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.

1 comment:

Anonymous said...

Did he make it?