Buckeye Surgeon

Single Incision Kidney Harvest

2008-07-18T08:51:00.002-04:00

Transplant surgeons at the Cleveland Clinic (i.e. the Evil Empire) are starting to perform donor nephrectomies through the new technique of single port laparoscopy. Generally, laparoscopic surgery is done via multiple tiny incisions for multiple ports; one for the camera, one for the retractors, one for the tools, etc. Single port access involves making one incision by the umbilicus through which a multi-holed port is placed. As a result, you are left with a single, small, unobtrusive scar deep in the folds of the belly button.

As far as I'm concerned, this is the next stage of minimally invasive surgery. Incisionless surgery (NOTES), on the other hand, is not the way of the future. Imagine presenting a hypothetical patient with the two options:

Option 1: Guess what Mrs. Y? I can slash a hole in your vagina, reach inside and wrench out your gallbladder! Isn't it cool that I can do that? Here, sign this consent form.

Option 2: You need your gallbladder out Mrs Y. To do so, I need to make a very small cut in the folds of your belly button through which all my tools and camera will enter your abdominal cavity. You'll go home the same day and have very little post-operative pain.

Obviously I'm being just a wee bit disingenuous, but the fact remains that most female patients requiring cholecystectomy or appendectomy or Gyne procedures are of child bearing age. I just don't see NOTES taking off when you have to get women to wrap their minds around the idea of having an intentional injury created in the vagina. Plus, it requires teaching thousands of surgeons an entirely new technique, whereas single port laparoscopy utilizes existing technical knowledge....

Anyway, This Dr Gill at the Cleveland Clinic has now done 11 donor nephrectomies via the single port technique, with good results so far. So if you're looking to put a kidney on the open market, make an appointment with this guy. Just think twice about having any kind of orthopedic intevention down there, especially if you're a professional athlete on the Cleveland Browns....

America's Turkish Prisons

2008-07-18T06:47:00.003-04:00

I ran across this lovely column in my local daily rag the other day. What a wonderful service Ms. Suchetka provides to her greater Cleveland readership with her insights on the dangers and horrors of being hospitalized in 21st century American hospitals. Because you know, having a loved one in the hospital is akin to sending them to some third world infirmary in a prison run by the local military junta. The horror, the horror....

She advocates constant surveillance of granny as she languishes in her air conditioned, wood floored private room. Family members ought to work in shifts, keeping a a close eye on her. Heck, you even might want to consider hiring personal bodyguards/thugs to make sure those evil doctors/nurses aren't doing anything in a typically malicious fashion. Because why else would 87 year old granny with her broken hip and pneumonia acquire something like a bedsore or c diff colitis? It must be the nefarious medical personnel! So gear up America! Get your Pinkertons gumshoe at the bedside of your loved one if fortune should ever necessitate a hospital stay; their lives may depend on it!

Tangled Up in Blue

2008-07-17T08:15:00.000-04:00

I was seeing a new patient the other day with regards to a hernia or a gallbladder or whatever and, during the interview, she related a history of having a "failed kidney" on the right side.

-Why did the kidney fail? I asked.
-When they were doing my hysterectomy, the "urether" got tangled up in some adhesions, she said.
-When was the hysterectomy?
-Oh lord, maybe 30 years ago.
-I see.
-They had to go back in and try to untangle it a few days later, but the kidney died anyway, she said.

Here's a translation: During her hysterectomy, the right ureter was injured and probably even tied off with a suture. She subsequently developed hydronephrosis and eventual right renal decompensation. The injury was probably not identified at the initial surgery because she returned to the OR a few days later for the "untangling". It's amazing what physicians could get away with back in the old days of paternalistic, ask no questions delivery of health care. Open disclosure, as more recent studies demonstrate, doesn't necessarily correlate with higher rates of litigation; moreover, it removes the unsavory taint of lies and distortion of the truth that can follow a patient around the rest of her life...

Antibiotic Nazis

2008-07-16T09:08:00.003-04:00

This was quite interesting. I operated on a little girl the other night for a perforated, gangrenous appendicitis. Laparoscopically, I removed the nasty little bugger and washed out her entire peritoneal cavity with liters and liters of irrigant fluid. [On a faintly related tangent, I still can't believe anyone is routinely doing open appendectomies anymore. Only laparoscopy allows you the capability to drain and lavage the peritoneal cavity for complicated appendicitis]. The next day, she looked remarkably better (normal WBC count, afebrile, etc) but I usually keep kids in the hospital for a few days for IV antibiotics, especially for perforated appendicitis. As I reviewed her chart, I noticed that her Zosyn had fallen off the med list. I asked the nurse and she replied that "pharmacy had called earlier notifying that they were terminating the IV antibiotics 24 hours post surgery."

At this point my jugular vein started throbbing in my neck and my face turned a deep shade of Buckeye scarlett. Why was pharmacy unilaterally cancelling my antibiotic orders and making crucial decisions on the care of my patient?

Here's the deal. My hospital has now implemented a policy of limiting unncecessary use of antibiotics by giving the pharmacy the power to cancel antibiotic orders that extend 24 hours past a patient's surgery date. On the surface, it seems like a reasonable policy. Unnecessary courses of antibiotics have certainly contributed to the preponderance of such modern dilemmas as widespread MRSA infections and toxic megacolon from C Diff colitis. And surgeons who lazily/carelessly forget to cancel prophylactic peri-operative antibiotics are certainly much to blame. But there's a difference between antibiotics for prophylaxis versus antibiotics for the treatment of an infectious process. For perforated appendicitis, I'm not giving Zosyn to reduce my rate of superficial surgical site infections, but rather to actually treat an established, complicated infectious disease.

I spoke with the lead ID pharmacist and he was cool and apologetic about the misunderstanding. But the policy remains unchanged. It is now the surgeon's obligation to write in the post op orders "antibiotic to be continued post operatively for X-disease process (appendicitis, diverticulitis, peritonitis, etc)"

Surgical Giant

2008-07-13T18:14:00.004-04:00

Farewell to Dr. Michael DeBakey, truly the pre-eminent surgeon of the 20th century. Through sheer effort and creative innovation, he almost single-handedly chiseled out the entire field of cardiovascular surgery on his own. Nowadays, triple and quadruple coronary artery bypass operations have become almost routine. Thoracic aneurysms and dissections are manageable entities. And the techniques were all initially described and honed by Dr. DeBakey. There are stories of him going straight from the OR to his engineer's office to discuss a tool he needed or a device that he had in mind to facillitate a procedure. Bypass roller pumps and Dacron vessel grafts and Ventricular Assist Devices (VAD) and a host of various eponymous surgical instruments were fruits of his labors and dedication. He was a giant of the golden era of medical innovation in general, and surgery in particular. His name goes etched into the pantheon right next to Billroth and Kocher and Halstead.

Some Debakey quotes:
"Man was born to work hard"
"Once you excise the skin, you find they are all very similar"
"I like my work very much. I like it so much I don't want to do anything else."

RIP, Dr DeBakey....

Internal hernia

2008-07-07T20:31:00.005-04:00

During my early training, my attendings always hammered home the notion of closing mesenteric defects after open bowel resection cases. The mesentery is a fan-like sheet of peritonealized fat that suspends the bowels and carries the feeding blood vessels. When you do a bowel resection and an anastomosis, there's always a gap in the mesentery that results. Generally, we close these to prevent internal hernias.

Toward the latter years of my training, with the rise of laparoscopic colectomies, I noticed that more often than not, the mesenteric defect would be left alone after a right colectomy. Too much of a pain in the ass to close it laparoscopically. Besides, I was told, the defect was so big, that even if the bowel herniated through it, there was little chance of strangulation.

Well, I saw a lady last week with a classic SBO on initial imaging. A year and a half ago, she had undergone a laparoscopic right hemicolectomy for a villous adenoma at a "major midwestern university program". I put an NG in but she didn't get better. By day #3, her films still looked lousy so I booked her for an exploration. The point of obstruction involved a loop of ileum that had slipped through the mesenteric defect down into the pelvis and, for whatever reason, formed a weird adhesions to the bowel on the other side of the mesentery, thus completely occluding the lumen at that point. The case itself took 5 minutes, snip snip. I also closed the defect with a running suture. I think it will be interesting to see if we start to see more internal hernias from mesenteric defects as we move deeper into the laparoscopic era of bowel surgery.....

Bowel Obstruction

2008-07-04T13:15:00.010-04:00

What is a bowel obstruction?
Small bowel obstructions are ubiquitious in the world of general surgery. Most surgeons have one or two lingering on their in-house list at any one time. In the above post, I discussed an unusual cause of SBO, but over 90% are secondary to adhesions. What are adhesions? Scar tissue, baby. Anytime a surgeon has had his/her grubby hands inside your belly, it incites an inflammatory reaction that leads to the formation of fibrous bands and webs. The adhesions can form anywhere; bowel to bowel, bowel to liver, bowel to abdominal wall, just about anything. Generally, the scarring isn't a problem but you have to realize the intestines are constantly in motion, peristalsing and wiggling around inside your belly. Every once in a while, a segment of bowel will flop around a band of scar tissue and it will twist in such a way that the lumen gets either partially or completely occluded.

What does an SBO feel like?
Crampy abdominal pain. Your belly swells. You can't move your stool. You get more and more nauseated until you start vomiting bile in torrents of green. It's miserable, in a word.

What can I do to avoid one?
Nothing. It's not your fault, there's no dietary changes you can implement, no exercise regimen, nothing. A history of abdominal surgery gives you about a 10-20% risk of developing a significant bowel obstruction. Sometimes I use an adhesion barrier product called "Seprafilm" at the end of an open case in the hope that future adhesions will be reduced. There isn't a lot of science to suggest Seprafilm and its competitors actually work, but theoretically it's worth a try. For what it's worth.

What's the treatment?
Most cases can be managed non-operatively. In fact, 70-75% of cases of SBO can be managed without the knife. The key tenets of management are bowel rest, nasogastric decompression, and aggressive rehydration. As a result of vomiting and third spacing of fluid in the bowel wall, patients can get quite dehydrated. You're going to need a couple of liters of saline pumped into you upon arrival in the hospital. And then you're going to have to endure the placement of the dreaded NG tube. On the list of top ten most painful things to undergo, getting an NG tube ranks just below "sawing off your own arm with a penknife to escape from underneath the giant boulder that has you trapped in the desert." Actually it's not that bad. Most of the time it goes in nice and smooth. Just lean forward, sip some water, and try not to fight it too much. The tube is very important and it needs to go down. It's a hose you drop into an overflowing toilet. The sump pump in your flooded basement. Usually a liter or two of foul, feculent greenish-brown slop gets sucked up immediately with a high grade obstruction.

When do you decide to operate Mr. Buckeye Surgeon?
Rarely is it necessary to zip someone off to OR the minute you see them in the emergency room. Bowel obstructions from incarcerated hernias and colonic obstructions obviously need immediate attention. But most SBO's can intially be managed non-operatively. The old adage "never let the sun set on a bowel obstruction" is a little dated. Sort of like catgut sutures and surgical residents working more than 80 hours in a week.

I monitor three things:
1. Pain: Increasing pain suggests bowel ischemia. This is the number one factor I pay attention to. Pain that develops despite NG decompression mandates a trip to the OR. Patients who present with pain will sometimes feel better after a couple hours of NG suctioning. The key thing is to examine the patient serially.

2. White blood cell counts: WBC counts ought to decrease over the first 24-48 hours. Persistent or rising counts are worrisome.

3. Xrays: Least reliable. If the NG is doing its job, the films may very well look better the following day. That doesn't mean the obstruction has resolved, though; it simply means the proximal bowel has been adequately decompressed. Persistent stacked loops of bowel, however, imply a possible closed loop obstruction (proximal and distal ends of a segment of bowel blocked), which will not get better without an operation.I also like CT scans for SBO's. It's a great tool for predicting the likelihood of spontaneous resolution of a patient's bowel obstruction. I look for transition points and possible occult hernias not appreciated on physical exam.

Ultimately, there is no magic formula. It's a judgment call. If the patient isn't progressing, then an operation is justified. The operation itself can often be one of the quickest abdominal procedures in all of general surgery. Sometimes it's a matter of one snip of a single band that has kinked the bowel. Other times, it can be one of the more stressful, time-consuming, and hazardous procedures one will encounter. Patients with multiple previous operations or those who have had radiation treatments for a previous cancer will develop what is known as a "frozen abdomen". Everything is matted together in a single mass. The fused loops of bowel almost look like the surface of a brain. Hours are spent just getting into the abdomen. It's an operation that demands patience and some cool tunes in the background. You can't rush. It shouldn't be a case you do at the end of a long day. Nor should it be the first case on a day when you have five others scheduled. I use the scalpel, for the most part. There's no role for electrocautery; not unless you want to take care of the patient's entercutaneous fistula in a few weeks. It's all sharp dissection, tediously slicing and shaving your way to something at least resembling normal anatomy. It's like carving a serpent out of cement. You can't go on autopilot, like for an inguinal hernia or an elective gallbladder. Every move is an act of improvisation....It's actually sort of fun.

Gastric Ulcer

2008-06-30T19:01:00.010-04:00

In this day and age of everyone and their brother being on protonix or nexium or some variant thereof, we rarely see patients present with peptic ulcer disease to such a degree that surgical intervention is necessary. The glory days of general surgery had to be back in the late seventies when guys like Phil Donahue MD (not Marlo Thomas' husband) were snipping vagus nerves in a highly selective fashion left and right. The old surgical textbooks had throngs of chapters on all the permutations of ulcer surgery. Vagotomies and Billroth I and Billroth II and roux-en-Y gatrojejunostomies and all the post-gastrectomy complications like dumping syndrome and gastroparesis and roux stasis. My god, I killed myself trying to memorize everything as a junior resident. And then.... I find out no one ever does surgery like that anymore except for the occasional graham patch for a perforated duodenal ulcer. Looking through the old Cameron and Schwartz textbook chapters on peptic ulcer diease is like reading an old scroll from Galen or Hippocrates. Interesting but not particularly relevant to modern surgical practice.

But every once in a while we see someone like Patient X. 50 years old, alcoholic, non-compliant with previous medical interventions. He smokes 2 packs a day and said that whenever he would "cough up blood" he could usually treat it by running out to Walgreens and scarfing down a bunch of Tagamet and/or Pepcid. He was admitted for weakness and his hemoglobin in the ER was noted to be 4.6. The upper endoscopy confirmed a large gastric ulcer (3x6cm) on the lesser curve of the stomach that was not actively bleeding. Further questioning found that he had a first degree relative who had died from a "stomach tumor". So he got transfused up to a normal level and was placed on a Protonix IV drip. Then what?

Peptic ulcer disease (PUD) encompasses ulcers in two distinct locations: duodenal and gastric. Duodenal ulcers are much more common. 95% of duodenal ulcers are associated with chronic H Pylori infection and nearly all are observed in the setting of acid hypersecretion.

Gastric ulcers are a slightly different animal. Gastric ulcers are further broken down into 4 categories:

Type I- Most common type, usually a single ulcer on the lesser curve, not typically associated with hypersecretion of acid, seen in patients infected with H Pylori or NSAID abusers.

Type II- Two ulcers present (duodenal and lesser curve of stomach), strong association with hypersecretion of acid.

Type III- Prepyloric ulcers, also have an association with hypersecretion of acid

Type IV- ulcers near the gastroesophageal junction, not associated with acid hypersecretion.

The classic indications for surgery for gastric ulcers are similar to those for duodenal ulcers: perforation, bleeding, obstruction, and intractability. In addition, gastric ulcers are a risk factor for the development of gastric adenocarcinoma. Therefore, all gastric ulcers need to be biopsied and followed over the course of time. Giant gastric ulcers (>3cm) have a 30% incidence of harboring a cancer.

Back to my patient. Non compliant borderline alcoholic male. Giant gastric ulcer. Strong family history of stomach cancer. Presents with significant blood loss and massive transfusion requirements....what would you do?

Well I did a distal gastrectomy with Billroth II reconstruction. No need for vagotomy because his was a true Type I ulcer (non-dependent on acid hypersecretion). He's doing well so far. The ulcer seemed smooth and rounded (more consistent with a benign etiology) but we'll have to see what the pathology shows in a few days. Surgery on the stomach is actually quite fun. You feel like a goddam surgeon when you're in there doing it. Sometimes futzing around with laparoscopes and tiny instruments all the time can be tiresome. Good to get your hands dirty every now and then....

Healthbeat

2008-06-26T19:23:00.005-04:00

Maggie Mahar over at Healthbeat was nice enough to feature a couple of my posts from this past month. Her blog is top notch. Definitely on my short list of med blogs I try to check 5-7 times a week.

I was amused by a comment from someone named Chris Johnson who had responded to my post about the distinction between surgeons who "own" the patient versus those who sort of "hit and run" after the procedure is done. Now Chris Johnson MD ,for all I know, may very well be the world's greatest pediatric intensivist but I don't think I've ever come across such an unintentionally pompous and condescending statement about the role general surgeons ought to play in the post operative period of a patient he/she has just operated on. Check this out:

I have to say that, from my prospective, Buckeye Surgeon represents an example of the kind of problems I encounter every day. For those of us who work in the ICU, the irritation of dealing with surgeons who truly believe they know everything I know (as an intensivist), and they can do surgery, too. On the other hand, I do appreciate the kind of proceduralist, be it surgeon, cardiologist, gastroenterologist, or whatever, who stops by regularly after they have done whatever they needed to do to see how the patient is doing and if we need any more of their help

That's nice that he appreciates when a "proceduralist" stops by occasionally just to make sure that the brilliant intensivist doesn't "need any more of their help". That's not patronizing in the least bit. Wait a second... yes it is. I write all the orders after a perforated bowel case, buddy. You can write your note and make your extravagant rounds with 16 people following you around (pharmacists, residents, students, social workers, etc) at 1pm (after the grand rounds lunch presentation) and I'll read it and implement anything I find beneficial to the patient and we can talk face to face about whatever issues you have, like professionals, but don't think I'm not going to be the Big Lebowski on the case. We're actually trained to take care of post-operative issues as general surgeons. Actually, we spend the majority of our time as residents learning and mastering pre and post-operative care of the extremely ill. So thanks for your help, Dr Johnson. I do appreciate your insight. But excuse me for a second... I have to go write orders for IV fluids, TPN, wound care, electrolyte replacement, and anything else that the sick patient down the hall needs....

Blunt force trauma

2008-06-23T20:15:00.008-04:00

For the most part, the sort of cases you see at a suburban level II trauma center are rather banal. The old ladies who fall and come in looking like Rocky Raccoon. The guy who breaks a leg trying to clean the leaves from his gutters. The kid who falls of the monkey bars at recess. But every once in a while I see something interesting. The other day I was called about a young guy who had been ejected from his car at the time of a high speed MVC. He showed up tachycardic and hypotensive, but sort meta-stabilized after the initial resuscitation maneuvers were implemented. This enabled the ER doc to get him quickly to the CT scanner. When I first saw him he was still tach-ing away in the 130's and he looked pale and ghostlike. And he had peritonitis. I called the OR and got the blood infusing while I reviewed the images. For one thing he had a hilar splenic injury with massive amounts of hemoperitoneum. Hence the initial shock and peritonitis. The other interesting finding is portrayed in the image above....can you guess what it is?

Well, I'm not in the mood to be coy and let you play guessing games. It's a traumatic rupture of the diaphragm and it's not an injury seen very frequently, even in large tertiary care centers. The amount of blunt force necessary to cause the diaphragm to blow out is substantial and often these patients present with multiple injuries. No exception in this case. In addition to the splenic rupture, this kid also had a complicated pelvic fracture that ultimately had to be addressed at downtown level I trauma center.

Traumatic diaphragmatic injuries can be tricky to diagnose, especially when the injury is isolated. Diagnostic peritoneal lavage, laparoscopy, and thoracoscopy have all been utilized in recent years in algorithms to help facilitate the early identification of even small diaphragmatic tears. Isolated diaphragmatic lacerations from penetrating wounds are notoriously difficult to diagnose early; often the patient will show up years later with a symptomatic chronic diaphragmatic hernia. The repair itself is pretty straightforward. Several interrupted non-absorbable sutures will usually do the trick. You also have to worry about pleural contamination, especially if there has been a concomittant bowel injury. Lavage and drainage of the pleural space with a chest tube is sometimes warranted....

Weekend Rounds

2008-06-14T11:41:00.010-04:00

I actually like coming in for rounds on weekends. I usually start early, around seven or so. The drive in is quiet and pleasant and I keep the windows rolled down and the fresh morning air all around me. The parking garage is nearly empty at this hour on a Saturday. I don't wear a tie; sometimes just a short sleeve Polo collared shirt under my white lab coat. The halls and lobbies are devoid of people. It's quiet. The bustle of action and people passing and trying to get somewhere fast is gone. There is a distinct lack of pace and urgency to the hospital that is quite refreshing. Remember when you were younger and you had to go into the middle school after hours for a practice or a meeting? How different and strange and interesting it seemed without the usual regimented fuss and human traffic? Weekend hospitals are similar...

I take my time. I visit with the nurses on the floor. Review the morning labs and vitals on the computer, sipping a large starbucks. There's no rush. I can spend some time with the patients. There're no cases to be done, usually. No office appointments. I can afford to review old CT scans, lab trends, variations in vital signs, the sort of things you sometimes miss or forget to check during the week when you're always running a little behind. It's a way to get caught up, reacquaint myself with all the little details on the patients.

Rounds are enjoyable. I usually examine patients a bit more thoroughly. I even use that thing that internists have hanging around their necks...a stethoscope, right? All dressings come off. Wounds are inspected. Stoma appliances are removed so I can see the cloaked beefy red bowel exposed at skin level. I look for erythematous IV sites and forgotten triple lumen catheters and foleys that have been left in too long. It's my chance to leave no stone unturned.

A lot of times, I'll pull up a chair after the exam is done. You can get a sense of how someone is doing, how he/she is really doing, by moving the conversation beyond the usual litany of "do you have pain, are you nauseous, have you pooped yet"...It's fun to shoot the breeze. Find out what interests them. What they like to do outside the hospital. The Nascar fanatic. The single parent divorced lady going to night school for her masters degree. The kid who works at the corner Subway. The guy who brags that his wife never had to buy a tomato from the grocery in 50 years of marriage because of the fecundity of his yearly backyard garden. I especially love finding out what old guys did before they retired. Policeman. Pharmacist at the drug store where I frequent. Math teacher at the local high school. The people who used to be all around us every day, the ones that time has passed by. I'm reminded that all these people stuck in the hospital on the weekend have lives, families, places and things they'd rather be doing. The least I can do is listen to them for a few minutes. You see, I get to eventually drive home in my truck. They don't. The weekend isn't a time to escape and relax for everyone. And that can be frustrating as hell. There's the lady on post operative day #6 after a colon resection with an ileus and the annoying nasogastric tube who thought she'd be home three days ago. She needs me to sit there in that chair holding her hand for an extra fifteen minutes, telling her she's not unusual, that everything is going to be all right. I owe her that. To a certain degree, there's a loss of one's dignity during hospitalization; all the shiny wood floors and smiling faces and fresh architecturally exquisite hospital lobbies can't mask the fundamental fact that you've been institutionalized temporarily. And the weekend can sometimes make it seem worse. Too often, I've seen docs try to whip through rounds on weekends in a half hour or so. Kids soccer game to get to. Or a barbecue. Or a Browns game. Weekend rounds are an underrated duty but I think the patients appreciate a doc who takes it seriously and it's one of my favorite parts of being a surgeon....

Well duh

2008-06-12T09:19:00.004-04:00

Sometimes it's necessary to dress up the obvious as science in order to remind people (surgeons) of certain fundamental truths. The Archives of Surgery this month published an article entitled "Early Laparoscopic Cholecystectomy is the Preferred Management of Acute Cholecystitis". Whoa! Stop the presses! Alert the Nobel committee in Stockholm!

Seriously though, it has to be done every so often. We've seen this nefarious idea of "cooling down hot gallbags" creep into general surgery culture over the past several years. Admit the patient, put them on broad spectrum IV antibiotics (Zosyn) and if they feel better the next day, bring the patient back in several weeks or months for an elective cholecystectomy. Although this article isn't particualrly strong (retrospective, non-randomized), there is a wealth of recent surgical literature supporting earlier surgical intervention for acutely inflamed gallbladders. Hospitalizations are shorter. Accrued costs to the patient and hospitals are less. Fewer complications are seen. It's a no brainer.

So why are we cooling off gallbladders instead of whacking them out? Several reasons. In the early days of laparoscopy, it was felt that acute cholecystitis was a contraindication to lap chole. We now know that not to be true; in fact the operation often proceeds much more easily because the edema facillitates dissection of the tissue planes. But that initial thinking has carried over for some older surgeons who learned lap chole on the fly as attendings. Another reason, I'm embarassed to admit, is one of convenience. Sometimes it's hard to get a lap chole on the schedule at the end of a long day. Or maybe you just don't feel like waiting around until 8 at night to get it done. As opposed to appendicitis, there is a perception that hot gallbladders can be delayed and put off as long as the patient is feeling better with antibiotics. Finally, it's a resource issue. Especially at county or charity hospitals, OR time is limited and it's hard enough to get your appendix and perforated bowel cases on in a timely fashion. My skin starts crawling even now just thinking about the hassle and frustration involved in trying to start an emergency case at Cook County Hospital in Chicago.

Conservative management of acute cholecystitis may initially be successful but it's more expensive and leads to multiple and prolonged hospitalizations. Moreover, when the acute inflammation subsides, the gallbladder and porta hepatis heal by forming scar tissue which can distort normal anatomy and make the surgery much more dangerous. Most surgeons will tell you that some of the most difficult cholecystectomies they have seen are the ones done for patients with a long history of multiple gallbladder attacks.

Acute cholecystitis is one of the more common causes of "acute abdomen". The ideal treatment is surgical. Sometimes it's good to be reminded of that, no matter how obvious it seems.....

2008-06-11T20:57:00.007-04:00

It always feels good when an operation goes perfectly: the ten minute lap appy, the flawless inguinal hernia, the 45 minute mastectomy. But nothing in the OR has ever given me the sort of rush I got when I was able to replace the sump pump in our basement. One day my wife was down there doing the treadmill thing and she noticed some discoloration of the carpet over by the far wall. It was completely saturated and we had to rip up a 10 x 10 foot section.

Water in the basement! Basically a newbie home owner's worst nightmare. We called a plumber who came out and told us our sump pump was busted and to fix it we had fork over 800 bucks. Now I dont know too much about furnaces or water heaters or car engines or sump pumps or any of that stuff. I'm actually sort of an idiot when it comes to handy-man activities. But I wasn't going to write out a panic check to some random plumber dude. So I got on the internet. I went to Lowe's about sixty times. I bought what I figured I needed. I wrenched the rusted old machine out of the pit and, because it was an old model, I had to attach adapters and cut PVC pipe to fit and apply this crazy hallucination-inducing liquid cement and use some tools I'd seen before. After about 6 hours of labor (and cursing and kicking things and dejectedly staring at the walls) I was able to get the son of a bitch in the ground. I plugged it in and damn if all that excess water didn't get sucked whoosh up into the drainage pipe and out of my basement. I screamed like I'd just struck out the last batter in a World Series game. I almost can't wait until our water heater breaks down.

One more thing....the global period

2008-06-09T21:31:00.007-04:00

Lots of great feedback from everyone regarding my post on the MedPac/general surgeon controversy. Shadowfax submitted an interesting response in the comments section about the idea of certain procedures being "over-reimbursed". Why should an ankle fracture be reimbursed far more than the hour he spends sifting through the critical care complexities of a patient in the ICU?

It's a good point but not an entirely fair one. First of all, let me back up for a second. There is a tendency to group all physicians who perform procedures together under one banner. GI, general surgery, ortho, vascular, dermatology, plastics, cardiology, etc. But they aren't all the same. Far from it. I see two distinct categories of "proceduralists".

1) The "Hit and Run Bandits": You're the PCP. You consult Specialist X. Specialist X sees the patient, books the case for the next day, does the case, says thank you very much, and signs off as soon as the patient gets wheeled out of the procedure room. Ortho is quite good at this. As is GI. In and out. No hassles. Easy billing.

2) The "You Operate, You Own It Crew": These poor saps (general surgeons) tend to get sucked into being the primary care provider for all the patient's needs as soon as the scalpel is unsheathed. Patient admitted to internist from ER with "nausea". CT shows volvulus. Surgeon consulted. Emergent, life saving operation. Patient to ICU, attending physician changed to "Dr. Buckeye".

Now I wouldn't have it any other way. I operate, I own it. That's the way I was trained. I run the show. I correct the electrolytes. I manage post op hypertension and pain. I write my own TPN. I order my own insulin drips. I make most of the critical care decisions for my sick patinets in the ICU. That's the way it is. My part doesn't end when I take off my mask. Often, it's only just beginning.

So what does this have to do with Shadowfax' point about the overcompensation of proceduralists? Well, there's this little thing called the 90 day global period in medical billing. Basically that fee you collect for the cholecystectomy or the cataract or the Whipple is supposed to include the cost of all the post operative care (with a few exceptions) that the patient receives for 90 days. If you're the GI guy and you do a negative colonoscopy for anemia, you could care less; you'll never see the patient again once the procedure is done. You collect your fee and that's the end of it. But imagine a perforated diverticulitis that comes into the ER and you do the left colectomy/end colostomy routine but the patient is septic and limps along in the ICU for a week and you're writing TPN and managing hyperglycemia ruling out pulmonary embolisms and your pager is always going off and its three and a half weeks until she/he finally leaves the hospital. Suddenly, that fat fee for the intial procedure doesn't look so great when you add up all the hours of work and stress you've put into the patient's recovery.....

Perhaps general surgeons are being dumb about the whole thing. Maybe we ought to just be like the orthopods and refuse to have anything to do with the care of patients outside the operating room. Just dump it all on the internists/hospitalists.

I don't see it happening though. The problem is I kinda like what I do. I actually like being, you know, a doctor. I don't see myself as a "proceduralist". Maybe I'm a dying breed. Maybe the concept of the "general surgeon" is becoming an anachronism. But until it actually happens, I'm going to continue doing things the only way I know how.

Let's assume for a minute that we are dealing with a zero sum game. There's only so many dollars to go around and the PCP's are scrambling to pay their bills and it's apparent some redistribution of funding is necessary. Should general surgeons be the first target? Really? We're ok with radiologists and dermatologists raking in half a million bucks a year? Maybe if these hit and run proceduralists weren't so "overly compensated", more of our bright medical students would opt to go into primary care and alleviate the growing shortages in that area.....

Physician owned and operated

2008-06-08T12:04:00.005-04:00

One response physicians have had over the years to the battle over dwindling reimbursements has been to seize the reins of health care delivery themselves, by building physician owned and operated hospitals and/or surgicenters. By controlling the means of health care delivery, doctors regain a certain sense of autonomy in an era where big government in America desperately tries to neuter our political voice. After all, aren't we just "providers"?

Recently, I was approached by group looking to build a physician owned facility a little south of me. They were looking for investors from all the subspecialties to assist in the construction of a unique health care facility that would be postioned to compete for those patients located between the giant Cleveland behemoths and the hospitals in Akron. For the most part, it would be entirely physican owned, with the internists/primary care docs getting in on the ground floor. It sounded interesting, I had to admit. But then I came across an article in the NY Times today that made me pause.

Apparently, there has been a steady, driving force from Democratic circles (Hi Pete Stark!) over the years to restrict the existence of physician owned facilities. The assumption is that when doctors own a hospital, they will order more unnecessary tests and procedures because there exists a financial incentive to do so. In other words, you can't trust those unscrupulous docs in such ethical dilemmas. Now I understand that not all physicians are angels sent down from the Mount. Think of the orthopedic guy who buys an MRI for his office and next thing you know, everybody in town gets magnetized. Or the General surgeon who buys an ultrasound machine and basically does a full body exam (breast and thyroid ultrasounds included) on all office consults (even when the patient is sent over for a hemorrhoid). Or the family practice doc who has his own lab and ends up ordering twice as much blood work as the guy down the street.

I'm not naive enough to think this doesn't happen. Doing the right thing for the patient always takes precedence over any financial gain. But at the same time, isn't this a market driven, capitalistic country? Just playing the devil's advocate, but why should physicians be excluded from playing the game? Or a better question: what drives physicians to feel the need to play such a game? And what if the doctor who buys his own ultrasound uses it justifiably? Like only when a patient comes in for a breast mass or a thyroid nodule? Why shouldn't he be able to bill for expertise in using a specialized instrument? Why should he have to send the patient off to the radiologist for an ultrasound that may be more expensive, and certainly wastes time? If you don't trust him, create a way to audit his billing records; if there is any question a third party arbitrator can determine whether the test is or isn't justified.

I just think the Pete Starks of Washington have it in for us. Once again, it's an attempt to demonize physicians as profiteers looking to wring everything they can out of the system. As if we are the source of the profligate waste of our country's health care dollars. Of course, as long as your local democratic politician (I mean you, Patty Murray!) is on your side, there is always the chance a "special dispensation" will get written into the law...

Those evil surgeons

2008-06-04T10:20:00.004-04:00

I've been wanting to write about this for a while. Recently, the Wall St Journal Health Blog highlighted a letter the American College of Surgeons sent to MedPac, the advisory group that makes recommendations to Congress with regards to Medicare funding. Essentially, the ACS objects to a plan to raise Medicare pay outs to primary care physicians in a "budget neutral" manner. What does this mean and why is the surgical community outraged? Because "budget neutral" is a code phrase for "take money from from those evil, greedy surgical specialists and give it to the family practice docs".

The headline of the WSJ article is frankly disingenuous. Surgeons aren't opposed to primary care docs getting more money. We're all for that. But don't obtain that funding from the already dwindling surgeon's piece of the pie. Many surgical procedures have seen reimbursements cut 40-60% over the past 20 years. And that's not an adjustment based on inflation; those are real, bottom-line dollars. If you want all specialties to be paid the same, that's fine. But if that's the case, then we all better share in the liability and the risk. You want part of my earnings? Then make sure we all pay the same malpractice premiums. Oh, and make sure that I get paid like an attending during my fourth and fifth years of residency and any additional years of fellowship I might pursue, to ensure my salary is equal to the family practice doc from the get-go. It's all about equality, right? It would only be "fair".

I believe Sid Schwab touched on this earlier, but it bears repeating. This is a perfect scenario for the federal government and the insurance companies: doctors from different specialties fighting each other for the piddly scraps of revenue that they decide to dole out to us. I don't need to write a treatise to defend the concept that some specialties ought to be paid more than others. It would be insulting to everyone's intelligence. Let's get beyond that. Primary care certainly needs to be better remunerated. Being forced to see 50 patients a day just to break even isn't a sustainable business model, nor is it good medicine. But the fault doesn't lie with the surgeons. We're right there in the trenches with you.

As an analogy, imagine major league baseball without a players union or a collective bargaining agreement. Owners with their multi-billion dollar TV contracts could dictate player salaries to be whatever they chose. Maybe the power hitting first basemen gets a lucrative contract because he produces and is a gate attraction. But what about the slick fielding shortstop who steals a lot of bases and hits for a high average? Maybe he doesn't hit a lot of homers, but he is arguably just as valuable as the first basemen. It wouldn't be fair to pay him a pittance for his efforts. Would he begrudge the power hitter his salary? Of course not. He might be jealous, but he would never demand that the first baseman fork over a portion of his salary to "make things more equitable". He knows the owner is sitting on a pile of cash. He'd call the owner and say, Pay me what I'm worth, dammit.

There's plenty of money to go around. The discrepancy in pay between the GI doc and the PCP is not the reason why health care is so expensive. The giant HMO's and the pharmaceutical conglomerates would love to have you believe that. There's a reason both are multi-billion dollar industries. Let's not nickel and dime each other. A united front is our only hope of ensuring that the backbone of the American health care system, i.e. the physicians, does not deteriorate into a collection of second- rate, infighting, backstabbing special interests.

Sleep

2008-06-03T20:33:00.003-04:00

Tough weekend. Trauma and ER emergencies kept me scrambling. I think I slept four or five hours Thursday, Friday, and Saturday combined. (Don't tell the work hour Nazis.) It happens every once in a while. The pager won't stop. Rounds go on forever. As soon as you get home, something else shows up and back you go. Waiting around in the office for a case to start at three in the morning, mindlessly playing TextTwist on Yahoo games......

So I've been a bit of a zombie the past couple days. A few nights of solid sleep should recharge me. In the meantime some random bits....

Nice post from the Pallimed blog about withdrawal of care. Interesting perspective from a non-surgeon. I still think my idea of leaving the endotracheal tube in, along with snowing the patient with propofol/morphine, is the way to go. Love to hear other opposing viewpoints...

I tuned in to Dr Anonymous' podcast last Thursday for the first time. He interviewed Bruce Froedtert MD, an ENT doc from Wisconsin. It's actually a cool thing he's got going. There's also a chat room where you can interact with other med bloggers and pose questions for the guest. Be sure to check out the next installment.....

Hillary roars to a win in Puerto Rico. Now, if only she can sweep the Grand Cayman Caucuses and the Aruba Primaries, she may yet win the nomination...

One of the hardest things about being a younger attending? Getting used to calling older physicians by their first names. Addressing silver haired guys who look like my grandpa as "Rich" or "Mike" is just a little bizarre. I'm getting used to it though....

Saying you're sorry

2008-05-28T09:42:00.004-04:00

The NY Times ran a story last week about a "full disclosure" policy some hospitals are implementing. Rather than trying to conceal the circumstances of medical errors or poor outcomes, hospitals and doctors at the University of Illinois-Chicago are disclosing all the details and even apologizing to patients. As a result, malpractice claims have dropped by half since the policy was instituted.

This correlates with what we already know about the likelihood of malpractice suits. A patient's decision to sue often has more to do with some deficit in the patient-physician relationship rather than with some perceived technical or diagnostic error. Doctors who are inattentive, who rush through office visits, who blame the patient for untoward outcomes are more likely to find themselves sitting in a courtroom. Listen to your patient. Be empathetic. Communicate from the beginning the risks and benefits of any scheduled procedure. These are the skills we as physicians need to cultivate.

I operated on a lady a few weeks ago for recurrent diverticulitis; she'd been hospitalized several times over the past year for recurrent attacks, and she had had an abscess drained percutaneously during the most recent attack. I had planned on performing a laparoscopic sigmoid colectomy. I told her that generally patients tolerate it well and are able to go home in 2-5 days time. Let's do it, she said.

Well the case was a disaster. I had to open. The colon was stuck to the uterus. There was pus in the pelvis and the inflammatory changes extended quite low down onto the distal rectum (usually diverticulitis is a disease of the sigmoid colon). The anastomosis ended up being just above the lower sphincter mechanism. I always get worried about low pelvic anastomoses, especially in the setting of acute inflammation. Consequently, I protected it by diverting her fecal stream with a loop ileostomy. So she ended up with a much bigger incision, an extended hospitalization, and a stoma (which will be reversed with another operation in 4-6 weeks). Understandably, she was initially quite disappointed. Not that I did anything wrong. I have no doubt that my intra-operative decision making was appropriate. But the outcome was unexpected.

As we neared discharge, she started to feel better and one morning she sort of opened up to me. Doctor, she said, I understand you did the right thing for me. I'm okay with the bag on a temporary basis. But I wish you would have been more forthcoming prior to the operation that something like this might have happened. You know, I signed up for several art shows this year (she paints in water colors and displays her work at shows all over the midwest) and those entry fees are non-refundable. I'm going to lose all that money. If I'd known that something like this was even possible, I would not have made any plans this summer.

Hell, I felt terrible. I told her I was sorry. In retrospect, looking at some of the old CT scans, maybe I ought to have anticipated a tougher case. She was right. And I told her that. I apologized and offered to write letters to the art shows on her behalf. As soon as the word "sorry" left my lips, I could almost detect a physical change sweeping over her. Her shoulders relaxed. She smiled warmly. The lines in her face smoothed out. She had heard what she needed to hear. It's OK, she said.

I think there is some merit in open communication and admitting culpability in adverse or unexpected outcomes. But it isn't a panacea. You have to be careful. I thought this article gives an interesting counterpoint to the NY Times story.

Never? Really?

2008-05-23T09:13:00.005-04:00

This case has been modified for obvious reasons.

When I was an intern, there was a patient who came in for gastric bypass surgery. This was in 2001 before reimbursement for bariatric surgery took a dive, and we usually had four or five patients at various stages of recovery from Roux-en-Y bypass in the hospital. This patient was a 35 year old male who weighed over 700 pounds. That's 700 pounds. His BMI was greater than 100. He had all the usual co-morbidities one would expect; diabetes, severe sleep apnea, pulmonary hypertension, etc.

Because of his body habitus, his bypass was done via an open laparotomy. Unfortunately, his ventilatory parameters were suboptimal at the end of the case and anesthesia kept him intubated, given the difficulty of placing the tube under duress. He never weaned. He acquired pneumonia. The tube stayed in for weeks. Ultimately, a tracheostomy was placed and he was eventually transferred to a long term care facility. His recovery was long and slow but he finally went home after several months of rehab. He lost close to 400 pounds over the next several years. His diabetes resolved. His heart function improved. And then the hospital and the attending physician (and, by extension, all the residents involved in his care) received a notice from a plaintiffs lawyer notifying of intent to sue for a ridiculous sum of money....

In the immediate post-operative period, the patient was vented and bed ridden in the ICU. Nursing records make note of skin breakdown and eventual development of a sacral decubitus ulcer, despite the use of an air mattress and preventative maneuvers to shift him every few hours. The chart describes 6,7, and sometimes 8 people being required to assist in rolling him one way or the other. Appropriate dressings were applied. Necrotic tissue was debrided when necessary. It never progressed to the point of being a septic wound. During the recovery phase, a plastic surgeon covered the resultant open wound with a tissue flap.

And this is what the suit is about. A decubitus ulcer in an extremely ill patient who weighed so much that the entire ICU staff was needed to roll him in such a way to take pressure off the skin and subcutaneous tissues of his ass. Well, the Herculean efforts of dedicated nursing personnel and doctors wasn't enough in this particular case..... But now we have "never events" as described by Medicare and Cigna and soon to be many other insurance companies. Line infections and UTI's and delirium and c diff colitis and decubitus ulcers aren't supposed to happen anymore. It's the doctor's and nurse's fault. Coincidentally, this lawsuit was posted shortly after this new designation came out. Never events. Is this the sort of vocabulary we want to be using? Never? I can't wait for the avalanche of lawsuits soon to be coming down the pipeline for the elderly lady with pneumonia who develops c diff or the old guy who goes into delirium after his Whipple....

Letting Go

2008-05-22T09:23:00.005-04:00

There's no protocol in the United States for the process of making a patient DNR. I don't mean the simple act of writing "DNR-CC" (Do Not Resuscitate, Comfort Care) in the chart after a long discussion with family members. What happens next? Do you open up the "death playbook" and run the offense with morphine and benzodiazepines? It doesn't exist. Palliative intervention varies from hospital to hospital, from doctor to doctor. It's something you make up as you go along.

As a surgeon, I get involved in futile cases more often than I would like. As the population ages, we find more and more 80-90 year olds in ICU's who develop acute abdominal emergencies, such as ischemic bowel, toxic megacolon, neoplastic colon obstructions, and perforated ulcers. Often, they show up without family or contact information. Dementia and/or toxic encephalopathy precludes an honest discussion of how aggressive the level of care will be. The patient will die without an operation. However, the concomitant coronary artery disease, COPD, and heart failure make any surgical intervention fraught with hazard. What do you do?

Sometimes surgery is life saving. That can't be denied. I've seen it with my own eyes; elderly patients smiling as they are wheeled out to the rehab facility, a week after being on death's door. There are few things as gratifying in a general surgeon's practice. Another year on earth. More time to be spent with loved ones. Some aren't ready to be done with this thing called life.

But there are others who don't do well no matter what you do. You can do the perfect operation in an expeditious manner and it's all for naught. They won't wean from the vent. They go into heart failure. Multiple organ failure develops. An inevitable, ineluctable downward decline hurtles them toward oblivion despite your best efforts. The futility of the situation eventually becomes obvious to all and the time comes for "the talk" with the family members.

I've had two patients in the last month who presented in extremis with peritnotis and/or ischemic bowel. One was an open and close case; entire length of small bowel gangrenous. The other was an incarcerated hernia with dead sigmoid colon that had perforated into the peritoneal cavity. Both patients were octogenarians. Both had lived full, enriched lives according to the respective families. It was time to say goodbye.

But how is this done? We agree to withdraw supportive care. Antibiotics are stopped. Vasopressors are halted. Directives are given not to run a code when the patient starts to deteriorate. There are no chest compressions. No epinephrine. The primary objective is palliation. Make the patient comfortable. In this synthetic environment, where some semblance of life is propped up with machines and tubes and drugs, it isn't ethical to merely "turn everything off". They've decompensated beyond the stage of self-sustaining life. Unplugging everything and stopping all the drips is about as cruel a thing as I can imagine. I never terminally extubate a patient. There's nothing more gruesome than watching a patient suffocate after terminal extubation. A wise old nurse made me experience it when I was a resident. No reason to pull that tube out. The dead bowel or the fecal peritonitis is going to stop the heart soon enough. No reason to expedite the death with unnecessary agony.

Here's my ICU orders for these cases:
-DNR-CC
-Do not extubate
-Morphine 4 mg IV q 15 minutes
-Propofol drip titrated to complete sedation/unconsciousness
-Turn down the sound on all monitors.

People don't die on cue. Sometimes it happens right away, as soon as the levophed is unhooked. But not always. I've seen patients linger for hours, heart rates in the 30's, blood pressure barely registering. The families are in the room, keeping vigil, together for the last moments of the loved one's life. The patient is peaceful looking, sedated, unrushed on his journey toward death. We cannot control the inevitable end, but we can control how gently we allow these poor souls to land.

Unforeseen Consequences

2008-05-15T10:02:00.009-04:00

Over a 100,000 weight loss operations are performed in the United States every year. It is an operation that is the only proven solution to the complications of refractory morbid obesity, aka the "metabolic syndrome". There are many surgical options including lap bands, laparoscopic roux-enY gastric bypass, duodenal switch, and sleeve gastrectomy.

The most common one performed for morbid obesity is the Roux-en Y, usually performed laparoscopically. As everyone knows, this is a difficult operation and the learning curve is steep. In the wild west early days, the complication rates were astoundingly high. Leak rates of 8-20% were described. Patients died. It was a dangerous endeavor. Nowadays, as residents and fellows are learning the procedure from seasoned specialists, the morbidity of the operation is much more palatable.

But it's still a rather new operation, relatively speaking. Long term complications are still being delineated. I saw a young woman yesterday ER who had a Roux-en-Y done in Oregon exactly one year ago. She presented with an acute onset of severe abdominal pain and nausea. A CT scan suggested free air. I took her for emergent laparotomy and the perforation was at the anterior surface of the gastrojejunostomy. She had formed a "marginal ulcer" after the surgery which, over the subsequent months, ultimately eroded through the full thickness of the jejunal limb. Since the gastric pouch was already so small, I had to simply Graham patch the hole, as if it were a perforated duodenal bulb ulcer. I also placed a gastrostomy tube into the gastric remnant, in case she needs enteral feeding access in the future. Drains were placed in the upper abdomen and I got out. I didn't do it laparoscopically, but I think it was the right thing to do. Long term, she's going to need treatment with proton pump inhibitors and endoscopic surveillance of the ulcer. Stricture is a definite possibility in the future.

Even though most general surgeons do not actually perform weight loss surgery, it's important to be familiar with the anatomic alterations of all the bariatric variations. You never know when someone is going to turn up in your ER with free air.

Thyroid Cancer

2008-05-12T17:25:00.010-04:00

I read a couple of weeks ago about the Arizona Diamondbacks pitcher, Doug Davis, who was diagnosed with thyroid cancer and underwent a thyroidectomy on April 10th. Last week I performed a partial thyroidectomy on a young woman who had an equivocal needle biopsy of a thyroid mass but the frozen section pathology on the right lobe fortunately was benign. So I decided the time had come for a post about thyroid cancer....my mind works in a simple fashion.

The thyroid gland sits atop our trachea like a shield. It is an endocrine organ that synthesizes and maintains our supply of thyroid hormone. (It also helps with calcium homeostasis, but that is perhaps a little too indepth.) About 37,000 new cases of thyroid cancer are diagnosed a year. Risk factors include goiter, Graves disease, family history, and female gender. But the biggest risk factor is a history of radiation exposure during childhood. Believe it or not, kids used to be radiated as a treatment for such conditions as acne, thymus enlargement, and tonsil/adenoid problems. Good thing Clearisil was invented. Nuclear fallout exposure is another biggie. People exposed to fallout from the Chernobyl accident have a significantly higher risk of developing thyroid cancer (something to keep in mind when your patient is a relatively recent immigrant from Russia or the former Soviet Republics).

Presentation
Thyroid cancer usually presents as a painless, hard mass in the neck. Most people are euthyroid. Things to ask about include voice changes, trouble swallowing, and a sense of not being able to get enough air when the arms are stretched high above the head.

Diagnosis
All suspicious thyroid masses get a Fine Needle Aspiration (FNA) on the initial office visit. I also like to ultrasound the gland myself. Other tests that an endocrinologist might order would be CT scans and nuclear medicine scintigraphy.

Pathophysiology/Prognosis
There are two major determinants of the course and prognosis of thyroid cancer. One is the degree of differentiation of the tumor. The other is the age of the patient.

Well differentiated = good
Poorly differentiated = bad

Patient <45 years old = good
Patient >45 years old = bad

Well differentiated cancers are reasonable cancers. These are the follicular and papillary cancers. The cells are malignant but they follow the rules to some extent. They spread in a fairly predictable fashion. They don't replicate like rabbits in heat. They're like an incorrigible child who gets in trouble at school, gets detentions, C student, but he's not going to embarass the family name. He's a good kid, just a little misguided. Poorly differentiated cancers, conversely, are the kids who torture animals in the basement. The kid who runs a drug ring out of his black wall-papered bedroom. They don't follow the rules. Poorly differentiated cancers are aggressive and fast growing and outcomes are much worse.

Age, interestingly, is also a big prognostic factor. If you're less than 45 years old, you can't be any worse than Stage II. Even with distant metastases, there is no such thing as Stage III or IV cancer for young patients with well differentiated thyroid cancers. Getting the disease at an older age protends worse outcomes.

Overall, however, well differentiated thyroid cancer is one of the best cancers to get. Ten year survival of early stage disease is over 90%. Unusual subtypes such as medullary thyroid cancer and anaplastic tumors have poorer survival rates.

Treatment
Definitive treatment of well differentiated thyroid cancer is surgical. Specifically, total thyroidectomy (removing the entire gland) is curative and allows one to monitor for recurrence. Several weeks post op, one can perform a "thyroid scan" in nuclear medicine to see if there is any residual thyroid tissue. Then you can specifically eradicate it with radioactive iodine (I-131), with is taken up solely by thyroid-like cells. Patients are kept on synthetic thyroid hormone (Synthroid) for the rest of their lives, with the dose titrated to such a level that Thyroid Stimulating Hormone (TSH) is down regulated (high TSH levels will stimulate growth of any residual cancerous cells).

Thyroidectomy
This is a fun operation. Generally, it's well tolerated and patients go home the next day. The procedure is pretty standardized, by the book. Incision in a skin line in the neck. Raise the platysmal flaps. Open the strap muscles in the midline. Note the gland, red like cranberry sauce, veins and arteries splayed across its surface and pulsating. Free the gland from the undersurface of the strap muscles. I go for the superior pedicle first. This is a branch of the external carotid artery that I always tie. Most of the rest of the vessels can be coagulated with the small, hand held Ligasure device. Two main structures to tighten your anus over. Have to preserve the parathyroid glands (control the body's calcium levels), especially if a total thyroidectomy is done. They look like carmelized little lima beans residing posterior to the thyroid. Sometimes they're hard to find, because embryology can take them in weird places. The other thing to ALWAYS find is the recurrent laryngeal nerve. Cutting one leaves the patient with a raspy, hoarse voice, usually for the rest of their lives. Cutting both sides will paralyze the vocal cords in the midline of the trachea, leading to respiratory compromise and often, an emergent tracheostomy. Never Bovie or cut or Ligasure anything near the trachea until you find it. It looks like a piece of vermicelli cut in half travelling deep in the neck, along the posterior aspect of the trachea.

Post operatively, you have to worry about bleeding. You end up tying off or Ligasuring a ton of vessels and any bleeding in the resultant closed space will collect and press on the trachea. I actually had to do an emergent neck exploration and tracheostomy on the floor on a post op thyroidectomy when I was a resident (the night before the rehearsal dinner of my wedding).

Medullary Cancer
Special side note on medullary cancer. These tumors only comprise 3-8% of all thyroid malignancies. Although 80% are sporadic, a good proportion are associated with the inherited endocrine cancer syndrome of MEN (multiple endocrine neoplasia syndrome). It's important to rule out the concommitant presence of things like pancreatic tumors and pheochromocytomas prior to definitive treatment of the medullary tumor. Outcomes are worse compared to well differeniated cancers, mainly because they are not susceptible to treatment with I-131. Furthermore, central compartment and sometimes modified radical neck dissections are indicated, in addition to total thyroidectomy, depending on presence or absence of local spread to regional lymphatic basins.

Anyway, I read the other day that Doug Davis has started throwing again, and may be due back to the team in a month or so.

2008-05-12T14:09:00.002-04:00

This is what happens when you're the junior surgeon at a community hospital. Today was one of those mornings where there happened to be three laparoscopic cholecystectomies scheduled at the same time. Apparently there's not enough video equipment to make this happen. When I arrived in the room, the surgical assistant was wheeling in this rickety looking video monitor that looked like it had last been used for some middle school study hall presentation.
-Where did you find that thing? I asked
-In the basement. It's all we have left.
-Oh. I see.

Meanwhile, two rooms away, the senior surgeon is toiling away happily with the latest in HD technology. Whatever. That's what you get when you're low man on the totem pole. So we flip the thing on and there's no color. It's a black and white monitor. It's like watching an episode of Leave it to Beaver, only with human organs and surgical instruments instead of Jerry Mathers. Fortunately, everything went well; routine chronic cholecystitis. The patient was never compromised. By the end of the case, I was starting to like the black and white look. In fact, I requested that for my next case they dust off the sterile rabbit ears. And to look around the basement to see if they had any hickory dissecting instruments.... Anyway, I'll always remember it as my "I Love Lucy Gallbladder".

Proud to be an American!

2008-05-10T19:06:00.002-04:00

This story is made me forget for a moment that we actually live in the 21st century. And it's shameful that Hillary Clinton has chosen this segment of the population (uneducated working class whites!) to pander to as a last ditch effort to salvage her failed campaign. Yeah Hillary, keep wearing that green John Deere hat when you crawl back to your fall sabbatical in the Hamptons.

Surgeon Tryouts

2008-05-07T18:56:00.004-04:00

I'm not a huge fan of this drive to designate hospitals as a "Center of Excellence" in some surgical sub-specialty. Bariatrics was the first to champion the idea. On the surface it sounds super-duper. Center of Excellence! That's where i want my surgery! Obtaining such designation, however, usually requires jumping through multiple hoops and making sure all the boxes are checked on an application form. It doesn't hurt to be affiliated with an institution that that can afford to fund the added resources required to meet the prerequisites. The emphasis is less on outcome measures, more on program compliance. For instance, a bariatric program needs to document that they have nutritionists, weight loss specialists, specialized equipment for the operating room and afterwards, and other ancillary services available for potential patients.

It seems like a good idea but now we're starting to see a push for other kinds of surgery to be restricted to such designated "Centers of Excellence". Some surgeons (i.e. academic ivory tower big shots) would like to restrict operations like Whipples and advanced laparoscopic procedures (colon resections, Nissens) to the big tertiary referral centers. Isn't that nice. Let all the community surgeons handle the gallbladders and hernias and butt pus. We'll handle the big cases, they say. Despite the fact that volume actually correlates poorly with reduced morbidity in major operations like pancreatic resections. Other factors like quality of the individual surgeon, nursing staff, and chracteristics of the hospital where the surgery is performed contribute to outcomes as well. Volume is sometimes an arbitrary number.

Anyway, I do actually like this idea. (See page 7 of the link) General surgeons in the Boston area have agreed to take the Fundamentals in Laparoscopic Surgery (FLS) exam in order to maintain laparoscopic operating privileges at hospitals such as Massachusetts General and Beth Israel Deaconess. Basically you show up, take a written exam, and then have to perform a series of timed maneuvers using a laparoscopic training module. Meritocracy in the purest sense. If you have the goods, the skills, then you get to stay in the game. Doesn't matter whether you practice at a vaunted "Center of Excellence" or not. It's based entirely on individual performance and proficiency. Now there are some things I dont like about the FLS test. For instance, moving a bunch of rubber balls from one cup to another or being able to tie a knot in a piece of styrofoam does not necessarily translate into real life excellence. It's like drafting a quarterback based on how fast they can run the 40 yard dash and how many footballs they throw through a tire in a 60 second period. Surely we can do better than rubber balls and styrofoam bowels. Perhaps an in vivo exam on an animal would be a better indicator..... just don't tell PETA.