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.