Kerry was only twenty
eight years old. He showed up in the ER one night complaining of upper
abdominal pain which started suddenly that day. The Emergency physician did the
usual workup and found two things which led to an urgent call: a large
intrabdominal mass and free intraperitoneal air.
The large mass was not
necessarily an emergency, but “free air”, that is, air outside its usual place
inside the bowel, almost always represents a surgical emergency; a perforation
somewhere along the long snaking tube sometimes referred to as the “alimentary
canal.”
It was about midnight
and I jumped, well more likely slowly crawled, out of bed and made my way to
the hospital.
Kerry had wispy brown hair
which was coupled with a receding hairline. He made his living playing the
guitar. He told me gigs came and went, but he managed to scrape by. He reported
vague discomfort for about three months and weight loss of almost thirty
pounds. He said he was able to eat, but often didn’t feel hungry.
He was thin, almost
cachectic, with pale skin and his face betrayed a fear that I could tell was permeating
his body and soul. The most significant finding on exam was diffuse abdominal
tenderness with signs of peritonitis, just what one would expect from a
perforated hollow viscus.
His abdominal CT scan
demonstrated a large mass in the left upper quadrant of the abdomen, in the
area of the left transverse colon, stomach, pancreas, spleen, left adrenal gland
and left kidney. There was obvious free air and fluid.
No
choice, he needs to go to surgery.
I explained the
findings and the proposed surgery to him, wrote orders, called the OR crew and
then went to the physicians lounge to wait. The usual hour spent waiting for
the team is something I’ve learned to avoid these days. But, back in the old
days, twenty years ago, I always came to see the patient first before deciding
if emergency surgery was necessary, be it a simple case of acute appendicitis
or a perforated colon with septic shock. This always afforded me an hour or so
to meditate on the upcoming procedure or, more often, watch remnants of whatever
old B movie happened to be on late night television.
Before starting Kerry’s
surgery I spent the time considering what I was going to find inside of him.
Free air suggested that the primary pathology was in the either the colon or
the stomach. The CT Scan suggested I be prepared to remove parts of the colon,
stomach, pancreas and spleen, a Left Upper Quadrantectomy, as I’d called it in
the past. I was sure he had a cancer of some sort, unusual and sad in someone so
young. The tenants of cancer surgery dictate that it is best to remove the
offending tumor en bloc, which means
removing it all in one piece, preferably with a margin of normal tissue,
something which is often not possible.
After my hour of
contemplation, the nurse, tech and Anesthesiologist were ready, Kerry was
wheeled into the room and moved himself over to the OR table. I couldn’t help
but notice the look in his eyes as he scooted from stretcher to OR table. It
reminded me of looks I’d seen in movies; seen on the faces of actors who are
made to walk up steps to the gallows or to the front of a firing squad; a look
of impending doom. I gave him what I hoped was a reassuring smile as he positioned
himself in the middle of the narrow table. He did his best to remain still as
EKG leads, pneumatic compression stockings and pulse oximeter were placed on
the appropriate parts of his body.
The steady, almost
monotone voice of the anesthesiologist began:
“…take a deep breath,
you may feel some burning in your arm, you’ll be asleep before…”
And Kerry was out.
Prep and drape, throw
off the Bovie and suction and we’re off.
I made a generous
midline incision and soon entered his abdomen, neatly, exactly through the
center, to be greeted by a big ugly tumor. There was some thin serous fluid and
inflammation around the tumor which was in closest proximity to the left side
of transverse colon. I could see the hole where the tumor had perforated into
the omentum and observed only a small amount of fecal contamination.
Good.
I gingerly moved the
tumor, back and forth, up and down. It was mobile. I’ve done cases in the past
where moving the tumor back and forth caused the whole patient to move,
suggesting fixation of the tumor to vital retroperitoneal structures, which means
it is almost surely unresectable and probably incurable. Finally, it’s time to
dive in and commit. First the colon.
I start on the left
side, dividing the left colon’s attachments up to its sharply angled turn at
the splenic flexure, as well as dissecting the omentum free. Then from the
right. Here I start at the colon’s beginning, the cecum. The appendix was stuck
down in the pelvis. I free it up and notice it looks a little inflamed.
Appendicitis
on top of everything else.
All along the right
side of the abdomen I work, freeing the right colon up to the hepatic flexure
and the proximal transverse colon, grateful that it easily lifts off the
duodenum, that the tumor does not involve this part of the bowel.
No emergency
Whipple tonight.
The right side of the
omentum also is liberated, to be removed with the tumor. (Years ago I read an
operative note where the surgeon described “liberating the splenic flexure of
the colon.” I immediately had a mental image of colons running free shouting ‘I’m
free, I’m free.’ But I digress.)
Now I’m starting to surround
the tumor. The back wall and greater curvature of the stomach are adherent, but
this is limited to only the most inferior portion. The vessels feeding this
portion of the stomach are identified and divided, the stomach is divided with
a large stapler and the uninvolved portion of the stomach retracted away and
out of sight.
One
organ out of my way. What’s next?
The colon needs to go
now. His right colon is pretty short. If I resect only the transverse colon I’m
not sure about the blood supply to the remaining segment on the right. I decide
to remove the complete right and transverse colon all the way to the proximal
descending colon. This will allow for an anastamosis between the small bowel
and descending colon, which should heal without problem, rather than a colon to
colon connection in unprepped bowel. It’s time for more staplers. GIA across
the terminal ileum (last part of small bowel before the colon starts), again
across the descending colon just beyond the splenic flexure.
I’m
really zeroing in on this nasty beast now.
Next I see that the
tumor may involve the distal pancreas.
Maybe
I can separate the two structures? No luck. The pancreas and the spleen will
need to go.
This actually doesn’t
take very long. Kerry is very thin and the border of the pancreas is easy to
see, as are the splenic artery and vein. Dissection is carried along the
inferior border of the pancreas and an area is identified at the neck of the
pancreas, uninvolved by tumor. The large splenic artery and vein are dissected
free, clamped and divided and ligated. The neck of the pancreas is divided using
the GIA stapler and the pancreatic duct is also separately sutured. Finally,
the vessels remaining which enter the spleen are divided and the specimen is
removed as one giant mass of tissue made up of the omentum, right and
transverse colon, greater curvature of stomach, tail of the pancreas and
spleen. I have performed the operation I have dubbed “Left Upper
Quadrantectomy.” This is only a partial LUQectomy, as I was able to leave the
left kidney and adrenal gland behind.
After removing this
massive tumor I’m left with the task of putting everything back together. In
this case this means only a single anastamosis, small bowel to colon. I do
leave a drain, just in case and finish the entire procedure in just under two
hours. Kerry is safely deposited in the Recovery room and I manage to get home
by about 4:30 am to grab a couple of hours rest before the new day starts.
Kerry had an uneventful
post operative course, out of the hospital in eight days. His tumor was adenocarcinoma
of the colon, which is the most common type of colon cancer, but still unusual in
someone so young. The size and presence of perforation put the cancer at a
later stage. He was treated with chemotherapy and I wish I could report that he
responded well and lived many years, but this was not the case. Even the best
operation sometimes cannot overcome a cancer’s inherent biology. Kerry’s cancer
recurred and he passed away eighteen months after his emergency operation.
Still, he was remarkably pain free during this time and was able to play his
guitar up to the end.
The LUQectomy is an
operation I do about once a year, most times planned, but sometimes emergent.
Mary was a case similar
to Kerry, only her tumor arose from the pancreas and presented with bleeding
and perforation. She also had middle of the night, emergency surgery, the night
cap to a day that included eight other scheduled and emergency cases.
I’ve attacked the left
upper quadrant for tumors arising from stomach, colon, pancreas, adrenal gland
and retroperitoneum. The pathology may vary, but the approach is almost always
the same. Find a plane free of cancer and isolate the tumor; try to get a
margin of normal tissue. Always be aware of what can be safely removed and what
needs to stay behind. Know where the major blood vessels are and treat them
with the proper respect.
It is truly amazing how
much can be removed with little or no subsequent physiologic impairment. Large
portions of the pancreas can be removed, yet the patient never develops
diabetes or malabsorption. All of the stomach could be removed and rebuilt with
small bowel. But the patient continues to eat, although some weight would
probably be lost. Portions of the colon are removed frequently for a variety of
reasons, but very well tolerated. The body has two kidneys and two adrenal
glands and can easily compensate for loss of one. The spleen is removed
routinely for trauma or disease, yet is often barely missed.
Thus the remarkable, incredible
resiliency of the human body is demonstrated. Despite invasion by cancer and serving
as a battlefield for the surgeon’s war against this malignant enemy, despite
the removal of large parts of vital organs, we are able to persevere. Truly
amazing.
