Bile duct tumors

　　Most cancers originate from the head of the pancreas, where the common bile duct runs through. The next most common origin is the bile duct itself at the junction of the bile duct and pancreatic duct, the gallbladder, or the intrahepatic bile duct. In rare cases, bile duct obstruction is caused by tumors that have metastasized from other parts of the body, or by lymphadenopathy that has swollen due to lymphosarcoma. Benign bile duct tumors can also cause obstruction.

　　Postoperative complications

　　1. Postoperative coagulation dysfunction and hemorrhage:It is often related to surgical causes and coagulation dysfunction, especially common in patients with bile duct tumors accompanied by severe liver cirrhosis and portal hypertension. Close observation of the patient's facial color, consciousness, vital signs, and abdominal drainage should be maintained, and the amount, color, and nature of the drainage fluid should be recorded, and an effective venous channel should be maintained.

　　2. Bile fistula and bile-enteric anastomosis fistula:It is a relatively common and serious complication after bile duct cancer surgery. The patient may have localized or diffuse peritonitis, which may be related to improper surgical treatment or the removal of support tubes or T tubes. In nursing care, attention should be paid to properly protecting various drainage tubes, keeping the drainage unobstructed, and appropriately extending the time of tube removal for the elderly, the weak, malnourished, those with diabetes, and those who must use hormones. After the occurrence of bile fistula, the original unobstructed drainage should be maintained, and the abdominal cavity should be flushed with antibacterial drugs. Take a semi-recumbent position to reduce abdominal contamination; closely observe whether the patient's abdominal pain worsens, whether the range expands, and whether there is an increase in body temperature, and be prepared for reoperation.

　　The symptoms of bile duct tumors include jaundice, abdominal discomfort, decreased appetite, weight loss, and itching. Generally, there is no fever and chills, and the symptoms gradually worsen. The early symptoms of bile duct cancer are not obvious. Ultrasonic examination can reveal the expansion of bile ducts inside and outside the liver, and a small number of cases may find the location of the mass.

　　Methods to prevent bile duct cancer

　　1. To prevent bile duct cancer, maintain a happy mental state, develop good eating habits, avoid spicy foods, eat less greasy food, and do not drink strong alcohol. Actively treat pre-cancerous changes to prevent bile duct cancer, and remove potential carcinogenic factors as soon as possible.

　　2. For people over 40 years old, especially women, regular ultrasound examination should be carried out. If cholecystitis, gallstones, or polyps are found, further follow-up examination should be performed. If there are changes in the condition, early treatment should be sought.

　　The early symptoms of bile duct cancer are not obvious. Ultrasonic examination can reveal the expansion of bile ducts inside and outside the liver, and a small number of cases may find the location of the mass. Further examinations include ERCP or PTC direct bile duct造影, which can show the growth site of bile duct tumors, but none can determine whether the lesions are benign or malignant. The final diagnosis still depends on biopsy during ERCP or pathological examination after surgery.

　　It is important to pay attention to a light diet, and it is best to consume easily digestible foods such as congee, noodles soup, and so on. Pay attention to a light diet with a refreshing taste. Fresh vegetables such as green vegetables, cabbage, radish, carrots, tomatoes, and so on, can provide a variety of vitamins and inorganic salts, which are beneficial to improve the body's self-regulatory ability and provide high resistance.

　　The treatment of biliary tract tumors depends on the cause and tumor situation. Surgical intervention is the most direct method to identify the type of tumor, determine whether the tumor can be resected, and establish a biliary bypass. The most common situation is that the tumor cannot be completely resected, and most of these tumors are insensitive to radiotherapy, and chemotherapy can sometimes alleviate some symptoms.

　　Some patients with cancerous biliary obstruction may have pain, itching, and abscesses caused by bacterial infection. If the condition does not allow surgery, the doctor can insert a catheter (bypass tube) through a fiberoptic endoscope to bypass the tumor and drain bile and pus. This method can not only drain accumulated bile and pus but also control pain and relieve itching.

　　First, preoperative care:

　　1. Psychological care:Create a good treatment and rest environment for the patient and complete the patient's role transition as soon as possible. Biliary tract tumor patients, due to pain, jaundice, and other reasons, have heavy psychological burden and low mood. Encourage patients to express themselves, eliminate anxiety, fear, and tension, and build confidence in enhancing recovery. At the same time, strengthen communication, introduce the progress of diagnosis and treatment of the disease; perform operations with standardization and proficiency to increase mutual trust; explain the surgical methods and possible situations to the patient to reduce anxiety and pressure caused by understanding the condition.

　　2. Improve nutrition and strengthen liver protection therapy:Obstructive jaundice patients due to the toxic effects of bilirubin and bile salts cause liver cell damage, fibrosis, and eventually lead to biliary cirrhosis, liver function damage; at the same time, bile cannot enter the intestines, which reduces the digestive and absorptive capacity and the absorption of fat-soluble vitamins, decreases the metabolic capacity of liver cells, reduces protein synthesis capacity, and can lead to poor overall nutritional status of the patient, ascites, hypoproteinemia, and reduced tolerance to surgery. Preoperative dietary care should be well coordinated, and low-fat, high-sugar, high-quality protein, and easily digestible diet rich in vitamins should be consumed to improve the patient's nutritional status and increase the tolerance to surgery. If necessary, enteric or parenteral nutrition can be coordinated with the physician. Generally, the serum total protein should reach 65g/L, and albumin 35g/L before surgery.

　　3. Closely observe vital signs, consciousness, and urine output changes:Biliary tract tumor patients with obstructive jaundice can lead to endotoxemia, which can exacerbate the functional damage of important organs such as the liver and kidneys, leading to liver-kidney syndrome. Therefore, careful observation of the condition should be made, and water, electrolyte, and acid-base imbalances should be corrected, and the 24-hour intake and output should be accurately recorded.

　　4. Observe the changes in abdominal symptoms and signs of the patient:Observe the nature and location of abdominal pain, whether there is radiation pain, etc. For patients with biliary tract tumors complicated by cholangitis, the condition often worsens, and more attention should be paid to changes in body temperature, jaundice, and peritoneal irritation signs. Antimicrobial drugs should be administered in a timely manner according to medical advice to control biliary tract infection.

　　In cases of malignant obstructive jaundice, hyperbilirubinemia and endotoxemia can weaken the compensatory and reserve functions of the liver, reduce the body's immunity and tolerance to surgery.In necessary cases, it should be coordinated with the physician to perform preoperative jaundice reduction and drainage, such as PTCD surgery, and closely observe the regression of jaundice and the results of laboratory tests. Generally, radical surgery should be performed when the blood bilirubin level decreases to below 171μmol/L and the overall condition improves.

　　6. Symptomatic care

　　(1) For patients with high fever, perform medication or physical cooling as prescribed, and closely monitor temperature changes.

　　(2) For patients with pain, strengthen psychological care, understand the cause of pain, observe the location, nature, and duration of pain, and, if necessary, administer analgesic treatment as prescribed by the physician, and observe the analgesic effect.

　　(3) Strengthen the skin care for patients with jaundice. When itching, instruct patients to take a warm water bath or use calamine lotion to relieve itching, wear cotton underwear, trim nails, keep hands clean, and strictly prohibit scratching to prevent skin damage and infection.

　　2. Postoperative care

　　1. Drainage tube care

　　(1) Observe and record the amount, nature, and color of abdominal drainage fluid. Generally, the abdominal drainage volume does not exceed 300ml within the first 24 hours, and it gradually decreases thereafter. If the drainage volume is large, bright red, and accompanied by low blood pressure and a rapid heart rate, one should be alert to the possibility of internal bleeding and immediately notify the physician for treatment. For patients who have undergone hepatectomy, more intensive monitoring should be performed.

　　(2) In the short term after cholecystectomy, choledochoenterostomy, or hepatectomy, a small amount of bile may渗出 from the liver section or anastomosis, which generally decreases and disappears gradually without the need for treatment.

　　Journal article classification search is available in the journal library. If there is bile leakage from the postoperative abdominal drainage tube, with a sustained or increasing amount, fever, and signs of peritoneal irritation, immediate assistance to the physician is required. If it persists for a week, it is considered that a bile fistula has formed, and it is essential to ensure unobstructed drainage to prevent the accumulation of bile causing subphrenic abscess or entering the abdominal cavity to form cholecystitis.

　　(3) Patients who undergo pancreaticoduodenectomy require especially important postoperative observation and care due to the complexity of the surgery and numerous anastomoses. Pancreatic fistula is a major concern for surgeons, with an early incidence rate of 15% to 20% and a mortality rate as high as 50%. Currently, with the development of surgical techniques and improved methods, the incidence rate is about 13%, and the mortality rate is about 17%. The high incidence of pancreatic fistula is closely related to the special structure and biochemical characteristics of the pancreas. The pancreas is mainly composed of glandular tissue with little supporting tissue, a thin capsule, and is fragile. During pancreaticoenteric anastomosis, the pancreas is easily cut and torn by sutures. Additionally, pancreatic juice has strong digestive activity, and once it leaks out and becomes activated, it can destroy the anastomosis and cause a pancreatic fistula. Pancreatic fistula usually occurs between 5 to 7 days after surgery and is related to factors such as poor anastomosis, excessive tension at the anastomosis, hemodynamic disorders, peripancreatic infection, and poor drainage of pancreatic juice. It often manifests as upper abdominal pain, fever, increased drainage, milky appearance, and amylase levels exceeding 1500U/L for more than 2 weeks. It is important to maintain unobstructed drainage, observe changes in drainage volume and nature, control infection; strengthen skin care, apply zinc oxide ointment to prevent skin damage caused by pancreatic juice stimulation; fasting, and strengthening nutritional support therapy; and using drugs that inhibit pancreatic juice secretion, such as somatostatin. For those with an unhealed pancreatic fistula for more than 6 months, a pancreatic fistula jejunal Roux-en-Y anastomosis or anastomosis between the fistula and the jejunum or stomach can be performed.

　　（4）The T-tube (T-tube) is the focus of nursing care after bile duct surgery, and the following issues should be noted:

　　①Fix it properly to prevent the T-tube from slipping off. The length of the T-tube should be appropriate to allow the patient to turn over without obstruction, and it is best not to fix it to the bed to avoid traction causing it to fall off, while also providing the patient and family with relevant nursing knowledge.

　　②Check at any time whether the T-tube is patent, avoid pressure, and if there is a blockage, assist the physician in using sterile normal saline for low-pressure flushing.

　　③Observe and record the color, nature, and amount of bile. The physiological secretion of bile is 600-800ml, with a golden color, thick and clear without sediment; usually, the T-tube has 300-500ml of bile drainage in the first 24 hours after surgery, and then as the edema of the common bile duct subsides, most of the bile enters the intestine, and the drainage volume gradually decreases to about 200ml per day. If the drainage exceeds 500ml, it often indicates obstruction of the lower end of the common bile duct or narrowing of the bile-enteric anastomosis; if the bile is cloudy with flocculent matter, it often indicates the presence of infection; if the bile is thin, even watery, and the amount reaches 1000ml, it indicates poor liver function; if the bile suddenly decreases, attention should be paid to whether there are stones, worms, or necrotic tissue blocking.

　　④Encourage patients to get out of bed and pay attention to prevent backflow to avoid infection; do not place the drainage bag too low when lying in bed to prevent excessive loss of bile. Before meals, the T-tube can be clamped 1 hour before eating to allow bile to enter the duodenum and help with fat digestion.

　　⑤For patients with long-term indwelling T-tubes, it is necessary to prevent excessive loss of bile. The bile of the patient can be collected, boiled and disinfected, and then mixed with fruit juice for consumption. Currently, with the development of medical technology, for patients with malignant obstructive jaundice, the placement of biliary stents is often adopted to avoid the problems caused by long-term indwelling drainage tubes, such as bile loss, electrolyte disorder, digestive dysfunction, infection, and impact on the quality of life of patients, in order to improve the quality of life of patients.

　　⑥ Observe the patient's skin and conjunctival jaundice regression and changes in blood bilirubin. Check for changes in the color of urine and stool to understand whether the bile duct drainage is unobstructed.

　　⑦ Perform T-tube angiography two weeks after surgery. Before the angiography, try to clamp the tube for 2 to 4 days and perform an iodine allergy test. With the improvement of contrast agents, currently, there is a view that it is not necessary to open the drainage after angiography, but in general, open drainage is still given to allow the contrast agent to flow out, reducing adverse reactions and infection. If vomiting, upper right abdominal pain, fever, and recurrence of jaundice occur during the clamping period after angiography, continued drainage should be performed, and ERCP examination and treatment can be performed later.

　　⑧ If the T-tube angiography shows normal, it can be considered to remove the tube. In the past, the postoperative half-month was the deadline for tube removal, but with the development of surgical technology, the application of techniques to prevent abdominal adhesions during surgery, and the improvement of drainage tube materials, clinical observations have found that the formation of T-tube sinus tracts is significantly delayed. Currently, the time for T-tube removal is mostly delayed to one month after surgery, even longer. Our hospital's liver and gallbladder center has had experience and lessons learned from the occurrence of cholecystitis due to T-tube removal one month after surgery, so the time for tube removal should be determined according to the specific condition of the patient. After tube removal, attention should be paid to observe the patient's abdominal and bile leakage, and proper skin care should be performed.

　　2. Observation and nursing of complications

　　(1) Postoperative coagulation dysfunction and excessive bleeding are often related to surgical causes and coagulation dysfunction, especially common in patients with biliary tract tumors accompanied by severe liver cirrhosis and portal hypertension. Close observation of the patient's facial color, consciousness, vital signs, and abdominal drainage should be made, and the amount, color, and nature of the drainage fluid should be recorded to maintain an effective venous access.

　　(2) Biliary fistula and biliary-enteric anastomotic fistula are relatively common and serious complications after biliary tract cancer surgery. Patients may present with localized or diffuse peritonitis, which may be related to improper surgical management or removal of support tubes or T-tubes. In nursing care, attention should be paid to properly protecting various drainage tubes, maintaining unobstructed drainage, and appropriately extending the time for tube removal for the elderly, the weak, malnourished patients, those with diabetes, and those who must use hormones. After biliary fistula occurs, the original drainage should be maintained unobstructed, and the abdominal cavity should be flushed with antibacterial solutions. The patient should be placed in a semi-recumbent position to reduce abdominal contamination; closely observe whether the patient's abdominal pain worsens, whether the range expands, and whether there is an increase in body temperature, and be prepared for a second operation.