Sunday, December 10, 2006

Pancreas stuff, #2

Hmm, seems like I've been a bit tardy getting back here. Sorry. Life: the blogger's enemy.

As I recall, I was saying something or other about the pancreas, pointing out its difficult anatomy, tucked back there behind the stomach and the colon (did I mention that the main artery to the spleen, a big one, passes right along the edge of the pancreas?), and suggesting ever so subtly that when aroused it can turn from a fluffy and pink-cheeked organ into a devouring juice-dripping and slobbering monster, the bane of a surgeon's existence, and the most awful of threats to its owner. Or something like that.

It's acute pancreatitis that's the most horrible (not that chronic pancreatitis is particulary serene: it might not kill you like its acute cousin, but under some circumstances it might make you wish it would. More later on that subject.) In a tidy private practice the bulk of the acute pancreatitidies show up as a result of gallstones. In the county hospital, mostly it's alcoholics on a bender. The latter are the worst, in part because they are generally in worse physiologic shape to withstand the assault, and in part because alcoholic pancreatitis just happens to be the baddest actor.

As I explained all too briefly, gallstone pancreatitis occurs when a stone passes out of the gallbladder into the bile duct (I've also been tardy in getting around to a series of posts on gallbladder disease. It'll happen.) If you refer to the diagram in my previous post, you can see that if a stone were to lodge in the south end of that duct, below where the pancreatic duct joins it, bile could, instead of passing into the gut where it belongs, be forced backwards into the pancreatic duct. Experiments have shown that squirting bile into a (mouse's, I think. Maybe a fruit fly's) pancreas causes pancreatitis; so that's the presumed mechanism. If the stone passes finally, the process may be self-limited; in fact, the bulk of patients with gallstone pancreatitis -- sick as they might be, and impressively scary as their lab work can get -- tend to get over it in a few days with only supportive measures, followed by a properly timed operation to get rid of their gallbladder. So ideally, when such a patient is admitted, the surgeon is involved early on, consultatively speaking, and hopefully the patient has the good fortune and the surgeon has the good sense to avoid early intervention, scalpelly speaking. If not, it's a hell of a mess.

Nowadays, as a result of some better-late-than-never studies showing that even with infection, non-operative management may be better than operative, surgical treatment of acute pancreatitis is done less often than when I was learning the game. Back then -- and, unavoidably and miserably, sometimes even in the age of reason -- I got involved in some pretty horrible morasseri. The most memorable was a lady of high social, political, and academic standing in her native Asian country, transferred to us by a surgeon who'd trained years earlier at UCSF, where I was then chief surgical resident. He'd operated on her once in their country and had arranged a special flight to San Franciso. After a long ride, she arrived in bad shape.

It would take a better writer than I to describe the hell-hole created by acute pancreatitis at its worst. It's that combination of highly unfortunate location and the power of self-digestion that turns the upper abdomen into a seething and distorted mess. Imagine a nicely-tended garden overtaken by sewage. Think of trying to find your way through a mine-field, knowing a misstep could cause death, while wearing size twenty shoes, and blindfolded. Compare being required to reach into a shallow pan of water to find by feel a couple of well-defined objects, with groping into hot mush, mittened and scared. See? I takes a better writer than I. None of that does it justice.

In a normal person, maybe one on the slim side. exposing the pancreas is among those surgical moves that I find quite cool: it's one of those little revelations of anatomy, the knowing of which (every surgeon does) feels like having been taught a secret handshake. The transverse colon travels just under the bottom edge of the stomach. (Strangely, the best illustration I could find is from an article containing complete bullshit.) Perfectly placed, a cut into the tissues that bridge those two organs can open into a delicate place, the "lesser sac (lousy diagram, but one that might make you think "Wow, you surgeons really need to know your stuff.") Tucked behind the stomach and colon, that space is clean and quiet, opens sort of magically; and its backside is -- ideally -- that pink and normally-firmer-than-normal organ, the pancreas. There for your viewing pleasure. With acute pancreatitis, not only is that space completely obliterated, it's filled with indistinguishable stinky goo, and the edges of the stomach and colon -- out of which you'd dearly like to stay -- are absolutely undecipherable, unrecognizable, and half-digested. Not good. Which is why, as I mentioned in my previous post, we used to navigate it with a spoon.

Draining pus is one of the most time-honored things a surgeon does. Open an abscess, liberating a well-defined collection of stomach-turningly stinking cream, and without question you've done a body good. Pancreatic infection is nearly never like that: it's a quart milk-carton-sized uncircumscribed (read that word carefully) zone of corruption, at the periphery of which you know is extreme danger if breached, but the outlines of which are indefinable. Your goal is to rid the area of all the infected tissue and to provide multiple avenues of egress for retained and future collections. That spoon helps: you figure if you can scrape it out with a some-what delicate sweep, it wasn't meant to be there any more. It's blunt enough that you might avoid stumbling into the colon or stomach, or important vessels. The corruption thusly removed contains the occasionally recognizable chunk of pancreas, globs of saponified fat, and lots of crud. Almost by definition, you can't do a thorough job; nearly always is it necessary to go back and do it again, once you've decided to take the surgical approach. Again; and often again and again. In fact the need to do so has led to a few inventive methods to facilitate reoperation; including an actual zipper, applications of plastic place-holders, and tacking the edges of the abdominal wall down into the hole, exposing the target area, and holding the rest of the abdominal cavity out of the way (that's called marsupializaion, descriptively enough.)

We just closed our Asian lady loosely each time with monster sutures. We left huge drains in the field, tubes that allowed irrigation of anti-biotic solution in and out. During one of the operations it was apparent the infective-digestive process (remember the digestive enzymes of the pancreas have been released and are eating away at the fats and proteins in the area, making the process an ongoing and self-perpetuating one) was working its way into the blood supply of the colon, and that the transverse colon was compromised. A portion got removed (not easily, given the absent landmarks), accompanied by colostomy, which added an ongoing source of contamination to the soup. In between operations, her splenic artery blew, requiring a hand into the wound in the ICU, followed rapidly by a trip back to the OR. She nearly died a few times, from sepsis, from organ failure, from that bleeding episode. But somehow she made it. Somewhere I have a beautiful hand-embroidered silk tablecloth she sent me when she returned home. Not everyone I saw with that disease made it. Not everyone who made it -- the county hospital alcoholics -- expressed gratitude.

Surgeons, when forced into it, can change; can recognize or even promote progress. The radiologists -- damn 'em and bless 'em -- have produced all sorts of techniques to bail out surgeons, as well as to supplant them. When a defined abscess occurs in a pancreas, they can guide a wire followed by a drainage tube into the area; it's enough to turn the tide without operation in many cases. Some things those guys do have robbed me of surgical fun (pancreatic pseudocyst is one example -- next post): taking away the need to operate on infected pancreii is a job happily ceded. Bolstered by the evidence of recent studies, and by the up-sleeved tricks of the radiologist, I've successfully observed the resolution of acute pancreatitis in several patients on whom I might have operated years ago. Most excellent. Next post, I'll talk about the pancreatitis-related operations I actually like to do...


Anonymous said...

Years ago when the TV show ER first came out, the local TV stations went nuts. They had many reporters tagging along with us on the trauma service. As the chief resident, I was asked on camera during the "Live at Five" o'clock evening news for my thoughts on coping with the intense, grueling schedule of a surgical residency. My response was something that my chief resident taught me when I was an intern. I repeated it verbatim, "Eat while you can, sleep while you can, but don't Fu@* with the pancreas!"

Anonymous said...

I left out the part that despite it was "live", there is always a few seconds delay...Yes, I was bleeped. All the attendings had a cow! Most of them had a big laugh about it, except for the department chairman. Needless to say, I received more than just a stern warning.

Unknown said...

Anon-9:16 I am a first year MS1 I had a meeting with a department chair here at UCLA and I asked him what I needed to know if I wanted to become a surgeon. His response was verbatim "Eat when you can, sleep when you can, and don't f@ck with the pancreas!" I think this saying is probably lore in surgery if I know it. Cheers

Sid Schwab said...

I think we've all heard it at some point (though not all have had the opportunity to blurt it onto live television. I'd have liked that.) It's just that it's not always possible to follow the rules. Any of them.

Unknown said...

Dr. Schwab,

I bought and read your book about 2 weeks ago. I thought it was fantastic. I've been silently reading your blog for awhile now and it inspired me to make the purchase. What can I say the the blogosphere is addictive and your book is a great expanded version of this blog. I thoroughly appreciate your insights and love your writing style. I hope you continue to blog for a long time.


Janet said...

Your recent posts have been very timely and helpful for me. My most recent patient has been hospitalized for pancreatitis.

Phoenix said...

Got to love those Glasgow/Ranson criteria. When I was a baby surgeon, our HDU loved to play tough, and quoting them mortality rates with acute pancreatitis was an easy way to get a sick patient into one of their beds.

Damn physicians just don't understand the pancreas though. I'll never forget admitting a patient in acute DKA to my ward. The physicians washed their hands of him when they saw he had an amylase of 110.

No amount of sensible discussion would convince the 1st year physician that her patient was in DKA. That amylase meant (according to her) that his acidosis was due to pancreatitis.

I admitted him, checked my textbook to make sure I'd done everything right for his DKA, updated the nurses (who weren't used to looking after acute DKAs but did a grand job all the same) and let the Consultants fight it out in the morning.

Sid Schwab said...

chris: thanks!! I love hearing from people who liked the book, and I'm glad my attempts at continuing its style in this blog seem to be succeeding.

janet: hopefully it won't be long before your patient is eating chocolate and raspberries.

h. phoenix: 110! Zounds! Get out the spoon!!

Anonymous said...

Actually, I rather enjoyed that illustration of the colon in repsect to the stomach... at least now I know where on my t-colon to push if I ever get a sinus infection....

XE said...

I discovered your blog today, and am really enjoying reading it! We had a patient with pancreatitis last year - luckily she didn't require surgery. It was actually kind of interesting though - cats can show weird symptoms, and the only symptoms she had were high blood glucose and a fever.

Anonymous said...

I just recently been directed to this blog and haven't read the previous comments regarding your pancreas musings. So forgive me if I am butting in and offering a pedestrian comment.

I am part of the medical profesional community that happened to experience traumatic (surgically induced?) acute pancreatitis 6 years ago as a complication from an exploratory laparotomy for multiple abdominal abscess therapy (inter-loop, subdiaphragmatic, paracolic gutter - both? and pelvic loci). I make this comment not to blame the surgeon - he saved my life when all others left me to die - but to make known, from a view "beneath the scapel" that while this saying is humourous, and on the surface elicits a sardonic laugh from me, it is a saying that I hope all surgeons take to heart.

Six years later I am still living with the daily impact of my surgeon "F'ing with the pancreas". Many days I wish he would have concurred with his colleagues and let nature take its course at the time.

Life after arousing the sleeping beast is often not worth living.

My conclusion, after dealing with surgeons, both professionally and personally, is that they concentrate too much on saving life for life's itself's sake, but they seldom think of the quality of life that they are creating. A dilemma that is best left to a higher power no doubt, but one that I think needs to be in the back of the cutters mind at all times.

Laugh to relieve stress, but recognize that there is a reason that lore is passed on through the generations.

Sid Schwab said...

Making life and death decisions is something I plan to post about in the very near future. It's a serious subject -- maybe the most serious of all. And here's the thing: you don't get do-overs. You have to put together information which is often less than complete and make a decision, sometimes very rapidly. To think that they will all end up perfect in retrospect is to give us way too much credit.

Anonymous said...

I think your response reinforces the point that I was trying to make in my previous post: that surgeons tend to see things from a "look to the past" view as opposed to "look at the future" when it comes to individual patients.

My statement of "saving life for life itself's sake" didn't clearly express what I meant. My intent was to explain that I get the impression that many surgeons believe that a job is well done if the patient "merely" (and I say that with sincere respect to the profession) survives the operation; that the quality of life that the patient is left with is not a matter of deep concern. "If the patient survives, wonderful - mission accomplished; if he survives with a resumption of a near normal life, then that is a bonus but out of our hands!"

No doubt in emergency situations a surgeon does what (s)he needs to do to "buy time" and hope that nature or other specialties will pick up the pieces. And I am amazed at the skill and knowledge that the surgical world has accumulated. If there is any branch of medicine that can be considered home to miracles, I think it is surgery.

But while you say expecting perfection in retrospect is giving you too much credit I do think that expecting perfection prospectively is what the patient hopes a surgeon strives for. There are times when it is a miracle that a patient merely survives the operation, but I am hoping that we can get to the point when not just surviving but also thriving after surgery will not be thought of as giving you too much credit.

My thoughts are wishful and probably unattainable.....I wish that the surgeon would not look back at what was but will look forward to what can be. I don't want to be told that I should be grateful just to be alive....I want to be told that I should be grateful to be alive AND for having as much as a healthy life as the surgeon was able to give me. I want to know that the surgeon looked beyond just saving my life; that he considered the longterm consequences of his decisions and actions while operating; why stop with just saving my life? why not go the extra mile and try to give me a life worth living.

I don't expect a surgeon to be God....but I do wish he could be God-like and consider the past, present AND future.

(I guess I got off track of the subject; I am looking forward to reading what you write about making life and death decisions)

Anonymous said...

Dear Anonymous, I read your comment and my eyes got tears. I had acute pancreatitis all my life due to incomplete pancreatic divisum. I did not have a duct that connected to the douedem and then I got SOD, so I had a sprictotomy and a stent place thinking that was the end, it was just the beginning. I had 11 procedures that year including the whipple. May of times I have said if I would have know then what I know now..I question if I would have done anything at all. I still have attacks and at some point I will probably take the dive to the cp/ict...There are so many thing about the pancreas that they never tell you, like that you could turn chronic, etc and what all of that and TPN, etc really means in day to day existing... I empathize. I do yoga and meditation. I have learned my limitations, though I constantly push the boundary. I live my life the best I can refusing to accept this as it is. It's a struggle, for sure, though, everytime I ride the motorcyle with my boyfriend and the wind blowd through my hair, I feel the sun's warmth on my backand I am thankful to be alive at that moment. My journey bought me that. I guess it's all in how you look at it.Take Care, Kathleen

Anonymous said...

I was interested in the photographs that are with the "Pancreas stuff, #2". Not to mention the worry after reading this, ha ha. I've had gallstones for a few years and have developed a pain that feels like my rt.. kidney, as you say, time to go see a doc. unfortunately, where I live it's hard to find good ones that take new patients.

Anonymous said...

About a year ago, I had some abdominal issues that snowballed into accute pancreatitis quickly. The surgeon/GI doctors that were "helping" me did not have the good sense to hold off for a little while before removing my gallbladder while my amylase and lipase were skyrocketing. Four weeks of TPN later (and at an unhealthy 93 pounds), I was finally released from the hospital. I wish I had read your blog prior to putting all of my trust into doctors that were truly unsure of what they were doing.

Anonymous said...

Seeing as this post is pretty old, I doubt many people are still reading it. However, if you are, and if you find yourself in a similar situation, you should check out the National Pancreas Foundation's website.


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