About Your Surgery to Treat Bile Duct Tumors

This information will tell you how to get ready for your surgery to remove tumors in your bile duct at Memorial Sloan Kettering (MSK). It will also help you understand what to expect during your recovery.

About Your Bile Ducts

Bile is a substance that helps you digest food. It’s made in your liver and travels through your bile ducts.

Your bile ducts have many small branches in your liver, like a tree. They join to form the common bile duct (see Figure 1). The bile travels through your bile ducts, from your liver and gallbladder to the first part of your small intestine (the duodenum).

If a tumor blocks your bile duct, the bile doesn’t empty into your small intestine. Instead, it’s absorbed into your bloodstream. Symptoms of a blocked bile duct are yellow skin color (jaundice), itching, pale-colored stools, and dark (tea-colored) urine.

You can have surgery on your bile ducts to remove a tumor blocking the flow of bile.

About Your Surgery

The tumor can either be high in your bile duct and closer to your liver, in the middle of your bile duct, or low in your bile-duct, closer to your duodenum and pancreas (see Figure 2).

The surgery that you’ll have depends on the size and location of the tumor in your bile duct. This will be determined by your surgeon at the time of your surgery.

There are several types of surgeries to remove tumors in the bile ducts. On average, these surgeries take 3 to 5 hours.

Bile-duct removal with reconstruction and liver resection for tumors high in the bile-ducts

In order to remove the whole tumor, the common bile duct and the gallbladder are removed. Your body will function normally without your gallbladder.

In this surgery, your surgeon will attach a piece of your small intestine to your remaining bile duct. This will allow the bile to flow directly from your liver into your small intestines.

Sometimes, the tumor involves the liver. If it does, your surgeon will take out a piece of your liver. Your nurse will give you a resource About Your Liver Surgery that explains your resection.

Bile-duct removal with reconstruction for mid to high bile-duct tumors

In order to remove the whole tumor, the common bile duct will be removed.

Your surgeon will attach a piece of your small intestine to your remaining bile duct. This allows the bile to flow directly from the liver into the small intestines.

Your surgeon may also need to take out a piece of your liver, pancreas, gallbladder, and small intestine. Your nurse will give you more information about this surgery.

Bile-duct removal for low bile-duct tumors with possible Whipple procedure

In order to remove the whole tumor, your surgeon will need to remove the head of the pancreas, the duodenum, the end of the common bile duct, and the gallbladder. A small portion of your stomach may also be removed. If you’re having this surgery, your nurse will also give you a resource About Your Whipple Procedure.

Biliary enteric bypass (going around the tumor in your bile ducts)

If your tumor can’t be removed, your surgeon will attach a piece of your small intestine directly to your bile duct. This allows the bile to go around the tumor and flow from your liver to your small intestine.

Before Your Surgery

Presurgical Testing (PST)

You’ll have a PST appointment before your surgery. The date, time, and location will be printed on the appointment reminder from your surgeon’s office. You can eat and take your usual medications the day of your appointment.

It’s helpful to bring these things to your appointment:

• A list of all the medications you’re taking, including prescription and over-the-counter medications, patches, and creams.
• Results of any tests done outside of MSK, such as a cardiac stress test, echocardiogram, or carotid doppler study.
• The names and telephone numbers of your healthcare providers.

During your PST appointment, you’ll meet with a nurse practitioner (NP). They work closely with anesthesiology staff (specialized healthcare providers who will give you anesthesia during your surgery). Your NP will review your medical and surgical history with you. You may have tests to plan your care. Examples are:

• An electrocardiogram (EKG) to check your heart rhythm.
• A chest X-ray.
• Blood tests.

Your NP may recommend you see other healthcare providers. They’ll also talk with you about which medications to take the morning of your surgery.

You’ll also get resources called Getting Ready for Surgery, Common Medications Containing Aspirin, Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs), or Vitamin E, and Herbal Remedies and Cancer Treatment. These resources have more instructions about how to prepare for your surgery.

Buy a 4% Chlorhexidine Gluconate (CHG) Solution Antiseptic Skin Cleanser (Such As Hibiclens®)

4% CHG solution is a skin cleanser that kills germs for 24 hours after you use it. Showering with it before your surgery will help lower your risk of infection after surgery. You can buy a 4% CHG solution antiseptic skin cleanser at your local pharmacy without a prescription.

Buy supplies for your bowel preparation, if needed

If you need to do a bowel preparation before your surgery, your nurse will tell you how to it. You’ll need the following supplies:

• 1 (5 mg) tablet of bisacodyl (Dulcolax®). These are usually sold as a box of 10 tablets.
• 1 (238 gram) bottle of polyethylene glycol (MiraLAX)
• 1 (64-ounce) bottle of a clear liquid

1 Day Before Your Surgery

Follow a clear liquid diet

You’ll need to follow a clear liquid diet the day before your surgery. A clear liquid diet includes only liquids you can see through. You can find examples in the “Clear liquid diet” table.

While you’re following a clear liquid diet:

• Try to drink at least 1 (8-ounce) cup of clear liquid every hour you’re awake.
• Drink different types of clear liquids. Do not just drink water, coffee, and tea.
• Do not drink any liquids you can’t see through, such as milk or smoothies.
• Do not drink sugar-free liquids unless you have diabetes and a member of your care team tells you to.
• Do not eat any solid foods.

How to follow a clear liquid diet if you have diabetes

Ask the healthcare provider who manages your diabetes:

• What to do while you’re following a clear liquid diet.
• If you need to change the dose of insulin or other diabetes medication, if you take them.
• If you should drink sugar-free clear liquids.

Check your blood sugar level often while you’re following a clear liquid diet. If you have questions, talk with your healthcare provider.

Start bowel preparation, if needed

If your surgeon or nurse told you that you’ll need to do a bowel preparation, you’ll need to start it 1 day before your surgery.

In the morning, mix all 238 grams of MiraLAX with the 64 ounces of clear liquid until the MiraLAX powder dissolves. Once the MiraLAX is dissolved, you can put the mixture in the refrigerator, if you prefer.

The MiraLAX will cause frequent bowel movements, so be sure to be near a bathroom the evening before your surgery.

At 3:00pm on the day before your surgery, take 1 bisacodyl tablet by mouth with a glass of water.

At 5:00 p.m. on the day before your surgery, start drinking the MiraLAX bowel preparation. Drink 1 (8-ounce) glass of the mixture every 15 minutes until it’s gone. When you’re finished drinking the MiraLAX, drink 4 to 6 glasses of clear liquids. You can keep drinking clear liquids until midnight, but you don’t have to.

Apply zinc oxide ointment or Desitin^® to the skin around your anus after every bowel movement. This helps prevent irritation.

Note the time of your surgery

A staff member from the Admitting Office will call you after 2 p.m. the day before your surgery. If your surgery is scheduled for a Monday, they’ll call you the Friday before. If you do not get a call by 7 p.m., call 212-639-5014.

The staff member will tell you what time to arrive at the hospital for your surgery. They’ll also remind you where to go.

This will be the following location:

MSK Presurgical Center (PSC)
1275 York Avenue (between East 67^th and East 68^th Streets) New York, NY
B elevator to 6^th floor

Shower with a 4% CHG solution antiseptic skin cleanser (such as Hibiclens)

The night before your surgery, shower with a 4% CHG solution antiseptic skin cleanser. An antiseptic kills germs that can cause disease.

Do not use any lotion, cream, deodorant, makeup, powder, perfume, or cologne after your shower.

Instructions for eating before your surgery

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Do not eat anything after midnight the night before your surgery. This includes hard candy and gum.



 

The Day of Your Surgery

Instructions for drinking before your surgery

‌  You can drink a total of 12 ounces of water between midnight and 2 hours before your scheduled arrival time. Do not drink anything else.

Do not drink anything starting 2 hours before your scheduled arrival time. This includes water.

Take your medications as instructed

A member of your care team will tell you which medications to take the morning of your surgery. Take only those medications with a sip of water. Depending on what medications you take, this may be all, some, or none of your usual morning medications.

Shower with a 4% CHG solution antiseptic skin cleanser (such as Hibiclens)

Shower with a 4% CHG solution antiseptic skin cleanser before you leave for the hospital. Use it the same way you did the night before.

Do not put on any lotion, cream, deodorant, makeup, powder, perfume, or cologne after your shower.

Things to remember

• Don’t wear any metal objects. Remove all jewelry, including body piercings.
• Leave all valuables, such as credit cards and jewelry, at home.
• If you wear contacts, wear your glasses instead.

What to bring with you

• A list of the medications you take at home.
• Your rescue inhaler (such as albuterol for asthma), if you have one.
• A case for your personal items, such as eyeglasses, hearing aid(s), dentures, prosthetic device(s), wig, and religious articles, if you have it.
• Your Health Care Proxy form, if you have completed one.

Where to park

MSK’s parking garage is on East 66^th Street between York and 1^st avenues. If you have questions about prices, call 212-639-2338.

To reach the garage, turn onto East 66^th Street from York Avenue. The garage is about a quarter of a block in from York Avenue. It’s on the right (north) side of the street. There’s a tunnel you can walk through that connects the garage to the hospital.

There are other parking garages located on:

• East 69th Street between 1st and 2nd avenues.
• East 67th Street between York and 1st avenues.
• East 65th Street between 1st and 2nd avenues.

What to expect

You’ll be asked to say and spell your name and date of birth many times. This is for your safety. People with the same or a similar name may be having surgery on the same day.

A nurse will meet with you before your surgery. Tell them the dose of any medications (including patches and creams) you took after midnight and the time you took them.

You’ll walk into the operating room or you can be taken in on a stretcher. A member of the operating room team will help you onto the operating bed. Compression boots will be placed on your lower legs. These gently inflate and deflate to help blood flow in your legs.

Your anesthesiologist will place an intravenous (IV) line into a vein, usually in your arm or hand. The IV line will be used to give you fluids and anesthesia (medication to make you sleep) during your surgery. Once you’re fully asleep, a breathing tube will be placed through your mouth and into your windpipe to help you breathe.

After Your Surgery

In the hospital

When you wake up, you’ll be in the Post-Anesthesia Care Unit (PACU). Most people stay in the PACU overnight for observation.

When you wake up after the operation you may have the following:

• An IV line to give you fluids.
• A Foley® catheter in your bladder to monitor the amount of urine you are making. The Foley should be removed 2 or 3 days after your surgery.
• Compression boots on your lower legs. They’ll be taken off when you’re able to walk.
• A pain pump called a patient-controlled analgesia (PCA) device. For more information, read Patient-Controlled Analgesia (PCA).
• A nasogastric (NG) tube that’ placed through your nose into your stomach. It drains secretions from your stomach and allows your stomach and intestines time to heal. The tube is usually removed on the first or second day after your surgery.
• A biliary drainage tube to drain bile. The tube is usually taken out a few days after your surgery, but some people may go home with it still in place. If you go home with the tube, your case manager will arrange for a visiting nurse to help you care for it at home.

After your stay in the PACU, you’ll be taken to your hospital room in the inpatient unit. There, your nurse will tell you how to recover from your surgery. Below are examples of ways you can help yourself recover safely.

• Move around. Walking every 2 hours is a good goal. This will help prevent blood clots in your legs and help to stimulate your bowel. Someone from the nursing staff will help you until you’re able to walk on your own. You’ll be taught how to get out of bed without causing pain to your incisions (surgical cuts).
• Use your incentive spirometer. This will help your lungs expand, which prevents pneumonia. For more information, read How To Use Your Incentive Spirometer.

Most people are in the hospital for 5 to 7 days after this surgery.

Managing your pain

You may have pain at your incision sites. Your doctor and nurse will ask you about your pain often and give you medication as needed. If your pain isn’t relieved, tell your doctor or nurse. It’s important to control your pain so you can cough, breathe deeply, use your incentive spirometer, and get out of bed and walk.

Eating and drinking

You won’t be allowed to eat for the first day or two after your surgery. You’ll then be on a clear liquid diet. After that, you’ll slowly go back to your usual diet.

Many people lose weight before surgery. You’ll regain the weight slowly as your appetite improves. Also, you may gain weight right after surgery because your body will hold on to water for a few days afterwards.

At home

Before you go home, your doctor or nurse will give you instructions and prescriptions for any medications that you need. Your nurse will review these instructions with you and give you a copy to keep. If you need a visiting nurse at home, arrangements will be made before you’re sent home.

Fatigue

It’s very common to feel fatigued (unusually tired or week) for up to 6 to 8 weeks after your surgery. Some of this fatigue is because of the surgery, and some is because of the weight you may have lost before you had the surgery. This will slowly improve over time.

Try to increase your activity level every day to help your fatigue. Get up, get dressed, and walk. Gradually increase the distance you walk each day. You may take a nap during the day, if you need. However, try to stay out of bed as much as possible so you’ll sleep at night. Your nurse will give you the resource Managing Cancer-Related Fatigue.

Managing Pain

You may get a prescription for pain medication. Take your medication as instructed by your doctor and as needed.

Don’t drive or drink alcohol while you’re taking prescription pain medication. Your doctor will tell you when you can resume driving.

As your incision heals, you’ll have less pain and need less pain medication. A mild pain reliever such as acetaminophen (Tylenol^®) or ibuprofen (Advil^®) will relieve aches and discomfort. However, large quantities of acetaminophen may be harmful to your liver. Don’t take more acetaminophen than the amount directed on the bottle or as instructed by your doctor or nurse.

Constipation

Pain medication may cause constipation (having fewer bowel movements than what is normal for you). To help prevent constipation, drink 8 (8-ounce) glasses (2 liters) of liquids daily, if you can. Slowly increase the fiber in your diet to 25 to 35 grams per day. Fruits, vegetables, whole grains, and cereals contain fiber.

You may also get a prescription for docusate sodium (Colace^®) 100 mg. This is a stool softener that causes few side effects. Don’t take it with mineral oil. Follow the instructions on the label or from your doctor or nurse.

If you become constipated, take 2 Senna (Senokot^®) tablets at bedtime. This is a stimulant laxative, which can cause cramping.

If you haven’t had a bowel movement in 2 days, call your doctor or nurse

Caring for your incision

The location of your incision will depend on the type of surgery you had. It’s normal to have numbness of the skin around the incision because some of the nerves were cut. This sensation will get better over time.

• If any fluid is draining from your incision, you should write down the amount and color. Call your doctor’s office and speak with the nurse about any drainage from your incision.
• Change your bandages at least once a day and more often if they become wet with drainage. When there is no longer any drainage coming from your incisions, they can be left uncovered.
• If you go home with Steri-StripsTM on your incision, they will loosen and fall off by themselves. If they haven’t fallen off within 10 days, you may remove them.
• If you go home with glue over your sutures (stitches), it will also loosen and peel off, similarly to the Steri-Strips.

Activity

Exercise will help you gain strength and feel better. Walking and stair climbing are good forms of exercise. Slowly increase the distance you walk. Ask your doctor or nurse before starting more strenuous exercises.

Check with your doctor before you do any heavy lifting. Normally, you should not lift anything heavier than 10 pounds (4.5 kilograms) for at least 6 weeks.

We also recommend that you do exercises that help you to stretch the incision. They also work on the muscles that have been cut during surgery. To do these exercises:

Repeat these exercises a few times a day. They will help to reduce any discomfort from the surgery.

Follow-up visit

In general, the first follow-up visit with your doctor will be 10 to 14 days after you’re sent home. Call your doctor’s office to schedule an appointment..

When to Call Your Doctor or Nurse

Call your doctor or nurse if you have:

• Chills
• A fever of 101° F (38.3° C) or higher
• Jaundice (yellow skin or eyes)
• Itching
• Redness or drainage from your incision
• Any sudden increase in pain or new pain
• Nausea
• Vomiting
• Diarrhea
• Constipation that is not relieved within 2 or 3 days
• Any new or unexplained symptom
• Any questions or concerns