Monday thoughts

1. Everything in surgery seems to come in threes. As a resident, you never just did one whipple while on the hepatobiliary rotation; a third one always seemed to show up on the schedule before you switched services. Same with Appendectomies. Sometimes I'll go a couple weeks without doing one and then I'll have a weekend where I just line 'em up. I had two back to back early Sunday morning, but then it was quiet the rest of the day. I couldn't relax though; you just know it's eventually going to come. Bedtime rolled around and still nothing. Maybe this would be an exception to the rule. And then the inevitable page at 4AM. Trifecta. Start some Zosyn and I'll be in after I shower. One of the cases was a classic argument for laparoscopic appendectomy. The kid was 17 and he'd been languishing for 4 days at home with abdominal pain. His parents were out of the country and his older brother was ostensibly "watching" him. He showed up tachycardic with a white count of 24,000. A CT scan suggested some fluid around the liver, in addition to peri-appendiceal inflammatory changes. The appendectomy went fine, but then with the scope I was able to look around. He had pure pus above and below his liver. I spent twice as much time irrigating and aspirating as I did taking out the appendix. I don't think the open approach affords you the ability to do that.

2. My liver transplant bowel obstruction guy is now on the regular floor. The Clinic had a bed available today but I cancelled the transfer. He's mine now. Hell, I operated on him; doesn't seem fair to dump a post-op on the BFH.

3. There's a professional tennis player named Nikolay Davydenko. Apparently, he's pretty good, the top ranked Russian male player and ranked fourth in the world overall. A couple of months ago he was involved in a peculiar situation at a tournament in Poland. Somebody named Martin Vassallo Arguello defeated him when Davydenko "retired" due to injury in the third set. I guess that kind of thing occasionally happens. The peculiar aspect was that a British online bookkeeper suspended payouts on the match because of "betting irregularities". Ten times the average amount had been placed on the match, most of it for Arguello. Suspicious, no? And now last week, at a tournament in St Petersburg, Davydenko was fined $2000 for "lack of effort" during the third set of a match against another nobody that he ultimately ended up losing. Lack of effort? Are you kidding me? Please let this be the final dagger that kills off tennis as a major sport. I hate tennis. Especially this post-modern mash and maul variety with the titanium oversized rackets and the three hit rallies and the women with their orgasmic grunts after every shot and Roger Federer winning everything and Rafael Nadal wearing clamdiggers for some godawful reason. What if Dwyane Wade had been fined for "not trying"? Could you take basketball seriously as a sport? Please go away tennis.

Bed Shortages

Doc Schwab had a post recently about whether to get your surgery at the community hospital or to go downtown to the "big freaking hospital". I posted a comment describing certain scenarios where I would recommend that the patient go to the tertiary referral center. Examples included major liver resections, cholangiocarcinomas, complicated entercutaneous fistulas, severe necrotizing pancreatitis, and liver transplant patients with any of their attendant complications. If I had to pick one case most appropriate for transfer, however, it would be the liver transplant patients. You just don't want to deal with the immunosuppression dosing, the complicated anatomy, and all the infectious issues that inevitably arise. I would assert that you ought to refer even something as seemingly benign as an inguinal hernia repair to the transplant surgeon. So what happens this week? My partner gets called at 3am one night on a patient with a bowel obstruction. He drowsily agrees to admit. The next day we find out the patient had a liver transplant in 2003. His films look terrible and he has some tenderness in the epigastrium. I called the Clinic downtown and they agree to have him transferred. A couple of hours later I get called by the floor because there's a bed shortage at the Clinic. Transfer delayed until the next day. So I have them get a CT scan, to be better delineate the obstruction, since it seems we're stuck with him at least over night. I'm raking my leaves at home and the radiologist calls. "I see a high grade SBO and, more ominously, a suggestion of portal venous gas", he says. There's also a couple of air bubbles that may or may not be outside the bowel lumen. Fantastic. I call the floor. The nurses say he's been asking for morphine every hour. I rush in to see him and he's stable, but certainly more tender. You can't mess around with a patient who's on cellcept and cyclosporine. The natural inflammatory response to stress is altered. You can't trust vitals, white count, xrays. It's all unreliable. He could be sitting there with dead bowel and you wouldn't know. You have to be aggressive. I explored him that evening. Luckily, no ischemic bowel. The "portal venous gas" was actually just pneumobilia from a choledochojejunostomy. His midjejunum was the size of a South American Anaconda, status post ingestion of a wild boar. The scrub nurse kept asking me why his "colon" was so big. She wouldn't believe me it was small bowel. I lysed everything (easily because the adhesions were flimsy and soft secondary to the chronic immunosuppression) and decompressed his bowel. He's actually extubated and progressing fairly well. We're not out of the woods yet, but so far so good. Hopefully that bed at the Clinic becomes available again on Monday.

On the Brink

One more win, and it's on to the World Series. I can taste it. It'd be nice to close it out tonight; you don't want to go back to Fenway where anything can happen. Just finish the job. Time for CC Sabathia to step up and stop the gagfest he's been enduring so far this post season. It's a good time to be from Northeast Ohio. Cavs in the Finals last spring. Indians on the cusp of the Series. Browns actually showing some signs of life. And of course the Buckeyes currently ranked #1 in the country. Couple of things have to happen tonight:
1. Sabathia, crooked cap, beer gut and all, keeps his cool and acts like the ace he was all season.
2. Something, anything out of Hafner. He's coming off a desultory 0-4, four strikeout performance. You can't have your #3 hitter posting a line that your wife could duplicate if she had to grab a piece of lumber.
3. Unexpected source of offense. Trot Nixon tonight? Blake?
4. Get an early lead. Put the pressure on. Keep the crowd in the game.
5. Borowski to keep inexplicably mystifying the Red Sox with that lame 88MPH cheese he tosses up when the game is on the line.
Go Tribe.

What took so long?

I saw this poor guy last week who'd been admitted for complaints of nausea/vomiting and abdominal pain. He was a frail, emaciated 83 year old guy who had the usual medical issues of that demographic (hypertension, CAD, urinary retention, etc). Interestingly, he had had a laparoscopic cholecystectomy done three weeks prior to this admission. He looked like a refugee from some war torn country. Weighed about 85 pounds. Clavicles and cheekbones protruding, hunched over in bed with an enormous nasogastric tube exiting his nose. He was putting out 500 cc a shift of pure green bile and his labs were consistent with advanced dehydration. He wasn't tender though, and seemed comfortable enough. Other than the lap chole, no previous abdominal surgeries. Then I started asking questions. A daughter arrived and more information started to flow. Apparently he'd been plagued by weight loss (50lbs) and intermittent vomiting for over a year. And the worst part, he'd been in and out of hospitals several times over the past few months. Huge work-ups had been done including EGD's, CAT scans, and ultrasounds. He kept getting diagnosed with "gastroenteritis" and sent home. I asked why the gallbladder surgery was done and the daughter explained that the "other doctors" felt it might do some good since they had no other explanation of his symptoms. My God. I love the old "take out the gallbladder because it might magically make the patient feel better" indication. So we got a CT scan. (see pics) It suggested a high grade bowel obstruction with an abrupt transition point in the proximal jejunum. GI decided to do a push enteroscopy rather than an UGI and he encountered a completely obstructing mass in the jejunum, which biopsies confirmed to be adenocarcinoma. So I took him for a laparoscopic small bowel resection yesterday. The mesentery was thickened and foreshortened, and the enlarged nodes appeared grossly positive. But we got it out. Hopefully he'll start to eat in a few days. But why the delay? A barium swallow evaluation months ago would have identified the problem. This wasn't rocket science figuring out what was going on. The poor guy wasted away to nothing while everyone dicked around. At least his gallbladder won't be causing him any more problems.

weekend coming up

Some thoughts before I start this breast biopsy.

1. Go Tribe. Sabathia against Beckett tonight. We'll see who really deserves the Cy Young.
2. Interesting info on Taxol based chemotherapy for breast cancer. A study in Europe suggests that it's not as useful for women with Her-2-Neu negative tumors.
3. I had a post op complication this week. We won't get into details but it involved bleeding, enough that mandated a return to the OR in the middle of the night. There's no job more humbling than being a surgeon. Errors are inevitable. This one was sort of fluky, but you always feel culpable. It's always tough facing the patient and their family afterward. How did this happen, they ask. I've found the best way to handle these potentially awkward situations is to be completely candid and humble. Don't lie. Tell them exactly what happened. I made a mistake. I found the problem. I fixed it. I think patients appreciate that. Just don't make too many mistakes.
4. I'm starting to really like the laparoscopic inguinal hernia. Patients recover quicker, unquestionably. I had a guy recently who does that Ultimate Fighting craziness, returned to training 3 weeks after a bilateral hernia repair.
5. Anyone out there utilizing the Mammosite partial breast irradiation technique? A rep is coming to our office next week to discuss the possibilities.

Big Cases

I mentioned the other day that the Whipple is the Big Daddy case of general surgery. When all subspecialties are considered, however, nothing can top the liver transplant. Not a CABG. Not brain surgery. Certainly not the total knee replacement. First you have to extract the native liver, liberating it from all its attachments, performing a complete portal dissection, lifting it right off the vena cava, and then implanting a cold, brownish donor organ, hooking it up to the hepatic artery, portal vein, vena cava, and restablishing biliary continuity. All in a patient population that arrives for surgery cirrhotic, coagulopathic, with renal dysfunction and other severe co-morbidities. When I was a resident, my training program hired an aggressive transplant surgeon from the University of Pittsburgh (home of Dr Starzl, father of modern liver transplants). His arrival quadrupled the number of livers that were done per year. The great thing for us residents was that our program didn't have any fellows. So, as a third year resident, I was scrubbing across from the transplant attending, performing half the anastomoses. By Chief year, he was letting us do most of the dissection ourselves. What a great experience. I remember one case we did when I was a third year. This cirrhotic guy arrived at midnight for a transplant looking like complete hell. Oh, and he was HIV positive. This was a little controversial; transplanting a limited commodity into a person with a chronic, often deadly underlying disease process. HIV positivity was initially thought to be a contraindication to liver transplant, but with the increased survival seen with triple anti-retroviral/protease therapy, HIV patients were just starting to be listed as candidates. It was a bear of a case. He'd had numerous operations previously, and the tissue planes were all disrupted. There was a lot of blood loss. Of course I was triple gloved and had safety goggles on. (I asked for a welder's shield). The attending (a total cowboy) never wore eye protection. We finally got the donor liver in and reperfused but he continued to be coagulopathic and oozed from every raw surface. He'd lost so much blood by this point, that we'd probably exsanguinated all his HIV blood and now he was just bleeding clean stuff from the blood bank. Finally his heart gave out after about 9 hours of struggling to stop the bleeding. We shocked him within his chest a few times and then called it. The room was a mess. My arms were soaked in blood to my elbows. All that work. The attending was on the phone as I filled in the death certificate. Another liver was available. He was calling to see who was next on the list.

Tough case

We'd been consulted on this cool guy a week ago regarding obstructive jaundice. Initially, this was thought to be a garden variety case of gallstones/choledocholithiasis but a couple of details didn't make sense. For one thing, he didn't have much pain. (Painless jaundice is a huge red flag.) Another, his total bilirubin was 12. You don't see that degree of hyperbilirubinemia, generally, in gallstone disease. I sent off a Ca 19-9 (tumor marker seen elevated in foregut cancers) and they scheduled him for ERCP. The ERCP was aborted because the endoscopist couldn't access the common duct secondary to either "stricture" or "extrinsic mass". The CT showed grossly dilated biliary ducts and pancreatic duct, suggesting chronic, high grade obstruction, but no obvious pancreatic head mass or evidence of metastases. Percutaneous transhepatic cholangiography was then done, demonstrating a high grade distal CBD cut-off suggestive of malignancy. Ca19-9 came back over 6,000 (off the charts). This was either a cholangiocarcinoma or pancreatic CA. He wanted his surgery done locally at our hospital, and he wanted me to do it. It was obvious that a Whipple was necessary. This is the Big Daddy of general surgery cases. There is some evidence to suggest that morbidity/mortality rates are lower when Whipples are performed at tertiary referral centers. But I know how to do the case. I've done two since leaving residency, with good outcomes. I did a lot when I was a chief resident, I was trained by excellent surgeons in Chicago, I didn't have any problem accepting the case myself. But I did offer to transfer him downtown to a hepatobiliary specialist, if he preferred. He declined. You take it all out, he said to me.

Initially, the case went well. No evidence of carcinomatosis. The liver looked cholestatic, but without gross metastases. I did the usual maneuvers. The gallbladder removed, duodenum kocherized, gastrocolic ligament divided. I identified the SMV below the pancreas. Right gastric artery tied off. And then some troubling things started to become apparent. The pancreas was diffusely rock hard. Tumor infiltration? Chronic changes from obstruction? And then my heart dropped as I went to identify the gastroduodenal artery. The Common hepatic artery seemed unusually close to the superior aspect of the pancreas. The tissues seemed harder, more fibrotic. Usually, dissection proceeds beautifully through thin, diaphanous planes that just fall away with the gentlest of prodding. This artery was stuck to the pancreas. No doubt about it. I futzed around for a while. A branch that appeared to be the GDA disappeared into the woody, matted mess near the head of the pancreas. The SMV was clear, however. Now what? Well, I paused. I had my partner scrub in and take a look. I sent off multiple core biopsies of the pancreatic head. I sent a choledochal lymph node that seemed abnormal, and some of the lymphatic tissue around the pancreas. It all came back on the frozen sections as cancer. Game over. Hepatic artery invasion with positive nodes in the porta hepatis. Unresectable disease. I did a roux choledochojejunostomy, placed a J-tube for feeding purposes, and left a few JP drains. His wife was devastated. Hopefully chemo can extend his life.

Loose ends

I'm going down to florida for a Laparoscopic course for a couple days. I figure, can't hurt to get a different perspective, see how other guys are doing lap colons. A couple of random notes.

1. Data starting to come back on CT Colonoscopies. Kevin MD links to this. It will be interesting to see the backlash from our esteemed GI colleagues. Dare I say, turnabout is fair play? A general surgeon who has the gall to perform EGD's or colonoscopies is demonized by his/her local medical community and effectively is frozen out of any future colon CA consults. Virtual colonoscopy can potentially eliminate the need for routine screeening scopes. Seems best for the patient, as long as the literature supports the safety of such practice. But that means thousands of scopes come off the billing dockets of gastroenterologists. Surgeons didn't complain (too much) when we lost endoscopy. Very interesting to see how this plays out.

2. I got a consult for small bowel obstruction this morning. I read through the chart and GI was consulted the previous day for "bowel obstruction". Guess what Dr. GI recommended? Surgical evaluation. I just don't get it.

3. Bob Woodward's series of books on Bush/Iraq are a must read.

4. Indians against the Yanks tonight. I have a good feeling. Sabathia and Carmona trump anything the Bombers can put on the mound.

5. Friday Night Lights is the best show on TV. Watch season one for free here.

Too many Cooks

I was consulted at 5pm on Friday night on a 74 year old guy who had just arrived in the ICU secondary to "hypotension". Other than some mild dementia and essential hypertension, he was a pretty healthy guy. When I walked in, his wife was sitting at bedside and he was groaning in obvious discomfort. Here's his intial vitals: HR 130, BP 60/40 RR 29. He's on 24mcg of Levophed and the nurse just received an order from the IM primary to start dopamine. Ok then. I'm going to need a few things, I tell the nurse. We'll start with the crash cart. I quickly place a central line and an arterial line and bolus a few liters of saline in over the next 30 minutes. I review the chart. This is his second admission for c difficile colitis within 2 weeks. A rectal tube shows a steady stream of liquid stool into a bag. His abdomen is tense, tender, and quiet. I talk frankly to the wife. Ma'am, your husband is suffering from something called fulminant c difficile colits. It has made him septic and if we don't take him for surgery and remove his entire colon he will almost certainly not survive the night. Even with surgery, his chance of survival is less than 30%. Do everything to save him, she says. With the volume resuscitation ongoing, his BP starts to stabilize. The Levophed is weaned to a more reasonable 8mcg. We go to surgery and I perform a total colectomy, leaving just a short rectal stump, and give him an end ileostomy. I finish at midnight on a friday night. My experience with these cases has taught me that outcomes are about a 50/50 proposition. I've had some live, but none that were as sick as this guy. By POD#1, the levophed is off. The next day he is extubated. His renal function normalizes. Now he's taking clears. I think we're going to make it. But here's the thing that kills me. On POD#1, the primary MD doesn't say anything to me, other than "you know his Phosphorous is 1.2". And then he consults renal (creatinine 2.4 when I first saw him, then down to normal by POD#2), hematology (because platelets are 80), cardiology (occasional PVC's with hypokalemia), and Infectious Disease (infection present). I check my orders from the morning rounds and my KPO4 infusion has been cancelled by the nephrologist. The Lovenox for DVT prophylaxis has been cancelled by the hematologist (r/o HIT?!?). And the cardiologist has changed my fluid orders (worried about possibly accumulating fluid in his legs). Then the nephrologist calls me the next day. Classic phone conversation. "I don't know how to say this without creating an awkward situation", he says to me, "but I think it would be better for the patient if I managed his electrolyte corrections. You ordered 30 mmol of KPO4 and that can sometimes cause vasodilatation. I would also like to manage the TPN." Um, ok, I say. His creatinine is normal now and his urine output is fantastic and I've actually replaced K and PO4 hundreds of times in my life. But that's fine. I don't mind if you perform those duties, I tell him. And then he adds, barely concealing the underlying condescension, "I mean, I couldn't do surgery, but... ha ha ha " just sort of trailing off; the patronizing implication being that, as a surgeon, I shouldn't presume to know what I'm doing in an ICU. Unbelievable. This pateint is going to live. I've busted my ass for him. And now everyone wants to shuffle the surgeon off to the sideline so the "smart" doctors can manage complicated, life threatening emergencies like hypophosphatemia. Just had to rant on that one

But this case reveals an unspoken source of the high cost of medical care in the USA; all the unnecessary consults. The Internist admits a patient from ER with abdominal pain and fever. That means, before the surgeon sees the patient, you're likely to see notes from Infectious Disease and Gastoenterology in the chart. All of them recommending "surgical evaluation " for abscess or hernia or cholecystitis. ID is biggest scam is American medicine. Everyone with a fever or a white count gets ID on board. Here's what they invariably recommend: blood cultures, urine culture, sputum culture, CXR, and maybe a CT. Einsteinian insight they bring to the game. Give me a break. It's a specialty that certainly has a place; HIV, Hepatitis, unusual organisms, non-Western hemispherean illnesses. But now every local hospital has these huge ID groups that are glorified culture-checkers. The biggest census in the hospital belongs to our ID group. I don't get it..... Damn I don't write for a few weeks and I come out all angry and bitter. Hopefully tomorrow I'll blog about the natural beauty of autumn leaves and how I have to rake them for three hours every freaking saturday and stuff them into paper bags, getting little leaf chiggers lodged in my finergtips... well, maybe some other topic.

Pneumatosis

This case drove me crazy. She was a mild mannered, soft spoken 38 year old African American woman who presented with nausea/emesis and abdominal pain. On exam her abdomen was distended and she was pretty tender in the periumbilical area. This was her third admission to a hospital over the past 12 months with such symptoms. She carried a past medical history of scleroderma, but no previous abdominal surgeries. Bowel obstruction in a young woman without previous surgeries sets off the alarm in my mind. On exam, she was actually pretty tender diffusely, arguably with rebound in the lower quadrants. Then I looked at the CT. The radiologist actually called me, and said I better hustle to see this lady because she had one of the worst examples of pneumatosis intestinalis he'd ever seen. Then i started reading up on scleroderma and its GI manifestations. There is an entity called Intestinal Pseudo-obstruction that has been described for patients with scleroderma. It's a chronic motility dysfunction attributed to the effect of the scleroderma on small bowel musculature. I dug a little deeper. Pneumatosis intestinalis has also been described in this clinical picture. The theory is that chronic stasis/dysmotility leads to build of of nitrogenous waste from intestinal bacteria that can track transmurally through the bowel. Well, that's all good and fine. But look at that image from the CT! And her bicarb on the BMP was 18. And she was tender. And..... I wasn't sure what the right move was. The literature suggests that bowel rest, NG decompression, and TPN invariably leads to resolution of symptoms. But, for whatever reason (arrogance, inexperience, anal rentive disorder), I didn't trust the data. The clinical picture was too troubling. So I took her to surgery. And I found nothing. Diffusely dilated bowel from Trietz to cecum; no transition points, no adhesions, nothing no suggest a mechanical obstruction. Moreover, the bowel looked perfectly pink and viable. No evidence of ischemia. By POD#2 the NG was out and she was tolerating clears. Went home the next day.

Humbling case. You learn to trust your instincts in surgery because so much of the diagnosis comes from recognizing signs and symptoms you've seen before. Peritonitis is universal. The history one sees with appendicitis is about as standard as a recipe. But everything was reversed in this case. I'd never seen it before. Not too many people have. But I had the clarifying information in front of me, and despite the medical literature, I did the opposite thing recommended. I certainly had an indication to operate but perhaps a cold, evidence based, algorithmic-programmed, decision making monkey would have made the better decision. The human factor always plays a role in medical care; usually it's to the benefit of the patient. In this case I would have been better off not looking at the CT, not examining her, not checking her labs. Then I might have been more likely to trust the literature.