Thursday, May 31, 2007

path updates

Unfortunately my right hemicolectomy/whipple guy has a T4N2 poorly differentiated adenocarcinoma. Several of the nodes, moreover, had extracapsular extension. Obviously not the ideal result. I sat with him and his wife, telling them the news. I appreciate that you don't bullshit me, doc, he said. My father died of colon cancer when he was 79, he went on, his voice cracking. He seems to know what the score is.

My lady with the obstructing colon CA interestingly ended up with a likely metastatic lesion from a breast primary (probably infiltrating lobular). She was successfully treated 9 years ago with MRM and post-op chemo. The literature is a little sparse, but breast metastases to the colon have been described. I think this finding explains the foreshortened mesentery/desmoplastic reaction I encountered during the resection. I had GU place ureteral catheters prior to starting and it probably saved my ass. The left ureter was stuck to thickened, fibrotic sigmoid mesentery and I would have had a hard time identifying it without them. She's actually progressing nicely.

cleveland sports

The Cavs are the better team. I can't believe I'm saying it, but it's become clear. They should win tonight. They should win this series. I suppose that shouldn't be all that surprising; they do have the best player. When Lebron decides to show up, makes a few jumpers, there's not a more unstoppable force in the NBA. Gibson is balling and Drew Gooden (neck muff and all) is turning into a poor man's Horace Grant. The Pistons are basically a jump shooting team. When Hamilton and Billups are off, they're in trouble. Webber, Wallace and Prince would all rather float around on the perimeter. Tonight has to be a defining Lebron game.

And the Indians avoided a sweep last night. How about this Shoppach dude, hitting .370. 33-19 and Sizemore/Hafner aren't even really that hot yet. I like the squad, but I don't trust the corner outfield situation. Delluci/Nixon/Michaels/Blake isn't the answer. A midseason trade for a big bat to play left field will be imperative. There's plenty of talent in the farm system. Make a move Shapiro.

I have to admit a vice. I listen to sports talk radio as I drive between hospitals during the day. I know it's nonsensical. I know my IQ probably drops 5-10 points with each hour I spend listening. But I can't help it. The problem is, Cleveland likely has the worst collection of on-air talent in the country. This Munch guy on WKNR is pitiful. He's like the 40 year old bachelor uncle at the thanksgiving dinner who drones on about his favorite teams. Only with a tinny, almost unlistenable voice. And there's no bigger blowhard than kenny roda. Such the sports dork. You can probably find him at your local sports bar pumping his fist and yelling after making a birdie at GoldenTee. And Mike Trivosonno, I don't get it. He's not funny. He really isn't. Surrounding himself with lackeys who giggle nervously at everything he says only makes it worse. I suppose he appeals to a certain common denominator in the Cleveland area, but his popularity is truly puzzling.

Are there any adult men's soccer leagues?

Tuesday, May 29, 2007

The combo whipple/right hemicolectomy guy now seems to have a pancreatic fistula (200-300 cc a day). Not entirely surprising given the circumstances (small duct, soft, friable pancreas). I have him on Octeotide 200mcg tid. Otherwise he seems to be doing rather well. Final path still pending.

Im not sure what to make of this book The Road by Cormac McCarthy. The plot is quite simple. Some sort of catastrophic apocalypse has occured and the narrative follows a man and his son as they wander the burned out American road searching for food and shelter. We're hammered with imagery of scrabbled, scarred, blackened earth, an absence of green, pelting cold rain, hazy gray skies, and sooty ash coating the ground like a shroud. Surrounded by death and decay, the man and the boy nevertheless forge ahead, seeking subsistence, seeking life. At one point, the boy asks, why are we doing this, what is our goal? Why go on? I can't go on I must go on, echoing from Beckett. The scarified landscape offers nothing, danger lurks around every corner. They head for the ocean, unsure what they'll find, at least it's a goal, a destination, a source of hope. The man and the boy scratch out a meager existence, the father constantly assuring his son that everything is going to be "okay". The man is a pragmatist, constantly assessing threats and benefits to his son's life. He trusts no one. He coughs blood along the road and knows he doesn't have long to live. He knows soon he'll have to abandon his boy, his entire world, to the cold harsh deadened world. The boy knows nothing of the past. He has no memories of anything other than the ashen images that pass before his eyes day after day. He believes in the possibility of a better life, as opposed to the father who knows the best has come and gone. Are we still the "good guys"? the boy asks. Yes, the man says. Because we "carry the fire?" the boys asks. Yes, the man says. Ultimately the boy is rewarded for trusting that a common decency still exists amongst men. Otherwise, there would be no point in going on. Footsteps coming around the curve, he stands in the middle of the road, alone, awaiting his fate.

Is it an adventure story? Science fiction thriller? An allegory about our own secular burned out American materialistic society? There is no mention of religion or faith. There is only the man and his son struggling for the bare necessities of existence. Mere existence. The question haunting them is whether it's even worth it. We dress up our own lives with material possessions and we assume identities and roles in society, but in the end, is our existential condition any different than theirs? Aren't we all on our own little road, acquiring things and food in order the live more comfortably. To stay warm. Dry. Avoidance of pain or embarassment. Hopefully all of us carry a little bit of our own fire along the way.

Sunday, May 27, 2007

karma kicks in

As I finish up my Sunday morning rounds, I run into one of our internal medicine colleagues who wants me to see a woman with, wouldn't you know it, an obstructing left colon lesion. I suppose it's the general surgery gods smiling down upon me for draining the rectal abscess yesterday. Eight days of symptoms. Lingered at an outside rural hospital for the past couple of days. Left lower quadrant tenderness. WBC 14,ooo. CT showing air fluid levels in dilated colon from cecum to descending/sigmoid junction. The GI guys don't do colonic stenting here, so she is likely to end up with an end colostomy. Is there anyone who would routinely perform subtotal colectomy for obstructing left colon lesions? I have in cases where the cecum appears dusky/ischemic with multiple serosal tears. Also, anyone comfortable doing on-table lavage and primary anastomosis in these difficult situations?

Saturday, May 26, 2007


Nothing like driving in on a saturday to drain a perirectal abscess. Ah, the joys of private practice. Enthusiastically telling the referring doctor, "Ill be right in !" Hell, maybe next time it will be an obstructing colon cancer. But not today. Today it's an indurated, flaming red painful as hell, pus filled buttock abscess. This is going to hurt ma'am. The numbing medicine sometimes can't anesthetize all the tissues when there's so much active infection. Nurse, can I get 4 of morphine?
But that's what I dig about general surgery. You never know what's going to show up in the ER or on the floor. I couldn't stand to do the same thing day after day, like cardiac surgeons or bariatric specialists. And what is the deal with this whole "Center of Excellence" designation if you want to do bariatric surgery? I understand the need for oversight, but we are graduating hundreds of chief residents every year who have learned how to do the procedure under the guidance of expert laparoscopists. If you're comfortable doing it, then what's the problem? Unfortunately, bariatric surgery was like the wild west in the late nineties. It payed well and it was new and exciting. So every general surgeon and his brother decided to learn on the fly, practicing on humans, after watching a few videos at some weekend crash training course. Hence the high morbidity/mortality numbers that resulted initially. It's not like that anymore. I scrubbed in on nearly 70 lap roux en y cases during my residency, doing a majority of the case as a senior resident. It's unfortunate that the recklessness of surgeons ten years ago has hampered an obese person's ability to get bariatric surgery at his/her community hospital....

Thursday, May 24, 2007

One mother of a colon case

A very pleasant, active, healthy 76 year old male who presented with a hemoglobin of four. Colonoscopy revealed a large circumferential, ulcerated lesion in the area of the hepatic flexure. The pre-op CEA was 81. No liver metastases obvious on CT. The CAT scan did, however, suggest an indistinct tissue plane between the second part of duodenum and the colon mass. The gallbladder also seemed to overlap with the tumor on some of the cuts. These findings, in my mind, precluded the possibility of safe, oncologically complete laparoscopic resection. So I took him for open right hemicolectomy. It became apparent as the dissection progressed that this tumor was tightly adherent to the duodenum and anterior surface of the pancreatic head. Not even a whiff of a plane; it was if the tumor had been superglued to the pancreaticoduodenal interface. So what do you do?

I paused. I stepped away for a second. I considered; this was a healthy guy without significant cardiac or pulmonary co-morbidities who acted and appeared much younger than his chronological age. What is the right thing to do? Shave the tumor off the pancreas and plan for post op radiation? Or proceed with the Whipple, and all its attendant post operative morbidity?

Well I broke scrub and talked to his wife. She said get it all out. So I did the combo whipple/right hemicolectomy. Of course the ducts were small and the pancreas soft and friable and kept wanting to tear with each suture. But ultimately it all came together. It's now post op day three and there's bile in his feeding tube and NG and the LFT's and Lipase are normal. I still don't know if I did the right thing. We'll have to see what the path shows.

In the back of my mind I worry about my motivations. All young surgeons start super-aggressive and learn patience and judiciousness with experience. Maybe I just wanted to do the "big" case. For my ego. For my sense of self worth. To prove my worthiness. How do I know for sure? In retrospect, I think I did the right thing. I tell myself I did the right thing. I think I did. God I hope he does all right.

Sunday, May 20, 2007

death wards

Every surgeon is going to lose someone during his/her career. It's inevitable. Especially in this era of an aging population. I can't even count how many times in the past nine months Ive been called upon to see an 80-85 year old lady/man with free air and laundry list of co-morbidities. Sometimes it works out. I even reversed a colostomy on a wonderful 88 year old fire plug a few weeks ago after she presented with perforated diverticulitis three months prior. But the odds aren't stacked in your favor. COPD/CHF/AFib/SIRS vex even the most vigilant of intensivists. Even if they survive the surgery, you never feel safe until you actually seem them wheeled off to home or rehab. I had one lady, arrived on deaths door with fulminant colitis secondary to C. Difficile; she underwent a near total proctocolectomy with end ileostomy. Amazingly, she did well over the first three days. I had started her on clear lquids and transferred her to a step down floor on post op day four when she suddenly fell over in her chair and died. Autopsy demonstrated massive myocardial infarction. It's frustrating. As a new surgeon, I tend to get a lot of the so called "disaster" cases. There's no room for error. Everything has to be perfect. You can't afford anastomotic leaks. You can't forget the IV beta blocker. You change your central lines. You look at the daily CXR's. You know all the cultures and susceptibilities. But sometimes, it doesn't matter what you do. You can't always make a Picasso out of crayons and cardboard. This doesn't absolve me of any guilt, however. When a patient dies, I feel responsible, regardless of the circumstances. You lose a little bit of yourself if you don't. There's always something else you could have done, another test, visited her a little more often, watched her potassium a little more closely. Something. You have to beat yourself over the head. You dont want it to happen again. You want to be better, more prepared for the next time.

Friday, May 18, 2007

Laparoscopic appendectomy

Is there anyone out there who preferentially performs open appendectomies rather than laparoscopic? I know, there's that prospective randomized trial from Archives of surgery (1997) that showed no benefit to laparoscopic versus open techniques. Moreover, it determined that OR time was longer and expenses higher with the laparoscopic approach. But let's be honest. 1997 was ten years ago. This was data accumulated by surgeons who were just getting comfortable with the technique. As a recent graduate of residency, I learned from talented laparoscopic surgeons, rather than making things up on the fly. People who regularly do laparoscopic appendectomies I think will concur that it's actually faster than an open approach. Pain usually is less. And, most important, the wound complication rate is negligible. The port sites simply don't get infected, but in rare cases, even in situations of advanced, perforated appendecitis. Abscess and fluid collections, even when located down in the pelvis, are easily irrigated and aspirated laparoscopically. Long term, fewer adhesions and a lower incidence of abdominal wall hernia would seem axiomatic. I don't get why people are electing to do these cases with open McBurney's incisions anymore. Similar to the holdovers who persisted in doing open cholecystectomies (albeit, with the so-called mini-incision) into the early nineties, I think if you're not doing laparoscopic appendectomies, you risk becoming a dinosaur much like them.


We're nearing closing time on our new home. Very exciting times. Or irritating. Currently I reside in this apartment complex off the highway. There's something not quite natural about living in an apartment. We're the apartment people, congested together in boxes carved out of stone. What is the general impression of a man in his thirties living in an apartment? I don't think it's too positive. It stigmatizes you as one of the following: 1) Divorced dad 2) creepy unemployed guy 3) single, slightly balding guy who works in a cubicle. I miss having a yard. Going into a different room if I feel like it. Turning the volume up real loud. Not hearing moans and bed springs squeaking through thin walls. I hate the mail room. My little number crammed into a metallic slot. I hate the elevator. Waiting. Making small talk on the way up. "Have a good one", everyone always wants to say to you as they get off. Yeah, you too. And laundry rooms. Just think about public laundry rooms for a second. A concept that involves throwing your clothes into a washer that some stranger just got done expunging their dirty underwear and semen stained sheets in. I try not to think about it. Use extra soap. Anyway, it will all be over soon. My apartment days numbered. It oughn't to be so stigmatized though. In Europe most people rent. But our American perspective demands "home ownership" as proof of your ascendancy to respectability. I guess I'll be falling into line. Just don't expect me to be buying an SUV anytime soon.

Wednesday, May 16, 2007

oral boards

As you can see in the profile, I proudly proclaim myself as a "Board Certified" general surgeon. That designation actually just came into being. I passed the oral boards a few weeks ago. Now I'm a significantly more adept surgeon. Or so they would have you believe. I was surprised how benign the whole experience was. I had one guy out of six who was a little surly. Everyone else went out of his/her way to make me feel comfortable. It was a little disappointing actually. Other than those last five minutes standing outside the hotel door fighting back massive diarrhea, I never really felt utter panic. Where was the intimidation?!?! I'm not sure what the big deal is. Clearly, they are more interested in whether or not you are a SAFE surgeon rather than if you can describe in detail the specific steps of a Sugiura esophagogastric devascularization procedure. Just don't do anything outlandish and I think you'll be ok. And honestly, unless you struggled to pass the Absite exams during residency, don't waste your time or money enrolling in those Osler-type review courses. Take your spouse to Cancun or Cabo for the thousand buckaroos instead. Im still not convinced there's any validity to a system that bestows "board certification" upon a candidate by distilling 5 years of residency down to a 90 minute quiz session at your local Motel 6. It was over so quickly, the lobby bar wasn't even open yet. The goddam waitress wouldnt even splash a little vodka into my OJ. Well, it's over at least. No more tests to take for another 10 years. No more cram sessions at the coffee shop. Not a student anymore. I think I sense an identity crisis coming on. Go Cavs.


An initial salvo into the world of unfettered spilling of soul into the public domain. The concept is revolutionary, as far as Im concerned. Whatever happened to locked leather journals, stashed under the bedframe? Away with private thoughts. This is me! I exist! Although reeking of narcissism and existential angst, you have to admit, it's compelling as hell. If you're any good, and people respond regularly with insightful feedback, an entire community is born, a community unavailable to us in non-cyber (so-called real) life, as we mindlessly pass through our waking days like automatons, driving the same routes to work, having the same superficial conversations with colleagues you know nothing about but have known for years, distracted by talk radio, ipods, sports scores, our minds cluttered with the nothingness. Maybe the modern mind isn't made for solitary contemplation with pen and paper. We make a deal. If we are going to, god forbid, think creatively, constructively, or insightfully, then it has to be done so everyone else can see. The age of exhibitionism. Watch me. Read me.

Anyway. I am a surgeon. I will be writing about the world of medicine on occasion. But not always. I recently finished Jeffrey Goldberg's "Prisoners", a non-fiction work about his relationships with palestinians during and after his time as a prison guard at Ketziot in Israel. He develops a friendship of sorts with one man named rafiq. Rafiq ends up in Washington DC after his release to complete a PhD in mathematics. They meet repeatedly over the course of a few years time. And they dont waste time talking Redskin football. Always the conversation drifts to the "problem" and potential solutions. Goldberg is an unabashed Zionist, so don't go looking for some "can't we all get along" fluff treatment. There seems to be a fundamental schism between Jews and Palestinians that may very well be unbridgeable. Each side takes an uncompromising position based on respective theologic dogmas that are not negotiable. How can that be resolved rationally? It's interesting how the two men come to this conclusion, yet remain friends. The unfortunate triumph of tribalism and ethnic loyalties over individual relationships. Very well written. Highly recommended.