Saturday, May 9, 2015
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.