Pleasin' Squeezin'

From my prior comments about my love for bowel surgery and for the old-fashion method of hooking the ends together, one might draw the erroneous conclusion that I eschew all forms of operative shortcuts. Untrue. While not the top priority, speed is an issue, and I've written about that, too. My reasons for preferring hand-sewing over staples -- aesthetics, cost savings, connection to the history of surgery -- don't apply when it comes to clamping and tying blood vessels. Surgical clips, particularly the old-style individually loaded ones (as opposed to the fancy disposable multi-fire guns) are cheap as dirt, simple as hell, and save lots of time.

For the first thousand years or so, surgical clips were made of stainless steel. More recently, and mainly because of concerns about clips being pulled off by MRI machines, they come in titanium or, most lately, are made of absorbable material. Whatever the composition, the idea is straightforward: shaped like the marriage-bed issue of a V and a U and grasped in the jaws of whatever instrument, the open part is slid across a vessel or duct, the holder-handles are squeezed, and the clip flattens into two legs tightly pressing the tubular structure in question and rendering it closed. Depending on size, pressure, and tightness of one's own sphincter, more than one clip might be closed onto the business end before cutting. Either way, it saves several seconds over clamping and tying; over a long operation with need for many ligatures, it adds up.

Blessedly uncommon, one teensy problem can occur: if the jaws of the applier are out of alignment, instead of bringing the "legs" of the clip properly together, they may overlap in such a way as to turn it into a scissor, cutting when the intent had been the opposite. Depending on where and what, it can fall anywhere along that line which connects "nuisance" with "disaster."

Practically every patient who's had his/her gallbladder out in recent years will have had two little clips placed, one on the artery to the gallbladder, and one on the duct that drains from it into the main bile duct. By the pattern and location, you can tell a person has had the operation just looking at a plain belly Xray. Consequently, I've had many patients return to me upset because their chiropracter took one of their infamous whole-body Xrays and told them that those clips near their spine are causing all sorts of problems, likely requiring monthly manipulations for the rest of their life. I'm guessing the regular reader will not have to wonder what I think of that. It did, however, lead me to be sure to inform everyone in advance, pointing out that we leave chunks of steel the size of doorknobs in hip sockets, and pacemakers aplenty, big as a pocket watch and housed happily.

Mother of all general surgical operations, the Whipple procedure (about which I've written here and in my book) affords many opportunities for applying clips, and I've always done so liberally. One such patient brought me an amazing story, which I'd never heard before and haven't since.

Other than being the color of a daffodil, when I met him he was a very healthy and vigorous man, in his sixties and in need of a Whipple, which I did promptly, slick and quick. His recovery was rapid (much more so than indicated in the preceding link) and he returned in short order to his major pleasure, golf. One day, several weeks after the operation, golfing as usual and on a dog-leg left, long par four, he explained, he felt a strange tickling sensation on his belly. Lifting his shirt and looking down, he noticed some activity at the small and previously healed scar from where I'd placed, and left for a few days, a drainage tube. He got his hand to the area in time to catch a whole series -- fourteen, to be exact -- of steel clips exiting out the former hole in single file like little tin soldiers, blip, blip, plop, plop. He brought them to me in a baggie.

Big Joe

When I think of Big Joe, I see his overalls, and how he filled them. And how a couple of months after I operated on him, there was room for both of us in there. Big Joe: farmer, salt of the earth, tough, stoic. On the day I met him, if it'd been Halloween, I might have tried to stick a candle in him. That's how orange he was. My initial recommendation, while probably justified, damn near killed him.

Big Joe hadn't been sick a day in his life. Well, he was diabetic, but it hadn't been much of a problem. He worked his tractor every day; took a hell of a lot to slow him down. He'd been feeling a little poorly, less appetite than usual, no pain really. It was the white stools that worried him, along with the brown urine. His color, well, he was in the sun all day, so that hadn't seemed too strange to him, although his wife was starting to notice. So he saw his doc, who ordered a battery of blood tests, an ultrasound followed by a CT scan, and then shot him over my way. It looked bad.

Jaundice comes in two basic categories: obstructive, and non-obstructive. Surgeons see the first category. The second is usually from "medical" liver disease, like hepatitis. What makes people yellow with liver trouble is bile pigments getting in the bloodstream, either because the liver isn't processing the chemicals properly, or because the bile can't flow out of the liver into the intestine where it belongs. (The liver makes about a quart of bile a day, which flows through a tube called the bile duct, into the upper small intestine. It helps to digest fat. A main component is bilirubin, which is yellow.) Obstructed flow begs an operation of some sort to relieve it. Once again there are two general categories: gallstones, and tumors. (There are also things that scar down the ducts which are fairly rare and often present supreme surgical challenges.) Gallstones, formed in the gallbladder (future series of posts), can pass out of the gallbladder and get stuck in the main bile duct, plugging it up. Typically, because it happens fairly suddenly, it hurts like hell. Painless jaundice, a result of a slow squeezing of the duct, most often says something bad like cancer. Big Joe didn't have pain; he had an enlarged duct consistent with obstruction, no duct stones on sonogram or CT scan, and an ominous enlargement of the head of his pancreas. Just to frost this sour cake, a blood test had been done that showed very high levels of a certain protein, associated with cancer. Walks like a duck, quacks like a duck, and has feathers. A duck. Duct.

He did have stones in his gallbladder, but no evidence they'd moved out to cause the problem. I decided to send him to a gastroenterologist before I operated, to Xray the bile duct just to be sure it wasn't stones causing the blockage (duct stones are hard to see on sonogram or CT scan, but the GI doc can pass a scope through the stomach, into the duodenum, and inject dye directly, for an excellent picture. It's called ERCP, for "endoscopic retrograde cholangio-pancreatogram." Plus, as long as he's there, he can insert a tube to allow bile flow pass the obstruction which, it was felt, can improve hepatic function before surgery, making healing more propitious. The ERCP showed no duct stones; the stent was successfully placed, so by the time I operated on Big Joe, his bilirubin levels were falling. The operation would be a Whipple Procedure, which I've referred to previously. A complex operation, which I expected to be doubly tough in a five-foot-ten, 350 pound guy.

It may seem paradoxical for such a huge operation, but there are times when we proceed on the assumption that it's for cancer, without trying to confirm the actual cancer: biopsy of the pancreas can be dangerous, and even if a biopsy doesn't show cancer, it can't rule it out. So we check certain adjacent areas to be sure there aren't signs of spread, and plow ahead. Plus, there are certain points beyond which bridges are burned, so you can't go back. In the case of Big Joe, the bridges were burned by the time I divided his bile duct. At which point a couple of large gallstones rolled out. Shit. Hardly an "Oh Well" situation; putting someone through a huge operation when a small thing would have sufficed is sickening. On the other hand, there was the mass in his pancreas, and there was that cancer blood test. The gallstones could have been incidental, and the pathologist might still find pancreatic cancer. They weren't, and he didn't.

The operation was surprisingly easy despite Big Joe's girth and fat upon internal fat, and everything looked great when I was done. I'd have felt pretty good, but for the fact that within eight hours, Big Joe was nearly dead.

Septic shock, happening so fast it couldn't be from surgical infection or leakage. This was infected bile, "cholangitis," undoubtedly a result of having the stent in for a few days ahead of time. Turns out, as with other medical ideas, placing a stent before a Whipple -- which was thought to make sense (it did to me, and was written about in journals) -- on further review was found to be associated with a high incidence of perioperative sepsis.

For about forty eight hours, he was as close to death as you can get and make it back. Drugs supporting blood pressure, maximum ventilatory assistance, kidneys not working, pathological bleeding ("DIC"). I spent lots of time at his bedside, sweating alongside my trusty angel, the intensivist; and consoling Big Joe's wife. Worse, at the absolute nadir is when the pathology report came back: no cancer.

You can't get that sick after a big operation and heal normally. He leaked pancreatic juices, his incision fell apart. Fortunately, per my routine, I'd put a feeding tube into his intestine during the operation, so we could feed him easily. He finally turned the corner and, after a long hospitalization and having passed many crises so severe I thought we'd lost him, he made it home. I saw him constantly for months, tending wounds, dealing with drainage, watching him get smaller and smaller. He always wore those overalls, as if to remind me what he was going through. But that wasn't Big Joe. Neither he nor his wife ever suggested I'd screwed up. They were glad for my constant care and, over time, he eventually dried up, healed up, had repair of his incisional hernia, climbed back on his tractor.

Big Joe: living proof of our fallibility. Useful tests, wrong answers. Procedures aimed toward helping, making things worse. Every time I saw him, I felt bad; really bad. Until he finally came in to the office, bulging out of his overalls, like the day I met him. Only pink.

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!