominal ultrasound, etc.
3.Postoperative medication: antibacterial drugs, acid control agents, intravenous nutrition (as appropriate).
4.Various tube treatment: remove gastric tube, urinary catheter, drainage tube as early as possible depending on the situation.
5.T-tube treatment (general principle): extraction time must be more than 2 weeks after surgery, no abnormality of T-tube clamping for 24-48h before extraction, T-tube imaging shows patency of lower bile duct, no stenosis, no residual stones in bile duct; T-tube sinus imaging indicates complete sinus tract formation (if necessary).
6.Recovery detection: monitor vital signs, the occurrence of complications, recovery of gastrointestinal function, and guide the patient’s postoperative diet.
7.Wound care.
(J) Discharge criteria.
1.Wound without infection, drainage tube removal.
2.No fever, normal blood leukocytes, and stable vital signs.
3.Eating and drinking resume, no need for intravenous rehydration.
4.No other complications and/or comorbidities that require hospitalization such as bile leak, pancreatitis, etc.
(XI) Analysis of variants and causes.
1, Patients with comorbidities and complications, such as systemic vital organ insufficiency, etc., have increased surgical risk and require relevant diagnosis and treatment.
2.Preoperative or intraoperative bile duct cancer, hepatocellular carcinoma, pancreatic head cancer, liver abscess, or with biliary cirrhosis and portal hypertension with decompensated liver function, are entered into the corresponding pathway.
3.Surgical period needs to be postponed due to malnutrition, sepsis, abnormal glucose metabolism and comorbidities, which prolong the hospital stay and increase the cost.
4. Perioperative complications and/or comorbidities (e.g., postoperative residual stones) that require related diagnosis and treatment, resulting in longer hospital stays and increased costs.