"Ouch!" she winced as I gently pressed her abdomen.
"Do you think it's appendicitis….or maybe something to do with my colon…?"
Elise Ong looked anxiously at me, searching my face for clues.
She spoke with a soft, calm measured voice, a bit like that Bond girl, Michelle Yeoh.
A fitness instructor in her forties, she looked the very picture of fitness and health.
Heck, she might even be a black belt something….
Except she wasn't feeling so good today.
I eyed her trim, bronzed figure enviously, ruefully reflecting that I seldom had time for exercise and even less inclination to do so. Exercise these days meant ward rounds interspersed with carrying a kicking 3 year old….does that count as weight lifting?
My gaze alighted upon a piece of paper with a list that read: APPENDICITIS, INFLAMMATION OF COLON etc.
"My husband wrote that…" she said, reading my mind.
She had a high fever too.
"I think you might have gallstones." I finally declared, clearing my throat. "Let's do a CT scan….."
And indeed she had.
The CT scan showed the gallbladder had become hugely distended with a thick wall. She also had a uterine fibroid which had nothing to do with her present problems.
"You need an operation to remove your gall bladder."
"How will I be after the operation?......
I mean…….will I be OK next Sunday?"
That Sunday was exactly 8 days away.
My eyes narrowed.
"Is anything special happening next Sunday?" I began.
"I have a wedding to attend…" came the reply.
Must be her son's wedding, I thought. Or maybe a friend's wedding.
"Is it anyone special?"
"Yes……I'm getting married!"
BIG PROBLEM !
Laparoscopic gall bladder operations in the acute setting (when the gall bladder is acutely inflammed) is more difficult. Sometimes, the gallbladder is so stuck down that it becomes difficult to identify the anatomy clearly. Other times, the gallbladder might even be gangrenous or perforated. There is always the small possibility of conversion to the conventional type of surgery. That would mean a bigger wound, and well, more pain and a slower recovery.
I was pretty sure she'd struggle through her wedding if we had to convert to conventional surgery.
"But we have people flying in from the States!" "And we have the trip to Bali all booked up!"
The wall of the gall bladder becomes thickened. The bile inside turns into pus. The patient now has a condition known as Empyema of the gall bladder. Fever and pain are usual.
Untreated, the vessels in the wall of the gall bladder clot off and the entire gall bladder turns black (gangrenous). This then leads to perforation. Usually, such perforations are walled off by dense adhesions that form around the inflamed gall bladder limiting the spillage of infected bile and pus. A tender mass results and laparoscopic surgery is often not possible or safe in this setting.
FINDING ANOTHER WAY...
I started exploring with her the alternatives.
Intravenous antibiotics, pain relief, delayed surgery.
But the gallbladder would still be really distended and that in itself could cause persistent pain.
Therefore I recommended draining the gall bladder under ultrasound guidance. A relatively small procedure under local anaesthetic, a small needle would be inserted through the liver into the gallbladder. A fine guide wire would then be inserted via the needle followed by a tube drain threaded over the guide wire. This would remove much of the infected bile, obtain a sample for culture to identify the offending bacteria as well as decompress the gallbladder. In short, it would greatly help the antibiotics subdue the infection in the gall bladder.
She seemed OK about the antibiotics but quite doubtful about the drainage part.
And after all that, there could be no guarantee that the gall bladder would not flare up on her wedding day.
Gall bladder pain can be pretty bad - she ranked her pain at 8/10 (0 being no pain, 10 being the worst pain imaginable).
"You'd better meet Brad." she finally said with a frown.
Brad came the next day.
A slim American with a lean face, he exuded boundless energy. His eyes darted intently from person to person, always seeking information, answers.
Working on an oil rig, he must be used to drilling for things.
He displayed an uncanny ability to rapidly drill down to the essential questions.
“What happens if we leave it alone?”
“Well, the gallbladder could become gangrenous or even perforate….”
“No, no, we can’t have that!” came the swift reply.
I then explained what I would do, given the same clinical circumstances without weddings and honeymoons clouding the issue.
"Early surgery is easier and what’s easier for the surgeon is generally safer for the patient.”
I added “It won’t be possible to know beforehand whether we have to convert to open surgery or not – and if we have to convert, she will have significantly more pain at the wedding…”
“But you can give strong painkillers, right?”
Indeed we can.
“Then that’s what we’ll do!” he exclaimed, decisively.
And with that, he was gone, rushing off to the airport to meet an incoming group of relatives from the US.
Elise looked apprehensively at me.
“It’ll be alright.” I tried reassuring her.
I will jolly well have to make sure it goes alright, I thought silently to myself.
As her Liver Function tests were abnormally raised, I needed to do an MRI scan of her bile ducts to make sure there were no stones in the common bile duct. That meant another day of delay.
She was going to have her operation 5 days before her wedding!
In the past, acute inflammation of the gall bladder (acute cholecystitis) was treated with intravenous antibiotics with surgery delayed till the inflammation had settled.
However, that often resulted in much scar tissue formation around the gall bladder and bile ducts as the patient's body tries to contain the problem. At times, the scar tissue is dense, making dissection difficult and occasionally dangerous. Moreover, that also meant the patient had to put up with persistent pain and discomfort while waiting 'for the inflammation to settle'.
Now, many surgeons prefer early surgery instead - Emergency Cholecystectomy. With a bit of care, the operation can usually be done laparoscopically with less discomfort to the patient. However, one of the incisions often has to be enlarged to allow removal of the swollen inflammed gall bladder.
There is still a role for conservative management of cholecystitis in the elderly and unfit and I have successfully employed intravenous antibiotics with gall bladder drainage in the past.
As it turned out, Brad’s decision proved absolutely right.
The gall bladder, though swollen and inflamed was not as bad as I’d imagined it might be.
And most definitely, if we’d postponed surgery till after the wedding, it would have been far worse with dense scar tissue obscuring the vital structures.
That’s not to say it wasn’t tricky. The cystic artery spiralled around the cystic duct pulling everything down.
“Can’t we clip the cystic artery together with the cystic duct?” asked one of the OT nurses helpfully.
“No. No shortcuts. We HAVE to make sure this operation goes well!”
Somehow, I had to ensure Elise could transform from Patient to Bride in 5 days. My lips tightened at the thought of her clutching her tummy saying “I do".
"GET ME TO THE BEACH ON TIME!"
In the end, it did go well. She stayed an extra day or two as I was certain if she went home she’d be rushing around doing things and not getting rest. Poor Brad had to do most of the work.
“Can I go to Bali?”
Well, I had to say no.
What if something happened while she was out there?
But I knew she wasn’t going to listen to me and go anyway.
And it would probably be OK to do so.
She bounced into my clinic one week later, looking bright and fresh.
Cheerfully, she reported the wedding had gone well, the weather had held up (it was a beach wedding).
And Bali was wonderful!
Sure, I’ve done lots of laparoscopic gallbladder operations before. But I’ve never had to operate so close to a patient’s wedding day!
“I want to thank you for work well done and your clear explanation had helped me understand a lot. I wasn't in doubt for even a minute that I'm in the care of good hands...YOU, Dr. Khoo!”