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.
