ERCP after Hepaticojejunostomy

This one's for the googlers who are seeking out information on an ERCP (Endoscopic Retrograde Cholangiopancreatography) after hepaticojejunostomy. (You can sort of see a diagram of hepaticojejunostomy here. Or you can look at the picture to the right - it's a little different than our situation, where there is not as much duct at 39, but gives you a little visual.)

Due to bile duct injury during a laparoscopic gall bladder surgery, my daughter had a hepaticojejunostomy. The bile ducts that were operated on began to narrow, as they do in about 20% of the cases after being operated on. Now we are looking at biliary stenting or stretching of the narrowed ducts.

Our regular local doctor who does plenty of ERCPs did not want to do the ERCP on Naomi because of the roux-en-y procedure done during the hepaticojejunostomy. He did not feel he could get the scope down into her because of the changed anatomy. This doctor had done a scope procedure on her immediately after the gall bladder surgery in February.

So we went to a regional super specialist, and had the procedure at a beautiful academic medical center where we felt they would have appropriate equipment and such. Unfortunately, after going under general anesthesia and having the scope down her throat pretty far down there, the doctors were unable to get to the area of the anastomosis in order to see what's going on and to use a balloon to stretch the bile ducts and/or insert a stent in the bile ducts.

So now we are evaluating other things, like trying to do an ERCP again or doing a PTC (Percutaneous Transhepatic Cholangiography). If they do a PTC, they will go through the skin and liver, guided by radiation the whole time, and do the balloon stretching of the duct or insert a stent in the duct. The downside is that you have a little tube hanging out of you for a few months.

So, we are thinking about the options for a few days. Our conclusion is that the ERCP is not always successful after hepaticojejunostomy. Our other conclusion is that if you are having laparoscopic gall bladder removal, try for a surgeon who has done more than 25 of the procedures. That is the magic number for improving the rate of success for surgery, according to the National Institutes of Health.

Bile Duct Update

So, this gets a little complicated to give an update on Naomi. So I will enlist some pictorial aids.

When Naomi had her gall bladder out, laparoscopically, the surgeon nicked the common bile

duct. Unfortunately, this is a known common risk in laparoscopic gall bladder surgery. This led to her leaking bile. Bile according to wikipedia is "a bitter-tasting, dark green to yellowish brown fluid, produced by the liver of most vertebrates, that aids the process of digestion of lipids in the small intestine. In many species, bile is stored in the gallbladder between meals and upon eating is discharged into the duodenum." In your mind you can equate bile to battery acid or something super painful. If you have this stuff leaking in you, you will lose your mind with pain and require Michael Jackson level painkillers. Which it did, and which she had.

So when the docs went in to repair the nicked common bile duct, they used her intestine and did a roux en y procedure to remove her common bile duct altogether, and suture the duodenum to the common hepatic duct. So the right and left bile ducts drain through the common hepatic duct directly into the duodenum.

Are you with me?

And BTW luckily we've had no problem with the Sphincter of Oddi or the Ampula of Vader.

These ducts are approximately 2 mm in size, and in a small person they are especially delicate. And she is very small, she has lost 14 pounds since this whole thing began. Because these ducts were sutured, and they are full of blood vessels, they get a little mad when you stitch them.

So she got fever and feeling punk, and when we checked it out the ducts were dilated. So it seems they were skinny in the middle and dilated on the ends. Also her liver numbers were all funky, and white blood cell count very high. We had an ultrasound and she threw up the water she was supposed to drink. So they made her drink contrast fluid and did a CAT scan and she threw up the contrast fluid. Later they did an MRI and that went fine.

So therefore, we re-entered the hospital this week on Wednesday and went on some wicked antibiotics. Oh, and in the midst of it she developed a stress ulcer because of everything going on. The treatment worked, and she is now out of the hospital as of Friday.

We will be watching her liver numbers by blood test monthly, and watching her like a hawk to see if she starts feeling punk. The doc gave her a medicine that will help her produce more bile, so we will whoosh a lot of bile through those little ducts to try to stretch them open bigger. If they don't, and they start to stricture (or narrow), then we will need maybe a stent or something which is like inserting a straw inside the bile ducts to make sure they don't close and can process enough bile.

We had plenty of new doctor and hospital adventures that are good tales to tell:

• We looked at old pictures in the hallway of all kinds of nuns - nuns kayaking, Alaskan nuns, nuns in school, and, well, lots of other funny situations but me without my camera


• We got a private room in the pediatric floor with the view and great nurses


• I had a very serious conversation with the surgeon while in my pajamas (those surgeons come to visit the patients early in the morning BTW)


• Naomi read The Last Song by Nicholas Sparks in its entirety


• I ate meat at the hospital (last time was during Lent) and amazingly enough, meat did not improve the quality of the cafeteria food


• We visited with our pal Chaplain Mark


• We went to the cafeteria and avoided Chaplain Mark, who was in the cafeteria and had a lady loudly crying due to some trauma, and let him do his job


• I very dramatically told the doc "I just don't want Naomi to end up on dialysis" and he patted my knee and said "dialysis is for the kidney, not the liver" and then we cracked up


• All the nurses admired Naomi's nails and were amazed she did the French tips and flowered toenails herself


• One of our doctors admired Naomi's attitude and positive spirit and tried to talk up his son, who is sixteen years old, in a fit of doctor-patient matchmaking


• We watched prehistoric TV with no Tivo that required us to purchase a TV Guide so we didn't miss anything good, and got all the good pictures from Glee


• We discovered that Matthew Morrison, the teacher in Glee, used to be in LMNT, which is the offshoot boy band of Otown, when we were watching Making the Band, and loved Ikaika Kahuano who formed LMNT, and whose album we own


• We found a very cool birthday gift for a friend of Naomi's in the gift shop, and her birthday is this month


• A giant hospital visiting dog came around and visited with Naomi


• We got to take home a giant foam mattress cover, the Geo Matt, which has allowed Naomi to sleep on her stomach for the first time since the surgery and solved her problem of waking up in the night


• We watched the Saturday Night Live celebration of the 2000s and I don't know who enjoyed it more


• I almost broke my nose when I flipped down the seats in the van to fit the Geo Matt in there so we could see out the back window

And that, my friends, is what the Blog Adventure staff did

What to Eat in the Hospital

For hospital parents, I have a lot of sympathy. Those chair beds hurt. You don't want to shower in the hospital where everyone with their fatal germs shower. Some days you don't even care, and wear the same sweatpants outfit for two days in a row. You are totally stressed out and start to adjust to the rhythm of the place, a little too much.

At our hospital, they had free coffee at the cafeteria 24/7. I didn't know this until day 3. Important to find out.

They also gave the parents a pass for the cafeteria. You had a voucher for one meal per breakfast, lunch, or dinner.

First of all, I suggest ordering all the meals that the patient is allowed. They usually split up the entree, side dish, appetizer, and dessert. At breakfast they give you a cereal, plus a meat, plus fruit, plus a dairy. Order it all. Save the extra for parents or for home. Don't think we didn't come home with a nice bag full of little fruit cups, saltines, and cranberry juices.

Here are the things that are good to eat at the hospital cafeteria:

1. Salad bar. It's usually simple but good enough.
2. Fresh sandwiches. They can make tuna, or turkey or lunchmeat sandwiches and you can add the condiments. Not bad.
3. Yogurt, fruit, and toast or bagel.
4. Lasagna, enchiladas, or other tray-style dishes.
5. Soup. Their soups are usually not bad.
6. Boiled eggs. What can they do to that?

Here are the things not to eat at the hospital cafeteria:

1. Green beans. They cook the life out of them.
2. Fish. They batter them and then cook them until they are dry, dry, dry.
3. Hamburgers. They keep the hamburgers in some sort of hot water until you order it. That's just weird. Although I must admit, true confessions, it didn't taste that bad.
4. Pancakes. Usually hard, or cold.
5. Scrambled eggs. They have that dry, scoop it with the ice cream scoop kind of eggs that have no flavor and the texture of rubber.
6. Cereal. They only have cheerios, rice krispies, or plain special K. Where are the fruit loops? Where are the apple cinnamon cheerios?

So. A few little tips. Any to add?

Hospital-ity

We have had some real blessings during these days and nights in the hospital.

• Hospital care packages. My friend delivered us homemade sandwiches, fruit, chips, sodas, and home baked goods for a few days. We also have some cookies and such. So so nice.
• Food for the home folk. People dropped off dinners now, when we need them, so the littles and their caretakers would not starve.
• Care for the littles. My in laws and some other nice friends have kindly taken care of our young kids who couldn't come to the hospital - you must be over 18 to visit this flu season.
• Parent voucher for the cafeteria and parking pass. So nice. Thank you, hospital.
• Friends to take over my work. One person took an interview. One made me plane reservations for a trip. One postponed a call until next week. One covered for me on calls I couldn't make.
• Flowers and balloons. They just brighten up the place.

Our situation is not ideal. But I sure appreciate the kindnesses we have received.

Naomi Update

Well. It's been quite a week.

Naomi's gall bladder procedure did not go according to plan. After we came home we had to return to the hospital in the middle of the night due to pain. The kind that makes a kid throw up three times in the lobby of the ER. The kind that makes a mom park in the ambulance parking spot and hijack a wheelchair to take their kid to the ER. The kind that makes a mom ready to whack the ER person who takes too long to check their kid into ER.

Then, we found that Naomi was leaking. Bile. Which is poison. Right into the pelvic cavity. Yech.

So there was an easy fix, laparoscopic. Yay. Signed us up with the rock star doctor who would lead our rock star pediatric surgeon to do this.

Easy fix did not work. Had to do a complicated intestinal surgery to improve the problems caused by a slip in the first laparoscopic GB surgery. Grr and Wah.

Now, I am trading off nights at the hospital with DH, and essentially taking off a week to take care of Naomi who is still in the hospital as of Tuesday, with a few more days expected.

She is dying for mashed potatoes. The hospital only apparently has baked. Will try to acquire some mashed potatoes tomorrow.

Tonight, we will rest until her roommate comes back from her appendix surgery. Exciting times here on the pediatric unit with the teenage girls.

Medical Excitement

We took Naomi to the doctor, and got a date for gall bladder surgery: February 18. Please pray for Naomi and her surgery.

Then, I stopped by the dentist to pick up a receipt to turn in to the company that does our health care savings account. Asked for an appointment for Luke, who is having toothaches. They had me bring him late in the day. Net net, he has to have two teeth extracted on Tuesday, February 16.

I am a little faklempt.

She Has Gall

But not for long.

Amazingly enough, Naomi had to go to the doctor today for a gall bladder ultrasound. The verdict: she is old enough and the gallstones are bothering her enough that the pediatrician feels the gall bladder should be removed.

We consult with a surgeon on Tuesday.