Veins and Ducts

Inside a vein, it's always perfect. No matter the state of the rest of the body, when you open a vein and look inside it's smooth and shiny and slippery. The inner wall glistens and lavishes the eye with a creamy-khaki surface. Not that it's common to get into one on purpose: but for things as minor as a cut-down (directly opening a vein to insert a large IV), or as major as a portal-vein decompression (a finger-in-the-dike procedure to stave off the effects of cirrhosis), the lumen of a vein seems impervious to the ravages going on around it. It's like pushing through an old house stacked full of garbage, and finding a tiny closet, empty and clean, floor all waxed and sparkling. A private, preserved space, kept pristine for secret reasons. (Arteries, not so much.)

The bile duct is like that, too, if a little less certainly. When there's obstruction with infection, it can get red and thick, the inner surface knobbly and cobbled. Mostly, though, it's a similar wonder: clean and crisp and sparkling on the inside. There's something about these vessels and ducts that foster their own brand of amazement. Springy and soft, yet turgid and tough. Sewing a vein, unlike anything else, (as long as it's not during a mad rescue attempt) is almost meditative. It's quiet; maybe because the suture is finer, the instruments more delicate than with other kinds. And because it demands the perfection of needlepoint: even bites, close, careful and exact. There's rubbery resistance to the needle which gives way with a little recoil. There's no tissue quite like it. If creating, say, an arteriovenous fistula for dialysis, or if sewing a vein-patch onto an artery, you go through the vein first with the needle, and the textural difference is clear. Sometimes, you hold the slender suture between thumb and index finger of one hand, gently tugging upward to tent and approximate the edges, while suturing with the other. Very gently. The vein is more plastic, thinner, versatile. And, always, cleaner. When you release flow, the vein bulges, and holds.

Sometimes, it's the same with a bile duct: you might be closing a hole, sewing edge to edge. More often it's to make a connection between duct and bowel, and the two couldn't be more different. (Well, yes, they could. But if they were, you probably couldn't connect them at all.) Then, it's more of a puzzle: getting together two things of entirely different thickness and texture, one of gross and separating layers and another of imperceptible ones. It's a challenge and has its own rewards, but not the quiet kind that veins provide.

A vein, laid open but stilled of flow. A silky surface even when lying next to corporeal corruption. It's not a big thing, really; but seeing it time and again, is somehow reassuring. A signal that things might be made right. If one place in this person is still okay, maybe the rest can still get there.

Rocks in a Bag: what I know about gallbladders

Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it's the thing upon which I operated most (if you don't count breast biopsies). And I liked it. When a person came to see me with a clear-cut gallbladder problem -- which was the case at least 90% of the time -- I could be quite confident that I was going to make him or her happy and, most likely, have a little fun while doing it. But there's the rub: it's not always a Tenantoid "slam dunk," nor is it always fun. A mysterious little bugger is that bag of bile: perhaps more than any other organ it's able to elude or confound diagnosis despite such apparent simplicity. And more than any other category, I sent people home from my office without surgery despite being referred with the idea of separating them from their gallbladders. Rocks get in your head.

First, some basics.

Among the many functions your liver performs for you (in addition to feeling neat) is the manufacture of bile, which is a clarified-butter-yellow liquid of complex composition and which serves to help with the absorption of fatty substances into your bloodstream. (The ancients believed it had something to do with emotions: "melancholia" means, literally, "black bile.") About a quart of bile per day is produced and flows from the liver through a tube called the bile duct, entering the duodenum just below the stomach. Of that quart, a few tablespoons are sidetracked into a pouch that hangs under the liver, and is called the gallbladder. It doesn't make bile; it stores a bit of it, with the intention of squirting a dose into the intestine once in a while, particularly after eating a fatty meal. (The picture to the left, by the way, is not to scale. It makes the gallbladder look much huger than it usually is.) There's some complicated anatomy involved, particularly since the south end of the bile duct passes through the pancreas, where it's joined by a duct therefrom, carrying digestive enzymes made therein. We'll get around to the implications thereof, later.

Here's my theory: the gallbladder evolved before refrigerators, when people might starve for a day or two or three while they hunted their next meal. After a kill, they'd gorge on a big greasy meal, at which point a supplemental blast of bile was useful. (During starvation, the gallbladder can get impressively large and full of bile.) Compared to those days, we eat more or less constantly: two, three, four meals a day, a few snacks. Bile remains a necessary component of digestion, but storage isn't really called for. Our food sort of steadily drips into the intestine, so constantly dripping bile works fine. Which is why the vast majority of people who have their gallbladder removed never miss it at all.

Bile is composed of many chemicals which are supposed to remain dissolved in the liquid medium. In some people, for various reasons (genetic, diet, certain prior operations, certain blood diseases, etc) one or another of the components of bile are in too high a concentration to remain dissolved, and they precipitate out, forming crystals, which tend to grow larger and larger -- like sugar candy on a string. Stones. Trouble.

Well, not always. Some people have gallstones all their lives and never hear from them. It's muscular contraction of the gallbladder that sends the bile into the bile duct. If a stone happens to be near the opening of the gallbladder when it squeezes, it clamps down and cramps up on the stone, gets plugged up, and that hurts or causes other problems. If the stones are out of the way during the squeeze, there may be no symptoms at all. Which means not everyone with gallstones needs surgery, a decision made easier with the use of a crystal ball. I'll see if I can do justice to that, and other concepts, in the next few posts...

[UPDATE: many readers who find this post by a web-search may be unaware it's the first in a series. The others are here, here, here, and here.  Answers to remaining questions might turn up within them. Please check them out.]

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.