Kerry was only 28-years-old. He showed up in the ER one night complaining of upper abdominal pain which started suddenly that day. The emergency physician did the usual workup and found two things which led to an urgent call: a large intrabdominal mass and free intraperitoneal air.
The large mass was not necessarily an emergency, but free air, that is, air outside its usual place inside the bowel, almost always represents a surgical emergency: a perforation somewhere along the long snaking tube sometimes referred to as the “alimentary canal.”
It was about midnight and I jumped, well more likely slowly crawled, out of bed and made my way to the hospital.
Kerry had wispy brown hair which was coupled with a receding hairline. He made his living playing the guitar. He told me gigs came and went, but he managed to scrape by. He reported vague discomfort for about three months and weight loss of almost thirty pounds. He said he was able to eat, but often didn’t feel hungry.
He was thin, almost cachectic, with pale skin and his face betrayed a fear that I could tell was permeating his body and soul. The most significant finding on exam was diffuse abdominal tenderness with signs of peritonitis, just what one would expect from a perforated hollow viscus.
His abdominal CT scan demonstrated a large mass in the left upper quadrant of the abdomen, in the area of the left transverse colon, stomach, pancreas, spleen, left adrenal gland and left kidney. There was obvious free air and fluid.
No choice, he needs to go to surgery.
I explained the findings and the proposed surgery to him, wrote orders, called the OR crew and then went to the physicians lounge to wait. The usual hour spent waiting for the team is something I’ve learned to avoid these days. But, back in the old days, twenty years ago, I always came to see the patient first before deciding if emergency surgery was necessary, be it a simple case of acute appendicitis or a perforated colon with septic shock. This always afforded me an hour or so to meditate on the upcoming procedure or, more often, watch remnants of whatever old B movie happened to be on late night television.
Before starting Kerry’s surgery I spent the time considering what I was going to find inside of him. Free air suggested that the primary pathology was in the either the colon or the stomach. The CT scan suggested I be prepared to remove parts of the colon, stomach, pancreas and spleen, a left upper quadrantectomy, as I’d called it in the past. I was sure he had a cancer of some sort, unusual and sad in someone so young. The tenants of cancer surgery dictate that it is best to remove the offending tumor en bloc, which means removing it all in one piece, preferably with a margin of normal tissue, something which is often not possible.
After my hour of contemplation, the nurse, tech and anesthesiologist were ready, Kerry was wheeled into the room and moved himself over to the OR table. I couldn’t help but notice the look in his eyes as he scooted from stretcher to OR table. It reminded me of looks I’d seen in movies; seen on the faces of actors who are made to walk up steps to the gallows or to the front of a firing squad; a look of impending doom. I gave him what I hoped was a reassuring smile as he positioned himself in the middle of the narrow table. He did his best to remain still as EKG leads, pneumatic compression stockings and pulse oximeter were placed on the appropriate parts of his body.
The steady, almost monotone voice of the anesthesiologist began:
“… take a deep breath, you may feel some burning in your arm, you’ll be asleep before…”
And Kerry was out.
Prep and drape, throw off the Bovie and suction and we’re off.
I made a generous midline incision and soon entered his abdomen, neatly, exactly through the center, to be greeted by a big ugly tumor. There was some thin serous fluid and inflammation around the tumor which was in closest proximity to the left side of transverse colon. I could see the hole where the tumor had perforated into the omentum and observed only a small amount of fecal contamination.
I gingerly moved the tumor, back and forth, up and down. It was mobile. I’ve done cases in the past where moving the tumor back and forth caused the whole patient to move, suggesting fixation of the tumor to vital retroperitoneal structures, which means it is almost surely unresectable and probably incurable. Finally, it’s time to dive in and commit. First the colon.
I start on the left side, dividing the left colon’s attachments up to its sharply angled turn at the splenic flexure, as well as dissecting the omentum free. Then from the right. Here I start at the colon’s beginning, the cecum. The appendix was stuck down in the pelvis. I free it up and notice it looks a little inflamed.
Appendicitis on top of everything else.
All along the right side of the abdomen I work, freeing the right colon up to the hepatic flexure and the proximal transverse colon, grateful that it easily lifts off the duodenum, that the tumor does not involve this part of the bowel.
No emergency Whipple tonight.
The right side of the omentum also is liberated, to be removed with the tumor. (Years ago I read an operative note where the surgeon described “liberating the splenic flexure of the colon.” I immediately had a mental image of colons running free shouting “I’m free, I’m free.” But I digress.)
Now I’m starting to surround the tumor. The back wall and greater curvature of the stomach are adherent, but this is limited to only the most inferior portion. The vessels feeding this portion of the stomach are identified and divided, the stomach is divided with a large stapler and the uninvolved portion of the stomach retracted away and out of sight.
One organ out of my way. What’s next?
The colon needs to go now. His right colon is pretty short. If I resect only the transverse colon I’m not sure about the blood supply to the remaining segment on the right. I decide to remove the complete right and transverse colon all the way to the proximal descending colon. This will allow for an anastamosis between the small bowel and descending colon, which should heal without problem, rather than a colon to colon connection in unprepped bowel. It’s time for more staplers. Gastrointestinal anastomosis (GIA)across the terminal ileum (last part of small bowel before the colon starts), again across the descending colon just beyond the splenic flexure.
I’m really zeroing in on this nasty beast now.
Next I see that the tumor may involve the distal pancreas.
Maybe I can separate the two structures? No luck. The pancreas and the spleen will need to go.
This actually doesn’t take very long. Kerry is very thin and the border of the pancreas is easy to see, as are the splenic artery and vein. Dissection is carried along the inferior border of the pancreas and an area is identified at the neck of the pancreas, uninvolved by tumor. The large splenic artery and vein are dissected free, clamped and divided and ligated. The neck of the pancreas is divided using the GIA stapler and the pancreatic duct is also separately sutured. Finally, the vessels remaining which enter the spleen are divided and the specimen is removed as one giant mass of tissue made up of the omentum, right and transverse colon, greater curvature of stomach, tail of the pancreas and spleen. I have performed the operation I have dubbed “left upper quadrantectomy.” This is only a partial LUQectomy, as I was able to leave the left kidney and adrenal gland behind.
After removing this massive tumor I’m left with the task of putting everything back together. In this case this means only a single anastamosis, small bowel to colon. I do leave a drain, just in case and finish the entire procedure in just under two hours. Kerry is safely deposited in the Recovery room and I manage to get home by about 4:30am to grab a couple of hours rest before the new day starts.
Kerry had an uneventful post-operative course, out of the hospital in eight days. His tumor was adenocarcinoma of the colon, which is the most common type of colon cancer, but still unusual in someone so young. The size and presence of perforation put the cancer at a later stage. He was treated with chemotherapy and I wish I could report that he responded well and lived many years, but this was not the case. Even the best operation sometimes cannot overcome a cancer’s inherent biology. Kerry’s cancer recurred and he passed away eighteen months after his emergency operation. Still, he was remarkably pain free during this time and was able to play his guitar up to the end.
The LUQectomy is an operation I do about once a year, most times planned, but sometimes emergent.
Mary was a case similar to Kerry, only her tumor arose from the pancreas and presented with bleeding and perforation. She also had middle of the night, emergency surgery, the night cap to a day that included eight other scheduled and emergency cases.
I’ve attacked the left upper quadrant for tumors arising from stomach, colon, pancreas, adrenal gland and retroperitoneum. The pathology may vary, but the approach is almost always the same. Find a plane free of cancer and isolate the tumor, try to get a margin of normal tissue. Always be aware of what can be safely removed and what needs to stay behind. Know where the major blood vessels are and treat them with the proper respect.
It is truly amazing how much can be removed with little or no subsequent physiologic impairment. Large portions of the pancreas can be removed, yet the patient never develops diabetes or malabsorption. All of the stomach could be removed and rebuilt with small bowel. But the patient continues to eat, although some weight would probably be lost. Portions of the colon are removed frequently for a variety of reasons, but very well tolerated. The body has two kidneys and two adrenal glands and can easily compensate for loss of one. The spleen is removed routinely for trauma or disease, yet is often barely missed.
Thus the remarkable, incredible resiliency of the human body is demonstrated. Despite invasion by cancer and serving as a battlefield for the surgeon’s war against this malignant enemy, despite the removal of large parts of vital organs, we are able to persevere. Truly amazing.
David Gelber is a general and vascular surgeon who blogs at Heard in the OR and author of Behind the Mask.