Thursday, October 1, 2015

Battle of the Bowels

                                                                                                                


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.
Wrong.
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.