Tuesday, December 4, 2007

the worst complication

Several months ago, I was on a rotation that dealt mainly with "foregut" surgery and hepatobiliary cases. On this service, that meant anything from the gastroesophageal junction to just below the ligament of Treitz, including the liver, common bile duct, pancreas, and duodenum. I got to see tons of gastric resections, whipples, ampullary tumors and pancreatic tail/body tumor resections. The operative (no pun intended) word here being *see*. These cases were often so big that the chiefs on the service were relegated to sucker/bovie monkey.

One of the operations we did was a vagotomy and antrectomy for gastric outlet obstruction - a surgery that is nearing it's end in the practicing world of surgery and being seen only in the text books. This is largely in part to the development and use of proton pump inhibitors, which have all but eliminated the worst complications of peptic ulcer disease. Sure, we'll occasionally see a perforation or hemorrhage from a gastric or duodenal ulcer, but gastric outlet obstruction? Most of my attendings haven't seen that in about 10 years and I, in my short amount of time in the OR have *never* seen one.

Our patient was skinny, but by no means cachetic. The EGD that was done said they could not pass the scope through the pylorus, but they could get a wire down... so liquids could pass. His nutrition is probably ok.

My attending and I proceeded with the antrectomy first. That was the easy part. We did a Roux-en-Y anastamosis instead of a Bilroth II. I'm not sure why we chose to do a roux, and I have yet to find a satisfactory answer, either from my attending at the time, any other attending, or the literature. He again reinforced his notion that we residents are relying too much on staplers and had me hand-sew the anstamoses, which was great.

Now for the vagotomy. We felt just above the gastroesophageal junction for the NG tube, which we had the anesthesia resident pull up for our anastamosis. He wasn't happy with how flimsy it felt in the esophagus, and asked him to replace it with a small bougie for easier palpation. The posterior vagus was the first and easiest to find. It was very large; almost as big as the sciatic nerve, and we were able to do the "plucking of the violin string" that I've read so much about. We sent a piece of it off to pathology to confirm nerve tissue because that's what the books tell us to do, but we were sure we had it.

The anterior vagus was quite a different story. My attending was dissecting through connective tissue, closer and closer to the esophagus. He would use the Angle of Truth (aka, right angle instrument) to lift up a few strands so I could use the electrocautery. I was getting uncomfortable at how close we were to the esophagus and I kept hearing other attendings in my head... "The esophagus has no serosa, so when there is a hole in it, it is very difficult to repair." More dissection... sh*t. There's the bougie. Ok, we'll fix that later. That happened about two more times with even more obscenities.

Then he called another senior surgeon who has experience with this operation into the room to help. (Which, by the way, gave me an immediate promotion to scrub tech assistant.) They got into the esophagus two more times. They found what they thought was a piece of nerve and then started to repair the esophagus as best they could by primary closure. We finished the case and took the patient to the ICU.

Five days later, we got an upper GI series, where the patient swallows water soluble contrast and we check for leaks or obstruction as seen on x-ray. No obstruction anymore, and reportedly no leaks per the attending radiologist. I checked the films myself, but saw an area that looked like a leak to me. I paged him anyway, unaware of the fact that my attending was about to do the same thing. He assured us both independently... no leak.

We gave him clears and that night he went into renal failure and respiratory distress. We got a CT scan and a *different* radiologist read the CT scan. He compared to the UGI we got two days prior.

"Who told you guys there was no leak?"

"The attending."

"Well... he was wrong. There's a BIG leak."

Oh. Crap. Back to the OR to suck out the cranberry juice and jello that was now free floating in his peritoneal cavity. We got an endoscope and checked the esophagus while other members of the team had the belly open. The esophagus was attached to the stomach by two tiny bridges of frail tissue... the rest had simply disintegrated, likely as a result of the holes that were made in the first place, his unrecognized malnutrition, and having food leak out through it and cause massive inflammation. The only saving grace here was that the damage was in the abdomen and the mediastinum was free from the bomb that was happening a few centimeters below. If he had mediastinitis on top of everything else, he would have likely died before we got to the operating room. Maybe it would have been better if he did...

We completely disrupted the esophago-gastric connection, with the inention to go back in 6-9 months to reconnect him. He spent months in the ICU and had multiple CT-guided drainage procedures. Fevers, bacteremia, fungemia, delerium, and pneumonia visited him during his course.

Then I rotated off service. I would occasionally see the chief who replaced me at conferences and I would ask how he was doing. "Oh, you know. Hanging in there," was usually the answer. Until last week, when I was told he was going to die.

And he did.

I'm not sure if I have a point, really. I'm just retelling a story that I was a part of. I feel horrible. He came to us a "walkie-talkie" as I like to call them, and we discharged him to God. And what about his family? They were constantly overwhelmed by the whole thing. His surgery went from, "Oh, yeah, we can fix that. He'll stay in the hospital for about a week, and then he'll be able to eat" to "I'm sorry, but your dad is very sick and may not live through the night."

There is obviously nothing we can do now for this patient. But it is my responsibility, nay, my moral obligation to learn what could have been done differently. I have a few things: 1) always check an albumin and maybe even prealbumin before a major, but elective case. If it is inadequate, arrange for supplemental nutrition. 2) If I ever get into the esophagus at the GE junction, I will protect my repair with a Nissen fundoplication (wrapping extra stomach around the repair for reinforcement). 3) If I'm in over my head in the OR, at any point in my career, call for help. It didn't really work this time, but at least he had someone else experienced in the room.


Jeffrey said...

intriguing case worthy of submission to SurgeXperiences.:)
i'm learning from your excellent attitude of taking positives and lessons away from what seemed to be the "worst complication" as u mentioned.
regards and condolences go out to the bereaved family.

Bongi said...

it happens. interesting to note that in our neck of the woods stomach outlet obstruction is still fairly common.

Buckeye Surgeon said...

Learn to read your own films and trust your own judgment. Genrally, you're going to end up being right rather than the radiologist. Early identification of leaks are the key to survival. Once you get on that MOF merry go round, it's too hard to get off. The radiologist doens't know what happens in the OR. You got the upper GI because your sense of alarm was heightened. You saw something abnormal on the study, something that didn't look right. Early re-operation might have saved the dude. Anyway, good post and great learning experience.

Buckeye Surgeon said...

Couple of more thoughts:
Mehthlene blue or saline/air insufflation testing on the distal esophagus may have helped demonstrate an unidentified leak during the case. Was a JP left under the diaphragm? Was the patient tachycardic immediately post op? (Best predictor of leaks in gastric bypass). Wrapping the distal esophagus with a nissen is a good idea; also consider omerntal wraps or using the falciform ligament.

lights n steel said...

Dr. Buckeye -- Thanks for your insight. At the original surgery we *did* do both air insufflation and methylene blue. No leaks at that time. We left JPs everywhere, including under the diaphragm. All were eventually removed except for that one. The falciform ligament idea is a good one.

Jgregg said...

Dr. Buckeye -

Would a Thal patch over the repair be a better mode of protection after esophageal injury in this setting?