Tuesday, August 15, 2006
Memorable patients: part six
"You can't just let me bleed like this, Doc. I need to get out of here." So said John, a man in his seventies, with kidney cancer spread to his Ampulla of Vater. Renal cell cancer is among those that sometimes behave in very strange ways. John had had his removed, along with his left kidney, about nine months earlier. At the time, it was thought likely to be a curative procedure. Now, he'd been admitted anemic, weak, with evidence of blood in his stools. Workup, including endoscopy, had shown a friable bloody tumor right at the ampulla, and biopsy had shown it to be the kidney cancer, now spread to this ultra-highly unusual place. It didn't seem to be anywhere else. He wasn't bleeding much, as these things go: about a pint a day. Easy to keep up with; hard to send him home.
Ordinarily, the operation for a tumor at this location is a choice between two options: local excision (done by opening the duodenum and carving the tumor out), or a Whipple procedure -- the biggest of the bigs. For a diminutive tumor, the former may suffice. Its main limitation is that you can't carve very deep without getting into the pancreas or going through the back wall of the duodenum. So it's pretty much reserved for those small tumors, preferably mild-mannered ones. If you're serious about cure, you go for the Whipple. I talked about a Whipple in my book: it's every surgical resident's dream: the full-meal deal, the three-ring circus, the Superbowl of surgery. It involves about every trick up the sleeve of a general surgeon: removing some stomach, some bowel, some bile duct, some pancreas, the gallbladder. Hooking things back together using -- because the organs are so structurally different -- every type of sewing technique you know. As challenging and fun as it is, it's also risky for the patient (mostly because of the possibility of leak of digestive enzymes from where you sew the pancreas to bowel, which begins a process of auto-digestion...) So doing it on a patient with metastatic -- and therefore statistically incurable -- cancer just aint' hardly done.
What a nice guy John was. Big, gregarious, talkative and congenitally humorous. Recently retired, he and his wife had bought a motor home and made plans. No way he was gonna spend his precious time in a hospital. Other than his need for a bag o' blood a day, he appeared healthy as a horse. The decision to operate was a no-brainer. And the obvious choice was a trans-duodenal local excision. Which I did, pushing the limit of the possible and, far as I could tell, leaving no obvious tumor behind. John recovered fast, and beat a path to home, no longer bleeding.
Not very surprisingly, he was back in about four months, bleeding in the same way, from the same place. This time, according to the CT scan, the tumor was infiltrated into the head of the pancreas. And, as before, there was no sign of it anywhere beyond that spot, in his belly or elsewhere. "Here we go again, Doc. Whacha gonna do? I feel fine, I really do." So now what? Send him home with arrangements for a daily transfusion? Made sense in many ways. But not to him. Or to me, really. So, despite what would seem on paper -- and probably to a review committee, were he to have problems -- to be contraindicated for metastatic cancer, I talked to him about a Whipple and signed on.
I've planned a number of Whipple procedures and more than once, despite the high quality of modern imaging, have been disappointed when I made the incision and went through the usual assessments to be sure it's really operable. In John's case, amazingly enough, everything was as advertised: not a sign of tumor anywhere else but in his pancreatic head. I gave him a nice job. There were no postop problems and he went home, as was his habit, on the fast-track. I saw him for a couple of routine office visits, and he disappeared back into his life.
As often happens, for magical reasons I guess, within a week or so of wondering whatever happened to ol' John, about a year and a half after the operation, he was back in my office. With a hernia. (Not -- I hasten to add -- in his incision. It was a garden-variety groin hernia.) "Damn thing bugs the hell out of me when I'm driving the motor home, Doc. Fix me up, willya? Oh, and Doc?"
"Hernia good jokes lately?"
He was, of course, back on the road in a few days.
Once again I lost track of John for a couple of years. Then one day I ran into his urologist, the one who'd done the original kidney removal. "Guess who I just operated on," he asked. "Your friend John. He showed up with his left testis big and sore. Turns out he had another metastasis, this time to his nut." The urologist had checked him out and found, per usual, no tumor elsewhere; he'd removed the testis and sent John back to his motor home. Last I heard, he'd moved to a nearby town and was still going strong. I have no doubt that at some point (if it hasn't already) the cancer will reappear and will sometime get the best of travelin' John. But in the meantime, he remains unique among my Whipple patients. I've done my share of them, nearly always for primary cancer of the pancreas. It's the only cure for that disease, but the results have been pretty dismal no matter who does it, and mine are no exception. Good surgery, bad outcome, sooner or later. But there goes John, in a situation that should have killed him years ago, guzzling gas, probably sideswiping Volkswagens, having a hell of a good time barreling down the road in his motor home, thumbing his nose at the odds. I must say this has almost nothing to do with me, and everything to do with the curious equilibrium between John and his tumor. Good for him!