Friday, July 6, 2018

Big Joe



My next newspaper column, pared down from the original, on Surgeonsblog. Taking a break from the din:
When I think of Big Joe, I see his mechanic's overalls, 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: salt of the earth, tough, stoic. Also, on the day I met him, yellow as summer squash. My initial recommendation, while justified, damn near killed him.
Jaundice comes in two categories: obstructive, and non-obstructive. Surgeons see the first. The second is usually from "medical" liver disease, like hepatitis or cirrhosis. The reason people turn yellow with liver trouble is bile, manufactured in the liver, getting into the bloodstream, because the liver is malfunctioning or because bile can't flow out into the intestine where it belongs. Obstructed flow begs an operation. The most common causes of obstruction are gallstones and tumors. 
Painless jaundice, resulting from slow squeezing of the duct, most often portends something bad, like cancer. Stones happen fast, and hurt. Big Joe didn't have pain; imaging studies found no stones in his bile duct but showed an ominous mass in the head of his pancreas. Plus, a blood test showed high levels of a protein associated with pancreatic cancer. 
He did have stones in his gallbladder, but no evidence they'd moved into the bile duct to cause the problem. To help decide on the best operation, I sent him for a specialized X-ray procedure, to be doubly sure there weren’t stones causing blockage. At the same time, a tube could be inserted to restore bile flow past the obstruction. The X-ray showed no duct stones; the stent was successfully placed.  
Testing every technique a general surgeon knows, surgery for an obstructing pancreatic tumor, called a Whipple procedure, is about as complex as it gets. It requires removing the duodenum, gallbladder, parts of the bile duct, pancreas, and, sometimes, part of the stomach; then reattaching the leftovers to the intestinal tract. Because biopsy of the pancreas can be dangerous, and can’t definitively rule out cancer, sometimes we proceed without that step, which I did. When I divided his bile duct, past the point of no return, two gallstones rolled out. 
Even now, writing that recalls the sickening feeling of putting the man through a pancreaticoduodenectomy when a simpler procedure might have sufficed. On the other hand, there was that mass in his pancreas, and the cancer blood test. Gallstones could have been incidental, and the pathologist might still find pancreatic cancer. They weren’t. He didn't. 
Despite Big Joe's girth, the operation went pleasingly well and everything looked perfect 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 it couldn't be from surgical infection or leakage. This was infected bile, undoubtedly a result of having manipulated the stent. Turns out, as with other innovations, placing this type of stent before a Whipple, positive studies notwithstanding, was later found to be associated with a high incidence of infection. (Stents of different composition are used now, and they work well.) 
For about forty-eight hours, Big Joe was as close to death as one can be and make it back. I spent hours at his bedside, dialing drugs and fluids, consulting an intensive care specialist, consoling Mrs. Joe. Worse, at the absolute nadir is when the pathology report came back. 
You can't get that sick after a big operation and heal normally. Joe leaked pancreatic juices, his incision fell apart, and I nearly did, too. Fortunately, per my routine, I'd put a tube into his intestine during the operation, so we could feed him effectively. After harrowing days, he turned the corner and, having passed crises so severe I thought we'd lost him, made it home. 
For weeks, I tended his wounds, dealing with drainage, watching him get smaller and smaller. Joe always wore those overalls, as if to remind me what he was going through. But that wasn't Big Joe. He and his wife were glad for my care, never complained, and, over time, he healed up, made it back to work. 
Big Joe: living proof of surgical fallibility, the dangerous flip-side of my chosen profession. Every time I saw him, I felt awful. Until he finally came to the office, bulging out of his overalls, like the day I met him. Only pink. 
[Image source]

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