(This piece it taken from Kevin Pho’s Blog, and from the book “Cutting Remarks”, f rom Sid Schwab, MD; very thought-provoking, showing the honest, inner workings of a mind of a surgeon.)

    | | January 24, 2013 ()

    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 a day, which flows through a tube called the , 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 , 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 , 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 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 . 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.

    , 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 (““). I spent lots of time at his bedside, sweating alongside my trusty angel, the ; 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.

    Sid Schwab is a retired surgeon and author of .


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