Saturday, May 9, 2015

Worry

                             

I’ve been practicing as a general surgeon for twenty five years, more or less. All these years have taught me one thing: how to worry. As a general surgeon I take care of very sick patients. I perform complicated operations on severely injured or septic people and care for them afterwards, watching for any little sign which may be the harbinger of something worse to come.
So, I worry. I worry about wounds healing, anastomoses leaking, infections brewing, blood clots forming and a variety of other events which can and do occur after surgery.
A case in point is Denny.
Denny was a young man who came to be my patient one night when I was on call for the emergency room. He had been stabbed eight years before I saw him and had sported a colostomy ever since that event. I guess he finally became tired of having a bag, because he had undergone a colonoscopy earlier that day in anticipation of having his colostomy reversed. Unfortunately, he developed severe pain after his colonoscopy. Despite his protests to the endoscopist that he was in pain, he was sent home. He returned to the ER, at a different facility from where his colonoscopy had been performed, where the work up revealed he had free intraperitoneal air, which meant his colon had been perforated during the colonoscopy.
Denny refused to go back to the hospital where the colonoscopy had been done and so I took him to surgery. I found that his colon had perforated at the splenic flexure, an area that was “defunctionalized,” which means that his colostomy was proximal to this injured segment of colon. The perforation was at the closed off “blind pouch.” There was essentially no fecal contamination and all that was required was to close the perforation. I did examine the rest of his colon and even contemplated reversing the colostomy at that time, but properly decided not to. I wasn’t privy to the findings from the colonoscopy and emergency surgery would not be considered optimal conditions to perform such a procedure. I did leave the blind end sutured to the segment of colon where the colostomy was so that subsequent reversal would be easier to perform. At least, that was my plan.
No real worries up to this point, but Denny’s troubles were just beginning.
He recovered uneventfully from this procedure and went home after about five days. During his post op visit he asked about reversing the colostomy.
“Sure,” I replied, “once you’ve healed enough from this surgery. I did leave the two ends of the colon together so that the reversal should be easier.”
He was happy with this answer and I sent him on his way with a follow up appointment for a month later and instructions to “take it easy” until I saw him again. Well, he missed his next appointment. I assumed he was recovering adequately as I had not heard from him. My office staff made their usual effort to contact him and found out his phone was disconnected. He had been well at the last visit so I wasn’t very concerned.
Two weeks later I was called from the ER where Denny had made a return visit, complaining of abdominal pain.
“Denny’s CT reveals some inflammation around his colon and Dr. M wants you to consult,” the ER physician reported.
“Sure,” I replied. “Is Denny stable?”
“Just left sided abdominal pain, otherwise he’s fine.”
I saw him later in the day and he already was feeling better. He quickly recovered and we made plans for him to have his colostomy reversed in about six weeks. He had preop evaluation with a barium enema. His recent colonoscopy had revealed only a bit of diverticulosis, which the BE confirmed.
He underwent a fairly uneventful reversal of his colostomy. There was a little bit of excitement as the distal colon which I had sutured adjacent to the colostomy was not where I had left it, but a bit of searching identified the wayward bowel and he sailed through his recovery and went home.
But, not for long.
Two months later I was called to the ER. Denny was there and complaining of lower abdominal pain.
“CT looks like sigmoid diverticulitis with a small abscess,” reported the ER doc. “he looks pretty stable. The hospitalist is admitting him and he’s consulted you.”
“OK, thanks,” I answered, “I’ll see him when I’m done in surgery.”
Denny didn’t look very ill and I fully expected his diverticulitis to resolve with only IV antibiotics. At first the plan worked. His pain improved, his low grade fever improved and his elevated WBC came down to nearly normal. But, after three days his condition changed. He developed fever and his WBC went back up. I repeated his CT scan and it revealed a new, larger abscess.
I made a call to Interventional Radiology and the abscess was drained and he settled down again…for a while. He continued to drain and then developed new onset of fever and abdominal pain. He had developed a second abscess. It was fast becoming apparent that he was headed to surgery again.
He was not so sick, however, that I needed to rush him to the Operating Room. Time was taken to drain the new abscess and properly prepare him for what I suspected was going to be a major undertaking. After a few more days of antibiotics, bowel preparation and soul searching his time arrived.
The operation was not what I expected. He had a few adhesions which were easily dispatched. The inflamed segment of colon was mid sigmoid, there was plenty of uninvolved proximal and distal colon.
Not nearly as bad as expected.
The time for worrying had not yet arrived.
I resected the inflamed segment of colon and prepared to do the anastamosis, that is to reconnect the two ends of the pipe, when I took a closer look at the bowel.
Is the blood supply to the proximal segment adequate?
Normally, I wouldn’t think twice about this. The surgery was for benign disease which means most of the blood supply is left intact. But, something about Denny made me pause and think twice. He had undergone several previous colon operations which almost certainly caused some sort of alteration to the normal blood supply.
The bowel did appear healthy and adequately perfused. I could see arteries in the mesentery which were intact and I even thought I could feel a pulse.
Perhaps check it with a Doppler? Better safe than sorry.
Unfortunately, this was not very helpful. The Doppler is a sort of ultrasound which detects flow in blood vessels. In Denny’s case there was definitely arterial blood flow in the mesentery, but I did not hear it very well in the bowel.
Perhaps it would be best to resect more colon? To remove more bowel would leave him with very little colon as I would be forced to remove the previous anastamosis and then there would be difficulty reconnecting the two ends.
What to do? Go with my gut? (I hate that expression)
Reason and experience told me that doing the anastamosis without removing any additional bowel would be OK and so I proceeded.
And the worry started, also.
Perhaps it is a part of growing older and wiser, but I worry much more now than when I first started out as a surgeon. We were always taught to not take chances, to be sure of what was being done or else pursue and alternative course, one that would eliminate uncertainty.
“If it’s not safe to do an anastamosis, do a colostomy. Better a live patient with a colostomy, than a dead patient,” my mentors said.
“If you’re not sure if it’s the cystic duct or common bile duct, don’t assume, don’t cut it, don’t do anything until you are sure,” another instructor bellowed.
“See the nerve, see the nerve,” a third teacher commanded.
But, what about those times when the operative course is not cut and dry?
Do it this way and the patient should be fine, unless this happens. But if I do it the other way, then this could happen.
Denny presented several options, each with positives and negatives:

1. Do the planned procedure, the resection and anastamosis and presume it will heal.
2. Extend the resection which will leave him with a very short colon, but less worry about healing.
3. Do the planned procedure, but add a proximal colostomy or ileostomy. The proximal diversion of the fecal stream would allow the colon anastomosis to heal and then could the ostomy could be closed in a few months.

There were plusses and minuses for each alternative. Number one was best for Denny, assuming he healed properly. No further surgery needed, fewer long term complications such as frequent diarrhea associated with a short colon.
There would be little worrying with Number two as the blood supply would not be in question and healing should proceed with little risk of anastamotic breakdown, but he would likely be troubled by very frequent bowel movements.
Number three might be best as it preserved his colon, but would require another operation down the road to reverse the colostomy or ileostomy.
What to do? What to do?
In the end I decided on Number one, my original plan. The colon looked OK, had been properly prepped and, if everything healed properly, this would be best for Denny.
But, it didn’t stop me from worrying.
What does this worrying entail?
That night I called to check him. Normally I check on my ICU patients, but Denny did not need to be in the unit.
His heart rate was a tad high at 110, but everything else was fine: good urine output, no fever, no unusual pain. I didn’t really expect any issues immediately post surgery. His issues, should they develop, would become manifest in 4 days or 10 days or 2 weeks.
So, I waited and checked and waited. I carefully palpated his abdomen on daily rounds, looking for any tenderness which was greater than expected. I looked at his heart rate, coming down from 110 to 104 to 95 and my confidence rose as it dropped.
Tachycardia is the first sign that something is amiss.
The first wisp of flatus almost brought cheers as his bowel function returned to normal. By the fourth day after surgery everything was normal: White blood cell count, heart rate, kidney function. He was tolerating a liquid diet and his bowel function was normal.
In addition, my heart rate, blood pressure and everything else was normal.
Denny went on to an uneventful recovery and is back to normal.
Was my worry warranted, productive, or unnecessary? Shouldn’t I be as vigilant and worry about every patient?
The vast majority of the surgery I do is cut and dry. Right upper quadrant abdominal pain with gallstones? Take out the gallbladder.
Malignant tumor in the cecum? Take out that part of the colon.
Single hyperfunctioning parathyroid gland causing severely elevated calcium level? Take out the offending gland.
Straightforward cases such as these, performed properly, usually have uncomplicated postoperative courses and rarely cause me to lose any sleep, except when they do. I always maintain a watchful eye, but complications in well planned and well executed surgeries rarely rear their ugly head.
But cases like Denny, where the proper course is not as clearly defined, are different. Suppose he had leaked from his anastamosis. Or suppose I had taken a different course, removed more colon and he developed intractable diarrhea. Or suppose I had taken the intermediate course and he developed a pulmonary embolus and died during the surgery to reverse his ostomy.
Worrying about complicated cases goes with the turf of being a physician. In the end all one can do is look back and say: “I looked at all the possibilities and chose the best option. If the same situation arises again I’ll do the same thing. Worrying doesn’t help.”

But, the little nagging pest named worry still whispers in my ear.

Sunday, February 8, 2015

Showtime

                 

Almost every morning I get to put on a show for a captive audience. I stand before my audience, employing a variety of tools inherent to the task at hand, performing my duties as an aura of solemnity pervades the air. This daily undertaking can be considered life saving, perhaps even life giving. I do know that as I near the end of my mission the sense of excitement grows until the triumphant climax. And, when I’ve finished there is a period of rest and relaxation.
Is this performance some sort of complex surgery? Or, a life saving medical procedure?  No, but it may be just as important. What I do is make the daily meal for five (sometimes six) dogs.
The dogs, in no particular order, are:

Coconut, 12 year old Westie, the elder statesman of the group

Daisy, about 8 years old, a one eyed Bassett Hound

Zoe (Baby Girl), 7 year old Norwich Terrier

Leo, 3 year old very, very stupid Shih Tzu, who thinks he’s the alpha dog

Freckles, about 2 year old Spaniel of some sort

Winston (sometimes home, but now away at school in Waco where he’s premed) 6 months old Miniature Schnauzer mix.

Every morning starts with the same routine. Wake up, attend to some personal needs, head downstairs with Zoe in tow (being Baby Girl entails some privilege), get the newspaper, make the daily food for Isaac, my fifteen year old Eclectus parrot and, finally, the show begins.
First, all the important props are gathered: food bowls, a knife and spoon, cans of dog food, cheese and any other fare I see fit to feed this pack. At first only Zoe will linger around the kitchen island where each dog’s meal is to be prepared.
Zoe came from Hungary and the first thing she did when she exited the plane was eat. She has lived for eating ever since. She hovers around the preparation site in case any stray bits of kibble or shreds of chicken should fall to the floor. Zoe has been on  a special diet which helps keep her love of food in check and has helped bring her weight from a far too heavy 19 pounds to a much more acceptable 14.
The show starts with The Preparation of the Leftovers. This may be chicken, steak, roast pork or anything that is appropriate for a dog’s stomach. This part of the meal is chopped into measured bits, cubes or strips which can be easily consumed by the canine crowd. It is microwaved for about thirty seconds and then distributed. Coconut, being the most senior and the most discerning gets a large portion. Leo, under the delusion that he’s the boss and should have everything Coconut has, gets a little less. Daisy and Freckles each get the same, while Zoe gets enough for her to think she’s getting what the others have, which is usually only 3 tiny bits and always lean.
Next comes the dry food. About a cup for Daisy, a bit more for Freckles and a bit less for Leo. Coconut hates dry food and never touches it under any circumstances. Zoe gets her special weight loss formula. By now, other dogs have started to gather around me in anticipation of the great climax. Leo, Daisy and Freckles will all be sitting staring up at me, while Zoe is still on the prowl for any tiny bits that may escape to the floor. Coconut, as always, maintains his cool and stays on his bed, confident that his breakfast will come to him.
The next ingredient is the canned food. I’ve been through many brands and styles, searching for the perfect one which appeals to them all. Alpo, Purina, Cesar, Science and many others have been tried and found wanting. One may be too chunky, another doesn’t taste right, still another may appeal to Daisy, but not Leo, or Freckles but not Coconut. Finally, I stumbled upon Blue Wilderness, a ground up variety which mixes well, comes in a variety of flavors and, so far, is acceptable to the entire pack.
Each gets their fair share, enough to fill up their tummies and add a bit of flavor to what I’m sure is  very bland dry food. Poor Zoe is limited to her weight loss formula, fighting a never ending battle which is familiar to many.
Finally the food is mixed. Of course, by now my pack of dogs is all around me, barely able to contain their enthusiasm as they anticipate the coming gourmet repast. Daisy, being a very verbal Bassett starts to half howl, half cry. She knows that she gets her food first. Leo and Freckles still sit quietly, staring at their food bowls and Zoe, never one to miss an opportunity, still mills about hoping to find a wayward morsel.
And, at last, the piece de resistance, cheese garnishes each bowl. Muenster, Cheddar, Colby Jack, anything but Pepper Jack, is broken up and put on top of each food dish. Three microscopic bits for Zoe and generous helpings for the rest. Voila, the daily meal is ready.
First, Daisy, who by now is in a frenzy of anticipation. She races into the “music room”, pushing any unsuspecting bystanders out of her way and she jumps onto her bed and sits as I put her bowl down. She sniffs it carefully, declares it good and digs in.
Next, Freckles smoothly glides out of the music room, where she followed Daisy, and takes her place just outside the door and stands to get her breakfast.
Zoe then runs to her spot, which is under a desk built into the breakfast area. She does a 360, sometimes a 720 while her bowl is placed into her nook and then digs in.
Coconut has coolly remained on his bed in the utility room. His meal, good enough for even the most discerning palate is laid in front of him. I bow to the king and then close the door, allowing our elder statesman to eat quietly in solitude.
Then there’s Leo, the dumbest dog ever born. He runs to his spot, which is on the Ottoman next to a big overstuffed chair. He jumps up and usually slides off the opposite side, crashing onto the floor, as I put his food in its place.
The show is now nearly over. Everyone is hunkered down, enjoying a gourmet meal. One by one they finish. But, they’re not finished. Because, they expect dessert. I gather up each bowl while Freckles sits by the large basket which holds a variety of dog treats. Zoe also appears, then Leo. Daisy and Coconut are still in their respective rooms, waiting. I don’t want to disappoint them, so they each get one treat, a Greenie or jerky treat. Each goes his or her own way; going off to savor the treat, while I’m left, like a good maid, to clean up; wash each bowl and put them away and to fill their four water bowls.
Each dog settles down for a nap. The show is over.
I leave for “work.”


Sunday, February 1, 2015

Super Bowl Prediciton

                            

I realize it’s a little late and the big game is nearly upon us, but I feel inspired to offer my analysis of the big game and, for all the bettors out there, my prediction.
New England Patriots vs. Seattle Seahawks
Patriots battling Seahawks
Who has the advantage? Who will win?
Let’s start with Patriots. These are individuals who are dedicated to a specific nation. In this case New England Patriots must refer to soldiers of the Revolutionary War. These combatants were equipped with muskets, sabers and cannons as well as loyalty to their cause.
On the other side are Sea Hawks another name for the Osprey. These large birds fly high above bodies of water looking for their prey which is almost always fish. Once spotted these birds swoop down and grab their hapless victim in their sharp claws and carry the fish away to be consumed. They have excellent eyesight, can fly at great height and speed and powerful claws.
Sea Hawks vs Patriots.
At first blush one would have to assume that Patriots, armed with muskets and cannons, would hold a great advantage over a mere bird. But, let’s examine things a little closer.
The musket is a weapon designed to fire in concert with many muskets. It fired a large ball, but was not very accurate. I seriously doubt that even the most skilled Patriot could hit a high flying Sea Hawk with a musket ball.
A Sea hawk’s claws and beak are not nearly as powerful as a musket ball, but large bird swooping down at high speed surely would inspire fear and can inflict considerable damage. Now imagine eleven birds doing the same thing. A flustered Patriot, seeing a vicious Osprey descend out of the desert sun may get the chance to fire once, but once set upon would likely turn and hightail it back to the safe confines of the snowy North.
Thus, my expert analysis clearly gives Seahawks the advantage over Patriots.

Final Score: Seahawks 24 Patriots 7

Thursday, January 15, 2015

Words from the World of “Night Clinic”

                      

1. That’s all your precious Andromeda is; Minotaur dung and that’s all you deserve.” - Medusa

2. “And, what is this truth? Just three things: you are born, you struggle for a brief period of time, and you die, and on the day an individual accepts the reality of this truth, real freedom begins.” – The Raven


3. “Let the pregnant lady have the last word.” – Dr. Barnes

4. “Mom, you know how you always give me things, toys and stuff to play with? And, you know I take them and play with it for a few minutes? But a lot of the time I bring those toys to school with me and give them to other kids. And you what? I feel much better giving the toys away than getting them.”-Andrew

 5. “True second chances should be cherished. They are a rare and precious gift.”  


6.“…sex just gets better and better even when you’re no longer spring chick­ens. When you’re young it’s all hurry up and then what? When you get older you can take the time to be indulgent…” - Cupcake

7. “God touches our lives in mysterious and unexpected ways.” – Caleb

8.“…please, stay away from Tribbles. You know they’re nothing but trouble.” – Dr. Barnes

9. “Come, come, Dr. Barnes, with everything that has happened since you’ve been working here? Besides Madame, I’ve also got a Priest, a Rabbi, a Buddhist Monk, a Hindu Shaman, the FBI, the CIA, the Fire Department, Animal Control, the Police Department, the Sheriff’s Office, and Ghostbusters on my contact list.” – Nurse James

10. “…there are only two types of politicians, those that are in jail for corruption and those who haven’t been caught yet.” – Dr. Barnes

11. “…for all the acts of kindness you and the people at this Clinic perform, we are all grateful and indebted to you.” –Medusa

Eleven memorable quotations from the world of “Night Clinic” provide a glimpse into this unique and bizarre world.

Unique? Who is Caleb or Medusa or Cupcake? Dive into “Night Clinic” and you will meet them and many more.

There is no other book that I’ve found which combines the medical and the supernatural, magical and mystical. Think about it. There are medical thrillers which combine medical expertise with a murder, or a rare disease or disaster. There is medical fiction which just means the setting is in a hospital or the characters are doctors and nurses. But, bringing the medical, mystical and magical together opens the doors to a world never before conceived.

I did search for a similar story and could find none. Thus, I invented a world where the only commonality among a bizarre mixture of characters is their need to receive medical care. And, where can Roachman or Medusa go when they are sick or injured? Where can a depressed delusional vampire turn when he finds himself fantasizing about being a werewolf? Surely not to a big city hospital or world famous clinic, places where he would face the ridicule of the medical establishment. No, it is to the anonymous, understaffed, storefront night clinic, where they will be treated with care and skill, and without any unnecessary questions.

Dr. Barnes and Nurse James do their best to mend the motley collection of  sick and injured patients who pass through their doors. In the process they are often healed themselves and make their small part of the world a better place.

“Night Clinic” started as a single short story, but the setting was perfect for story upon story until the climactic finale. But, then again, is it finished, done, terminated? As the poet once said: “It’s never over until it’s over.” People, monsters, aliens and ordinary people will always get sick or shot or stabbed at all hours. “Night Clinic” can never truly end. Maybe, it’s just moving down the road a few blocks.





Sunday, December 28, 2014

Creative Magic

(An article from the recent Night Clinic blog tour)          

God carried out the act of creation by his spoken word. The heavens and Earth and everything else came into being by the power of his voice. Humans are far more limited in their acts of creation. From the depths of the brain ideas emerge, grow into a concept and then pass to our hands to be shaped into the objects we take for granted every day. Each new thing is an act of creation. The pinnacle of human creation is art. G. K. Chesterton said it was art which separates humanity from all the other beasts of the world.
The act of writing is one of the artistic forms of creation. A germ of an idea in the depths of the mind sprouts and, magically, grows to be nurtured and polished into a story.
Thus, this magic of creation which began within the depths of my imagination became “Night Clinic,” a collection of short stories unlike any others. There is a genre called medical fiction, usually a story set in a hospital with doctors and nurses as the protagonists or apocalyptic stories where humanity is nearly destroyed by some sort of dread disease, but there has never been a collection of stories like “Night Clinic,” a totally original set of stories where the medical intersects with the magical, mystical and supernatural.
A morbidly obese man is imbued with all the resilience of the common cockroach and becomes Roachman. The venerable space epics Star Trek and Star Wars clash pitting Captain Kirk and Mr. Spock against Darth Vader. A child is granted her wish to be with her mother who has succumbed to the ravages of cancer, but in a way that leaves the reader both happy and sad. It is at the “Night Clinic” where such a diverse cast of characters converge.
Stories filled with mystical and magical creations abound with only one commonality. All of these unusual characters need medical care and, for better or worse, they are drawn to this clinic.
Where is the magic? Every story has its own touch of magic, a creative force which sets it apart. The writer looks at the words on the page until that moment when “Aha, that would be funny, or clever, or inspirational, or sad or so many other things” pops into his head and the words find their way to the printed page.
Is it magic, this act of creation? That is a decision I leave to the reader.



Sunday, November 16, 2014

To Cut is to Cure

                 

The title above is an old medical saying which means “the act of performing surgery often cures a patient from whatever condition is ailing him or her.” This contrasts with “medical” management which is the way of treatment for many chronic medical conditions such as Congestive Heart Failure, Diabetes, Hypertension and so many others. These conditions are treated primarily with pills and life style changes, surgery being reserved for complications of the underlying illness.  Examples of such surgery are joint replacement in the severe arthritic or amputation of a limb as a complication of Diabetes. These operations relieve symptoms, can be life saving, but are not curative.
There are, however, many instances where surgery is truly curative. Appendicitis comes to mind. The inflamed appendix is removed and the patient is never troubled by appendicitis again.
Then there are instances where a patient has suffered for years, seen a multitude of doctors and been treated with pills, surgery and everything else but continues to suffer. It seems like nothing will provide relief. Even so, such patients grasp at the narrowest of straws, hoping against hope that surgery, ie “to cut” will lead to a cure. Patricia was such a patient.
She was 37 years old and I was asked to see her for small bowel obstruction. She had previously undergone twelve abdominal surgeries which included a subtotal gastrectomy for a “lazy stomach” (a condition called gastroparesis), cholecystectomy, hysterectomy, appendectomy, and multiple operations for small bowel obstruction. The records indicated that over the prior 18 months she had been operated five times for small bowel obstruction, four by the same surgeon. Each time the procedure was “lysis of adhesions” which means cutting away scar tissue. And, each time she would feel better for a short time, but her symptoms always returned.
She had become dependent on pain medication, taking narcotics on a daily basis. Her abdomen had scars running up and down and crossways. Her imaging studies looked like a classic small bowel obstruction, dilated small bowel transitioning to collapsed bowel. Her post gastrectomy reconstruction was with a  Roux-en-Y gastrojejunostomy, which is common after most of the stomach has been removed.
She reported nausea and vomiting of bilious fluid which is very uncommon after Roux-en-Y reconstruction. She also reported passing flatus and having regular bowel movements which suggested she was not completely obstructed.
Gathering all the information together I elected not to operate on her initially. She was managed with a nasogastric tube and gradually improved so that she could eat and she was sent home. She returned three weeks later with the exact same symptoms and X-Ray findings.
She’ll probably need another surgery, I thought.
Before plunging back into what I was sure would be a very difficult surgical exploration more workup was called for. Upper GI endoscopy revealed a very small gastric pouch, some gastritis but nothing to explain her X-ray findings. UGI series was done and these X-Rays corroborated the CT Scan findings of incomplete small bowel obstruction. The ingested contrast did pass all the way through, the proximal bowel was dilated and there was no discernible stricture.
Maybe I should watch her a bit longer, maybe she’ll open up. Maybe it’s all related to her narcotic use.
So I watched and waited and she didn’t get better.
No choice. Operation number 13 coming up.
I did have a plan of sorts. As best as I could determine she always presented with a dilation of her Roux-en-Y limb which was connected to her stomach and then the bowel became normal a short distance beyond.
There must be an adhesion or stricture in that area.
The big day came. She looked up at me in the moments before she went to sleep with a look of hope in her eyes. I wondered if her previous surgeons had seen that same look.
I made a midline incision and gingerly worked my way into her abdomen. I managed to get into the peritoneal cavity without causing any serious damage. The adhesions were not nearly as nasty as I’d encountered in other patients, at least not yet. I cut my way through the web of scar tissue which was encrusting some normal caliber small bowel, suggesting that this bowel was downstream from the real problem area. As I made my way towards the small bowel’s beginnings the adhesions became denser and I soon encountered a very dilated loop of small intestine. This told me I was at least getting close to an area where her pathology might be found.
After a while I reached a point where the scar tissue was extremely dense. Usually when I encounter something like this I will change direction. Look for another angle or approach which might make the task simpler. I began my assault on the adhesions at a different point, an easier point and, at first I was rewarded.
I figured out that I was dissecting the Roux-en-Y limb and that this would lead to what was left of her stomach. This loop of bowel was very dilated suggesting that it was obstructed. After a bit more careful snipping I struck gold or was it oil. Anyway, I found where two segments of small bowel had been anastamosed (connected together) and a point where the dilated bowel collapsed to normal caliber. This was just beyond the point where the bowel coming from the stomach was reconnected to the rest of the small bowel. There were extensive adhesions here and my first thought was that cutting away this scar tissue would solve poor Patricia’s problem.
In the course of my dissection I reattacked the area of dense adhesions and was able to discern that this was a segment of bowel which originated at her duodenum and it was also very dilated. So, I had two limbs of small bowel which were both dilated. Where they met and were anastamosed was also dilated, but just beyond this the small bowel was normal. There had been extensive adhesions in this area which I had already removed.
Could it be that simple?
It was at this point I either was very smart or very lucky. In the course of my dissection I had inadvertently made a hole in the small bowel. (Nobody’s perfect). It was just beyond the point of obstruction. Palpation of the area did not suggest anything particularly unusual. The anastamosis from her previous surgery was wide open and the bowel itself felt soft, rather than fibrotic. But, I decided to put my finger inside the bowel. After all, I already had a hole in the bowel.
Much to my surprise and relief there was a definite stricture, a ring of hard, fibrotic tissue which narrowed the bowel to about 1/3 its normal caliber. This was at the point of obstruction, where the dilated bowel collapsed to normal.
This is her problem. But, how to fix it?
It really didn’t take much thought. I could have redone the entire Roux-en-Y limb, which would have involved taking all the previous connections apart and starting over. Or, I could do a stricturoplasty, which would means doing something at the point of the stricture to widen it. This probably would have worked, but I worried that it could restructure and then Patricia would be back where she started.
I decide to let physics rule and bypass around the stricture. Physics comes into play because fluid passing through a tube will tend to take the path of least resistance. In Patricia’s case the fluid which originated in the duodenum, which is composed of bile from the liver and pancreatic juices, was, for the most part taking the path of least resistance which was up the Roux-en-Y limb to her stomach instead of downstream through the rest of her small bowel. Creating a new outlet from the Roux-en-y limb should have provided relief.
Therefore, I took the simple, easy way out and connected the Roux-en-Y limb, which was attached to her stomach, to the small bowel which was beyond the stricture. This allowed food from the stomach to avoid the stricture and the duodenal fluid to go around the stricture also, passing briefly into the Roux-en-y limb, but then exiting via the newly created outlet.
This task completed, I made a graceful exit form Patricia’s abdomen and then sat back and waited. The first morning after surgery I was greeted by a definite absence of bile draining from her NG tube. And, she noticed a difference immediately. She sailed through an uneventful post op course and was discharged home after about a week, eating a regular diet.
On her post op visit in the office she had gained four pounds and she made this comment:
“For the first time in seven years I don’t wake up with the taste of bile in my mouth.”
She has continued to heal uneventfully.
Truly, “To cut is to cure,” but sometimes it helps to be lucky.


                    


Sunday, November 2, 2014

A Sense of Where You Are



Years ago I read a book about former US Senator and basketball great Bill Bradley which was titled “A Sense of Where You Are.”
The title derived from a basketball move he could perform which had him drive along the baseline to blindly shoot a reverse layup. He described how  he had developed a sort of sixth sense which allowed him to make this shot, even though he couldn’t see the basket. He had played so much basketball and knew the court so well that he had developed “a sense of where you are.”

This saying popped into my head the other day as I was doing a parathyroidectomy. Now don’t get the idea that I perform surgery blindly. But, parathyroid surgery sometimes requires this sixth sense to track down these pesky little glands. For those of you unfamiliar with the anatomy of the human neck, the parathyroids are four separate glands which hide behind the thyroid gland. A normal parathyroid is about 4-5 millimeters in diameter. Each gland is described relative to its position to the thyroid gland, which is a butterfly shaped organ sitting in the middle of the neck. Thus, there are right and left, upper and lower parathyroid glands, depending on their position behind or adjacent to the thyroid gland. Sometimes, (often) these parathyroids like to hide. They may be lower in the neck closer to the carotid artery or even lower, in the mediastinum (behind the breast bone). It’s sort of like they know someone is searching for them and they don’t want to be found, so, decide to take shelter away from their usual residence.

I’ve done a lot of parathyroid surgeries over the years. Most of the time preoperative testing provides some guidance as to where the abnormal gland is residing. But, these preop scans usually only tell me right or left, upper of lower. I still have to find the offending little beast. This is where it is helpful to have a good sense of where one is.

So, I start by getting the thyroid out of the way which requires dividing a few veins which are collectively called the middle thyroid vein. Then it’s time to look, first for “the nerve”, but also for bulges rising from beneath fat which don’t look like they belong or send a signal which says, “there’s something hiding under here.” The vast majority of the time it is this “something looks out of place” sense that leads me straight to the offending parathyroid gland. After that, it is relatively simple to remove the gland and have a friendly neighborhood Pathologist confirm it is abnormal.

Unfortunately, it’s not always easy.

Vince was in his sixties when he came to me with long standing hypercalcemia and very elevated parathyroid hormone levels, lab tests which led to the diagnosis of primary hyperparathyroidism. Surgery was recommended. His pre operative imaging studies were all normal. Despite this, he still needed surgery, only with him I had nothing to tell me where to look. So I started, first in the left lower position, which is the easiest area to explore. I was heartened as I saw a nodule that appeared to be separate from the thyroid gland. However, as my dissection continued it became clear that this nodule was part of the thyroid itself. Onward went the dissection. In the left upper thyroid I found a tiny, normal appearing parathyroid, about 2 mm in diameter. I looked at the right side and saw a tiny gland behind the lower pole of the thyroid. I didn’t find anything that looked like parathyroid on the upper end. I did identify the recurrent laryngeal nerves and both carotid arteries on both sides. I went back to searching. Perhaps behind the mound of fat next to the right carotid. There was something there. As I removed it my heart sank. It looked more like a lymph node. I sent it off anyway and was not surprised when the Pathologist confirmed that it was a lymph node and not parathyroid.

Where are you, you irritating, mischievous sprite?

Well, maybe down in the mediastinum, which is behind the sternum. So I start pulling tissue, mostly fat, out of the upper chest. Nothing, nothing and more nothing. I had been searching for more than two hours without success.

Maybe it’s time to give up, do more tests, perhaps?

I looked a bit more, farther down in the chest, more towards the middle. I found something. It looked like a parathyroid, kidney bean size, shape and color. Out it came and off it went to the lab.

“Hyperplastic parathyroid.”

Thank you, Pathologist.

Vince’s parathyroid hormone was checked before we woke him up. It fell from a preop level of 2200 down to 500 and then to 40 prior to discharge. His calcium levels dropped to normal. He was cured.


This “sense of where you are” is important in surgeries beside parathyroidectomy. Every operation requires knowledge of anatomy, with all its variants. Plus, normal anatomy is often distorted by cancer or inflammation or trauma.

Operations require dissection and cutting and more dissection, all the time knowing that an important structures may be lurking nearby. Colon surgery requires the surgeon to be aware that the ureter and iliac artery and vein are just behind the bowel; biliary tract surgery requires cognizance of the proximity of the common bile duct, hepatic artery, inferior vena cava, portal vein, duodenum and pancreas. The spleen is always hanging around gastric and pancreatic surgery. A sense of where you are becomes important in almost all operations.

All surgeons must be aware of the potential pitfalls of each operation they perform. Some surgeons have this “sixth sense” that tells them to be careful, to dissect gingerly as catastrophe and disaster may be only a small snip away.
This “sense of where you are” is honed by experience. It isn’t “evidence based,” but it is real and helps make surgery cleaner, quicker and safer.