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Robert C Wright, MD, PS – Puyallup, Washington Informed Consent – Biliary Surgery Your symptoms, physical exam, and laboratory studies suggest that you have an obstruction or disease in your bile ducts requiring surgical correction of the problem. The causes for a problem with the biliary ducts are many, including previous infections in the biliary system, a history of gallstone disease, a history of pancreatic, or possible cancer. After careful consideration, biliary surgery is now recommended. Description of the Procedure An incision is placed either under the right rib cage or in the midline above the navel. The gallbladder (if present) is identified, along with its attachment to the bile ducts. The gallbladder is removed if planned. The common bile duct is identified and opened. If a choledochoduodenostomy is planned, the duodenum is opened, the opening of the biliary and pancreatic duct into the duodenum is identified, and this opening is surgically enlarged. The duodenum is closed, and a tube is brought out through the opening in the common bile duct to the skin. The abdomen is then closed. Additional Procedures that may be done while in Surgery It is impossible to accurately predict what we will see or encounter when we do this operation. The following procedures will be performed only if necessary: 1. Cholangiogram – this is a dye picture of the ducts draining your gallbladder. We usually like to obtain a cholangiogram to see if there are abnormalities in your bile ducts, or if there are gallstones which have migrated into the bile ducts. 2. Loop or Roux-en-Y choledocho(cholecyst)jejunostomy – if we are unable to gain access to the main bile ducts, or if the duodenum itself is obstructed, as may be found with severe inflammation or cancer, an alternative bypass of the obstruction in the bile ducts will still be necessary. This might be done by bringing up a loop or limb of bowel and attaching it to the main bile ducts or gall bladder in a standard fashion. Alternatives for Treatment 1. ERCP sphincterotomy – this is often first attempted, in an effort to open up an obstruction of the main bile ducts. If ineffective, or if recurring obstruction occurs, or if there are reasons why an ERCP sphincterotomy cannot be done, surgery is usually offered. 2. Percutaneous transbiliary drainage – this is an alternative for short term relief of obstruction of the biliary system. It is done by a radiologist, usually with CT guidance. Benefits of Treatment Chronic biliary obstruction will lead to life threatening problems, including jaundice leading to irreversible liver failure, or pancreatitis. Surgery in a timely fashion will permit drainage of the bile and pancreatic secretions in an unimpeded fashion. Risks/Complications of Treatment Treatment risks fall into two categories; those that could happen during any operation under anesthesia, and those that are specific for biliary surgery. In any medical treatment, it is impossible to predict all the things that could go wrong. Fortunately, complications are the exception rather than the rule. Every reasonable effort is made to avoid complications. The most common possible complications are as follows: Possible complications of major surgery 1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood transfusion is rare. 2. Infection – we take special care to prevent an infection, but it is always a possibility, especially for emergency surgery. 3. Reactions to medications – this could be many things from a minor rash to possible death 4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia, sore throat, or potential death, in rare cases. 5. Poor wound healing – breakdown of the incision. (see other side) Possible complications of biliary surgery 1. Inability to relieve the obstruction – multiple strictures, or advanced disease in the biliary system may lead to a condition that not even surgery can remedy. 2. Injury to bowel or other abdominal organs – an injury to a portion of the bowel or other organs in uncommon but possible. Should this occur, we will repair the injury. Re-operation may be required. Anticipated Recovery/Expected Rehabilitation Recovery is quite variable, depending on the individual. You should begin walking on the evening of the surgery. Your diet may be restricted for a while (2-5 days or more) requiring you to stay on IV fluids during that time. You should not drive a motor vehicle while on pain medication. You should not lift anything greater than fifteen pounds for several weeks following the operation. After that time, you will only be restricted from activity that causes discomfort. You will be on unrestricted activity six weeks following the operation. Most people are able to return to office work or “light duty” three weeks following the operation. Consent for Treatment I understand my condition to be a problem with obstruction or other disease in my bile ducts, and am aware of its risks if untreated. I have read and understand the above explanation of the operation required. My surgeon has answered my questions, and I choose to proceed with surgery. I understand that every operation may yield unexpected finding. I give the surgeon permission to act on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding that complications may arise from that action. I understand that while most people receiving biliary surgery benefit from the operation, I may not. My condition may not improve, and it may worsen. No absolute guarantee can be made. HIPAA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you invite to attend the surgery will be informed of the surgical finding, your surgical status, and anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or may not remember these important details PRINT NAME OF PATIENT __________________________________________________________________ SIGNATURE __________________________________________________________ DATE _________________ WITNESS ____________________________________________________________ DATE _________________ SURGEON ____________________________________________________________ DATE _________________ RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________ I waive the right to read this form, and do not want to be educated and informed of treatment risks; nonetheless I understand the need for this surgery and grant permission to the surgeon to proceed on my behalf. SIGNATURE _____________________________________________________ DATE _________________ rev 6-03/kab