Sunday, October 18, 2015
I met Alice almost by accident. Sunday morning rounds were nearly completed when I passed Dr. T. in the hallway. We exchanged pleasantries and then walked on in opposite directions. But, seemingly as an afterthought, he called out.
“”Do you think you can go by and see a patient for me? Her name is Alice. She’s in room 402. She’s in the hospital with constipation and she’s pretty distended. I plan a colonoscopy tomorrow, but, maybe, just give her a quick look. She had a CT that just showed constipation.”
“Sure,” I replied, “I’m going in that direction anyway.”
Alice was petite, weighing in at 98 pounds and she certainly was distended, almost like she was about to deliver twins. She was 46, had always had “bowel trouble,” had previous back surgery and was on chronic pain medication, taking Percocet several times a day. She had not had previous abdominal surgery.
“Does your abdomen hurt?” I began.
“All over, but the Dilaudid helps,” she replied.
“When did the pain start?”
“About three weeks ago, but it got worse three days ago.”
“When’s the last time you had a bowel movement?”
“Nine weeks before I came into the hospital.”
I had to stop for a moment to completely absorb this statement.
I think this is a record.
“Did you say nine weeks?” I asked again.
“Yes, nine weeks.”
“…and you’ve been here three days, so it’s been nine and half weeks since you had a BM? Is that unusual for you?”
“Normally I go every three or four days. I did start to panic after a week, but I didn’t know what to do.”
“Are you able to pass gas?”
“I’m not sure.”
“Let me check your abdomen.”
She was extremely distended and had diffuse tenderness, and some signs of peritonitis, particularly tenderness to light percussion on the right side of her abdomen.
“I’m going to look at your CAT Scan and then I’ll be back.”
So much for getting rounds done at a reasonable time.
The CT Scan done the day before revealed just what one would expect in patient who had been constipated for nine and half weeks. The colon was dilated, filled with stool, but not much air. The cecum, the first part measured ten centimeters, approaching the diameter where blowout becomes a concern. The dilated colon stopped in the mid sigmoid colon, which is just above the rectum. There was no definite tumor or mass, but there was a definite transition point from dilated to collapsed colon.
I checked her labs next. Her white Blood Cell Count had been slightly elevated at 12,000 the day before, but today it had jumped up to 35,000. Her bicarbonate level was 14, which is low, normal being around 25. Low Bicarbonate suggests metabolic acidosis, a sign of severe metabolic derangement and sepsis.
Taking everything together there was no question. She needed surgery. She either had perforated her colon or she had dead or dying colon. Either way it was a life threatening surgical emergency.
Of course, Sunday is not the best day to get anything done quickly. There were a series of Orthopedic cases scheduled already.
“I need to do this lady soon,” I explained to the crew.
“It looks like you’re in luck. Dr. R. just cancelled his last two cases and we are finishing up with him now,” the OR nurse reported.
I explained my findings and concerns to Alice and her family, put her orders in the computer and waited for the OR crew.
Maybe just a colostomy will suffice. But, it would be better to eliminate the cause of the obstruction. Quick and simple will be best for her.
After about 25 minutes Alice was wheeled into OR room ten and was asleep a few minutes later.
A midline incision through the taut abdominal wall brought me into her abdomen which was filled with a few hundred cc’s of slightly cloudy yellowish fluid. I could see that the sigmoid colon was massively dilated, but it was not gangrenous. There was a faint, pungent odor.
Looks like I should be able to remove the offending portion of colon.
I could see where the colon transitioned to normal caliber just above the pelvis. I began to mobilize the colon by dividing the peritoneal attachments that tethered the sigmoid and left colon.
“Feels like there’s a hard mass in the colon causing the obstruction,” I observed out loud to no one in particular, my assistant nodding her head,
I should be able to get this colon free and then…
Before I could finish this thought the dam busted and I was suddenly up to my elbows in thick, liquid stool.
“Suction, lap, more laps, more suction.”
The suction became plugged with stool. I squeezed the colon closed with my hand and it fell apart. Like The Blob from the 1950’s or the river of slime from “Ghostbusters” liquid stool took over.
“I need an intestinal clamp, something atraumatic,” I said loudly.
The circulator scurried out of the room and came back with the GI instruments. In the meantime I had managed to isolate the source, rather the sources of the river of stool and began to get at least a semblance of control.
The evil culprit rears its ugly head.
“There’s a big rock of poop causing the obstruction,” I noted.
Indeed, this “fecaloma” had completely blocked the sigmoid colon and eroded into the wall of the bowel, setting a trap for me as I mobilized the colon. As soon as the colon was free it exploded, releasing its noxious contents. The resultant inundation left poop everywhere, on every loop of bowel and filled the pelvis.
With the proper intestinal clamp in hand I stemmed the flow and went on with the resection. I had to make two passes with the GIA to divided the dilated bowel while there was no difficulty dividing the distal colon, stapling it closed with the RL60 stapler.
I finished resecting the sigmoid colon and examined it on a separate table.
This colon is as strong as soggy Kleenex.
“Uh, Dr. Gelber, I think there’s a problem here.”
Liquid stool was filling up the abdomen again.
I hurried back to the cesspool which was Alice’s open belly and valiantly struggled to stem the flow again. The staples had not held the friable colon together. Once again, we went to work, sponging and suctioning until I could see enough to mobilize the colon away from its usual position on the left side of the abdomen, find the hole and carefully put a clamp across it.
This time it held, at least enough to allow me to get my bearings and assess the situation in a calmer, more orderly manner. I made a closer inspection of the remaining bowel.
The right side of the colon didn’t look very good either. Muscle fibers in the cecum were split under the tension caused by massive dilation, the ascending colon had patches of frank gangrene as did the splenic flexure.
It all needs to come out.
Back to work. I began by dividing the attachments to the cecum and was then able to liberate the hepatic flexure with minimal fuss and the remainder of the colon followed until everything was free. I zipped through the mesentery with the Ligasure and before long the colon was resting in a large basin on the back table. At this point we all changed gowns and gloves and tried to put banish the pungent odor from our nostrils. Even with benzoin (a fragrant compound often used in surgery) on our masks and repeated washing of hands I knew that the fine aroma of stool and dead bowel would linger with me for the rest of the day.
This nasty beast has been far too much trouble. Time to finish this case.
We spent the next twenty minutes washing, washing and more washing. Liter upon liter of warm saline was poured, sprayed, percolated and pumped into every nook and cranny of her abdomen. We squirted irrigation fluid into the pelvis, above the liver, around the spleen and between every loop of bowel until the fluid came out as clean as it went in.
Finally, I brought the end of the small bowel out as an ileostomy, took one more look around her belly and closed her up. Ensconced safely in the ICU, I washed my hands one more time, wrote orders, dictated the op note and, last of all, told her family the sordid tale of her surgery.
I called Alice’s Attending physician and consulted one of the Pulmonary docs, checked on Alice one more time and finally left the hospital for the day.
Alice was kept on the ventilator, she was very slow to wake up from anesthesia and her blood pressure hovered in the 80’s; occasionally dipping into the 70’s. A massive volume of IV fluid and support with Levophed and Vasopressin were necessary to maintain an acceptable blood pressure. (These two medications help maintain vascular tone, which helps maintain blood pressure in patients with septic shock). Her kidneys started to shut down, but timely adjustment of her fluids and medications by a Renal consultant turned this around.
The following day she looked a little better, more awake, good urine output, but still requiring pressor support with Levophed and Vasopressin. She continued to smolder along over the next 48 hours, neither improving nor deteriorating. I became a little concerned about her abdomen at this time as it became more distended and the ileostomy stoma looked dark purple instead of pink. Her lactic acid level rose to a very high 14, a sign of worsening acidosis, which indicated seriously poor perfusion of something and worsening sepsis. Although she maintained adequate blood pressure and kidney function, it became clear that something was amiss or amuck or afoul.
Alice was taken back to surgery.
The previous wound was opened and a couple of liters of clear fluid was drained.
That explains the abdominal distention.
In the lower abdomen there was some cloudy, foul smelling fluid. As I gently freed up the small bowel and delivered it out of the abdomen I discovered the new source of Alice’s woes. The distal small bowel was dead, not completely, but patches had frank gangrene. I resected about 25 centimeters of terminal ileum and redid her ileostomy.
She also had a portion of abdominal wall which was dying and this also was excised. I put her back together as well as I could and delivered her to the ICU and hoped for the best.
The next twenty four hours brought hope as she required less support with the pressors. However, she didn’t wake up.
The following day came with new events which proved to be too much. She began to have cardiac arrhythmias, frequent Premature Ventricular Contractions (PVC’s) and runs of, Atrial flutter and Ventricular Tachycardia. The Cardiology consultant added his words of wisdom to the already exhaustive list of consultants.
“Acute MI,” he said with a solemn expression on his face. “Ejection fraction is only 30%,” he said shaking his head.
She’s not going to make it.
Alice continued along for a couple of more days, but she didn’t wake up, her kidney function gradually declined and her family wisely withdrew support, allowing her to pass away.
I wish I could report that timely surgery had rescued Alice. I don’t know how many similar patients I’ve taken care of, how many times I’ve told families “We’ve eliminated the source of infection; the perforation, the blockage, the gangrene, the abscess; now it’s time to heal.”
Very often it’s this healing phase which proves to be too much. Organ systems which have suffered the supreme shock of serious systemic infection are unable to recover and gradually shut down. The initial sepsis leads to what is called multi organ system dysfunction which progresses to multi organ failure which often leads to death.
After I finish operations such as Alice’s I’ve learned not to say: “Alice (or Andy or Mabel or anyone) will be better now.”
I’ve learned that the human body often does not suffer lightly intrusions by combinations of bile, blood, GI contents or urine mixed with microorganisms which thrive in such an environment. The body does its best to fight such invasions and may be successful. But, sometimes as the battle is fought and the war looks like it will be won, the body dies.
And, nine and a half week’s worth of poop is more than most of us could handle.
Tuesday, October 13, 2015
I have, on occasion, described the perfect surgical practice as one where one operates every day, performing a wide variety of cases, while never having any patients in the hospital. Perhaps this fantasy is a bit facetious. Boiled down it means that the surgeon gets to perform the most interesting part of surgery, that is the actual operation (unless it’s a vein stripping) while never having to deal with the more mundane and frustrating aspects of the surgical practice, such as dealing with a draining wound or impatiently waiting for the post op ileus to resolve.
There is one aspect of the surgical practice, even a perfect one, which is absolutely necessary: the office.
In the office new patients are seen for the first time, evaluated, examined, treatment options explained and discussed and decisions made. Patients recovering from surgery come to have their wounds checked and concerns addressed:
“When can I go back to work?”
“When can I drive?”
“What can I or can I not eat?”
“When can I start having sex?”
“Will this lump go away?”
“Is it supposed to be numb?”
“Do I have cancer?”
Each question is patiently answered, worries and fears are laid to rest, as the patients make their way down the path towards recovery.
Most clinic days are a predictable mix of patients who suffer from hernias, gallbladder disease, lumps, bumps and pockets of pus, with an intermittent spattering of thyroid conditions, gastrointestinal masses, hyperparathyroidism and other less common ailments.
There was a day however when my office patient was filled with a stream of colorful patients. I should have known something was up when I saw the name of the first patient:
Hazy Racy Autumn.
Unusual name…swollen groin…here I come, Hazy.
I knocked on the exam room door and went in.
“Ms. Autumn? I’m Dr. Gelber. What brings you in here today?” I began.
I’m not sure how to describe Hazy Racy Autumn. She was tall, taller than me and her height was accentuated by a tall furry hat perched upon long blonde hair. She looked to be the forty years she had reported on her history form. She had a long silken blue and pink housecoat on and fuzzy Winnie the Pooh house slippers on her feet.
“Racy, please,” she replied as I shook her hand.
“Ok, but what brings you in here?”
“Dr. N. said it was my nose; my limp nose.”
Her nose looks OK to me. Besides, I’m not much of an ENT doctor. Limp nose, swollen groin…lymph nodes.
“You mean your lymph nodes, I think,” I explained.
“That’s right. Lymph nodes. Under my arm and in my groin. There swollen according to Dr. N.”
“Is that why you went to see him?”
“Three months ago. He gave me antibiotics and then more antibiotics, but the swelling is still there.”
We went through the rest of her unremarkable medical history and then it came time for me to examine her. I’d already noticed that her submaxillary glands looked enlarged, giving he a little bit of a chipmunk look.
“Put this on so I can examine you,” I requested, handing her one of our cheap paper gowns.
“Oh, I don’t need that,” she decided as she jumped up on the exam table and opened her housecoat, which revealed Hazy Racy Autumn and nothing else.
She had neatly trimmed her pubic hair into a blonde replication of Adolph Hitler’s mustache, the remainder was clean and smooth.
I saw Miss Autumn in the early 1990’s, a time when the current custom of clean shaven pubic areas was not in vogue. The only women who regularly shaved “down there” were strippers and hookers. Perhaps I was presumptuous to assume that Ms. Autumn was in one of these lines of work. My inquiries as to what she did for a living were answered by a vague, “I work from home” response.
I proceeded with my exam, noting multiple enlarged nodes in each groin as well as each axilla, all 2-3 centimeters in size.
“I think we should take out one of these lymph nodes. That’s what Dr. N. wants me to do and I agree with him,” I explained.
“Is it something bad, Doctor?”
“Well, I worry that it could be lymphoma, a cancer of the lymph nodes, but there are other less serious possibilities. The simplest thing would be to biopsy one of the groin nodes. Do you want to have that done?” I asked.
“Yes, yes, of course,” she replied with a shrug.
I finished my exam and explained the procedure and Hazy Racy Autumn was scheduled for a lymph node excision two days hence.
A fine start to the afternoon. What’s next? J.F. Romanov, lump on foot and buttock.
I picked up the chart, knocked and went into the next exam room.
“Ms Romanov?” I asked, “I’m Dr. Gelber, what can I do for you today?”
“Hello, Doctor,” she answered with a bit of an accent, holding out her hand. “I am glad to meet you.”
She was stocky, didn’t wear any makeup, and had dark brown hair with wisps of gray which was tied back in a ponytail.
“I have a lump on my, what do you call it, butt and one on my foot. They do not pain.”
“How long have they been there?”
“About two months.”
The rest of her history was unremarkable.
“Ok, put this gown on and I’ll be back in a minute to examine you.”
I left her alone and sat at my desk and wrote out her history while she changed. When I’d finished I knocked on the exam room door and went in, with my Medical assistant, as always, in tow.
Ms. Romanov sat on the exam table, completely naked. My assistant handed her one of our paper gowns, which my patient loosely placed across her waist.
“Where are the lumps which you feel?”
“You Americans are always so ‘funny’ about nakedness,” she observed. “Let me show you what I can do.”
She shifted her legs up and down before deftly bringing each leg up and placed it behind her head as the paper gown floated to the floor; a remarkable demonstration of her flexibility.
“You must have been in the ballet to be so flexible,” I commented, doing my best to act nonchalantly.
“Ukrainian circus,” she answered. “But, you see the lump good, no?”
As she said those words I looked at her right buttock and, sure enough, her exhibition did demonstrate the outline of a mass in the right buttock, about 6 cm in diameter, mobile, discreet, almost certainly a lipoma.
“And, you see my foot, the left one?” she added.
I palpated the left foot and felt another mass on the lateral aspect, about 3 cm in diameter, likely a fibroma.
“Anything else?” I wondered out loud, referring to the physical findings. Ms. Romanov, however, interpreted these words differently.
She pulled her legs from behind her head and jumped on the floor and executed a handstand and began moving her legs back and forth in a scissors-like manner.
“I’m sorry, Ms. Romanov, I meant, do you have any other lumps that you are concerned about?”
She went back to sitting on the exam table and answered in the negative.
She related that she wanted to have the lumps removed and we set a date for her surgery. I left her to get dressed and went on to the next room.
Next was Karen Smythe, 58, breast cancer. She came with a mammogram showing a suspicious mass in her right breast and biopsy which revealed infiltrating duct cell carcinoma, the most common type of breast cancer. The mass appeared to be about 2.5 centimeters on the mammogram and there was an enlarged lymph node, also apparent on the mammogram.
“Good morning, Ms. Smythe, I’m Dr. Gelber. What brings you in here today?”
“Mrs. Smythe, my husband is Malcolm Smythe. He’s on City Council. Dr. Z sent me. She said there’s a lump in my breast,” she answered, her voice quiet, but steady.
“She’s right, there is a lump and I see they did a biopsy. Did Dr. Z tell you the results?”
“No, she just told me to come here.”
Great, I get to tell this poor lady, whom I’ve just met for the first time, that she has breast cancer. Here goes.
“Well, Mrs. Smythe, I’ve looked through all the reports and the biopsy show that the lump in your breast is cancer.”
“I’m afraid yes, it is.”
Her calm quiet demeanor started to change as tears welled up in her eyes. She did her best to compose herself as I handed her a Kleenex.
“Am I going to die, can it be treated?”
“It certainly can be treated,” I replied, “there are far more women living and walking around with breast cancer than die from it. Let me ask you a few questions.”
I took some more history and then left the room while she changed into an exam gown.
My heart sank a little when I looked at her breast. There was some retraction of the skin and dimpling over the area of the tumor. The mass was about three centimeters and there was a hard, but mobile mass in the right axilla.
Stage III at least. She’ll need chemo before any surgery.
“Mrs. Smythe, I think it might be best to have you see one of the cancer doctors, an Oncologist, before we think about doing surgery. Let me call one that’s on your insurance. I’ll be back in a few minutes.”
I called Dr. S and arranged for her to be seen that afternoon. We sent Mrs. Smythe away with some literature on breast cancer, instructions to call with any questions or concerns, and a box of tissues.
Something isn’t right when a patient has to first hear that he or she has cancer, particularly breast cancer, from a complete stranger, even if that stranger is a doctor.
I zipped through the next five patients who were all post op from hernia or gallbladder surgery.
I reached my last patient, Billie Jean Muller, 59, abdominal pain.
“Good morning, Ms. Muller, I’m Dr. Gelber. What brings you in here today?”
I’m not very creative with my introductions.
“Dr. M sent me. I’ve been having pain in my abdomen for a while.”
“How long is a ‘while’?”
“Ever since my hysterectomy.”
“And, when was that?”
“I wrote it down on the paper.”
‘I know, but I like to hear what you have to say. I find it helpful when trying to figure out what’s wrong; helps me do the right thing or order the right tests.”
This could take a while.
“Tests? I’ve already had every test. I’ve had CAT Scans, Ultrasounds, EGD, colonoscopy, HIDA Scan, and MRI’s. My gallbladder is gone, along with my uterus.”
I glanced at her history form.
“Your hysterectomy was eight years ago. Did the pain start immediately afterwards? Or a few weeks or months later.”
“I think it was immediately, or, maybe a month or two later. Then again, maybe I had the pain before that surgery.”
I need a different approach.
“Has the pain become worse recently? Why did you decide to come today?”
“Dr. M. told me you could help me. I guess he’s tired of seeing me.”
“Where is the pain the worst? Upper abdomen, around your belly button or lower down?”
“Lower down, I guess. It’s really bad when have to go to the bathroom. I have to push on the left side of my old hysterectomy scar or else it doubles me over.”
Really? Could it be something so simple?
Let me have you put this gown on so I can examine you, Ms. Muller.”
I gave her a few minutes to change.
“Let me check you standing up first. Can you cough?”
She gave a weak cough.
“A bit harder, if you can?”
Sure enough, there was a definite bulge along with the typical findings of a hernia. I finished my exam, not finding any other abnormality.
“I think you have a hernia, that is, I’m sure you have a hernia at the end of you hysterectomy wound. You will definitely benefit from having it fixed.”
I explained the procedure and surgery was scheduled.
Hazy Racy Autumn had an inguinal node excised which was benign, a reactive node. The enlarged nodes eventually were determined to be caused by Epstein Barr Virus, a benign condition.
J. F. Romanov had two lipomas removed. I did not get any more demonstrations of acrobatic ability.
Karen Smythe was treated with neoadjuvant chemotherapy which shrank her tumor to almost nothing. She underwent a lumpectomy and axillary node dissection months later and is still with us today.
Billie Jean Muller had an uneventful repair of her Spigelian Hernia. She did feel better, but still complained of some pain. She saw a Pain Management specialist who helped her get the pain under control.
All in an afternoon’s work.
Thursday, October 1, 2015
It was Friday afternoon and I was on call for the weekend. Dr. A. from the ER was on the other end of the phone.
I really don’t feel like working.”
“I’ve got a good case for you,” she began, “Mickey M., forty five, no medical problems has had abdominal pain for four days and CT shows a large amount of free intraperitoneal air.”
“Is he stable?” I asked.
“Vital signs are normal, no fever, white count is eighteen thousand, but…”
There’s always a but.
“…he weighs four hundred and ten pounds.”
“Okay,” I sighed, “I’ll be there to see him shortly.”
A good case?
I called the OR and scheduled him for surgery and then walked across the street to see Mickey.
At least he had the courtesy to come in at 1:30 in the afternoon instead of midnight.
Mickey was large in every sense of the word. He was six foot three, his belly was almost as tall as he lay on the ER stretcher, his face was flushed and he was a little sweaty and a more than a little short of breath.
His numbers didn’t look that bad: heart rate 90, Blood pressure 145/85, respirations 24, oxygen saturation 97% on room air, temperature normal. He had never had previous surgery, took no medications. He winced when I tapped his abdomen.
Besides the elevated white blood count he was anemic with a hemoglobin of 9.2.
The CT Scan of his abdomen revealed inflammation around the sigmoid colon with free fluid and air.
“Perforated colon,” I explained to Mickey, “which will need surgery today. Most likely the cause is diverticulitis, but it could also be a tumor. We’ll probably need to do a temporary colostomy also.”
“Whatever you need to do, Dr. Gelber, just make the pain better,” he answered.
Funny thing about peritonitis; nobody that truly has generalized peritonitis ever says “I don’t think I want any surgery.”
Mickey was wheeled into OR ten about an hour later. A generous midline incision was made and, upon entering the peritoneal cavity, the surgical team was greeted by the foul odor of stool and pus which began to well up into the wound.
Ah, the fine smell of festering stool. A fine way to start my weekend.
“Suction, cultures, more suction,” I called out as what seemed to be gallons of fetid, infected fluid were evacuated from his abdomen. There were thin adhesions between the loops of dilated small bowel which were broken with light finger dissection. This small bowel kept trying to insinuate itself between me and the source of Mickey’s woes. The inflammation led me deeper and deeper into the lower abdomen and upper pelvis until the culprit was isolated: a perforation in the colon at the rectosigmoid junction.
The small bowel was packed out of the way as I prepared to attack the evil villain who had fouled poor Mickey. The attachments of the left colon were divided to help me approach the area of perforation. As I carefully dissected, the small bowel decided it should try to help and escaped the barrier of lap pads which vainly tried to contain them out of my way. I packed the small bowel out of the way again, this time using a wet towel instead of mere lap pads. I next did my best to identify the ureter and I was pretty sure I saw it as I gingerly searched beneath inflamed layers of fat and fluid.
My hands, then forearms, elbows and almost my shoulders disappeared into the depths of Mickey’s abdomen as I did my best to dissect below the area of perforation.
Maybe I should have someone tie a rope around my waist so I don’t get lost in this pelvis.
“There’s a mass here,” I announced to no one in particular as I managed to bring the diseased segment of bowel out of the pelvis.
At this point the resection proceeded quickly. The proximal colon was divided with a stapler, I managed to get a stapler below the area of perforation and the bowel was divided and stapled closed. The mesentery, which contains the blood vessels, was divided with the usual clamp, clamp, cut and tie of most bowel resections and the rectosigmoid colon was removed, thrown on the back table to be examined later.
I checked Mickey’s abdomen for bleeding, looked at the ureter again and then washed out his abdomen with bucket after bucket of warm saline solution. Once I was satisfied that Mickey was clean I examine the resected specimen.
It was about twenty centimeters long. About five centimeters from the distal end there was a hole about one centimeter in diameter. There was a hard mass just distal to this hole. I opened up the bowel and saw the tumor, ugly, ulcerated, almost filling the lumen.
“Not good for Mickey,” I concluded. “Maybe all the stool in the belly killed any cancer cells that may have escaped.”
Time to get on with the surgery.
“Three O Prolene,” I requested. The blue Prolene sutures are used to tag the end of the rectum, making it easier to find should I came back in the future to reverse the colostomy Mickey was about to receive.
A colostomy is where the colon is brought out to the skin surface. Stool then passes into a bag, rather than its normal passage through the rectum and into the toilet. The bag is necessary because there is no sphincter muscle to control when and where the stool will pass.
Mickey stayed on a ventilator overnight. His recovery was remarkably uncomplicated, considering how sick he should have been, He left the hospital nine days after his surgery.
One week later he rolled into my office, smiling, feeling quite well.
“I feel great, Dr. G,” he reported, “no pain, everything’s working.”
“That’s great, Mickey. You look good,” I answered as I took out his staples, perused his colostomy stoma, and palpated his rotund belly.
“When can I get rid of this bag?” he asked.
“Well, you need to heal a bit more and I think you’ll need chemotherapy. The pathology report says there was cancer in two of your lymph nodes and the cancer was perforated. We’ll get you an appointment with Dr. H to get his opinion about chemotherapy. After you’re done with chemo, and assuming everything else is OK, we can schedule surgery to reverse the colostomy. I’ll see you again in about a month.”
And I sent him on his way.
Should be about six months until I have to tackle that belly again.
It was about 5 weeks later that Mickey’s wife called my office and reported that Mickey was bleeding from his colostomy, mostly dark blood, but sometimes bright red. As an afterthought she added that he was having intermittent drainage from the midline wound through a tiny, pinhole opening.
“Bring him in,” I responded.
An hour later the massive form of Mickey along with his diminutive wife graced exam room three.
“So, tell me what the problem is, Mickey,” I began.
“Just take a look,” he answered and he pulled up his shirt.
His colostomy bag was full of thin dark, bloody fluid. The skin was retracted, although he had done a good job of keeping his appliance in place. Adjacent to the colostomy his midline wound had a gauze dressing which was stained with yellow brown fluid.
“You’re right, you are definitely bleeding. When did this start?” I asked.
“Two days ago. I’m not having any pain, Oh, and the colostomy doesn’t stick out any more. It’s been quite a chore getting the bag to stay.”
“Well, I think you need to be back in the hospital; I’ll get the GI doc to check out your colon to figure out why you’re bleeding.”
Please be something simple, I’m not ready to attack Mickey and his bowels so soon.
As he stood up to leave I immediately figured out the problem. Mickey’s big belly hung down about eight inches below his belt line. Following his belly was his colostomy stoma, except his poor colon was tethered by its blood supply, causing it to pull on the skin. The stoma retracted under the skin while the blood vessels were stretched.
The final result was a portion of colon which was both congested and ischemic leading to the dark bloody drainage. The retracted stoma allowed the stool to collect beneath the skin level and form the sinus tract which was draining through his wound.
I shared my thoughts with Mickey and his wife and tried to formulate a plan to correct the problem, something simple I hoped. Alas, it was to be everything but simple.
Once he was safely ensconced on the surgical floor at the hospital, Mickey stayed mostly in bed and the bleeding abated. My friendly neighborhood Gastroenterologist was consulted and colonoscopy scheduled.
I sat at Mickey’s bedside and presented my plan to him and his wife.
“It’s a little earlier than I’d like, but the simplest way to fix this problem is to reverse your colostomy,” I explained.
They were both in agreement, his colonoscopy checked out OK and surgery was scheduled for the following day, Friday.
It was noon when Mickey was rolled into OR five. He scooted from stretcher to table like a lithe teenager and, in short order, the operation began.
The midline incision was made and the peritoneal cavity entered in the upper abdomen, above the area of his previous surgery and, I hoped, any adhesions.
Maybe this won’t be too bad.
As if to punish me for having such thoughts I ran into the proverbial wall, or, in this particular case, net of adhesions. Omentum plastered to colon which was wrapped around small bowel which filled the pelvis. No blue sutures to tell me where the closed off stump of colon was hiding, but also, no cancer.
Minutes rolled into hours as I inched my way around bowels, omentum and adhesions, finally spying one of my Prolene sutures after more than three hours of chiseling away.
I’m supposed to be doing a gallbladder in ten minutes.
“Could you please call ‘elsewhere hospital’ and let them know I’m late. I may be there by four or four thirty,” I requested of my kind circulating nurse.
“Maybe doing this surgery earlier than planned was a bad idea,” I remarked out loud to no one in particular.
“Looks like we’re almost there,” my assistant commented as more blue suture popped into view.
Sure enough the blue sutures which would lead me to the closed off stump of rectum now loomed large in front of me. A final snip freed the last loop of small bowel, which was then examined from beginning to end and safely tucked away.
I now stared at a long tunnel which was Mickey’s pelvis. Down in the depths was the object of my intentions: a stump of rectum which I hoped would accommodate the EEA stapler.
The proximal colon was dissected free from the abdominal wall and the big moment arrived.
The EEA stapler is a clever device which fires two rows of staples while cutting out two donuts of tissue between the circular staple lines. This leaves an opening between the two organs which have been stapled together. I find it most useful for constructing anastomoses at the ends of the GI tract, those involving esophagus or rectum.
This stapling device has a detachable part call the anvil which goes into one end of the colon, usually the proximal portion. An opening is made and the anvil is passed through this opening which has had a “pursestring” suture placed which is tied around the “anvil”, closing the colon wall around this anvil.
I’ll get one shot at this, it better work.
Mickey’s bottom had already been prepped and I began the process of passing the stapler. First the anus was stretched with a series of lubricated metal dilators up to a size adequate to allow passage of the stapling device. After the device has been inserted it is guided to the proximal end of the closed off rectum. The stapler is then opened and a spike appears which pierces through the closed off rectum and is connected to the anvil. The stapler is tightened and fired and then withdrawn.
The big moment arrives as the stapler is opened and the donuts removed. In Mickey’s case the donuts looked complete, but very thin on one side. I next checked the anastomosis to see if it was airtight. I filled Mickey’s pelvis with water so that the colorectal anastomosis was completely submerged. Next, I instilled air into the rectum and watched for bubbles. If the colon inflates, but there are no bubbles released, then the anastomosis is airtight. Bubbles percolating through the water mean there is a hole somewhere.
Much to my disappointment, a large number of bubbles appeared.
Now what? Do it again? You had one shot and you blew it.
Maybe do another colostomy? But, what about his big belly? Problems, problems, always problems. Only skinny people should be allowed to get sick. At least they should pay us by the pound.
“We’ll need to do a transverse colostomy,” I announced to the OR crew.
I decided that creating a loop colostomy in the upper abdomen would minimize the pendulous abdomen issue while allowing my newly constructed coloproctostomy (colorectal anastomosis) the time to heal.
The new stoma was constructed with my usual workmanlike efficiency and Mickey was closed up. I had spent five and a half hours in Mickey’s belly, battling large and small bowel, scar tissue and fat. As I pulled off my gloves I felt a tightness in my knee, a common occurrence after long surgeries which command my utmost attention for a long period of time. Over the years I’ve discovered that cases like this which require concentration to the extent that I forget to move or change position, block out much of what is happening around me, be it my cellphone or music which may be playing or the beeps and chimes coming from anesthesia’s machines. The patient increasingly becomes my only focus as I become oblivious even to the pain which grows in my knee.
I wish I could say that every patient requires such intense concentration, but that wouldn’t be true. Most surgeries are straightforward and, thank God, uncomplicated, such that this level of concentration is not necessary. If every case was like Mickey, I don’t think I would still be practicing surgery.
Mickey recovered uneventfully. Three months later I checked his colon and found that the anastomosis in his pelvis had completely healed. He underwent an uncomplicated reversal of the transverse loop colostomy. I felt fortunate that I could stay out of his big abdomen and avoid further skirmishes with his bowel.
He has remained cancer free to this day.