I was supposed to have the whole weekend off. Quite a rarity for a surgical resident, acutally. So imagine the dread that I woke up with when my pager went off on Sunday at 0115. The resident responsible for the page regretted to tell me that the vascular attending had accepted the transfer of a patient with a ruptured AAA and that the other on-call people were far to busy with traumas to scrub the case. I'd have to come in and the patient was on his way.
Maybe it was being just woken up with really bad news. Maybe it was knowing that I was going to spend Sunday studying for my in-service training exam that is coming up with week, and now I probably won't. Maybe it was knowing the futility of the proposed surgery and there is a 50% mortality associated with it and there is likely an even higher mortality with the on-call attending. Maybe because I was going to have to scrub with the attending who bathed me in blood a few months ago. But for whatever reason, in a very uncharacteristically surgeon move, I started to cry.
I pulled myself together, got my contacts in, and drove to the hospital. When I arrived, they were checking him at the front desk of the OR. He was begging for another pillow.
We opened the abdomen and didn't find an intraperitoneal rupture; rather there was a quite extenisve retroperitoneal hematoma. In addition to the infrarenal AAA, he had aneurysmal extension into the right common iliac and a separate common femoral aneurysm. Just to add something interesting to the mix, his INR was 3 (normal is 1) because he was on coumadin for his chronic atrial fibrillation.
Just when we were gaining control of the neck of the aneurysm, my attending and I had a very interesting exchange:
"You know, I should have probably never accepted this transfer."
"Why, because of his INR?"
"Yeah. That and the fact that he was turned down by seventeen other surgeons before they called me." Seventeen may have been a bit of an hyperbole, but you get the point. I certainly did.
"Well, then why did you accept him?" A little insolent for me, but it was 3:30am, after all.
...
"Just before I received the call about this patient, I had won a $600 hand of poker." The only way I took that unfinished thought was that he'd just had a bit of luck and thought it would continue.
I'm sure you can predict how things went from here. We had some hairy moments of hemodynamic instability in the operating room. 16L of blood loss; 4.2 of which we returned. Dozens of blood and blood products. A tube graft was sewn in; we never even laid eyes on the right iliac. Due to the massive and ongoing fluid resuscitation, his bowel was too edematous to close the abdomen, so we had to place an abdominal wound vac on.
I told my attending we weren't dry when we placed the wound vac. (Meaning that there was something still actively bleeding.) He insisted that he was diffusely oozing from all exposed surfaces from his hypothermia and coagulopathy.
In the recovery room, the wound vac put out another 6L. The family didn't want us to go back to the operating room to find the source of the bleeding. We stopped transfusing and he died there.
I am not cut out for vascular surgery. I admit it.
Showing posts with label complications. Show all posts
Showing posts with label complications. Show all posts
Tuesday, January 22, 2008
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.
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.
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