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.
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