Wednesday, October 10, 2007

Big Cases

I mentioned the other day that the Whipple is the Big Daddy case of general surgery. When all subspecialties are considered, however, nothing can top the liver transplant. Not a CABG. Not brain surgery. Certainly not the total knee replacement. First you have to extract the native liver, liberating it from all its attachments, performing a complete portal dissection, lifting it right off the vena cava, and then implanting a cold, brownish donor organ, hooking it up to the hepatic artery, portal vein, vena cava, and restablishing biliary continuity. All in a patient population that arrives for surgery cirrhotic, coagulopathic, with renal dysfunction and other severe co-morbidities. When I was a resident, my training program hired an aggressive transplant surgeon from the University of Pittsburgh (home of Dr Starzl, father of modern liver transplants). His arrival quadrupled the number of livers that were done per year. The great thing for us residents was that our program didn't have any fellows. So, as a third year resident, I was scrubbing across from the transplant attending, performing half the anastomoses. By Chief year, he was letting us do most of the dissection ourselves. What a great experience. I remember one case we did when I was a third year. This cirrhotic guy arrived at midnight for a transplant looking like complete hell. Oh, and he was HIV positive. This was a little controversial; transplanting a limited commodity into a person with a chronic, often deadly underlying disease process. HIV positivity was initially thought to be a contraindication to liver transplant, but with the increased survival seen with triple anti-retroviral/protease therapy, HIV patients were just starting to be listed as candidates. It was a bear of a case. He'd had numerous operations previously, and the tissue planes were all disrupted. There was a lot of blood loss. Of course I was triple gloved and had safety goggles on. (I asked for a welder's shield). The attending (a total cowboy) never wore eye protection. We finally got the donor liver in and reperfused but he continued to be coagulopathic and oozed from every raw surface. He'd lost so much blood by this point, that we'd probably exsanguinated all his HIV blood and now he was just bleeding clean stuff from the blood bank. Finally his heart gave out after about 9 hours of struggling to stop the bleeding. We shocked him within his chest a few times and then called it. The room was a mess. My arms were soaked in blood to my elbows. All that work. The attending was on the phone as I filled in the death certificate. Another liver was available. He was calling to see who was next on the list.

8 comments:

enrico said...

How is an HIV-contaminated liver going to be used for another patient?

Buckeye Surgeon said...

A different liver bro. The patient who died takes the transplanted liver with him.

Bongi said...

before i even started surgery, our government, in their infinite wisdom, put a moratorium on liver transplants and finally only allowed them in cape town. as a result i have never been involved in one. i envy you.

Sid Schwab said...

I was involved, as an intern, in the first one ever done at UCSF, a long time ago. Starzl was in full force in Denver. Ours didn't turn out well, unsurprisingly. I think you're right though: even though a Whipple requires more breadth of techniques, a liver transplant is more technically demanding and, as opposed to a Whipple, well left to the tertiary centers. I agree with you, though. Even though I didn't do them regularly, when Whipples came along I felt as competent as anyone in doing them, and I don't think it was bluster. A well-trained and busy general surgeon ought to know everything needed, even in a community hospital.

Sid Schwab said...

I suppose if I'd tried, I could have used the word "though" a couple more times.

Buckeye Surgeon said...

You'e a published author Sid. Don't you have people on your payroll to edit your blog posts? They probably would have cut you off after the third "though".

Kacey said...

Reading your posts are great for old retired medical people. It's sort of like checking out naughty novels at the library --- we don't get to hear the things we were accostomed to reading in patients' charts. The most exciting patient I ever cared for was an avulsion hemipelvectomy, but I have never seen a liver transplant. Keep blogging and when you are old, you can take up where Robin Cook leaves off.

enrico said...

OK, whew! I totally misread the post like "Now that xplant pt expired, a new liver was available." It seemed impossible to me, but I don't take anything for granted from those way further along than I. :)