Saturday, May 28, 2016

Day of the Gallbladders

                                      

It looked like it was going to be a good day. I wasn’t on call, I would be off the weekend and all I had scheduled for the day was four elective cases, all laparoscopic cholecystectomies.
How could the day be any better?
The surgeon’s prayer popped into my head:

“Lord, please protect me from the interesting cases and don’t let me screw up today.”


Cholecystectomy is the most common operation that is performed in the United States. Gallbladder disease occurs as a consequence of diet, hormonal changes, genetics and physiologic changes involving the rest of the body. It seems that everything affects the gallbladder. Gaining weight, losing weight, pregnancy, illness, stress and probably a whole bunch of other things cause the gallbladder to form stones, stop functioning or become inflamed. Whenever the gallbladder starts to behave badly one can rest assured that a friendly general surgeon is nearby to address the problem.
It was six thirty in the morning, the dogs were fed and I was scheduled to start in an hour.
Maybe I can get rounds done before I surgery.
It was a rare day. I only had patients at one hospital, the same venue where the cases were scheduled. I arrived at six fifty five and greeted my first patient in Day surgery.
Maria was forty, about five foot one and weighed in at two hundred sixty pounds. She had multiple gallstones and had suffered through repeated episodes of right upper quadrant abdominal pain. She had gone to the ER once, but otherwise had endured multiple nights of suffering.
“I just get up and walk around or sit in the chair until the pain goes away, usually after a couple of hours. I take some Motrin, which helps a little.”
Textbook case. All Four F’s: Female, Fertile, Forty and ‘Rotund’.
I went to the hospital computer and checked on each of my in house patients, their vital signs, lab results and such. I only had five patients to see. Everyone looked good in the computer.
I guess I need to see each one in person.
I ran up to the third floor, the post surgical unit. I saw Bill and Irma and Lucille, each post op from laparotomies and each was doing well. Notes and orders were written (the good old days, before computerized everything) and then I ran down to the OR to start Maria’s surgery.
She was just going to sleep when I walked into OR five. I went out to wash my hands while she was being prepped.
“Draperies please,” I asked.
The tech handed me a towel and I began to drape Maria.
All the proper tools were passed off and connected and surgery commenced.
I infiltrated some long acting local anesthetic in Maria’s belly button area, made a small incision, elevated her abdominal wall and tried to pass the Veress needle. This needle is what I commonly use to insufflate the abdomen, that is blow it up with carbon dioxide gas. Only the needle wouldn’t pass. I put it in up the hilt, but no go.
She doesn’t look to be that large. But, women tend to have their adipose tissue in the abdominal wall, I guess Maria has a bit more than I thought.
“I need a longer Veress needle.”
In about a minute the circulator returned with the 150 cm needle which I was able to pass into the abdomen without difficulty.
I hope that’s the only glitch for the day.
And Maria’s case went off without a hitch. Inside her abdomen there wasn’t much fat. Each structure stood out. The gallbladder was hanging off the liver, the common bile duct was easily seen, and the cystic artery nearly jumped out at me. It was spread, spread, clip, clip, clip, cut, clip, clip, clip, clip, cut, then snip, snip, snip, snoop and in five minutes the gallbladder was in a pouch, pulled out through the epigastric wound and on the back table. Ten minutes later the final band aids were laid over the last of Maria’s wounds as she began to wake up. Thirty five minutes after she had gone to sleep she was in the Recovery Room.
I should have time to see my other two hospital patients.
I saw Joe and Juana on the fourth floor. Neither had a problem which would require surgery. I stopped to say “hello, how are you, you should be going home soon and then went back to the OR to operate on Michael.
Michael had been having pain for years, always in the upper abdomen, radiating to his back, occurring almost every day. He had gone through endoscopies, CT Scans, MRI’s, ultrasounds and more endoscopies. Finally, he found a GI specialist who ordered a HIDA Scan. This is an anatomic and functional test of the gallbladder. In Michael’s case the HIDA revealed his gallbladder only emptied 4% when stimulated and, maybe more important, his symptoms were reproduced, exactly. I told his there was an 85-90% chance his pain would be relieved by surgery.
He was being wheeled into the OR as I finished my rounds.
Should be straightforward. No stones, chronic symptoms, overall in excellent health.
Never make such assumptions.
Michael’s surgery started off simple enough. The gallbladder was partially intrahepatic, but that just means a little more dissection until the gallbladder is free. I began in the usual way, incising the thin layer of peritoneum over the neck of the gallbladder and dissecting this peritoneum and the some surrounding fat away from the wall of the gallbladder. I lmost always start on the inferio lateral aspect of the gallbladder, where I should be safely away from the common bile duct.
As I began Michael’s dissection I saw a bluish structure just below the cystic duct and going towards the liver.
Not the right spot for the common bile duct or any bile duct. Be careful. Maybe it will be easier on the other side of the gallbladder.
I began dissecting on the medial aspect of the gallbladder.
It looks like there is another duct on this side. Maybe the gallbladder is lying between the right and left hepatic ducts? The structure in the middle looks like the cystic duct.
I started working higher on the gallbladder, away from any ducts, I hoped.
This is becoming far too much work. This was supposed to be my easy case.
As I dissected along the medial wall of the gallbladder I was able to identify a duct running along this part of the gallbladder and then going towards the liver. Luckily, I was able to separate this duct from the gallbladder.
That must be the left hepatic duct. At least Michael is not too chunky.
I retracted the gallbladder to the right and began teasing out the cystic duct.
Better check that duct like structure on the right side of the gallbladder.
It’s a good thing I did, because what I thought was all cystic duct turned out to be what I now presumed to be the right hepatic duct almost fused to the back wall of the gallbladder. I tried to separate these two structures. No luck. I did manage to find what I presumed was the cystic artery, very short and running along the medial aspect of the gallbladder, almost tethering the gallbladder between the two hepatic ducts.
Maybe take it from the top down, like the old days.
And so I began working on the fundus of the gallbladder. I pushed the liver up and retracted the gallbladder down and was able to separate the gallbladder until it was attached buy only the cystic duct, which was still fused to the right hepatic duct.
I’ll just take where it’s safe and leave the rest behind.
I used a stapling device to divide the gallbladder at its neck, being careful not to injure the bile ducts.
Finally it’s done. This was far too much work.
Michael woke up without a hitch, oblivious to the torture I had suffered. His operation which normally would have taken about thirty minutes had lasted over two hours.
Next was Michelle, twenty one, with pain for a week and a big stone impacted in the neck of the gallbladder. Michelle was typical of most patients with cholecystitis. That is she had persistent episodes of pain, and stones which either intermittently passed from the gallbladder through the bile duct, causing “biliary colic” or had big stones which would cause obstruction of the gallbladder with either acute symptoms of severe pain and tenderness, “acute cholecystitis” or paroxysmal pain, “chronic cholecystitis.”
Michael and Michelle, good name for a duo. And now we present “Michelle and Michael” the gallbladder singers.
My first glance at Michelle’s gallbladder revealed only that is was very distended. It wasn’t very inflamed and there was only a brief moment when it seemed like there might be some difficulty grasping it. There was a big stone filling the gallbladder neck, but I was able to retract the gallbladder to the right so that I could dissect the cystic artery and duct. Fifteen minutes later the gallbladder was in the endopouch.
Homefree.
But, it wouldn’t come out. The pouch was half in and half out of the abdomen, pulling it out through on of the larger trocar sites. I grabbed the gallbladder and tried to deliver it out of the pouch and abdomen. I was rewarded with a tiny piece of the gallbladder wall.
Keep at it. You always win in the end.
I tried to grab the stone with the ring Forceps, a clamp which has two rings which is ideally suited to grasping gallstones and pulling them out of the Endopouch. Michelle’s stone was big, really big. With one lucky swoop I managed to get the jaws of this clamp around the stone. I pulled it up towards the small opening in the abdominal wall. It was equivalent to trying to put a camel through the eye of a needle.
Maybe I can break the stone up.
I tried to close the jaws of the clamp and break the stone into pieces. There was a “snap” and then I was able to pull the clamp out, minus one of its jaws.
That is one tough stone.
I tried a different type of clamp. No luck.
After twenty minutes of pulling, prying and hoping I did what I needed to do.
“Knife please.”
I made the incision bigger, big enough to deliver this baby. I made it bigger and bigger until it was a mini laparotomy. Finally, I pulled pouch gallbladder and stone out of Michelle’s abdomen. T
The stone was five and a half centimeters in diameter, the size of a chicken egg. I took a break for a minute, shaking my hand to relieve a cramp and stretching my fingers after this ordeal. I closed Michelle in short order and got ready for Owen.
I’m not sure they pay me enough. Maybe Owen will treat me better.
I shouldn’t think such thoughts, surely I jinxed myself. Owen. Even now the name makes me shudder.
Owen was 78 years old and had typical complaints of RUQ abdominal pain. He had been having pain almost daily for 6 weeks. His ultrasound revealed, and I quote, “Multiple mobile stones,” and the gallbladder was not visualized on HIDA scan, which suggests cystic duct obstruction and certainly explained Owen’s frequent symptoms.
“Are you ready to get this over with?” I asked.
“Sure thing, Doc. I’m planning to play eighteen holes tomorrow,” He answered.
“Well, you may want to wait until the weekend,” I countered.
Owen’s case started well enough. Pneumoperitoneum established without difficulty, all the trocars placed and then I looked in with the scope.
No gallbladder.
All I saw was a bit of omentum stuck to the spot where the gallbladder was supposed to be.
It must be underneath those adhesions.
I teased the omentum away and was rewarded with a structure which looked like it was the gallbladder. It was small to say the least, but it was where the gallbladder was supposed to sit and I was sure I could see the common bile duct.
Once the adhesions were gone I began to retract the gallbladder superiorly as is almost always done during laparoscopic gallbladder surgery. The gallbladder was not only shrunken it was very hard to grasp. Every time I tried to grab it, it would slip away. Finally, all I could do was push the liver superiorly. As I tried to dissect this diminutive little beast it tore. I did see some stones inside but I realized I was fighting a losing battle.
“Scalpel, please and get all the instruments to open,” I requested.
Better to have a big incision and a healthy, whole patient, than four small incisions and a piece of the common bile duct in the specimen jar.
Over the years I have never had a patient complain that they had to have open surgery. However, they definitely are not happy if they require multiple surgeries to fix a complication.
For the next hour and a half I wrestled with Owen’s little nubbin of a gallbladder. I managed to separate it from the liver and I thought I found his cystic duct and junction with the common bile duct. The cystic duct was very short. I stitched it closed, being careful not to narrow his CBD and I left a drain in place.
I delivered a gallbladder which was the size of a nickel and contained a couple of stones which filled its tiny lumen.
Two hours of work for that little thing?
Owen woke up without a hitch.
“No golf for a few weeks,” I informed him.
“There goes my handicap,” he answered.
At least I’m done.
My phone went off.
“Consult, ICU 21. Tad Schultz, acute cholecystitis.”
I thought I was done.
It was now 3:30 in the afternoon. My plan to be done and home by one was just a fading memory.
I guess I need to go check out Tad. I wonder why he’s in ICU if it’s just his gallbladder which is the problem?
Tad was not in the ICU just because of his gallbladder. He had undergone coronary artery bypass surgery thirty six hours ago. Now he was complaining of severe upper abdominal pain, nausea and vomiting, all of which had commenced twelve hours earlier.
“Hello, Mr. Schultz. I’m Dr. Gelber, one of the General surgeons here. They tell me you have pain in your abdomen?” I inquired.
He was sitting still in his bed, an oxygen cannula draped across his face which was flushed. The monitor to the right of his bed gave a clue to his condition. Heart rate was 112, blood pressure 100/50, Respirations 22, oxygen saturation was 100%.
Looks like something is going on; something more than just post op discomfort.
“It hurts right here,” he replied as he pointed to the right upper quadrant of his abdomen, right where his gallbladder sat.
“It hurts to move, to breath, even to smile,” he added.
I wonder if it’s more than just his gallbladder?
“Any nausea or vomiting?”
“All night.”
“Had a pain like this before?”
“Never.”
I palpated his abdomen. He winced when I lightly tapped beneath the right costal margin (below the ribs).
It feels like there’s a mass there.”
“I’ll be back in a few minutes,” I said and I went to check the results of any testing which had been done.
I sat a the computer, waiting for Tad’s data to appear.
I don’t feel like ding another surgery today, especially on someone fresh from open heart surgery.
The tests revealed that his white Blood Cell count was 23,000, H/H 10.5 and 32. Total bilirubin was 2.0, ALT 125, AST 114 and Alkaline Phosphatase 201. His other labs were more or less normal. Ultrasound revealed a very distended gallbladder with stones and a thickened wall at 10 mm.
No question, Tad is sick and the culprit is his gallbladder. Surgery would best be avoided if possible. Maybe Dr. L can help.
Dr. L was our local, friendly Interventional Radiologist.
“Percutaneous cholecystostomy, if you have the time,” I requested from Dr. L. “Mr. Schultz, ICU 21. I think it would be best if he does not have to have surgery again so soon.”
Dr. L agreed and two hours later Tad was sitting up, smiling with a tube running from his right flank to a bag which was filled with golden brown bile.
It was not definitive treatment, but the drainage procedure bought time, allowing Tad to recover from his open heart surgery without further complication. Six weeks later he had a second surgery, an uncomplicated laparoscopic cholecystectomy.
The day ended at around 6:00 pm. I had performed four cholecystectomies, tackling gallbladders of a variety of shapes and complexities. My hand was still a little sore from battling Michelle’s ostrich egg of a gallstone, but otherwise it had been a successful day.
Cholecystectomy can be one of the easiest surgeries to perform or extremely difficult. An elective gallbladder surgery in a thin patient with little inflammation and normal anatomy may take all of ten minutes. Meanwhile, at the other end of the spectrum, a case like Owen, a small contracted, fibrotic gallbladder with anatomy which is unclear will cause the best surgeon to pause and rue the day he chose to work with a scalpel, rather than sit a dark room all day and read chest X-Rays.
I thought about the surgeon’s prayer.
“Lord, please protect me from the interesting cases and don’t let me screw up today.”
Maybe it needs an addendum:
“And please make all the gallbladder surgeries easy.”







Saturday, March 26, 2016

Legacies

                           

We read a great deal these days about President Obama’s legacy, about he is trying to create a list of accomplishments which historians will cite as the highlights of his eight years in office.
But, when we think about our former leaders what pops into our head are the quotes which we associate with each man. Reflecting on this idea I present a list of famous quotes which are attributed to some of our past Presidents. President Obama presents a stark contrast to the others, which provides commentary on his memorable accomplishments.


“My fellow Americans, ask not what your country can do for you, ask what you can do for your country.”  John F. Kennedy

“The only thing we have to fear is fear itself.” Franklin D. Roosevelt

“Four score and seven years ago our fathers brought forth, upon this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.” Abraham Lincoln

“With Malice toward none, with charity for all, with firmness in the right, as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation's wounds.” Abraham Lincoln

“I feel your pain.” Bill Clinton

“Mr. Gorbachev, tear down this wall!” Ronald Reagan

“States like (Iraq, Iran, & North Korea), and their terrorist allies, constitute an axis of evil, arming to threaten the peace of the world.”  George W. Bush

“Until justice is blind to color, until education is unaware of race, until opportunity is unconcerned with the color of men's skins, emancipation will be a proclamation but not a fact.” Lyndon Johnson

“If you've got a business—you didn't build that. Somebody else made that happen.” Barack Obama

"If you like your health care plan, you can keep it.” Barack Obama

I did not include the famous “lead from behind” quote because I cannot find documentation that President Obama actually said this. I also must admit that thre is nothing scholarly about these quotes. Each is a quote that popped into my head when I considered what was memorable about these past presidents.

Just a little food for thought.

Monday, March 14, 2016

A Horse is a Horse of Course...

                                      

Jeremy was a cowboy in the rodeo. He also was responsible for keeping me up for most of three nights in a row. He was the fortunate survivor of a run in with a very angry horse.
Animals are supposed to be our friends, at least dogs and cats, horses, pigs and cows. Some birds, the occasional snake and even tarantulas have been companions to humanity. Our encounters with these domesticated beasts are supposed to bring pleasure, happiness and feelings of wellbeing. Except, when they don’t.
Melvin was set upon unmercifully by two feral dogs, losing large chunks of skin and muscle from each leg and one arm before the beasts could be restrained. Sandy was a young lady tattooed from head to toe. She had a pet python who mistook her for his dinner one day and tried to swallow her whole. I see half a dozen patients every year with fever and painful swollen lymph nodes secondary to cat scratch disease. Bird bites, tarantula bites, dog bites and so many other bites have made it into the hospital over the years.
But Jeremy; he stands out. Maybe it’s because he showed up in the ER very early in my career in private practice; maybe it was the running battle between his divorced parents, maybe it was the conversation with Dr. Red Duke, or the lack of sleep I accumulated over the four days it took to stabilize him. Probably all of the above combined to make him one of my more memorable disasters.
I had been out in private practice for about four months and I still had the feeling of invincibility common to surgeons as they leave the safety of residency and head out to save the real world.  It was eleven pm when the phone rang.
“Dr. G this is Dr. F in the ER. I’ve got an eighteen year old man here who got kicked in the right side by a horse. His heart rate is 130 and BP is 90. There’s a big area of swelling on his right side. He’s on his way to CT as we speak.”
“OK, thanks, I’ll be in to see him,” I answered. I turned to my wife.
“I need to go to work,” I said.
“Surgery?” she asked.
“Don’t know. I hope it’s nothing major.”
I pulled on some clean scrubs and left.
Jeremy was just finishing his CT as I arrived. As he was wheeled back to the ER I scrolled through his scan.
Broken rib, looks like a pretty big subcapsular hematoma of the liver, not much else.
This was my reading of the scan, but usually I was pretty accurate, as I had spent the last two years of my residency reading abdominal CT’s with the senior Radiology residents.
The Radiologist’s official reading was in agreement.
Jeremy was awake and alert, complaining of pain in his right side. He had been competing in a local rodeo and one of the horses decided nobody was going to ride him and decided to vent his anger on Jeremy,  delivering a solid kick squarely to Jeremy’s right side. There was a big bruise on his right side and I was sure I could make out the imprint of a horseshoe. Certainly not lucky for Jeremy.
Jeremy’s Dad was at his bedside showing nothing but the proper concern. Mom and fireworks would come later.
Jeremy stabilized after a couple of liters of IV fluids and I decided surgery was not needed at this time. I tucked him away in the ICU and was back in bed by 2:00 am.
Later in the morning Jeremy was looking fairly stable. Heart rate was around 110, blood pressure was 110/70, urine output and oxygen saturation were good. His hgb had dropped for 14 to 10.5.
“Looks like he’s pretty stable,” I reassured his dad.
“His mother will be happy,” he replied.
“I haven’t met his mother yet,” I answered.
“She’s been away, on a business trip. She’s flying in this afternoon and will be here later.”
“Oh, well I guess I’ll meet her later. I’ll check on him this evening,” I added and I left to attend to other sick people.
A few hours later a message came to call the ICU regarding lab results.
“Jeremy’s hemoglobin has dropped to seven,” the nurse reported, “and his heart rate is 125. Blood pressure is 100/60.”
“Give him two units of Packed RBC’s,” I ordered.
Looks like he’s going to need surgery. I hate operating on the liver.
That was the truth. I loved operating on the biliary system, pancreas and everything else around the liver, but the liver itself was one of my least favorite organs to work on.
Maybe it’s because you can’t really take it out. Every other intra-abdominal organ could be removed if necessary, its functions then assumed by other organs or replaced with medication. The esophagus can be replaced by a segment of colon or even small bowel, stomach can be reconstructed, much of the bowel can be resected with impunity, dialysis can replace kidneys if necessary, there is insulin and enzymes for the pancreas, but the liver is different.
No other organ does its job. It metabolizes and excretes bilirubin, detoxifies noxious chemicals releases glucose along with so many other functions. Liver transplant is the only real viable alternative if a liver fails or has to be removed. I was not really anticipating having to remove all of Jeremy’s liver, but the point is that the bleeding needed to be stopped and sometimes this can be problematic when dealing with the liver.
I considered repeating his CT scan, but decided that this wouldn’t change the inevitable.
So the blood transfusion was started and he was scheduled for surgery. It was six thirty when I went to explain the situation to his parents, both Mom and Dad now present.
“You let him ride in the rodeo. I told you to stop it,” I heard Mom hissing loudly.
“He’s an adult. I can’t live his life,” Dad replied in more of a whisper.
“You could if you were more of a man,” Mom answered, the hissing growing louder.
I took that moment to interrupt and introduce myself to Mom.
I’m Dr. G, I’m pleased to meet you,” I began, addressing Mom. “I think you know that Jeremy needs surgery. I’d hoped he would stabilize, but that hasn’t happened.”
“I’d like to send him to the Med Center,” she stated.
“That would be fine with me,” I answered, “but he’s not stable at the moment. He really needs to go to surgery. I think we’re just about ready to start. Afterwards, when he is stable, we can try to arrange for a transfer.”
She looked at me with an expression which said, “You better take care of my Jeremy or else…”
I left the worried family and met the OR crew as they began to wheel Jeremy down the hall from ICU to the OR.
“Don’t worry,” I reassured him, “we’re going to take good care of you.” This has been my standard line to worried patients over the years, short and to the point, but very effective.
Jeremy was fairly stable as I made my long midline incision. His heart rate was 120, BP 110/60.
Upon entering the abdomen I was greeted by blood, blood and more blood, dark blood wafting up from between loops of slightly pale bowel. There was more blood around the liver, redder, fresher along with large congealed clots.
We, that is myself and my assistant, scooped out all the blood and began by packing “laps” all around the abdomen, starting with right upper quadrant around the liver, then around the spleen and in the lower abdomen.
The money is on the liver. At least I don’t see a lot of active bleeding.
I pulled the packs from the lower abdomen. This area was pristine, no active bleeding, no hematoma. Next I “ran the bowel” which means I checked the small bowel from its beginning at the Ligament of Treitz until it terminated in the cecum. No injury. The packs were pulled from around the spleen. The left upper quadrant was also spotless; without bleeding or injury.
Time to work.
I gingerly removed the packs from around the liver. There was adherent clot over most of the right lobe with a laceration into the parenchyma and a small amount of oozing of red blood. The capsule of the liver had been disrupted over most of the right lobe.
Maybe just leave a drain? No, he’s been bleeding. I definitely need to do something.
I left the clotted blood which coated the denuded liver surface in place and approached the laceration. This was a crevice which ran from the superior right lobe laterally and inferiorly. Bright red blood was slowly welling up and then running down the liver’s surface. Carefully, carefully I put my hand behind the liver and gingerly lifted the right lobe, this brought the laceration closer to me so that I could actually see what I was doing. I packed laps behind the liver which helped hold it in place. I divided the right triangular ligament, which is a peritoneal attachment holding the right lobe. This allowed me to bring the laceration even closer. Now I could see into the depths of the liver, clean out the clot under direct vision, find what was bleeding and stop it,
I hope.
I began by washing away the clot, irrigating it with saline, doing my best to cause as little disturbance as possible so as not to stir up new bleeding.
What’s happening?
My thoughts preceded my words.
“Is there a problem?” I asked the anesthesiologist. “All of a sudden everything is bleeding.”
Indeed, the surface of the liver was now a continuous ooze of blood which was filling up the belly. The laceration was briskly filling up with bright red blood. The trickle had become a flood.
“Nothing’s changed…wait, how did that happen?” the anesthesiologist replied.
“How did what happen?” I inquired, a sense of urgency in my voice.
“His temp is 93.5. I’ve only given him 2 units of blood, but something has caused his temp to drop. I don’t know how long it will take to warm him.”
How did he get so cold? Maybe a transfusion reaction? Just pack him for now, get him warmed up and then come back and fix the problem.
The commotion at the head of the table faded away as I tuned out everything and concentrated on the problem at hand.
“Laps, a bunch of them,” I ordered, the level of my voice rising only slightly.
I packed laps into and around the lacerated liver, holding pressure and then packing more until they stayed dry.
I closed his belly quickly and we rolled him back to the ICU. His blood pressure was 100/60, heart rate 110, temp 93.7.
I rushed through the immediate post op tasks of dictation and orders and then went to face his worried family.
I found Mom and Dad in heated discussion.
“Would you believe it?” Mom stated as she turned to me. “Wonder man here has an insurance plan that doesn’t cover ‘animal related injuries.’ What kind of insurance is that?”
“One of the questions was about animal related activities,” he replied, a bit sheepishly. “I couldn’t lie.”
“That is not a concern at present,” I said. “Worry about that later. Right now I have some news for you. I guess you can tell that I’m out of surgery. We had a bit of a problem…”
“Jeremy’s OK isn’t he? He better be OK,” Mom almost threatened.
“He’s OK, at the moment, but as we were working he started bleeding more, bleeding from places that should not have bled. His blood wasn’t clotting. I did what I could do to control everything, but he’s still not out of the woods and I’m not a hundred per cent sure what the problem is.”
“How is he now?” Dad asked, his voice filled with nothing but anxiety and worry.
“He’s stable, blood pressure is normal, all his organs seem to be functioning. It looks like his body temperature dropped and blood doesn’t clot well if you’re cold. We’re doing what we can to warm him and make sure there are no other clotting problems. I packed a bunch of surgical pads around the sites which were bleeding and that has controlled everything, at least for the moment. He will need to go back to surgery in about 48 hours to remove them. In the meantime we need to correct his temperature and any other abnormalities. And, hope he doesn’t bleed anymore.”
But, he did continue to bleed. Besides his low body temp, his coagulation studies were abnormal. Most likely everything was intertwined. Blood clotting is a complicated series of events which starts with platelets plugging a hole in a blood vessel, followed by a cascade of enzymatic reactions which lead to a mature clot. Biochemistry teaches us that such reactions work best at normal body temperature. Significant lowering of body temperature causes derangement of normal clotting. And, once a body starts oozing it tends to beget more oozing, sometimes leading to the flood I witnessed within Jeremy’s belly. Thus, my decision to pack around the site of bleeding and stem the tide for the moment. This action, I hoped, would buy time to correct the underlying problem.
It worked, at first. I checked his coagulation status. His PT was elevated at 22 and his PTT was 48. His platelets were OK at 110,000. The nurses were working on warming his with a heating blanket and warmed fluids. He was transfused two jumbo units of FFP, plasma which would replace the clotting factors which had been consumed.
Maybe he’s out of the woods.
But, eight hours later, at four in the morning, his heart rate started to rise, his blood pressure dipped and his hemoglobin dropped from 10 to 8. There were a few bright spots. His body temperature was normal and his PT was down to 17 and PTT was normal.
“Transfuse two units PRBC’s and give another jumbo unit of FFP,” I ordered. “I’ll be in to see him.”
What to do? What to do? There must be some blood vessel which continues to bleed. Should I operate again? I’ve already been there. Maybe, maybe there’s a better alternative? Yes,  there is another alternative which might work. I hope Dr. L. is on call.
My plan was simple. Rather than dig through the injured liver looking for the source of bleeding, the problem would be approached from a different angle.
“I know you don’t like to get up early, but I really need your help,” I explained to Dr. L. I told him the whole story.
“Do you think you can do an arteriogram and embolize whatever hepatic artery is bleeding?” I finally requested.
“It might work,” he concluded, “although I’ve never embolized for this type of injury before.”
It was true. Angiography and embolization of arteries for trauma is commonplace these days, 25 years ago such a practice was sporadic.
I called Jeremy’s Mom and Dad and explained his condition and the plan.
An hour later he was wheeled down to the angiography suite.
I stretched out on the couch in the doctor’s lounge.
Maybe I should go home and sleep for a couple of hours. With my luck I’ll get called back as soon as I walk in the door.
I closed my eyes for a few minutes, until I was interrupted by a call from Dr. L.
“There was a tiny blush from a branch of the right hepatic artery. I did a subselective embolization of the right hepatic. I think he’ll be better,” Dr. L. reported.
“Thank you,” was all I said.
Six thirty. I guess I’ll make rounds and then check on Jeremy.
Jeremy did stabilize. His heart rate came down to 95, BP stayed around 110/60, he was awake and alert, talking, wanting to eat.
“Clear liquids for now and we need to take you back to surgery tomorrow to remove all those packs,” I reminded him and his parents.
I scheduled the next procedure for the next day to be done around 4 pm. Unfortunately, I was on call and had to deal with a perforated ulcer before tackling Jeremy. It was around 7 pm when the OR crew came to pick him up.
“I’ll be out to talk to you as soon as I’m done I reassured Mom and Dad and a multitude of other relatives and friends.
“Could you talk to another doctor on the phone” Mom asked.
Really, do I have to?
“Another relative?” I asked, a bit facetiously.
“It’s Dr. Red Duke,” she added.
“Oh, OK.”
Dr. Red Duke was a local celebrity. He was a general surgeon at the Texas Medical Center, was regularly featured on local news shows where he would explain a variety of medical and surgical maladies and what to do about them. Outside of that I really didn’t know him.
“Hello, this is Dr. G.”
“This is Dr. Red Duke,” he answered in his thick Texas drawl. “Tell me what you’re dealin’ with thar, young fella.”
I presented the case as succinctly as I could and he listened without interruption.
“Sounds like you’ve done a fine job, doctor. My only advice is that when you remove those lap pads, soak them in peroxide first. If you do that, they won’t stick and you won’t stir up any new bleeding. Good Luck.”
“Thank you, now I think they’re waiting for me.”
I hung up and headed to the OR where they really were waiting on me.
“Sorry to keep you waiting,” I explained, “but I had to get some advice from Dr. Duke.”
“You mean Red Duke.”
“Sho ‘nuff,” I answered in my best Texas accent, “the family called him. Now let’s get this done with.”
This return to OR was most uneventful. There was only a couple hundred cc’s of old dark blood, the packs easily came out after soaking them with saline and there was no bleeding. The abdomen was washed out, I left a drain by the liver and closed him up.
Maybe I can get a full night’s sleep.
No such luck. I was in bed by ten, but at 1:00 the phone rang.
“Jeremy is very short of breath. He’s breathing at about 36 (normal 12-16), his oxygen saturation is 90% on 100% nonrebreather, heart rate is 120, BP is high at 150/95.”
“I’ll be in to see him.”
I’m getting tired of this.
For the third night in a row I climbed out of bed and made the twenty minute drive to the hospital.
Jeremy was sitting upright in bed, his oxygen mask in place, breathing at a rate of about twenty eight.
“What’s going on, Jeremy?” I began. “Any pain?”
“Just feel winded, like I can’t get enough air into my lungs.”
His oxygen saturation was at 91%, heart rate was 120. BP, urine output were OK. His chest X-ray looked a bit congested and there were bilateral pleural effusions, which means fluid around his lungs.
“Do you think we need to intubate him, Dr. G?” the ICU nurse asked.
“Give him some Lasix, 40 mg, now. I’m going to talk to Pulmonary.”
I called Dr. P. and told him the story, while Jeremy got the Lasix.
“Dr. P. will be in,” I told the nurse, but I could already see improvement with the Lasix.
Jeremy put out about 4 liters of urine. His breathing calmed and he began a steady improvement. His bilirubin rose to about 6, possibly related to the embolization of his liver, but then came down to normal.
There was no more bleeding, no respiratory difficulty, he was soon up walking and eating and he went home about twelve days after the original injury.
The control of bleeding utilizing angiography and embolization was a technique I had used prior to Jeremy, primarily for bleeding secondary to pelvic fractures and bleeding from tumors which could not be accessed surgically. The technique now is more common, often being used for trauma to the spleen, as well as liver and the aforementioned pelvic fractures. It is a true life saver in those cases where the patient has an isolated injury to an organ which will tolerate the embolization.
The liver has a dual blood supply, receiving blood from the hepatic artery and the portal vein. In this case, embolization of the artery did the trick.
I saw Jeremy about four years later. He came to see me because he thought he had a hernia. He had given up riding in the rodeo and was working locally as an electrician. He did not have a hernia.
His Dad paid me ten dollars a month for a couple of years, determined to make up for the lack of insurance. I told my office staff to write off the balance and forgive the rest of his debt after about two years.
I stay away from horses, except for the occasional trips to the race track.












                  











Sunday, February 21, 2016

Why Did This Happen?

                   

It was a Whipple. Not Mr. Whipple of Charmin fame, but the operation which carried the name of Whipple. The proper name is Pancreatoduodenectomy and it is a procedure which most surgeons decline to undertake.
Named for Allen Whipple, the operation consists of removal of the gallbladder, a portion of the common bile duct, the head of the pancreas and the duodenum with the most proximal jejunum. In its original form it was performed in 2 stages, first the resection and then, the following day, the reconstruction. It is an operation for tumors in the head of the pancreas, distal common bile duct and duodenum. Occasionally it is utilized for benign strictures of the distal bile duct, often due to chronic pancreatitis.
To me the operation presents a study in anatomy and an exercise of careful dissection. The portal triad, consisting of bile duct, hepatic artery and portal vein must be teased apart, vessels to the liver preserved and the pancreas gently lifted off the superior mesenteric and portal vein.
Mark needed such an operation.
Mark was 52 and came to the hospital because he had turned yellow. He had noticed the color change for about two weeks. He also felt weak, had vague abdominal discomfort and had lost about fifteen pounds. In the Emergency Room he was found to have gallstones, dilated bile ducts and “focal” pancreatitis on CT Scan of the abdomen.
His bilirubin level was 12, which is why he looked yellow. Normal bilirubin level is under 1.0.
Fortune put me on call for the ER that day and I was consulted by Mark’s admitting physician. His presentation was not typical of gallstone pancreatitis. His pain was mild. The bilirubin was too high, weight loss did not go along with acute pancreatitis.
And, when I reviewed his CT Scan, the finding of “focal” pancreatitis looked like a tumor to me and to another Radiologist colleague with whom I was reviewing the images.
Further work up with MRCP revealed the stricture in the bile duct and a definite mass in the pancreas.
Mark needed a Whipple.
He was otherwise healthy. The surgery was scheduled for two days later.
At 9:08 am on a Tuesday I made my chevron incision in Mark’s upper abdomen, dealt with the usual bleeders in the abdominal wall and entered his peritoneal cavity. There was no fluid, usually a good sign, the liver was discolored from his jaundice, but free of any masses. Palpation of the head of the pancreas revealed the expected hard mass, a sign of either inflammation or tumor.
Next came the first decision. Should I biopsy the pancreas? Would such a biopsy change anything? Suppose the biopsy revealed cancer. The treatment would be to resect the tumor, that is, to continue with the Whipple procedure. But, suppose the biopsy only revealed inflammation, or fibrosis, without any tumor? The answer is that it wouldn’t make a difference. Mark still needed the Whipple. Pancreatic cancer is a funny beast. It causes an intense fibrotic reaction. The tumor often is obscured by this fibrosis and diagnosis, particularly on intraoperative frozen section is often very difficult. Mark’s presentation was textbook cancer of the pancreas. Even if his jaundice turned out to be benign disease, which was unlikely, the proper treatment was still the Whipple.
The first decision was, therefore, simple; no biopsy.
Next I removed the gallbladder. It contained a bunch of stones, but otherwise wasn’t inflamed. It was in the bucket in about ten minutes.
Time to get going.
I Kocherized the duodenum, which meant I divided the peritoneal attachments of the duodenum which allowed me to lift the pancreas and duodenum off any underlying retroperitoneal structures. The main structure of concern was the Inferior Vena Cava. I was now able to hold the entire head of the pancreas in my hand. The mass felt hard, while the neck felt soft and spongy, the way normal pancreas was supposed to feel. I mobilized as much as I could, until I could feel the pulse of aorta adjacent to the pancreas.
Time to tackle the porta hepatis.
This part of the operation is the time to be careful and methodical. The common hepatic artery arises from the celiac axis, a major branch from the aorta. This common hepatic artery branches into the proper hepatic artery which is one of the major structures of the porta hepatis and supplies arterial blood to the liver, and the gastroduodenal which supplies the duodenum and the pancreas, but also gives rise to the right gastric artery which is important to preserve in the so called pylorus preserving Whipple which is what I planned for Mark.
Carefully I exposed the arteries. It turned out to be one of the easier dissections of these structures I’d ever performed. There was considerable space between the common bile duct and the arteries, making separation of these structures very straightforward. All the branches were dissected and encircled with silk ties, but none of these arteries were divided yet.
Next the bile duct was identified, dissected free and also encircled. It was dilated to about 1.6 cm, about twice normal size. Behind the bile duct was the portal vein, usually the make or break structure in Whipples. This large vein is formed where the superior mesenteric vein and splenic vein meet. It abuts the head of the pancreas and tumors often grow into and around it, which renders these tumors unresectable, at least for cure. The anterior surface of the vein is dissected free so that the neck of the pancreas can be lifted off the vein.
Mark’s portal vein easily separated from the pancreas.
Once all this dissection being done it was time for the real operation to start.
The gastroduodenal artery was ligated and divided, while the proper hepatic and right gastric arteries were preserved. The bile duct was also transected, an act which always fills me with an oxymoronic combination of fear and delight. This unusual feeling is due to the repeated drilling during residency to “know where the bile duct is, do not injure the bile duct,” every time a gallbladder was removed.
Next the neck of the pancreas is lifted off the portal vein and divided, vessels running with this organ are sutured as there is always some bleeding. Great care is taken to not suture the pancreatic duct.
The portal vein is now separated from the pancreas. There are always a number of small branches running from this vein into the head of the pancreas. Each is dissected free, clipped and divided.
The jejunum, just beyond the ligament of Treitz is divided and the vessels going to the distal duodenum are divided, mostly using my trusty “Ligasure” device.
Finally, the uncinate process of the pancreas is freed from the its connections posterior to the portal vein. Mark had an unusually large collateral vessel in this area which required special attention to control. The vessel was feeding into the pancreatic mass and could not be preserved. I always worry when I find, and sacrifice, an unexpected and unusually large artery; worry that it might be important. In Mark’s case I my worries were well founded.
These final maneuvers completed the resection and the specimen: head of the pancreas, duodenum and portion of bile duct was handed off to the circulator who passed it on to Pathology for immediate examination.
“Looks like adenocarcinoma of the Pancreas,” the friendly neighborhood Pathologist reported, “margins are free.”
“Thank you,” I replied and I set about the task of reconstructing the damage I had created.
At this point in the operation what I have is the divided pancreas, bile duct and duodenum. These organs are designed to meet at the Ampulla of Vater where bile and pancreatic juice are dumped into the duodenum to join and digest ingested food. The task at hand is to reconnect each structure to the intestine to restore the normal digestive function. Connecting the Pancreas to the bowel is considered the Achilles heel of the Whipple procedure.
Back to work. The divided pancreas was dissected free a bit more which allowed me to put the about three centimeters of the divided pancreas inside the small bowel. Sutures of 3-0 Prolene were used to suture the thin, weak capsule of the pancreas to the bowel. Sometimes the pancreas is more fibrotic and will hold suture fairly well. Mark’s pancreas was more normal and the sutures held, but I knew I was going to worry for a few days.
The bile duct was next, an anastomosis using 4-0 Vicryl in a single layer, straightforward and uncomplicated.
Finally, the duodenum, just beyond the stomach, was anastamosed in 2 layers to the small bowel, using 3-0 Vicryl and 3-0 silk. Drains were placed, the belly closed and he was brought to the recovery room.
Mark was very stable for the first 24 hours. There was slight tachycardia, heart rate around 105, but nothing else unusual. The two drains put out serosanguinous fluid as expected and the volume of fluid put out was low.
Labs on the first day revealed a bilirubin of seven, down from thirteen preop. His white blood cell count was high at 21k, but this is not uncommon with the stress of such a major operation. His hemoglobin level actually was higher than preop.
Hemoconcentration, very common after Whipples.
I increased his fluids and went on my way. That evening I made my usual call to the ICU to check on Mark and my other ICU patient.
“He’s more tachycardic now, heart rate 130,” his nurse reported. “Urine output is OK and oxygen saturation is 100%. He looks comfortable.
“Give him a fluid bolus, a liter of lactated ringer’s,” I ordered and I went to bed.
I didn’t hear anything more that night. I saw Mark first thing the following morning. His heart rate still was hovering around 130. His WBC was 20k, he had a mild metabolic acidosis and his renal function was a little worse.
I ordered a stat CT of the abdomen and gave him more fluid and antibiotics.
What’s wrong with Mark?
His drains weren’t putting out very much and the fluid was the expected serosanguinous. The NG tube was bile, his abdominal exam was unremarkable.
Everything looks OK, except for him. Maybe the CT will help.
The CT was finished later in the day: Post op changes, no fluid collections, nothing that would explain Mark’s persistent tachycardia and elevated WBC.
Maybe he’s just one of those patients who becomes tachycardic under the stress of surgery.
Over the years I’ve had a handful of patients whose heart rates go up for a few days after surgery, even after a relatively minor procedures. For example, one young woman had excision of a retroperitoneal node to diagnose lymphoma. She maintained a heart rate in the 120’s for five days afterwards. The resident staff, including me, scratched our collective heads and searched for an etiology. None was ever found and her heart rate eventually became normal and she went home.
Unfortunately, this was not the case for Mark.
The next day I noticed that one of his abdominal drains now was putting out bile. Even worse, Mark was tachypneic, respiratory of 36.
He’s septic. I need to take him back to surgery.
I expected that he had a leak from the pancreatic anastomosis. What I found was very unexpected.
There was bilious fluid in the abdomen, as I anticipated, but the some of the bowel was dead. Specifically, the loop of small bowel which I had used to reconstruct the GI tract was necrotic, about forty centimeters. The small bowel beyond the duodeno-jejunostomy was pink and viable. In addition the right colon didn’t look right.
I began by taking down each anastomosis. The pancreas, bile duct, stomach and duodenum all looked OK, well perfused and essentially healthy. I resected the gangrenous bowel and redid each anastomosis. The pancreas was even more difficult to handle, due to the surrounding inflammation and edema.
Maybe I should ligate the pancreatic duct and not do a pancreatic anstamosis? Or, maybe remove the rest of the pancreas?
There were plus and minuses on each side. Ligating the pancreatic duct likely would preserve the pancreatic endocrine function and prevent Mark from becoming a very brittle diabetic, but would also likely lead to pancreatitis which could be severe. I wasn’t sure Mark would survive a bout of rip roaring pancreatitis.
Removing the pancreas eliminated the risk of pancreatitis, but would leave Mark with pancreatic endocrine insufficiency, which meant diabetes which could be difficult to manage as well as the need to take supplemental pancreatic enzymes for the rest of his life.
In the end I redid the pancreatic anastomosis, wrapped it with omentum and put drains all around it. The bile duct and duodenal anastomosis were straightforward.
I looked at the right colon again.
It looks dead.
Fifteen minutes later this part of the colon was sitting in a bucket and I was creating an ileostomy.
Finally finished, Mark was deposited in the ICU where his overall condition improved immediately. His heart rate came down, his bilirubin came down, he maintained his blood pressure, renal function remained stable and the drains were only putting out serous fluid.
Still, a question nagged at me.
Why did Mark develop this devastating complication?
I wish I knew. I’ve postulated that the unusually large vessel which was supplying the pancreas may have also been the major arterial supply to the proximal small bowel. The colon gangrene I chalked up to low flow and vasoconstriction, although it is possible that sacrificing that vessel also affected the colon.
Perhaps the middle colic artery, which is the major blood supply to the right colon took an anomalous course adjacent to the pancreas. Maybe the mesentery twisted causing the gangrene, although it didn’t look this way at the second operation.
I never found out for sure.
I had planned to return Mark to surgery 48 hours later, to examine the bowel for further ischemia and necrosis, but his overall condition so dramatically improved that I cancelled this procedure.
I also wish I could say that Mark made a 100% complete and uncomplicated recovery, but this was not the case. He improved for about ten days. But, on the eleventh day he started putting out more fluid from one of the drains adjacent to the pancreatic anastomosis.
He required prolonged support on a ventilator, dialysis for a time and TPN. He had this fistula for about three months before it finally healed and he was able to get on with his life.
His pathology revealed adenocarcinoma of the pancreas, no spread to any lymph nodes.
I hope he is cured.