Monday, November 20, 2006
I suppose under the right circumstances, a person might think he was peeing champagne. Maybe if it happened early New Year's day, after intense celebration. Perhaps the hangover would dull the senses enough to make it seem like no big deal to piss air bubbles. Most people, though, find it disconcerting.
Colovesical fistula is the term for a connection between the colon and the urinary bladder, and pneumaturia is the name for air in the urine. It's most commonly due to diverticulits. In that circumstance, the sigmoid colon would have developed an abscess which plastered itself against the bladder and eventually eroded into it, creating a connection between the two organs, leading to leakage of air and stool from the one into the other. A similar connection can be made due to a cancer in the colon. In either case, rather than peeing champagne, the signs may be subtle for awhile: recurrent urinary infections are a frequent scenario. But for some people, the first sign of a problem is the passing of air in the urine. If it weren't scary, I'd think it would be sort of cool: "Hey, lookie here, honey! My dick's a damn bubble machine." "I don't care if it lights up like a Roman candle and plays the Star Spangled Banner, Charlie. Y'ain't getting any tonight."
I know I shouldn't make light of a serious situation, but the fact is fixing a colovesical fistula is fun. One of my favorite -- if uncommon -- operations, matter of fact. And it's a nice way to explain a couple of things along the way. Things like how different surgical specialties help one another; or foist themselves upon one another, depending how you look at it. And it's a literary vehicle for explaining the mysteries of complicated colon surgery.
General surgery is, we must agree, the queen of the surgical sciences, the fount from which all others have flowed. There may still be living (but likely no longer practicing) some icons from the day when a general surgeon was the only kind there was: drill heads, screw together bones, lift out uteri, remove a lung, repair an artery, while not otherwise occupied fixing hernias, taking out gallbladders, resecting colons. Our training still has us rotating through the various specialties, in part to give a taste on the basis of which to choose our future; but no less, I'd say, to give us the tools we need to handle things that have a way of arising in the course of an operation. After committing to general surgery, while still in training, we'd think nothing of removing a kidney, repairing a ureter, even yanking a uterus if it were attached, say, to an offending colon. And why not? They're all in or damn near in the belly; and the belly is the prime territory over which the general surgeon claims dominion. You simply can't be a general surgeon and not know the techniques involved in operating on any kind of tissue. The same cannot be said for other specialties; or at least for some who practice them. As I said in my book, with enough bananas you could teach a chimp to take out an ovary. If you only do a couple of operations, you could (can, in fact) learn to get through them without every really mastering certain subtleties. It's like this: I'm fairly sure a sculptor, if blessed with great patience, could teach me to chisel out something that might pass for a given body part. "Left index finger Schwab," they might call me. But there's no way in hell I'd be called Michaelangelo.
Brother Angelo, of course, made a hell of a left index finger. So I'm not saying if all you do is a couple of operations you don't know how to operate. I know some gynecologists who can handle pretty much any surgical surprises they encounter; others who call for help at the first sign of a fibroblast (the scar-tissue forming cells.) The same goes for urologists (a certain uroblogger, I have no doubt, is in the former category.) Nevertheless, it ought to surprise no one that it bugs the hell out of me to have a urologist assist me with the colovesical fistula, and to let him close up the bladder. Same guys who've, on occasion, called me in to find the ureter (the ureter!! the only tube in the whole damn body they need to know a thing about!!), or who needed bailing out after getting into the colon during a bladder removal, making their own colostomy without asking for help, and brought the wrong end out to the skin! (Yep.)( And yike.)
You'll pardon a second reference to my book. After it was too late, I thought that instead of calling it "Cutting Remarks" I should have used "Delicate Brutality," which is a phrase I conjured up in the writing. I meant it to describe the very technique needed when addressing a colovesical fistula. Most surgery is better when done delicately. Tissues like that, even though most of the time you can't tell if delicacy was used or not. Resecting a colon, for example, you can clamp a wad of fat and blood vessels and tie them off like a cowboy trussing a calf. I know a few who do. Or you can tease away the fat, see the important vessels and ligate them cleanly. The brutal method, in addition to being less artful and pleasing, leaves a lot of tissue beyond the suture to die. I'm not aware of any studies -- nor do I think they could be constructed -- that address it; but I think the more dead stuff for the body to deal with in the healing process, the less good it is. On the other hand, there are times when delicacy is simply impossible and if attempted has its own downside, in unnecessarily prolonging the anesthesia time. There's such a thing as brutality rendered with delicacy and gentle purpose. Delicate brutality.
For the most part, it seems the body was designed with surgeons in mind, like a Honda engine vis a vis a mechanic, as opposed to a crazy Italian car. There are ways to get to and around every organ in the body; planes exist -- even if subtly -- that separate one thing from another, so that it's nearly always possible to find your way around without poking holes in wrong places, or causing bleeding or other calamity. The ability to separate things gently is a very thrilling aspect of being a surgeon; knowing the little tricks that allow it. On the other hand, all bets are off when it comes to inflammation or big tumors; which is what causes today's subject. Approaching a colovesical fistula, you can expect a mess, complete with obliterated planes, unrecognizable and distorted tissues, often with the omentum having interloped its way into the mass-mess. A generation ago, it was considered so difficult and dangerous that the problem was solved in two or three stages: colostomy to keep stool from getting in the bladder, then remove the diseased section and close the bladder, then get rid of the colostomy. Now it's a one step procedure, if a little gross.
As messy as it occasionally can be, for some reason I really like slogging through a mess of colon; probably because I've managed to do it without disaster. Maybe "like" is the wrong word: I'm ok with it, because I always feel I'll be able to unravel the mystery. Instead of tidy dissection with scissors, as you get where the action is, usually you're insinuating a finger into the area, wiggling your way into non-planes, pinching between your fingers to thin things out: it's not likely you'd be able to pinch through something important. Or you're using the end of a suction catheter, or the unopened jaws of those scissors. As wooden as it can often be, an amazing fact is that practically without exception, when you get beyond the inflammatory mass attached to the bladder, at some point you will work your way to soft and normal upper rectum, to which it's going to be possible safely to sew or staple the other end of the colon.
I got an email the other day about blogging, asking on what basis I decide how long a post should be. When do I break it into more than one day? I just got back from New York a couple of hours ago. Feeling behind in my writing, I started writing this on the plane. Now, I'm going to bed. No editorial reason. Tired. I hope when I read this tomorrow, I'll know where to pick it up, and won't wonder what the hell I had in mind when I began this convoluted mess....