Fournier's Gangrene

It has been a while since I've seen a case like this one. An 83 year old diabetic male presented over the weekend with perianal pain, fevers, and a leukocytosis to 28,000. The surgeon on call performed an incisional drainage of a large abscess at bedside and intially he seemed to do well. WBC came down to 15 and fever curve improved. However, when I saw him this morning he seemed somnolent and his white count had bumped to 20k. Exam revealed several ominous pathonogmonic findings including a wide area of bruising and ecchymosis involving most of the gluteal skin, crepitus, and some skin changes over the base of the scrotum. I spoke to the surgeon from the weekend and apparently all these findings were new.

Fournier's Gangrene is a specific form of necrotizing fasciitis that afflicts the perineum. Classically, it involves the penis and scrotum and is usually described in textbooks as a "urological emergency". Jean Fournier was the eponymous French scientist who first described the disease in 1883. Nowadays, general surgeons get involved in more complicated Fournier's because often the underlying cause is related to a perianal/ischiorectal abscess gone wild. The tissue planes in the perineum and groin are all connected and the aggressive agents of destruction in necrotizing infections tend to spread along these planes unabated.

This is not a diagnosis you want. Not unless you're someone who would look forward to the idea of having your penis skinned as primary treatment. Because that's what often ensues. These patients all need to be in the OR as soon as you suspect it. The fundamentals of the surgery are quite simple: wide, extensive debridement of all non-viable or infected skin, fat, fascia, and muscle. The patient is usually left with large, gruesome wounds that can be very difficult to care for post-operatively.

My poor guy had one of the more extensive cases of Fournier's I've seen. Basically, the entire ischiorectal fossa (horseshoe abscess) was full of pus, deep to the necrotic skin and fat. Furthermore, the infectious process extended down into the scrotum and the right testicle was non-viable. Literally pounds of flesh were debrided and an orchiectomy was performed. I also had to excise most of the skin covering the scrotum and penis. Just a hideous, awful surgery. Finally, we turned him over so I could do a loop sigmoid colostomy to divert fecal contents away from the raw, exposed wound. It's going to be a long haul to get him through it all. Tomorrow I take him back for a second look, further debridement, lavage, etc.....

Jackson-Pratt

I must admit I have a Jackson-Pratt fetish. No, it isn't as sordid as it sounds. I just love leaving these babies inside the human body (in the appropriate clinical scenario, of course). Nothing helps a frazzled general surgeon sleep better at night after a tough, dicey case than knowing you've left a drain behind.

What's a Jackson-Pratt (JP)?
A closed suction, silastic tube with multiple perforations on the flat part that resides in the body. You can attach it to a bulb which applies a constant negative pressure to the intracorporeal portion of the tubing.

What purpose do they serve?
Helps evacuate fluid/blood/pus from spaces in the body.

When do you decide to leave one?
-Lap appy for perforated/gangrenous appendicitis
-Nasty gallbladders with spillage of foul bile during a lap chole
-If there are common duct stones seen on a cholangiogram and I can't clear the duct laparoscopically; higher risk of the clips coming off from elevated ductal pressure.
-Emergency lap chole on a patient on plavix/aspirin, or even if the liver bed looks a little "oozy". Gives you an idea of any "bright red" blood loss.
-Next to low colorectal anastomoses
-Most pancreatic surgery
-Patients who present with peritonitis and massive fecal contamination
-After mastectomies/axillary dissections
-After excision of large lipomas (dead space can fill with serous fluid)
-Under the flaps after a large open ventral hernia repair
-Groin dissections
-Those cases where I just sorta feel like it.....

Now you don't want to stick a JP in the belly after every case. They provide a route for skin bacteria to enter the abdomen and cause abscesses. The closed suction design makes this less likely compared to say, the Penrose drain, but you have to be careful nonetheless. There is good literature to suggest that leaving a drain in after splenectomy will lead to higher rates of infectious complications. Also, you have to be careful leaving drains in too long around a fresh anastomosis. Sometimes the JP can erode into healing bowel and cause a fistula. I've even had a patient yank at the JP and snap it off flush at the skin surface, and have to go back in to retrieve the tip laparoscopically.

When do you take out a JP?
Depends. Breast drains I leave in until daily outputs are consistently less than 30cc a day. Most JP's left in after gallbladder surgery come out the next day unless I'm waiting for an ERCP to be done. Drains left after complicated cases of perforated appendicitis usually come out in a day or two. It's a judgment call for the most part.

Does it hurt?
A bit. Usually not much at all, and it comes out fast.

Going home with a JP happens occasionally, especially in breast and pancreatic surgery. They're not too difficult to care for; patients receive teaching from nursing staff and me prior to discharge, and are instructed to measure daily outputs. I usually send them home with a JP instruction packet, something like this.

Odds and ends

1) From the American College of Surgeons "Surgery News" April edition: Future Surgeon Shortage Predicted. Interesting. But is it valid? Where exactly in America are we anticipating a "shortage"? Topeka, Kansas? Fargo, North Dakota? Truly, there will never be a shortage of general surgeons in places like Chicago and New York and San Francisco. Never. Guys are clawing each others eyes out to get every last gallbladder and hernia they can. Moreover, there's another study from the JACS in April which studied workforce projections for hepato-pancreato-biliary surgery. According to this study, the current levels of fellowship training will result in an excess of subspecialists in that field by 2020. What does that tell you? More and more chief residents (over 50%) are opting to pursue further fellowship training prior to embarking on a career. Training more surgeons, expanding residencies, or building more medical schools is not the answer to the so-called shortage. You can train all the residents you want, but if most of them ultimately decide to become vascular surgeons, or CT surgeons, or plastic surgeons, or "laparoscopists", then you aren't doing society any favors. We're trying to sub-specialize general surgery to death. That won't be a problem in the large metropolitan areas with multiple academic institutions because you'll have your colorectal guy, your foregut guy, your bariatric guy, and your hernia man, but in the rural and semi-rural communities across America, it's going to be a gigantic problem. The general surgeon who can do breast and bowel and endocrine and advanced laparoscopy is going to be in great demand. If American residency programs don't provide them, be assured that hospitals will seek qualified surgeons from somewhere (the foreign talent pool).

2) Any reason why GI needs to be consulted on a bowel obstruction? Yeah, I don't know either. Good way to drive up costs. If I'm wrong, please let me know in what way. You don't need two specialists to come by, examine a belly, put in a nasogastric tube, check abdominal films, and decide whether or not the patient needs an operation and when. Especially when one of the specialties doesn't actually do operations...

3) The controversy over "never events". Cigna recently published a revised list of "potentially non-reimbursable" events that has the medical blogosphere all aflutter. Me included. Apparently, urinary tract infections from indwelling Foley catheters ought NEVER to happen. Nor is it conceivable that the little old lady on the floor one week after abdominal surgery could lose her balance, fall and break a hip. And central lines aren't allowed to get infected anymore. Decubitus ulcers in demented nursing home invalids who swing by the ICU for a short stay will no longer be accepted. The sickening thing is that this is all done under the guise of "improving patient care". In reality it's about controlling costs. So I don't get paid when I get consulted to debride a rancid sacral ulcer that's been there for probably a year? ID doesn't get paid for their consultation on an elderly patient with urosepsis?

4) Go Cavs. Deshawn Stevenson maybe ought to re-think the wisdom of calling Lebron "overrated".

5) The Tribe can't hit. CC Sabathia can't find the plate. Could be a long season for the Indians..... so glad I got a ticket package.

Mission....... Possible

Lovely case last week. 99 year old lady (yeah, that's right) came in with abdominal distention, pain and dehydration. She was a pretty sharp old broad, though. Knew what was going on and lived independently. CT scan showed evidence of a large bowel obstruction, transition point somewhere in the rectosigmoid area. Flexible sigmoidoscopy was unable to maneuver the scope past the narrowed area, but it didn't look like a mass. I saw her and she had focal peritoneal signs and feculent matter coming out her NG. Her daughter was there and we went through the options. Option one: Do nothing, make her comfortable, with the understanding that she probably wouldn't survive much longer. Option two: Big operation, bowel resection, likely colostomy, with significant risk of perioperative complications.

They went for option #2. My mission, which I accepted, was to try and get this lady to her centennial birthday. She turns 100 in the middle of May. Lot of pressure, no?

Basically, she had a diverticular stricture with a mass of small bowel matted to the inflammatory process. Tough operation but she tolerated it rather well, even extubated at the end. Today she goes to a rehab facility. I still have to get her through the next 4 weeks, but I'm starting to like our chances.

Operating on the extreme elderly is starting to become commonplace as our society ages. I'm sure in ten years residents will be competing to fill fellowship slots in the highly lucrative sub-specialty of "Geriatric Surgery" but that's a topic for another day......

Chaperones

I've always been opposed to the idea of having a "female attendant" in the room while I perform a physical examination on a woman. In medical school you always had to have a chaperone in the room when you performed a pelvic or breast exam on a woman and I always thought that doing so made a potentially uncomfortable situation even more awkward. Sends a message to the patient that either you don't trust her or she ought not to trust you. Gave me the creeps. Besides, contrary to popular thought (with the ubiquity of CT scans), physical exam is still a big part of what we do as doctors. I give my female patients a special gown and only expose what is necessary for a thorough exam. It's not a big deal. I can't remember the last time it was ever awkward; usually there's a steady stream of banter to keep things light and then I leave the room so they can dress.

But then I came across this horrible story of a GI doc who was falsely accused of "sodomy" during a colonoscopy. The guy basically lost everything before finally being exonerated years after the intial verdict. Sure, the lady had some serious red flags, but you'd never expect a patient to make up something so outlandish. Read the link if you have time.... it even won a Pulitzer Prize.

Welcome to the real world

This was the first year my wife and I paid income taxes on a two-income household. I'm a general surgeon and she's been a full-time anesthesiologist since last August. Our combined salaries put us in the 33% tax bracket this year. Next year we'll be in the highest bracket (35%). Now I don't want to complain about our state of affairs. We live confortably enough. We have a nice home. We don't live paycheck to paycheck. We're able to donate to charity and help out family members in need. It's everything I could have hoped for when I was a younger man just trying to get through college. But nothing can prepare you for the first time you receive notice that you owe the federal governmemt a five figure check on April 15. It literally takes your breath away. When you factor in the not insignificant chunks of change that the state and local agencies hit you up for, the final tabulation ends up being somewhere close to 40% of your income. That's a big number, folks. Forty percent. Even for a two doctor household. Now, I'm all for the concept of "doing your share" for society. But I'm being taxed at the same rate as the Warren Buffets and Peyton Mannings of this country. When your income is well over a million dollars a year, the difference in being taxed at 25% versus 38% may mean one less summer home, or perhaps having to wait another year for that 80 foot yacht. For people like us, it means a whole lot more. It means plumbing into retirement funds to help pay for a child's college education. It means living modestly and watching your monthly budget. The highest tax bracket is meaningless to the Forbes 500 guys. For a family like my own, it's a significant burden. Doctors are still remunerated well in this country. No doubt. But you have to keep in mind that most graduates of medical school these days, in addition to a diploma, are burdened with a school loan debts totaling $150,000. Moreover, physicians defer their wage earning days until after the age of thirty, sometimes into the mid-thirties when you factor in fellowships. College graduates who go into finance or consulting or take jobs on Wall Street have already accumulated 10 years of earning power by the time a doctor deposits his/her first significant paycheck.

There's a piece in Parade magazine today that discusses corporate tactics to evade income taxes. Last year, corporations shouldered just 14% of the federal tax burden. Ordinary wage earners will pay $1.21 trillion in taxes in 2007. That strikes me as outrageous. It's shocking that this country isn't in an uproar. That there aren't protests in the streets. You have disgraced corporate CEO's walking away with $10 million dollar settlements. Bear Stearns gets bailed out by the federal reserve. A hundred million dollars a day is spent in Iraq. And now we have the two leading democratic candidates unabashedly saying that Bush's tax cuts need to be repealed and that "sacrifice", i.e. higher taxes, will be necessary in order to implement universal health care. It's easy to say: just raise the taxes on the "rich". But that burden increasingly falls on people like my family. The people who have worked hard, delayed gratification, and provide a service for the community in which they live that goes beyond merely increasing the exchange of commodities. Is that just? Is it reasonable to expect the individual taxpayer to foot the bill for our gargantuan, overwrought, inefficient bureaucratic monster rather than the multi-billion dollar corporations that sell out the American worker in the blink of an eye given the opportunity to reduce labor costs by moving manufacturing operations to Thailand or India or wherever they can play third world workers $1.50 an hour?

I grew up in modest circumstances. Single parent household. Latchkey kid through grade school. We lived paycheck to paycheck. Summer vacations were spent visiting a trailer on a local lake on weekends. I never had the cool shoes or the latest video game equipment. Fortunately, I was able to rise above that with hard work, family support, and a little bit of luck. And now I find out that the subsidization for all the solutions to our nation's ills is going to fall squarely on the shoulders of people like my wife and I. Welcome to the real world. Oh well... better make sure my schedule is full next week....

The NOTES beat drums louder

Well, Time magazine has decided to bring national exposure to the "NOTES Revolution". In San Diego last month, Drs. Horgan and Talamini removed an appendix (hopefully inflammed) from a healthy 24 year old female via her vagina. For those who haven't heard, Natural Orifice Transendoscopic Surgery (NOTES)is the "next big thing" in general surgery, or so we're told by the innovators. Instead of three ghastly quarter inch incisions on the abdominal wall, surgeons are now exploring the utility of slicing open a woman's vagina for access to the abdominal cavity. Call me crazy but I'm a little skeptical. It sounds so appealing to have "incisionless surgery" but new techniques have to justify that they are as safe as the previous standard of care, improve outcomes, and are justifiable on a cost basis.

Let's look at the typical laparoscopic appendectomy. I make a half inch incision deep on the downslope of your navel. I make a quarter inch incision in your left lower quadrant and another quarter inch incision above the pubic bone (usually in the area covered with pubic hair). Post operatively, I usually have a hard time finding the suprapubic incision (once shaved hair grows back) and the incision by the navel is often obscured by the folds of your belly button. Cosmetically, the result is impressive. Young women have never complained. Parents of children who have it done this way are amazed. So you have to ask yourself: how much better can we get? And are women really going to be excited about having knives flaying open their vaginas? In the article, the patient raves about having minimal pain on post-op day#1 (1-2 on a scale of 10). Well, guess what? My patients will make the same claim for routine, uncomplicated laparoscopic appendecomy. Most return to work in less than five days.

The whole thing strikes me as absurd. This country struggles enough with containment of health care costs. Currently, laparoscopy affords patients the ability to undergo outpatient surgery for conditions such as cholecystitis and appendicitis with minimal morbidity and quick return to normal activity. The cost of hospitals purchasing the equipment required for NOTES, along with the costs of teaching thousands of surgeons how to do it is just mind boggling. If we're going to go down that road, there damn well better be a good reason. And I don't think "women prefer incisionless surgery for cosmetic reasons" is a valid answer.

Laparoscopy revolutionized surgery because, well, it revolutionized the way patients tolerated and recovered from open procedures. An open cholecystectomy would mandate 3-5 days of hospitalization. Plus increased pain. Plus a higher risk of wound complications and hernias. Laparoscopic appendectomy has essentially removed wound infection from the equation, even in perforated cases. Laparoscopic colon resections are reducing hospitalization and post op pain requirements. These are measurable, quantifiable variables. How measurable is something qualitative like "I don't want any scars"? I just don't see the universalization of this procedure happening anytime soon, given our current health care economic climate. It's fine if the really smart doctors at places like Mass General and Mayo Clinic and the like want to work at it and develop expertise, but at some point it should become obvious that the mere "ability to do something" is not justifiable grounds for restructuring how surgical diseases are cured. Take a baseball analogy. Your shortstop is Hanley Ramirez of the Marlins. He bats .300, hits homers, and steals a lot of bases. One of the top two or three SS in the game. But you decide you want someone better. You want Jose Reyes. Maybe he steals a few more bases, score a couple more runs, but overall, his stats are equal to Ramirez. But you want him. You like that he plays for the Mets. You like his "passion" for the game. The problem is, you have to pay twice as much for Jose Reyes. For a guy who gives you essentially the same output as the guy you already have. To get him you have to pay other guys on the team less and sacrifice talent in other spots, like pitching and defense. The advocates for NOTES are like the guy who will trade Hanley Ramirez for a more expensive Jose Reyes. It's crazy. You don't get to the World Series making deals like that. And we won't arrive at a more equitable distribution of health care dollars if we make the big move to NOTES over the next ten years.....

Anal Fissure

Few maladies are as disconcerting and uncomfortable as the dreaded anal fissure. What is it? Simply a tear in the skin and mucosa of the anus. This area is highly innervated and the tear causes severe pain and often bleeding, especially with bowel movements.

Etiology: Constipation and passing hard stool, anal trauma (use your imagination)

Pathophysiology: Mechanical trauma which leads to sphincter spasm which leads to inability for the anoderm to heal, which leads to more sphincter spasm and pain, which leads to less healing, which leads to.... you get the idea. It's a vicious cycle that won't stop until you either control the pain or relieve the sphincter spasm.

Presentation: Horrendous, excruciating tearing sensation with BM's, often accompanied by bright red blood on the toilet paper. Patients adapt by trying to avoid the toilet, which leads to worsening comstipation and harder stools which leads to..... get it?

What the hell should I do? See your doctor. Don't screw around with expensive, useless over the counter products like Preparation H or laxatives, etc. You're just wasting time and money. 90% of anal fissures will heal on their own, without surgical intervention, but it isn't something you should self-treat. Often your PCP will refer early in the game to a surgeon.

Medical Treatment Options:
1. Sitz Baths- soothing soaks can relieve the itching and pain and relax the sphincter. Plan on sitting in a warm bath two or three times a day for twenty minutes at a time
2. Proctofoam- Some docs will rpescribe this; I haven't seen much efficacy though.
3. Nitroglycerin ointment (0.2%)- I've actually seen this work. It relaxes the internal sphincter and some studies have demonstrated healing rates of 60-80%, but the recurrence rate is rather high. Some patients develop headaches which can be quite severe. Also, patients will significant cardiac history need to be careful.
4. Diltiazem ointment (2%) - Essentially works by same mechanism. Efficacy similar to nitro.
5. Botox- Paralyzes the sphincter, but overall, outcomes are worse compared to nitro and diltiazem.
6. Stool softeners, high fiber diet- Soft and regular is the way to go. Hard pieces of coal dropping out your back end are not good for the ballclub.
7. Lidocaine jelly- I always prescribe this; seems to help.

The reason the pharmaceutical agents don't always work is that some fissures become chronic and form a triad of a deep ulcer, a sentinel pile, and a hypertrophic anal papilla. This situation often needs the attention of a surgeon

Surgical Therapy:
Defintive treatment involves doing a lateral internal sphincterotomy. This procedure will heal 97% of fissures. Often, a fissurectomy can be done at the same time, excising the chronic triad. I do these in the OR with the patient either asleep or anesthitized with a spinal block. Patient is placed in prone jack-knife position with the butt cheeks taped open. It's a cool, highly satisfying operation. I make a small incision right at the anal verge and dissect out the thickened internal anal sphincter. You can't miss it; it's like one of those Lance Armstrong Livestrong bracelets encircling your anus, deep to the skin. A quick cut and the tension in the anus almost immediately decompresses. If the fissure is nasty looking and edematous, I'll also sometimes excise the whole fissure complex as well. The case takes about five minutes usually. Relief comes a bit more slowly, hours to days (after all, the treatment does involve using knives on your ass). Sitz baths are resumed and stool softeners maintained for several weeks. Complications are rare but sometimes patients will note incontinence of flatus in the immediate post-op period. Incontinence of stool is an extremely rare and devastating complication.

Paging Dr Buckeye......

I get a lot of pages during the day. That's part of the deal if you want to be a general surgeon. I start checking the batteries if it hasn't gone off in a couple hours. You pretty much memorize where the numbers are coming from after a while, and you can often predict which nurse is calling about which patient. I love when the ER calls (something fresh and exciting!) Pages from the ICU make me nervous, especially with regards to post-op patients. Direct calls from other doctors can be good or bad. It could be the GI guy who wants you to know about a colon cancer he just scoped. Alternatively, it could be the internist who needs you to see a perianal abscess "stat". That's the life. You never know what is going to show up. There are certain pages at specific times of the day, however, that, without a Herculean effort of self-control, would lead to a melt down of epic proportions on my part (think Dennis Green after that Monday night game between the Bears/Cardinals a few years ago.)

5) The page to a floor I just left about a patient I just saw and wrote a note/orders on. I usually will try to find the nurse when I make rounds on a patient, inform her/him of the plan, ask if there are any issues, just to avoid this sort of page. But I still get it occasionally. "Dr Buckeye, did you want that dressing change done wet to dry or just dry?"......after she just watched me pack a wound with gauze.

4) The page for a consult when I'm half way home and half starving to death. Then you have to pull over, dig out your phone and try and figure out if it's something that needs to be seen stat (acute abdomen) or perhaps can wait until the morning (80 year old lady with constipation).

3) The nurse who pages you 5 times in an hour about a multitude of minor details. It's usually a younger nurse in the ICU. First they call about pain meds. Then, they see the potassium is 3.7. Then, they just want to know of they can use the NG tube to give meds. Then, it's a question about the rash on the patients neck. After the fifth call, I'lll usually make the nurse go through all her notes and charting and make sure there isn't ANYTHING ELSE before I hang up.

2) The call at 6:30 AM about a patient's low urine output or tachycardia or some other sphincter tightening issue in a post-op patient. Here's the deal: nurses have shift change at 7AM. I'm not stupid. The incoming nurse will ask," did you call Dr X about the urine output?". The 6:30 AM call allows the leaving nurse to say "of course". But it's half assed. How long has the urine output been low? Since last night, you hear. Well, why didnt you call me about it earlier, I ask? I didn't want to wake you up in the middle of the night...... Early intervention is the key for things like volume depletion and arrythmias and pulmonary embolism. The astute nurses don't do crap like this.

1) Calls between 2:30 and 3:30 in the morning. This is the witching hour. My brain is a seeping ball of mush at this time. Unless I hear the words "free air" or "appendicitis" or "peritonitis" you arent going to get much intelligible out of me. Moans and grunts if you're lucky. Half the time, I look at the pager, see I got a call at 3:17AM and can't for the life of me remember what the hell it was about.