In my first week of the 3rd year surgery clerkship, I was introduced to some of the “Rules of Surgery.” For example, “All bleeding stops eventually,” or, “Everyone doesn’t need to die with an incision,” and even “The enemy of good is better.”
Boarded for this particular afternoon was a pancreaticoduodenectomy (the Whipple procedure), which for students is known to be a must-see operation if given the opportunity. However, the night prior I had stayed in-house to help the intern with overnight consults. Scrubbing this case would mean sacrificing precious post-call sleep, but, as an aspiring surgeon, there was no question that it definitely was worth it.
There was an as-usual progression to this day. Patients were pre-op’ed, operations proceeded smoothly and team morale was high, which continued with our next patient: a pleasant, 50 year-old gentleman with a half-glass-full optimism at baseline. His story began with a pancreatic mass incidentally found on CT that was unfortunately biopsy-confirmed pancreatic adenocarcinoma, the 4th most common cause of cancer-related death.
But, as I soon realized, his diagnosis was not much of a setback. He was asymptomatic and confident that, by undergoing an operation, his experienced surgeon could improve his prognosis. In pre-op holding, after the attending surgeon and chief resident detailed the anticipated procedure with the patient, I stayed behind for small talk since this was my first time meeting him. We bonded over a common hobby—golf. And, in his last round, I learned that he finished his last round eagle - birdie on his last two holes, quite the feat for a golfer of any skill level. It was clear from our brief conversation that he was one of those revered as “world’s best dad” and was likewise admired dearly by his wife.
Meanwhile in the OR, the plan was clear: based on CT, the mass was resectable and confined to the head of the pancreas with no evidence of local or abdominal organ invasion. After brief dissection, the surgeon began his abdominal exploration highlighting the first lesson of the case, “Any time you enter the abdomen, always inspect the liver.” Then, following his own teaching, he placed his left hand along the right lobe of the liver. However, he discovered the unexpected—three chalk-colored, firm nodules about 1-2mm in diameter. Based on experience, after gross inspection, the surgeon confidently suspected the worst: liver metastases from his pancreatic lesion, a detour which would change both the patient’s staging diagnosis and operative management. The morale in OR #17 took a U-turn. For presumed stage IV cancer, the only management option was closure of the abdomen while awaiting histological diagnosis from pathology.
As the saying goes, “Hindsight is 20/20.” Had metastasis been discovered pre-op, this unlucky gentleman would have been presented with a decision regarding adjuvant chemoradiation, and more importantly, been spared an abdominal dissection through the muscles utilized in his golf swing. But, in retrospect, these metastases were just small enough to escape detection on CT.
Midway through closure, the surgical pathologist returned with a succinct declaration, “Adenocarcinoma of the pancreas with metastases to the liver.” Here, I learned yet another maxim as the surgeon regretfully pointed out, “Why it is, I don’t know, but unfortunately, bad things happen to good people.”
One moment there’s a pre-operative, optimistic plan that disease is locally confined, and surgical resection would significantly increase his 5-year survival to 15-25% from the expected 1-4% with non-operative management. Resection and adjuvant treatment offered a median survival of 20-22 months. However, this metastatic U-turn drastically altered his prognosis to an expected survival of 6 months.
Post-op, the patient was appropriately loaded with questions pertaining to treatment and prognosis. Specifically regarding prognosis, I answered factually without false hope. In the back of my mind, I knew the aforementioned prognostic figures were derived from studies of a population of patients. And, I relayed this concept to the patient and his family.
Truthfully, with the spring season approaching, I hoped that he would be a statistical outlier enough to squeeze in several more rounds of golf. At his discharge, I wished him the best and hoped he would one day finish another round of golf eagle – birdie.
Jake McClure is a medical student who blogs at Checking the Pulse.
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