Gastric Volvulus

Interesting case the other day. A reasonably healthy 51 year old lady presented to the ER with acute, severe epigastric pain, accompanied by unrelenting vomiting. Her history included an operation 7 years ago for "twisting of the stomach". Not clear what was done at that time, however. When I saw her she looked beaten and worn out. Electrolytes out of whack, severely dehydrated. A nasogastric tube had fortunately been placed and she was feeling a little better. The CT scan showed most of the stomach up in the chest and it appeared that none of the oral contrast was making it into the decompressed duodenum. Classic gastric volvulus. Her lactate was elevated and I was worried about ongoing ischemia.

I took her to OR in the middle of the night and the volvulus was easily reduced and the stomach returned to the peritoneal cavity. No ischemic changes; it actually pinked up and looked pretty healthy. There was a large posterior hiatal hernia with the sac extending high up into the mediastinum. I'm still not sure what was done at the initial operation, but the adhesions and scarring made things difficult. The key thing is to get that sac down, otherwise the hernia will recur and you'll end up in the same position in a few months/years. I didn't wrap the fundus around the esophagus (Nissen/Toupet) because I didn't know anything about her esophageal motility and I didn't want to potentiate dysphagia at the GE junction. Instead, I did a primary crural repair and then fixed the greater curve of the stomach to the anterior abdominal wall with sutures (gastropexy) and placed a Stamm gastrostomy tube to further fix the stomach intra-abdominally. Ideally, I'll remove the tube in 6weeks or so. She had a barium study today that confirmed easy passage of contrast through the GE junction and into a completely intra-abdominal stomach.

Lower GI Bleeds

Ah, the sweet smell of melena. Inhale deep the sharp, metallic odor. Feel it burn the sinuses as it wafts its way slowly down into your lungs. Nothing beats it. You won't ever forget it. As a surgeon, I am lucky to get not so infrequent reminders of its distinctive stench.

Little old lady (LOL) with renal failure, peripheral vascular disease, coronary artery disease, etc, presented to the ER with a liter of marroon currant jelly stool between her legs. She'd been diagnosed with "diverticular bleeds" twice in the past year; both episodes resolved without invasive intervention. She was also on Plavix (the evil anti-platelet medicine) and was due to be dialyzed that day. There's a playbook for these situations, like many things in medicine. No need to think; just run the scripted offense:
1. Airway, breathing, circulation. Get good IV's and run some fluid in.

2. You drop an NG to make sure the source of bleeding isn't proximal to the ligament of trietz.

3. Good rectal exam/anoscopy/proctoscopy to rule out hemorrhoids or bleeding rectal mass.

4. If bleed is slow or has stopped, consider colonscopy

5. Massive bleeds that stabilize--- Tagged red blood cell scan. This is done in nuclear medicine and is pretty sensitive for blood loss that exceeds .1cc/min. It helps localize the bleed to general areas, i.e "right side" or "left side". Most of the time it's useless, but you see it in the algorithms in all the textbooks.

6. Mesenteric Angiography---- Usually the tagged cell scan is done first to help direct the angiogram to the bleeding vessel. This isn't as sensitive a test; the bleeding has to exceed 1cc/min.

7. Surgery---- hemodynamic instability or unrelenting transfusion requirements mandate the cold knife. The tricky part is deciding what sort of surgery to do. Total colectomy? Left colectomy? Hopefully some information can be gleaned from the above studies to help guide your decision.

When I saw this particular lady, she looked like hell. BP 70/30. A continuous lava flow of red stool emanating from between her legs. The bed was saturated. She looked pale and ghostly. He husband sat in the corner reading a magazine. The nephrologist was running the show, giving blood via her dialysis catheters. That's a lot of blood, I told him. Yes, he said. We may need to visit the OR this evening, I said. He said, she's not a candidate for surgery; her coronary artery disease is quite severe. That may be, I replied. But bleeding to death is also problematic.

With three units of blood she sort of, kind of stabilized and went for tagged red blood cell scan. Left colon, about as positive a scan as I've ever seen. Now it's eleven at night and I'm the only one left. I hear the nurse taking an order from the GI consultant for a mesenteric angiogram. I call him back and tell him that the patient is dropping her pressure again and the bloody river continues to flow from between her legs. It's time to stop screwing around and fix the problem. Angiography is notoriously user-dependent in these situations. It's not always successful. Moreover, there's complications; some quote a 20% incidence of colonic ischemia. Plus, it was snowing and the radiologist said it would take two members of his team 45-60 minutes to arrive. No thanks. I'm the one sitting at the patient's bedside. I'm the one whose ass is on the line if she crashes in the angio suite. I booked the case and did the extended left colectomy. She actually did well. I was even able to perform a primary anastomosis.

The point is, playbooks are for shit if you don't look at the patient. I know it's fun to mess around with all these new-fangled tests and non-invasive procedures, but sometimes a timely operation isn't the worst thing in the world.

Obamas race speech

This is a great read. Defusing a potential political snafu with intellect and compassion.....

The Smart Doctors

This poor 77 year old guy showed up in the SICU one day as a transfer from some LTAC facility. He'd been in a car accident a couple of years ago and suffered anoxic brain injury, rendering him in a persistent vegetative state. Trached and pegged, and curled up tense and taut from contractures, he looked like the quintessential gork. One of his legs had been lopped off because of injuries sustained during the initial trauma. He was unshaven and gaunt-faced, temples completely wasted on both sides; a skeleton covered by skin. We were called because he wasn't tolerating his tube feeds and had developed abdominal distention. A CT scan suggested a distal small bowel obstruction and a possible cecal mass as the underlying etiology.

Normally in these situations, you explore the guy in the OR and resect the tumor. Or maybe colonoscopy first, if he isn't too obstructed. But this guy was merely existing. There was no life there. Cells and fluids and proteins supported by machines, maintaining a facade of humanity. We all knew better, but the family was entirely unreasonable. Multiple conferences with doctors couldn't dissuade them from a desire to "have everything done". They asked about transfer to the downtown medical mecca, if nobody wanted to operate on him at our hospital. Frankly, it seemed unethical to me to slice open this withered apparition. I figured reason would eventually set in, but no. The other day, life flight whisked him off to the downtown mecca. The internist at our hospital who arranged the transfer (reluctantly) told me that the surgeon accepting the patient told him that "we know how to do diverting colostomies at this institution." Just outrageous pompousness. First of all, if he'd looked at the films, he'd realize a colostomy isn't going to do anything about a cecal mass obstructing the ileum. Second, I also know how to do diverting procedures; it isn't hard. The hard part is deciding when to do nothing. Oh well.... I suppose when you're dealing with difficult family members, sometimes the best option is to give them what they want, i.e. second opinions from the "smart doctors" downtown.

Monsieur Laplace

I like that song "It was a Crazy Game of Poker" by O.A.R. Over the weekend I had a crazy game of "Take the Old Guy to the OR a Couple of Times after he Intitially Presented with a Myocardial Infarction" Fun times!

Nice 88 year old guy presented to the ER with chest pain and was ultimately diagnosed with a non-ST segment elevation myocardial infarction (NSTEMI). They had him on heparin and aspirin and the cardiologist had determined that he wasn't a candidate for intervention. So he was hanging out on the floor being anti-coagulated, waiting for a bed at the local rehab facility. And then he developed acute, severe left groin pain. PCP gets the CT scan and I get called friday evening about an incarcerated iguinal hernia. My wife loves those calls. It means dinner is off and she gets to eat leftover scraps from the fridge. When I saw him, his belly was distended and tympanitic, but non-tender. He did have a hard mass in the groin that wasn't going anywhere without a knife. I looked at the CT scan (no comments from the peanut gallery on why it was ordered) and it showed what appeared to be sigmoid colon incarcerated in a left sided inguinal hernia. Proximally the colon was understandably dilated, transverse and cecum looked to be about 8cm. I approached the hernia via a standard groin incision. The bowel-containing sac was separated from the cord structures and then I carefully opened the thick walled sac to inspect the contents. Sure enough, it was sigmoid colon, pink and healthy. I pushed everything back through the internal ring and performed a standard plug and patch repair with mesh. We did the case under spinal and the old guy tolerated it quite well. The next day he looked pretty darn good. His belly was softer and I thought a moment about removing his NG but in the end decided not to. I started thinking maybe I was going to get away with a nice save on the guy...

And then Sunday I made rounds and he seemed disoriented and anxious. He kept clutching at his belly and it was firmer and certainly more tender. I sent for a stat CT and finished seeing the last five patients on my list. Half an hour later the scan is done and he's got free air. Lots of it. I rush back and he's starting to drop his pressures and look a little mottled. For the love of God. I'm not thinking he can handle anymore surgery but the family wants the full court press so back to the OR we go. Thankfully the sigmoid looks fine. The hernia site doesn't seem to be the problem. But the cecum is bluish-black and paper thin and there's a dime sized hole in the anterior wall. Ileocecectomy, end ileostomy, mucus fistula in about 20 minutes. Stool evacuated and peritoneum lavaged with saline. Back to the ICU on multiple pressors and a few prayers.... He's actually doing well today. Fingers still crossed though.

So what happened? There's an entity in physics known as the Law of Laplace which describes the relationship between pressure, tension and a hollow tube's diameter. Essentially, bigger tubes have a larger amount of wall tension at a given pressure compared to smaller tubes. The cecum is the widest part of the large bowel. Therefore, any obstructive situation that raises the pressure of the colon will generally put the cecum at risk of rupture prior to anywhere else. But I relieved the obstruction with the hernia repair. What happened? Well, my theory is that he simply did not spontaneously decompress the accumulated air as expected when the mechanical obstruction had been resolved. He developed a peristent ileus and time and pressure did the rest. What could I have done differently? Maybe repaired the hernia via a laparotomy. That way I could have examined the entire contents of the abdominal cavity. But I'm not convinced I would have seen evidence of ischemia at that time. His WBC was normal and there no real abdominal tenderness, other than directly over the incarcerated hernia. More likely, I would have seen a dilated cecum, maybe with non-specific inflammatory changes. Then what? Cecostomy tube for decompression, with all the attendant morbidity of such a procedure? Tough call. At the very least I was able to prove that recent acute MI is not a contraindication to performing multiple operations on frail 88 year old men. Just kidding. Don't do what I do. Go into dermatology. Anyway, time for a Guinness. Happy St. Pats.

Not acceptable

I've been reading the Stoic philosopher Seneca lately. Don't ask me why. It was one of those $5 books you can get at Borders. But certain parts of it have made an impression on me. As we move deeper into this secular age, it's interesting to read outlooks from the pagan age. Thinkers such as Seneca encountered the same injustices and moral quandaries as we do today, and it's edifying to see how difficult issues are resolved from a pre-Judeo-Christian perspective. At it is least for me.

Anyway, Seneca said "what can happen to somebody can happen to anybody". I wrote about a patient last November who was 28 and presented with perforated cecal cancer (T4N2). He started Folfox chemotherapy in Jauary and things seemed to be going well. He regained lost weight, returned to work, and was starting to look forward to the rest of his life. Then his CEA bumped up to 45 and the medical oncologist ordered a CT scan. The right lower quadrant showed a concerning mass/phlegmon that seemed to be invading the lateral abdominal wall. The liver looked clean and he was non-toxic. I told him, frankly, that I was worried about recurrent disease, given that the intial presentation involved a perforation and spillage of tumor cells throughout the abdominal cavity. Naw, it's probably just an abscess, doc, he told me. I nodded my head grimly. I hope so, I said. But let's prove it.

So I explored him today and I encountered carcinomatosis. Knobbly tumor implants were everywhere; abdominal wall, omentum, superficial liver capsule, serosa of bowel. Palpating the undersurface of the abdominal wall was like running your hands along a wall imbedded with marbles. Cancer is unmistakable. It's hard and frozen and all wrong amongst the soft suppleness of the liver, omentum and bowels. Your heart breaks. You get all geared up for an operation like this, anticipating a possible major en bloc resection, and then it all comes to a halt. There's nothing to do. Not today. So I bypassed a segment of bowel intimately involved in the main tumor mass, sent numerous biopsies, and then closed up shop. It took me a while to gather myseslf for the post op family talk. It went as you would expect. Devastation. Grown men and women crying. A wife stoically trying to keep herself together. Nothing cuts like the unabashed wail of a mother grieving her son.....

He's 28 years old. He has a young child. Why is he the one who gets the short straw? Is there a cosmic reason? What solace can be sought from a buffet selection of religion, philosophy, new age mysticism, and whatever else? Why should something like this happen? Life is very short indeed. You never know when your time is going to come. I understand that. But that doesn't mean I have to accept such a structure at this point in my life. I'm not ready for that. Seneca says that "we are all chained to fortune" and that "when the order to return the deposits comes, the sage will not quarrel with Fortune, but will say, 'I am thankful for what I have held and enjoyed'". The essence of stoicism. I'm not sure that does it for me either. After all, Seneca, apparently, was Nero's right hand man...

Back in town

Back from a much needed vacation. I get a little strung out this time of year, seasonal affective disorder I suppose. Wife and I went to the Island of Kauai (part of the Hawaiian Islands) for a week. An absolutely breathtaking trip. We hiked part of the Kalalau Trail along the Na Pali coast and were both just awestruck. I definitely recommend it. Of course, the karma gods evened things out by dumping two feet of snow on Cleveland over the weekend; always nice to spend three hours shoveling just to get your car back in the garage.

On another note, I noticed an interesting study discussing the significance of "flat lesions" with regards to colorectal cancer. These are lesions that are, well, flat, as opposed to the pedunculated appearance of colorectal polyps. The study's main finding was that flat lesions are 10 times more likely to harbor malignancy compared to polypoid lesions, irrespective of size. What's worrisome is that these lesions are very difficult to identify on routine screening colonoscopy or even virtual colonoscopy. Moreover, even if identified, removing them endoscopically with adequate clean margins can be challenging. What is the long term significance? Hard to say until better data comes back. The days of GI specialists and surgeons lining up 8-10 quickie scopes for a day may be over; the time necessary to slowly pore over the entire mucosal surface looking for these suckers may preclude such behavior. I like the idea of having these lesions biopsied and tattoed and proceeding with laparoscopic resections if any dysplasia seen on path. We will see.....