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?"
"Yessir?"
"Knock Knock."
"Who's there?"
"Hernia."
"Hernia who?"
"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!

20 comments:

Jordan said...

You say it has nothing to do with you but the truth is you had the vision to buck the odds and tradition and operate when it was best for your patient. That certainly had something to do with you.

keagirl said...

RCCa does behave very very strangely sometimes. There are always case reports in the Journal of Urology reporting yet another weird location of a met. The weirdest was to someone's thumb.

By the way, I finally got around to ordering your book and reading it. Quite entertaining and it brought back a lot of my memories from residency.

Intelinurse2B said...

nice hood ornament...lol.

Moof said...

That's amazing! This fellow has more "lives" than a cat! Hopefully, each time a metastasis shows up, it's operable ...

He's lucky you were there for him ...

Cathy said...

Wow, good stories you write! I have been reading for a couple hours here this morning.

enrico said...

amazing luck for the pt, but he had good surgical management as well.

I gotta say, I'm stoked about that sweet ride you have pictured. My late grandfather left behind a Buick Century station wagon complete with faux wood paneling. Whenever I was visiting home and flying in, since I was w/o a car, I'd often borrow it from my grandmother. I'd always joke w/Claudia that I wasn't responsible for the women throwing themselves on me after seeing me in that studmobile (the keychain from my grandmother that said, "I Love Bingo" sealed the deal if there were any doubts)

I'd pay real money to drive this Chariot of Love blasting "Low Rider" from the stereo, yes indeed.

Now that I've exposed my extreme weirdness, I'll slink away now...

Sid Schwab said...

Enrico: wish I had that baby myself. Found the pix online, of course. Hardly weird: you're a man of classic taste and great widom.

Spiritual Recovery said...

Thank you. I enjoyed that story immensely. Whoever John was, he almost makes cancer look easy -- as if it's simply an annoyance and diversion from the bigger business of living.

All things considered, it's probably not a bad attitide to adopt if one can get away with it.

Sid Schwab said...

Keagirl: well, it's always thumbthing

Intellinurse: glad someone's noticing my links...

Prisca said...

This was a great education about the Whipple for me as I keep running into the term over the last few weeks and hadn't had the time to thoroughly look it up (I made the time today--interesting stuff)! Thanks for that and the interesting story about John! My fingers are crosssed for him...

Dr. Willow-Esque said...

Like a Timex...takes a licking and keeps on ticking?

Kim said...

Great story, great patient!

I say my aunt died of "not having cancer". Her tumor in the head of her pancreas turned out to be benign.

For whatever reason, I'm sure there was no other choice, the surgeon did a full Whipple.

She died of multi-system organ failure/septic shock.

I've always said tumors are like real estate, it's location, location, location. Even a benign tumor can kill you in the wrong location. This "benign" tumor caused so much discomfort, and was actually growing, that my aunt would have just kept getting worse without the surgery.

I do have to admit my heart sunk when I heard she was having a whipple, even when we did think it was cancer.

The surgery was actually successful, if that makes sense. She was able to eat a full breakfast four days post-op!h

The MSILF said...

The first Whipple patient I saw was a slightly retarded immigrant - about 4 years after his procedure for pancreatic ca. He had come in for a consult with the surgeon because he had a small incisional hernia, and wanted to know if it was ok for him to help his older neighbor move because it popped out when he lifted heavy stuff. He felt bad when the neighbors saw a seemingly young man hesitate to help.

The surgeon, after they finished finding someone to translate and seeing him and so on, and then the surgeon turned around to us students, and said, "And that shows that you CAN get a good outcome sometimes with a Whipple." It was impressive.

judygold said...

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” William Osler

This is one of my favorite quotes and a good explanation for John's repeated successful operations, besides your skill as a surgeon.

Sid Schwab said...

I completely agree, which is why I always tried to impart a positive attitude.

schnitzelbank said...

I'm intrigued by your blog- I just stumbled upon it today. My grandfather was feeling run-down and one morning woke up jaundiced as an egg yolk. He was about 80 at the time. A trip to the ER netted him a pancreatic cancer dx and a surgeon who offered to do a Whipple, followed by chemo and radiation. The chemo and radiation was stopped after a few weeks, he just didn't have the strength. Despite this, he lingered for another 18 months, miserable, retching, death-belches. I was 20 at the time - this was about 20 years ago, before much internet. Before I knew much about anything. I spent an agonizing summer feeding him a steady supply of my college pot stash, helping him on and off the toilet, cleaning up, and listening to him want to die. During one of many trips to the ER for intractable pain, a nurse pulled me aside and said, "You let Dr. So-n-So do a Whipple? I wouldn't have let him operate on my dog." Indeed, the gaping incision across his belly never healed and we went to the wound clinic frequently to dab it with this and that. It oozed and leaked and hurt until he mercifully died.
After he was gone, I smoked up the last of the pot I had given to him. Unbeknownst to me, it had been laced with something and I hallucinated something wonderfully fierce. That was my only solace, that at least the pot at the end was probably a nice respite for him. He told me it reminded him of his time in the Phillipines.
Anyways.... I guess my point is, I would hope that no surgeon worth his salt would prolong an old man's misery with a surgery that's only going to drag out a painful death. He never recovered from that surgery, I feel, and he would've been better off just dying from the cancer to begin with.

Veteranshelper said...

Very interesting the life of a surgeon. I like the way you approach your patients.

Sid Schwab said...

Thanks, Mike.

Maia said...

Hi! I'm 15 and thinking about being a general surgeon and specializing in abdomen surgeries. When I was 10 I was diagnosed with pancreatitis caused by gall stones in my bile duct. The surgeon told us everything and basically that I needed surgery to remove the gall stones and remove the gall bladder, but I was so early on that if my parents wanted to, they could delay the surgery until the summer when I was out of school or maybe even a year later if they wanted to. But he said that if I did not get the surgery then I might get cancer or diabetes down the line. Knowing my parents they of course wanted to delay, delay, delay even though I would not had to have gone through as much as I have if they had just went along with the surgery then or even if they had waited a year... Well THEY WAITED FIVE YEARS! Not surprisingly my (I almost want to say idiotic parents because of how much pain this disease caused me but I know they have done a lot for me and I don't want to be rude. But, if you knew your child was going through all this pain... wouldn't you take action?) So back to what I was saying, not surprisingly my parents did not get the surgery when they were suppose to and I had about 7 pancreatitis attacks throughout that time period that left me in the hospital for 1-2 weeks at a time. You know, because when you get the attacks no eating or drinking only intravenous fluids. BTW, I would think my parents would have just caved in at around the second attack and let me have the surgery. I'm sorry this is becoming more of a rant than a question. But anyways long story short I got the surgery about 3 weeks ago after a long road of attacks. They went in and because I had waited so long they found stones everywhere and said something like the duct was twisted? Of course I woke up with the tube going down my nose into my stomach for draining(I don't know what that is called) and that was horrible. Anyways I am recovering am still healing now and have to deal with the low fat, low sugar diet for a while still. I don't know if you have ever had pancreatitis attacks as bad as mine because of the added damage, but they have been the most painful thing I have ever felt in my entire life. I love helping people, I love the guts and gore of surgery, and I want to help people with problems similar to mine. I know you cant ONLY do abdominal surgeries but that is at least what I want to specialize in. People keep trying to deter me from wanting to be a surgeon by saying things like, "they have no lives", "They have to do a LOT of math in college" (knowing that I don't like math)... Could you give me your thoughts on those things and other things people say to try to make you not want to become a surgeon. See, the reason I want to become a surgeon is because one, I know how terrible it is to have pancreatitis and other abdominal problems and I want to help people with that, also I love interesting things like cutting people open, examining what is inside them, seeing things most people don't get to see, also I love the human body. Biology, the way it is taught in my high school is not very good... so it is hard for me or anyone else in my classroom to enjoy it. (we have a bad teacher) But I like the whole concept of biology. I have really steady hands and I can focus hard on something hands on. (I'm also really good at hands on things. Thanks for taking the time to read this and sorry for writing something so long. :)

Sidney Schwab said...

Maia, the good news is you have plenty of time to decide, first, whether you want to go to med school, and, second, whether general surgery is where you'd end up. You certainly have some experiences that would give you empathy for your patients.

For the record, when someone had gallstone pancreatitis, unless there were strong reasons why surgery would be dangerous, I always recommended surgery, for reasons of which you're well aware: it's one of the most serious and potentially dangerous complications of gallstones.

I'm not so sure lots of math is a requirement for getting into med school, especially in the last few years, when requirements have loosened some. Biology, yes. I don't think I had much in high school, but I majored in it in college, and had really great teachers.

You should go to the last post in this blog and follow some of the links: there are many that try to describe what it's like to do surgery, what internal organs are like, and more. And if you want an idea of what surgical training is like (or used to be, before new hour-limiting rules) you could get my book!

You're right that general surgeons are the ones that do mostly abdominal surgery; nowadays (in part because of those newly limited hours) lots of people finishing general surgery residency feel the need for more training, and go on to do a fellowship (ie extra specialty training) in a particular area, like biliary surgery, or colorectal surgery, or cancer surgery. But there are still plenty of general surgeons who do the broad range of stuff.

And whereas compared to lots of kinds of doctors it's true that general surgeons have more demanding professional lives than most, that may well be different when you're at that age. It already is in many places, including in my community. Here we have surgical hospitalists who do nothing but on-call surgery, emergencies, consults, unscheduled stuff. They lead very predictable lives, working in assigned shifts. And it means that the other surgeons, who have office-based practices, and do scheduled operations of all sorts, don't have to come in in the middle of the night very much, nor have their daily schedules interrupted by emergencies. A much better life!

Good luck in finding your passion.