Sunday, April 28, 2013
“First do no harm…” Hippocratic Oath
What should a surgeon do with an impossible case? For the first time in my career I asked myself that question. Over the years, I’ve had more than my share of difficult cases. I’ve had patients with life threatening conditions whom I wished I could offer more than to just shake my head and speak empty words of encouragement. They stare back at me and I see their eyes full of hope. How many times have been forced to say: “I’m sorry, there’s nothing I can do that will make you better, or cure you, or ease your pain.”
I hate moments like those.
A patient comes to me with cancer of the stomach. Major surgery is scheduled. All the preoperative testing indicates that there is a good chance for the surgery to be curative. An incision is made and the abdomen is explored. My heart sinks with the first glance. Grayish white nodules stud the abdomen. The normal yellow fat of my trusted friend, the omentum, is caked with an ugly gray mass of cancer. Nothing can be done. “Maybe chemotherapy will shrink the tumor,” I say, although I know that this cancer rarely responds. The tumor was there before the operation. The surgery offered hope and no harm was done. And, the patient thanks me. Irony.
Another patient comes with pain in his legs and black patches on his feet. He smokes two packs of cigarettes a day, has been hypertensive for years and sporadically takes his medication. My exam reveals areas of dry (not infected) gangrene on his feet, bluish discoloration of his toes and no pulses can be felt in the groins or feet. The patient is sent off for a battery of tests which confirm my suspicions. All of his major arteries from just below the aorta and throughout his legs are occluded. In this case there is no reason to try to do any surgery. Any operation will surely fail and probably leave the patient worse than he is now.
The two cases above are difficult, no question. But they were handled in the best way possible and in neither case was the patient harmed; Hippocrates fulfilled. They were difficult, but not impossible.
But then there was Lucia, a thirty seven year lady who had been in federal prison for three years; the reason for her incarceration unknown. She had previous surgery performed in Mexico, one for Crohn’s disease, the other for carcinoma of the colon. Details of these surgeries were unavailable. During her three years in prison she had been on and off Total Parenteral Nutrition, which is receiving all of one’s nutrition through an IV, and had required nasogastric tube placement for bowel obstructions on a regular basis. Her sentence finished while she was in the prison hospital. Her TPN was stopped and she was discharged from the prison with instructions to go to the hospital right away.
Of course, she doesn’t choose to go to a hospital close to the prison. No, she must travel 250 miles and show up in the ER where I happen to be on call. The workup demonstrates a definite small bowel obstruction characterized by dilated proximal bowel and a paucity of air in the colon. She tells me she has had no passage of stool or flatus by for three weeks, hallmarks of a complete intestinal obstruction. She appears, on CT Scan, to have some sort of mass surrounding and encasing her small bowel and possibly a portion of her colon.
Lucia is admitted to the hospital. A biopsy of the mass seen on CT reveals only inflammation, no cancer. Her obstruction persists. From my perspective there is no choice. After four days in the hospital without improvement, I bite the bullet and bring her to surgery to embark on the impossible.
Her abdomen was marked by a wide scar running from xiphoid to pubis which meant that I should expect to find adhesions (scar tissue) along the entire length of her abdomen and I should not anticipate any relatively easy spot, free from adhesions, to enter the peritoneal cavity. Start with the simple things first. The wide scar is excised which carries me into the subcutaneous tissue, usually marked by yellow fat. Hers is filled with fat and off white scar. Gingerly I go deeper, through the scar to the expected fascia, the fibrous tissue which surrounds our muscles and provides the strength we needed to hold our abdomen together.
Carefully the fascia is incised, separating as it is divided. I am greeted by bowel, intact and pink. Maybe this won’t be as hard as I thought. Wrong, wrong, wrong. I tease the bowel away from the undersurface of the abdominal wall and what should have been peritoneum, the thin membrane which lines and surrounds our abdominal viscera.
Careful, gentle, not too much tension or traction. No good, the distinctive flower of bowel mucosa stares back at me, indicating a hole in the bowel, as I my worst fears are realized and I settle in for what is sure to be a very long process. And, the hole in the bowel means I’m committed to finishing what I’ve started, no backing out now. I suppose I could have just repaired the hole, but such a repair without freeing the bowel from all the adhesions is very likely to break down. So, it’s onward into the morass of fused bowels and adhesions. Lucia’s and my troubles had barely started. Very gradually I manage to separate the abdominal wall from the underlying viscera. In the process I discover there is no “peritoneal cavity,” only a solid mass of congealed intestine.
There must be one place where the bowel can be freed in a safe manner, I think.
Aha, this looks promising. It turns out that it was and it wasn’t. I was able to free that particular loop, but it was transverse colon, which does nothing to help me cure her small bowel obstruction.
Maybe here, no just more colon.
The bowel in the middle is definitely small bowel and from its collapsed appearance and the CT Scan images, it is probably beyond the point of obstruction. So, I start to try to free it from some very dense adhesions. No luck, however; every attempt to pry even a centimeter loose threatens irreparable damage. At this point I also realize that she doesn’t have much small bowel. She wasn’t sure exactly what surgery she’d had before, but it appears to me that she only has about three feet of small intestine and cannot afford to lose anymore.
Try somewhere else. Maybe find the most proximal small bowel.
I gingerly attack the left upper quadrant and am rewarded with some definitely dilated small bowel, which means I’m proximal to the point of obstruction. Unfortunately, despite my cautious zeal, I’ve made another hole in the small bowel. I toil onward, gradually delineating the entire colon.
I am now left with the colon which is completely free, a loop of dilated bowel, probably jejunum just beyond the Ligament of Trietz, (which marks the beginning of the small bowel beyond the duodenum) and then a solid mass of small bowel which is congealed together as if someone had embedded it in concrete.
If I try to pry apart the remaining small bowel I may cause such damage as to leave it all unsalvageable which would require its resection and leave her with almost no small bowel. If I just close the holes I’ve made I may be able to back off, but she would still be obstructed and the closures would likely to leak. Impossible.
I am now faced with a situation I’ve never faced before. Over the years I’ve been in some very difficult abdomens, spent hours and hours teasing apart fused and fibrotic intestines. But I’ve always managed to get it all unstuck. Sometimes resection of irreparably damaged small bowel was necessary, most of the time only a few sutures to repair partial tears were needed. Now I’m facing a new and, I hope, unique situation. My instinct says back off, close the holes I’ve made and see if she’ll resolve the obstruction without needing further intervention. My head tells me this will leave her on TPN and with an NG tube forever. Should I forge ahead, chisel away the concrete and pick up the pieces later, running the risk that irreparable damage could be done, which would be a death sentence? Maybe there’s something else to do.
I know that the loop of small bowel that I’ve freed from adhesions is dilated which means it’s proximal to the point of obstruction. The bowel in the midabdomen is not dilated and thus is beyond the obstruction. What to do? Maybe a bit of probing will help. That’s what doctors are supposed to do best. I stick my finger into the hole in the dilated bowel and feel downstream.
Yes, there is a definite tight stricture, a narrowed area which is most likely responsible for the obstruction. But how to fix it? My finger tells me that the stricture is fairly short, less than two centimeters. I ask for a GIA stapler. This is a device which places parallel rows of staples and cuts the tissue in between, closing off where the staples are fired, while opening in between. GIA stands for gastrointestinal anastamoser, or something like that. I pass the one side of the stapler through the stricture and leave the other on the obstructed side, this all being done through the hole I previously made in the dilated bowel. Once I’m sure everything is positioned properly I fire the stapler, performing what is properly termed a “stricturoplasty.” Looking inside the bowel I see each staple line is where it should be and no bleeding. I feel the area of the stricture and it’s gone. Success, I hope. Now it’s just a matter of closing the holes I’ve made and keeping my fingers crossed, praying that everything will heal.
I finished this impossible ordeal in about three hours. Now I will have to wait to see if anything I did actually works. Have I relived her obstruction? Will she heal the “stricturoplasty”? Will she heal the intestinal closures. Will she ever be able to eat normally? There is plenty to worry about; everything about this case has been a compromise and is far from perfect. Normally, I would take down all the adhesions on a case like this, doing my best to be sure there are no unseen points of obstruction. Also, our bowels are not passive conduits. They are muscular tubes constantly contracting and moving. Repairing holes in bowels which are encased in adhesions allows for increased tension on the closure and, subsequently, increased risk of breakdown and development of a fistula. A fistula is an abnormal communication between two structures.
I’ve been toiling away at surgery for almost thirty years and this is the first time I ever found myself in such a difficult situation. Maybe I’ve been lucky, maybe it’s been good planning, but I cannot recall any other case where there were no good intraoperative options, where it was impossible to back off and look for an alternative treatment, while going forward threatens to create bigger problems.
I suppose this case really did have options, but none of them was particularly satisfying. Even my final solution was fraught with danger, running the risk that she may still be obstructed with a high likelihood she will develop a fistula; I’ll just have to wait and see if I did Lucia any good.
“To cut is to cure” goes the old saying, but for Lucia I’m not so sure. In retrospect her troubles started years before I ever saw her and my part in her care is only the end product of her disease process and previous treatment. Even so, the case leaves me with the feeling I could have done better.