Wednesday, August 26, 2015
It was 4:45 on a Wednesday afternoon, clinic had just finished and I’d be on my way home in fifteen minutes, unless…
Rats, it’s the emergency room.
“Dr. Gelber, we’ve got an 85 year old lady from the county nursing home with a distended abdomen. Could you come and take a look at her?”
So much for going home on time. You think they could have waited fifteen minutes.
I made my way to the surgical side of the ER and found Madge. She was a wrinkled old lady, weighed in at 102 pounds, white hair, black glasses which magnified sharp blue eyes. Her most distinguishing feature at that moment was a belly that was the size of a medicine ball.
“Hello, Ms. W, I’m Dr. Gelber. How long has your abdomen been so blown up?”
“Glad to know you Dr. Gelber. Call me Madge. This old belly’s been growing for the last five days. I think it’s a boy.”
“Well, Madge, I think we’ll need to deliver it soon,” I answered. “Are you having any pain, nausea or vomiting?”
Her look turned a bit serious as she answered, “Mostly pressure, not really pain and a little nausea. And, I haven’t pooped in a week.”
“Passing anything out? Gas, diarrhea?”
“Nope, not a toot or tweet for five days.”
She had a collection of associated medical problems, typical for your average octogenarian. She had a little hypertension, a bit more congestive heart failure, atrial fibrillation, myocardial infarction a year ago, previous hysterectomy, nothing unusual, but enough to cause the Cardiologist to say she was at considerable risk for complications. She had mild abdominal tenderness, but her abdomen was tight as a ripe watermelon and about the same size. Her heart was beating at a rate of 124, blood pressure was 85/50.
Plain abdominal X-rays revealed massively dilated colon. In particular, the cecum (first part of the colon) measured eighteen centimeters in diameter, well beyond the 12 centimeter diameter when one begins to worry about it bursting.
I called my Chief resident, Dr. J, who deferred to the Chief on call, Dr. B., who came to see the patient and then disappeared. In the meantime I did all the paper work to get Madge admitted and prepared to go to the OR.
Her diagnosis was acute large bowel obstruction.
“At last I get to be around some young blood,” she commented as I finished my H&P. “All the men at AHP (the nursing home) are wet noodles, if you get my drift; you know soft and limp. Maybe, when I’m better, you can show me around the hospital, Dr. G?”
“Let’s get you better first. But, I don’t think my wife would appreciate me carrying on.”
“She’d never know. Besides I don’t see any wedding ring.”
I glanced at my naked finger.
“I don’t wear it. Too much taking it off and putting it on. I’d lose it in a week.”
Dr B. returned and he said a cecostomy was in order, under local anesthesia.
“I guess you talked to the Chief?” I asked.
Our Chairman, Dr. Di was a staunch proponent of cecostomy in this situation.
We took her up to surgery and performed the cecostomy, which means decompressing her cecum by placing a tube into it, under local anesthesia. The cecum was massively distended with the muscle fibers of the outer layer split apart by the distension, but there was no gangrene or perforation. It was the size of a volley ball. After it was decompressed it looked much healthier. The tube was left connected to a drainage bag and Madge went to the ICU.
Her journey was just beginning.
Over the next forty eight hours she stabilized. Her vital signs, renal function, lab abnormalities all normalized. She was ready to embark on the next stage of her odyssey.
The next step was to figure out the cause of her severe distention. Based on the tests that had been done, the assumption was that she had a mechanical obstruction on the left side of the colon. The most likely causes would be a tumor or narrowing secondary to diverticulitis. There was an outside possibility she had suffered from Ogilvie’s syndrome, otherwise called colonic pseudobstruction, although the initial X-Rays were more suggestive of a mechanical cause.
She was wheeled from the ICU to Radiology where she underwent a barium enema (BE), a test where a radiopaque dye is instilled into the colon and X-rays are taken at various points. This provides information as to the length, contour of the colon, demonstrating areas of narrowing (stricture) or dilation. Large tumors also can be seen with this test. Madge’s BE revealed an abrupt termination of the column of dye in the distal sigmoid colon.
“She’s going to need another operation,” I told Dr. B.
“Try to prep her using the cecostomy and we’ll try to do her surgery in three days.
It fell on me and my junior residents and interns to begin to flush her colon with saline every few hours, attempting to clean the abundance of stool trapped within the obstructed colon. The hope was that a clean colon would allow for a single stage resection and anastamosis, avoiding a colostomy and the necessity that she wear a bag.
It was a tedious job. Instill a few hundred cc’s of saline and let it drain, add some more and let it drain. At first it seemed hopeless as we kept getting some light brown saline, but little else.
Through it all Madge managed to keep her sassy edge.
“You know, Dr. G, when I’m all better and back at the home you should come and see. I’ve got my own room and it’s so cold and lonely at times. All the men there are just wrinkled old prunes.”
“Let’s just get you well first, Madge,” I answered.
“Oh, I’m not worried about that. You doctors here are so hard working and caring and conscientious. Some are pretty sexy, too. I know I’ll be back on the dance floor in no time.”
“Were you a dancer, Madge?”
“Third prize in the Queens borough ballroom dance off 1919. Leon and me knocked them over with our cha cha. Poor Leon, he was killed a few years later; run over by a horse. He was the love of my life, definitely not a dried up prune or a wet noodle, if you get my drift.”
I smiled at her as I finished my flushing of her colon.
“One of my interns will be back a couple of hours. Sorry about Leon.”
She didn’t answer. She was staring off at nothing, a smile on her face, lost in memories of Leon and happier days.
After four days and flushing and draining, flushing and draining we pronounced Madge clean. By we I meant my Chief resident, the Chairman of Surgery, myself, the second year resident, the intern, four ICU nurses, the custodian and two cockroaches who called the ICU home. Her surgery was scheduled for the next morning.
It was a big event. Dr. B was operating with the Chairman, with the intern and second year resident on hand to provide proper retraction. I was left out to hold down the fort in the rest of the hospital, but I managed to hover around the OR to see what was happening.
The surgery started uneventfully, but, as the colon was examined the surgical team was greeted by a left colon full of solid stool. The plan for a single stage resection and anastamosis faded away in a column of poop as they went to plan B.
Madge’s sigmoid colon was resected, the end was brought out to the skin as a colostomy and the distal colon was closed off and left in the pelvis, a so called Hartmann’s pouch.
Madge came through the surgery without a hitch and was wide awake and ready to flirt when I saw her on afternoon rounds.
“Did you guys give me a nice flat tummy? I want to look good in my string bikini this summer,” she quipped.
“You’re already nothing but skin and bones,” I answered, “but you do have a colostomy now, at least for a while.”
She gave us a pout and look of disappointment, followed by a shrug of her shoulders as we continued on rounds. She had completed stage two of her journey.
Her recovery was uneventful and she was back tormenting the male residents of the nursing home in a little more than a week. She came back to the clinic a week later where she was seen by one of the interns.
“An ole lady named Madge is asking about you, Dr. G,” Intern reported. “She says you missed ballroom night at the nursing home.”
I made my way into her room.
“I really can’t dance, Madge,” I confessed. “Dr. B, now he can dance.”
“Well, I guess we can skip the dancing and go straight to bed,” she propositioned.
“I think you’re more than I can handle, Madge.”
And, she went on her way.
She made a second appearance in the clinic a month later, looking quite well, eating, walking, she even gained three pounds.
“When can I get fid of this shit bag?” she asked.
She was now about six weeks post op and she still had the cecostomy tube, which was clamped.
“Let’s get your colon checked and then we can think about reversing the colostomy,” I explained.
“Good, the sooner the better. Even the old prunes at the home won’t give me the time of day with this bag.”
I set her up for a colonoscopy the following week, to be done by me, one of the last colonoscopies I ever performed.
As she was wheeling back to the endoscopy suite she remarked:
“You really know how to show a girl a good time.”
I smiled, “We’ll take good care of you Madge and we’ll get you all put back together as soon as we can.”
“I like a man who whispers sweet nothings …” and she was out.
The colonoscopy was uneventful, revealing diverticular disease in the descending and proximal sigmoid colon. She was scheduled for reversal of her colostomy ten days hence.
“We’ll leave her cecostomy for now. It may add a bit of protection for her after the colostomy reversal,” my Chief decided.
At 7:15 am ten days later Madge was rolled into OR room 12. Miss C, our cranky, dour, and very experienced circulator and Mrs. J, our equally skilled scrub tech made up our crew along with Dr. B, me and one of our interns. The Chairman, officially the Attending surgeon on the case, sat nearby in the OR lounge. Dr. B was in the last month of his residency and was functioning independently and was acting as teaching resident on this case. I was to be the surgeon of record.
And so it started. A midline incision was made and we entered the abdomen, greeted by a few adhesions to the abdominal wall which were quickly and easily dispatched. The small bowel was examined and packed out of the way. The colon leading to the colostomy was identified and freed from scar tissue. All that remained was to find the other end of the colon, dissect enough of it so that the two ends could be connected.
It was like running into a stone wall. Madge’s pelvis, where the elusive segment of colon resided, was socked in, a mass of adhesions with tissues more resembling concrete than colon.
Where’s the colon?
Where’s the bladder?
Where are the ureters?
Where, oh where will I dissect next?
“Let’s find the ureters first,” I announced to no one in particular.
“Good plan,” Dr. B responded.
Starting higher up in the abdomen away from the dense mass of pelvic scar I began my search. The proximal colon which led to her colostomy was freed from adhesions first. Behind was a mass of small bowel. I commenced the tedious dissection of this small bowel.
“Do you really need to free up all the small bowel?” Dr. B asked.
“You know the rules: either you leave it all alone or cut away all the adhesions,” I recited.
“Ok, Ok,” he answered.
Like the barber/surgeons of old I began to snip and trim, starting where it was easy and them moving along centimeter by centimeter until, an hour and a half later, all the small bowel was free.
This actually was very helpful. Some of the bowel, as expected, had occupied the pelvis and now it was liberated and safely tucked away in the upper abdomen.
(I have to comment on my terminology, specifically the term liberated. It’s a bit tongue in cheek. I remember reading an operative note for a colon resection. The surgeon dictated that “the splenic flexure was liberated…” I immediately had visions of colons running through the streets chanting, “I’m free, I’m free…” the term “liberated” in this context always brings a smile to my face.)
Progress was slowly being made. With small bowel out of the way, the ureter was easily identified. The foley was palpable within the bladder and careful dissection behind the bladder revealed a staple line; the staples within the closed off end of the colon.
“I think I just need to dissect enough to be sure that there is only colon, no vagina or bladder”, I concluded.
My Chief disagreed.
“You need to be sure it is free enough so there is not tension and adequate blood supply,” he answered.
I disagreed, believing that the more the distal colon was dissected, the greater the likelihood that blood supply would be compromised or a nearby structure would be injured. But, I complied with his wishes. He was, after all, more senior, more experienced and had the power to make my life miserable should he so choose.
With the ureters safely in view and the bladder now out of the way I worked on the colon and rectum.
First, straight down to the sacral prominence, a safe area where there were no vital structures. Then in front of the colon, separating it from the posterior vagina.
“Is this free enough,” I wondered out loud, clearly conveying my view that it was more than enough.
I received nod of acquiescence.
The colostomy was quickly freed from the skin, the actual stoma was resected (removed) to provide a clean end to anastamose to the distal colon. It was immediately apparent that the two ends would not reach each other. More dissection of the left colon followed, which meant liberating the splenic flexure (there’s that image again) which allowed the two ends to meet.
“Use the EEA?” I asked, requested, implored.
“Hand sew. You know what they’ll say in conference,” Dr. B replied, alluding to the required presentation of the case at one, or several, of our weekly meetings where the cases done that week were presented and discussed.
“And, I’ll take the heat,” he continued, “not you.”
“Ok, I’ll sew it. But it won’t be easy. We’re pretty far down in the pelvis.”
I did my best to put the two ends back together. First the back wall of interrupted silk sutures, then the inner layer of continuous Vicryl, an absorbable suture material, and, finally, the outer front layer of silk.
Each suture placement was a chore as I endeavored to be precise; to be sure I caught the full thickness of the bowel wall, while not compromising the lumen diameter. When I finally finished, something just didn’t feel right.
“You know,” I commented, “something isn’t right. I just can’t be sure that the two ends have come together properly. Do you think the cecostomy will provide some protection for the anastamosis?”
“You know it won’t,” Dr. B replied.
“Well, I just don’t trust my anastamosis. Maybe we should do a proximal colostomy?” I wondered out loud, a bit facetiously.
Dr. B didn’t say a word at first. I suspected he was wondering if he should call the Dr. Di, the Chairman of the Department and the official Attending on the case.
“I’ll be back in minute,” he said and he broke scrub.
“Dr. Di agrees. We should do a transverse colostomy,” he announced when he returned.
While he scrubbed his hands again, I mobilized the right transverse colon and we created a transverse loop colostomy, fashioned so that it functioned to completely divert the fecal stream away from my pelvic anastamosis. We closed Madge up and she woke up without a problem, after five hours of surgery.
She sailed through the post operative recovery. Stage Three was over. She still wasn’t finished, however. Now she sported a tranverse colostomy and the cecostomy was not completely closed either. She was going to need at least one more surgery.
A month later I was walking past one of the exam rooms in the surgery clinic when I heard a familiar voice.
“There goes my young stud,” she cackled.
I made an abrupt U turn and went into the room where Madge was being checked by one of the interns.
“You know I’d be with you in a minute, Madge,” I answered, “but I’m spoken for.”
“Another broken heart,” she replied, “and I’m stuck with dried up prunes. And, I still have to wear this bag.”
“Let’s see,” I mused as I perused her chart, “it’s about six weeks from the last surgery. I think we may be able to do something about that in the next few weeks.”
I was Chief Resident now, so I went to talk with Dr. Di., who agreed Madge could have her next procedure in two or three weeks.
I examined her again that day. Her midline wound was healing well, the colostomy looked pink and healthy, but the cecostomy site still had not closed completely. There was a five millimeter open wound with some mucus draining.
“It’s getting smaller,” Madge commented, “doesn’t hurt a bit.”
She was scheduled for the seventh, which was in three weeks. Orders were written and she went on her way, with plans to be admitted to the hospital on the sixth, the day before surgery, when she would have all the necessary preoperative preparation.
The big day came and Madge said she would be happy to be rid of the bag. Of course she took the opportunity to offer herself to me one more time.
“After this surgery you must stop by and see me in my rook over at the home, Room 202. Every night it’s the same routine: dinner, television, the sounds of arteries hardening and saliva dribbling. Come by and see me. We can go dancing.”
And she winked at me as she was rolled into Room twelve.
This surgery was a straightforward closure of a loop colostomy. The actual surgery was done by my fourth year resident with me acting as teaching assistant.
The incision was made around the stoma and the dissection carried down into the subcutaneous tissue.
“Did you take your slow pill today?” I wondered out loud. My junior resident, Dr. T., was moving like a glacier, one cell layer at a time.
“Open your eyes and see,” I suggested. “There is a plane of dissection between the colon and the subcutaneous fat. The mesentery and the subq fat look different and, look, god has left a white line which says ‘cut here’.”
With a bit of guidance the fascia, the layer below the fat was finally reached.
“Now, dissect along the fascia so that the colon can be liberated (there’s that word again),” I instructed.
My words were greeted by a lost stare out into space.
“Right angle clamp, please,” I requested.
I hated to do it, that is take over the dissection, but, poor Madge was not getting any younger.
I dissected the colon free from the fascia using the clamp, allowing my junior resident to cut in between the jaws of the clamp, which provided some semblance of “doing the case.”
The colon finally free, it was delivered up into the wound and continuity restored via a two layered, sutured, side to side anastamosis.
“What next?” I asked as the fourth finished tying the final silk suture.
“Put it back inside, close her up and then make rounds?” he answered.
“Well, some people would consider that a right answer. If I were actually doing the surgery, I would tack some omentum over the sutures lines. It adds an extra layer of protection, although the way Madge handles surgery, I think you could have used paste to put her back together and it would have healed just fine.
The surgery finally done, after four tedious hours, Madge was tucked away in the Post Anesthesia Care Unit and proceeded through another smooth and uneventful recovery.
She did manage to proposition me on a daily basis until she was discharged once again.
I thought she was done with surgery. Four stages for the treatment of a colon obstruction was a bit unusual. One of the frequent discussions/controversies in general surgery was how to handle acute large bowel obstruction. Should it be a one stage procedure with resection of the offending segment of colon coupled with some sort of on the OR table bowel cleansing, a two stage procedure with resection of the diseased segment and creation of a temporary diverting colostomy, followed by a second operation to restore colonic continuity, or a three stage procedure with an initial diverting colostomy, a second operation to remove the cause of the obstruction and then a third procedure to reverse the colostomy.
Dear Madge had undergone four stages.
I saw Madge in the clinic a week later, healing quite well, eating normally, having normal bowel movements and overall quite satisfied. Her only complaint was persistent drainage from the cecostomy site.
“It should close, just give it some time,” I reassured her.
“I’m sure it will, Dr. G,” she replied and then she smiled at me. “of course, It might be best if you came to check on it over at the home a couple of times a month.”
I smiled back. Good old, dependable Madge.
“I think your coming to the clinic will be adequate,” I answered.
“Stuck with all the old prunes,” she murmured.
I saw her again a month later. She was still draining from the cecostomy site. As a matter of fact, the open area looked larger, with a bit of intestinal mucosa poking out.
“It looks like you’ll need another surgery to close up the cecostomy,” I informed her.
She shrugged her shoulders and nodded her approval. Then, as if sensing some disappointment on my part, she added, “Can I have a private room this visit? One never knows when a handsome young red headed doctor will come calling and try to take advantage of a girl.”
I smiled and said, “See you next week.”
The surgery came and went off without a hitch. My second year resident performed the surgery while I acted as teaching assistant.
We dissected around the cecum, following it down to the fascia, cutting away all the scar tissue and, finally, delivering the cecum into the wound. There was a 1.5 cm hole which was closed in two layers, then reinforced with a bit of fat before it was dunked back into its rightful home within the peritoneal cavity. We closed her up and she went to the PACU, for the final time, I hoped.
Sure enough, except for shifting her affections from me to the younger and handsomer junior resident, her post operative recovery was smooth sailing.
“I’m a little disappointed, Madge,” I explained to her on the day she was discharged, “you seem to have shifted your amorous affections from me to Dr. K.”
“Well, Dr G., I’m not getting any younger. You had your chance and you blew it. Besides, Dr. K is really hot,” she answered.
“Good luck, Madge,” I responded. “And, I say this with all affection, but, I hope I don’t ever see you on my OR table again.”
She smiled and nodded her understanding, but then added, “Do you have Dr. K’s phone number?”
“You’ll have to ask him yourself. I’m sure he’ll be around to see you before you leave.”
She sighed and then added, “I guess it’s back to the prunes.”
I did see her back in the clinic about a week later, one last time. She healed without a problem and thanked me for helping to save her life.
Her case had been different than most. There was no discussion about one stage, two stage or three stage procedures.
Madge had undergone a five stage procedure.
A few weeks later I had a meeting with our Chairman, Dr. Di, and I brought up her case.
“Remember Madge, the old lady who had the large bowel obstruction and had the five stage colon resection?” I asked the Chairman.
“She was a rat,” he answered, his response taking me by surprise.
“I thought she was very nice,” I answered.
“I don’t mean a rat, as in James Cagney, ‘you dirty rat’, sense,” he said in his grandfatherly tone. “No, I meant she’s a rat because she could be operated on over and over and never turn a hair.”
He explained further.
“Years ago there was an experiment done. A number of rats had surgery, all the same sham operation. After the first operation, some of the rats died. The survivors were operated on a second time and a few more died. The third time a few more. But, after a number of operations some of those rats just went on like nothing happened. You could operate on those rats every week and they wouldn’t turn a hair. They just woke up and went on their way.
“Madge was a one of those rats.”