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.