Wednesday, October 31, 2007
A new Paradigm?
Surgical dogma has long dictated a Hartman's procedure (sigmoid colectomy, end colostomy) for complicated acute diverticulitis requiring surgical intervention. A one stage procedure was considered substandard care in the acute phase. Ideally, a patient responds to antibiotics, has an abscess percutaneously drained, and then, 8 weeks later or so, returns for an elective laparoscopic sigmoid colectomy with primary anastomosis. That's the playbook I studied when I was a resident while preparing for oral boards. Then I started hearing stories from community general surgeons about draining an abscess, cooling the patient down for a few days with antibiotics, and then doing a one stage procedure on the same admission. I reviewed the surgical literature. It was apparent that people are certainly challenging the so-called standard of care. So I had an unfortunate woman come in a couple weeks ago with diverticulitis and a peri-diverticular abscess. I had interventional radiology place a drain. She got better and went home. Four days later she returns with worsening pain, fevers and a WBC of 24,000. Repeat CT scan sugested another abscess, more lateral to the original one. She clearly wasn't doing well. She hadn't been eating, she simply looked miserable. IV antibiotics were reinstituted and I considered my options. Surgery was obviously going to be necessary; she had failed conservative therapy, but what was the right surgery? Options: 1) Open sigmoid colectomy, end colostomy 2) Laparoscopic colectomy, end colostomy 3) Laparoscopic one stage procedure 4) Laparoscopic colectomy, primary anastomosis and diverting temporary ileostomy. She wasn't too thrilled to hear the word colostomy but I prepared her for the possibility. 50/50 chance. I started with a scope and of course the sigmoid looked lousy, but there wasn't gross contamination of the peritoneal cavity. There was a well contained abscess on the lateral side wall where the sigmoid was stuck and that was about it. I went about the usual business of medial to lateral mobilization of the colon, found the ureter, took down the IMA, and prepared the rectum. The splenic flexure was a bitch, but it came down. Going into the case I had prepared myself for some sort of ostomy, but now...... as I washed out the left lower quadrant I started thinking, reconsidering. It didn't look so bad. The rectum was nice and clean and pink and healthy looking. Same with the descending colon. I made the colorectostomy with the EEA stapler and then stepped back and thought a good three minutes about doing a diverting ileostomy. She was septic. Hadn't been eating well for over a week. But she was young and otherwise healthy. You hate these moments in an operation. Self doubt. Wanting to do what's best for the patient. You're always taught in surgery to take the "safe" option over anything heroic. Guess what? I skipped the ileostomy. It just seemed right. I left a couple drains in and closed up shop. Post op day #3 I get called because her heart rate has spiked to 135. Ah hell, I'm thinking. She's leaking. I send her down for CT abdomen and chest and, miraculously, the pelvis looks fantastic. No air out of place. No free fluid. She did have a small pulmonary embolism (despite compression boots and lovenox) to explain the tachycardia. Currently she's doing great. Just waiting for INR to be therapeutic and she'll go home. Did I just get lucky? Was that truly the right operation? In this case maybe it was. Not always. There are no cook books in surgery. Patients are individuals, not automatons. They don't always behave and react the way they're supposed to. I suppose that's where the "art" comes into play.