Tuesday, October 30, 2007

it was all going well until...

Today was a very busy day in the OR. Both of my attendings were operating. We asked for help from some other attendings on one of the cases from another attending, but he couldn't come at the last minute because of an emergency. One of the cases was supposed to be a Whipple and the other was a partial/subtotal gastrectomy. Both are fabulous Chief level cases and, as much as I would have liked to do both, I haven't yet developed the ability to be in two places at once (much to the chagrin of my attendings). I've already participated in about 6 Whipples, which is about five more than most Chiefs at other surgical programs get, so I chose the gastrectomy. Besides, there is a much higher chance that I'll do a gastrectomy when I'm done with training than a whipple.

First thing was first; find where the stupid thing is in the stomach. One might think we should have known before we got into the operating room, but because of insurance reasons, the gastroeneterologist and the CT scans were done at outside facilities. Reports from both the EGD and the CT scan were woefully inadequate and didn't give us enough information.

So we did the EGD and found that the lesion was in the worst possible part -- on the lesser curvature about 1cm from the GE (gastroesophageal) junction. The board answer for an adenocarcinoma in the cardia is to do an Ivor-Lewis esophagectomy. But what does one do for a benign lesion? We decided to do a proximal gastrectomy. Risky, I know because of the retained antrum, but this guy really didn't want a total gastrectomy and he's so old I'm not sure that he would have tolerated it very well.

The dissection was difficult because he was so fat, but it went well. We did our resection, anastomosis, vagotomy, pyloroplasty and it all went well. At the appropriate time, we asked the anesthesiology resident to place an NGT tube (N=naso) so we could safely navigate it past our fresh anastomosis.

We finish the case, I carefully apply the dressings and take the dressings down. Just in time to see the anesthesia resident pulling out the OGT (O=oral).

"What the hell are you doing?" I asked.

"Oh you want this to stay? But it's an OGT."

"Yeah. That's why we asked for an NGT."

"F--K," comes flying across the room from my attending. "You've got to be f--king kidding me."

We got the EGD tower and scope back in there. Our anastomosis was intact. We had to blindly place an NGT and check an x-ray in the recovery room. It looked ok. But only time will tell. If he goes into a-fib or becomes febrile tonight, we'll know it really wasn't ok.


rlbates said...

Welcome to the blog world! Would love for you to submit this one or another to SurgeXperiences (http://surgexperiences.wordpress.com/). The next one will be hosted by Aggravated DocSurg.

Alice said...

I'm enjoying discovering your blog.

Interesting, we've been collecting a couple misadventures like this with NG tubes and anesthesia at my institution lately.

make mine trauma said...

Yea, another surgery blog! Love your blog name. Found you on SurgeXperiences. Look forward to reading more.

lightsnsteel said...

Alice: thanks!

trauma: I love reading other surgery blogs, too. I'll be sure to frequent yours!