Tuesday, August 31, 2010

It's never easy....

The life of a general surgeon is one fraught with contingency, soul-crushing doubt, unexpected disaster, and overwhelming stress. I wouldn't wish it upon my worst enemy. Fortunately, I was brainwashed to a sufficient degree during residency such that I actually don't mind my job.

One of the reasons general surgery is so tough is that it is nearly impossible to map out your week according to a strict schedule. Maybe at some point in a career, when you're the established, Big Kahuna of the group, you can load up your work week with elective breast biopsies, hernia repairs and lap choles and leave the middle of the night disasters for your more junior partners. In general, however, most surgeons never reach this stage of "easy livin'". It's a lifetime of inconvenience and last minute alterations and ulcer inducing pressure. If you're worth anything as a surgeon, you figure out a way to make things work.

Beyond the scheduling squeeze, the actual business of doing surgery can get to be pretty nerve wracking, no matter how routine the procedure. Anatomic variants, sick patients, hostile abdomens, and the inexorably crushing statistical likelihood of complications (no matter how careful you are) all contribute to the inordinately tight sphincters of surgeons even during the seemingly routine elective gallbladder or breast biopsy.

A few weeks ago I had one of those cases that take a few years off your life. An older thin lady visiting from New Mexico presented to the ER with a partial large bowel obstruction. Her ileocecal valve was incompetent so we were able to decompress her with an NG and prep for colonoscopy. The scope showed a partially obstructing lesion in the hepatic flexure of the colon. She had had a Whipple procedure back in the 80's for benign disease so I planned to do a standard open right hemicolectomy.

The surgery went beautifully. She was one of those thin old ladies with very little intra-abdominal fat. Even her mesentery was an ochre yellow sheet of semi-translucent tissue, like a smudged window in the attic. You could see everything. The case took 45 minutes. The ileocolic anastomosis looked perfect. She then did well for the first three days. On the fourth morning, she looked like hell. She was diffusely tender and had developed an elevated white blood cell count. I'm thinking worst case scenarios----anastomotic leak, inadvertent bowel injury, ureteral transection, etc. So I take her back to the OR and encounter something entirely unexpected: 25 inches of dead distal small bowel. I resect frankly gangrenous bowel and start to investigate. First thing I notice is a lack of pulsatile flow in the area where one would normally be able to palpate the superior mesenteric artery (SMA). Then, as I start to mobilize the left colon for either a new anastomosis or a stoma, I discover a rope-like, pounding arterial branch in the sigmoid mesentery, arising from the IMA. I follow it to the transverse colonic mesentery. I think I know what's going on, but I scrub out at this point and open up the CAT scan on the OR computer and get on the phone with the radiologist. I always get a pre-op CT scan of the abdomen on patients with colon cancer. I ask the radiologist to reconstruct the images in a coronal fashion. He calls back in five minutes and confirms my worst fears.

The lady suffered from severe mesenteric arteriosclerosis. We depend on three main arteries to feed the bowels; the celiac, SMA, and IMA. Her celiac artery and SMA were both occluded by thrombus. Her IMA was open and there was a giant meandering mesenteric artery that had developed over the years to compensate for her lack of flow through the other main trunks. So when I performed an oncologic resection of her right colon cancer, I basically transected that lifeline of blood coming over from her IMA to feed her small bowel. When I scrubbed back in, her remaining intestine was starting to look worse. She didn't have a lot of time. She was about to infarct her entire intestinal tract.

While I waited for the vascular surgeon to arrive, I dissected out the SMA origin and harvested some saphenous vein. Then we revascularized the SMA via a saphenous graft coming off the IMA. The next day, her stoma looked awful and I took her back for a second look. I resected another 6 feet of small bowel. The graft had clotted on the SMA side so I did a quick throbectomy to re-establish flow. I heparinized her and said a little prayer. The graft stayed open. She ended up leaving the hospital. Her life will never be normal again. She will suffer from short bowel syndrome and severe fluid/electrolyte disturbances from the high output stoma. The graft could shut down again anytime. But she made it through this battle. I'll take it.

We wade into shark infested waters every time we press scalpel into flesh. Your eyes better be wide open and your head on a swivel. There's no such thing as routine in general surgery. If you have masochistic tendencies, then by all means come join our club. Otherwise you might be better off in dermatology.

14 comments:

S said...

Agreed. I am 16 years out in "practice" (funny word that). My last weekend was SMA embolus patient, pancreatic necrosis patient (everyday - "you need to operate") , hydrops on a cirrhotic patient, PSBO on a 95 year old (Family: "what do you mean he might have postop complications?"). The stress of it came home with me to significant personal family disruption wish is crushing my soul. I truly wish we (general surgeons) could collaborate more. Forums like your help.

Anonymous said...

I am in total agreement. It's tough..I still think every day (and sometimes perseverate) about complications I have had. And "S," I agree with you as well. We have to find a way to better further one another.

BTW- Sure it wasn't a saggital reconstruction? That usually shows the takeoff disease best?

Frank Drackman said...

and if bein a Surgeon wasn't bad enough the Indians are 60 games out of first place...
But hey, you've got the Browns!!!!!!!!!
I know, Ohio State's ranked #2, which is just a publicity stunt to keep interest up in the rust belt, you know they'd be lucky to finish 3rd in the SEC...
The SEC WEST, that is...

But can't wait for that great Ohio St tradition, Woody Hayes punching the Clemson Player...

Frank "SEC RULES" Drackman

Frank Drackman said...

OK, Buckeye, got a serious question...

Was Woody Hayes Gay??? Would explain alot.

I mean, did your patient really get a Whipple for BENIGN DISEASE!?!?!?!?!
WTF??? is that even ethical? Hate to see what she'd have gotten if it was malignant.
I mean, sure I once put in a spinal to take out an ingrown toenail in the ER, say what you will, he didn't feel nuthin...

Frank

Anonymous said...

Ok. This really terrifies me. I'm only an MSI, and was gunning for surgery.... but as I said, this really scares me.

I do have to say however, that your a true professional-well trained, steely-eyed. You very quickly figured out what was wrong with the patient and somewhat ameliorated the effects. This counts for something. I guess I'll have to wait until 3rd and 4th year to figure out if gen surg (with the glory, terror, and shame) is right for me.

nik

ParatrooperJJ said...

I assume the second operation was at no charge?

Buckeye Surgeon said...

Paratrooper: That's a pretty asinine question. But I wouldn't expect anything else from someone who mindlessly supports state sanctioned torture, warrantless surveillance of AMerican citizens, and illegal constant war.

ParatrooperJJ said...

I guess that means you did charge.

Buckeye Surgeon said...

Trooper-
You seem to be implying that I've somehow exploited this patient for financial gain by submitting an insurance claim on the second operation. Let me explain it in a another way. Say your brakes go out on your car. You take it into the shop and the brakes are fixed. Two weeks later your transmission goes out. You mean to say that the transmission ought to be repaired for free?

The idea of "surgical warranties" does have some validity however. Take back operations for leaks or bleeding maybe ought to be billed at half or reduced reimbursement levels.

But your implication on this particular case is absurd.

DHS said...

How did you do the hemi? was the roux limb for the whipples antecolic or retrocolic?

The reason I ask is that my attending and I did one of these (hepatic flexure tumours post whipples) a couple of weeks back; the tumour was right under the roux limb (antecolic) which was quite stuck down so after all of the adhesiolysis the transverse colon was transected with stapler, ligasure of the mesocolon, and then delivery under the roux limb.

Anyhow, we couldn't find any literature on post-whipples right hemi; I can't imagine that any one surgeon's experience with them is particularly large. do you know of any?

ParatrooperJJ said...

Perhaps did not read your post correctly. It sounded like it was your error in the original operation that stopped her blood supply to her small bowel and caused it to die. That's what I was referring to. As far as billing, does Medicare allow billing of remedial operations to correct physician error?

Buckeye Surgeon said...

Trooper-
An error like that one you assumed would be like inadvertently cutting a known blood supply to an end organ, i.e. if one had mistakely divided the hepatic artery while doing a cholecystectomy. This case is much different. The small bowel almost never receives blood supply from the IMA. She needed the exact operation i performed for the colon cancer, which necessarily divided the arterial branch feeding her bowel. The complication was unexpected and unforeseen. The arterial anatomy only showed up on CT scan in retrospect, after reconstructing coronal/saggital views.

Anonymous said...

Great case and write-up, doc. I am a surgeon too, and I was with you the entire way until you chose to demean our dermatology colleagues.

I don't know about your level of familiarity with dermatology, but let me tell you, this specialty has contributed volumes to principles of wound healing and pathology for many decades before you ever picked up Netter's atlas. If you've never set foot in a busy dermatology clinic or made rounds with them, I can understand the infantile misconceptions about a stress-free life filled with "routine" cases.

The same goes for many, many other specialties that are traditionally frowned upon by surgeons. It's OK to illuminate the fundamental stress of the surgical lifestyle, but let's not come across as flippant and dismissive of our colleagues in other disciplines.

Philo Calhoun MD said...

All I can say is I hear you. Good job saving her. You describe the profession accurately.