When I think of Big Joe, I see his overalls and how he filled them. And how a couple of months after I operated on him, there was room for both of us in there. Big Joe: farmer, salt of the earth, tough, stoic. And now, bright orange. My initial recommendation, while probably justified, damn near killed him. Big Joe hadn’t been sick a day in his life. He worked his tractor every day; took a hell of a lot to slow him down. He’d been feeling a little poorly, with less appetite than usual and no pain, really. The white stools worried him, along with the brown urine. His color was in the sun all day, so that hadn’t seemed too strange to him, although his wife was starting to notice. So he saw his doc, who ordered a battery of blood tests, an ultrasound followed by a CT scan, and then shot him over my way. It looked bad.
What makes people yellow with liver trouble is bile pigments getting into the bloodstream, either because the liver isn’t processing the chemicals properly or because the bile can’t flow out of the liver into the intestine where it belongs. Obstructed flow begs an operation of some sort to relieve it. Once again, there are two general categories: gallstones and tumors. Gallstones, formed in the gallbladder, can pass out of the gallbladder and get stuck in the main bile duct, plugging it up. Typically, because it happens fairly suddenly, it hurts like hell. Painless jaundice, a result of a slow squeezing of the duct, most often says something bad like cancer. Big Joe didn’t have pain; he had an enlarged duct consistent with obstruction, no duct stones on a sonogram or CT scan, and an ominous enlargement of the head of his pancreas. Also, a blood test had been done that showed very high levels of a protein associated with cancer.
He did have stones in his gallbladder, but no evidence they’d moved out to cause the problem. I decided to send him to a gastroenterologist before I operated to X-ray the bile duct just to be sure it wasn’t stones causing the blockage. The GI doc can pass a scope through the stomach, into the duodenum, and inject dye directly for an excellent picture. It’s called ERCP, for “endoscopic retrograde cholangiopancreatogram.” Plus, as long as he’s there, he can insert a tube (stent) to allow bile flow pass the obstruction which, it was felt, can improve hepatic function before surgery, making healing more propitious. The ERCP showed no duct stones; the stent was successfully placed, so his bilirubin levels were falling when I operated on Big Joe. The operation would be a complex and lengthy Whipple Procedure, which I expected to be doubly tough for a five-foot-ten, 350-pound guy. It may seem paradoxical for such a huge operation, but there are times when we proceed on the assumption that it’s for cancer without trying to confirm actual cancer: Biopsy of the pancreas can be dangerous, and even if a biopsy doesn’t show cancer, it can’t rule it out. So, under some circumstances, we plow ahead without definitive confirmation.
In the case of Big Joe, bridges were burned by the time I divided his bile duct. At which point a couple of large gallstones rolled out. Hardly an “oh well” situation; putting someone through a huge operation when a small thing would have sufficed is sickening. On the other hand, there was a mass in his pancreas, and that cancer blood test. The gallstones could have been incidental, and the pathologist might still find pancreatic cancer.
They weren’t, and he didn’t.
The operation was surprisingly easy despite Big Joe’s girth and fat upon internal fat, and everything looked great when I was done. I’d have felt pretty good, but for the fact that within eight hours, Big Joe was nearly dead. Septic shock, happening so fast that it couldn’t be from surgical infection or leakage. This was infected bile, “cholangitis,” undoubtedly a result of having the stent in for a few days ahead of time. Turns out, as with other medical ideas, placing a stent before a Whipple — which was thought to make sense (it did to me and was written about in journals) — on further review was found to be associated with a high incidence of perioperative sepsis. For about forty-eight hours, he was as close to death as you can get and make it back. Drugs supporting blood pressure, maximum ventilatory assistance, kidneys not working, pathological bleeding. I spent hours at his bedside, sweating alongside my trusty angel, the intensivist, and consoling Big Joe’s wife. Worse, at the absolute nadir is when the pathology report came back: no cancer. You can’t get that sick after a big operation and heal normally. He leaked pancreatic juices, his incision fell apart. Fortunately, per my routine, I’d put a feeding tube into his intestine during the operation so that we could feed him easily.
He finally turned the corner and, after a long hospitalization and having passed many crises so severe I thought we’d lost him, he made it home. I saw him constantly for months, tending wounds, dealing with drainage, and watching him get smaller and smaller. He always wore those overalls as if to remind me what he was going through. But that wasn’t Big Joe. Neither he nor his wife ever suggested I’d screwed up. They were glad for my constant care, and over time, he eventually dried up, healed up, had repair of his incisional hernia, and climbed back on his tractor.
Big Joe: living proof of our fallibility. Useful tests, wrong answers. Procedures aimed toward helping, making things worse. Every time I saw him, I felt really bad. Until he finally came into the office, bulging out of his overalls, like the day I met him. Only pink.
Sid Schwab is a retired surgeon who blogs at Surgeonsblog and is the author of Cutting Remarks: Insights and Recollections of a Surgeon.
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