In My Hands

by Steven A. Curley

  A few examples: During my general-surgery rotation as a third-year medical student, our team of medical students and junior residents began each morning long before the sun rose. Our first daily job, before 6 a.m., was to collect all of the requisite information on vital signs and laboratory data from the hospitalized surgical patients. We would then tag along behind the chief surgical resident as he or she went from room to room to evaluate and examine the inpatients before beginning the day’s schedule of operations. If asked, we students were expected to recite from memory a specific lab value, maximum temperature, or urine output from the previous shift. It was commonplace for the chief resident to ask, “How’s the gallbladder in forty-three doing?” or “What’s the drain output from the pancreas in ICU?” As we completed rounds, the residents would begin discussing the operations to be performed: “I’m doing the aorta today, are you doing the right colon?” and “Did you remember to consent the hernia?”

  What exactly is the hernia consenting to?

  It was rare to hear one of the surgery residents state correctly and deferentially, “I am going to perform the gastric resection on Mr. Smith today. Why don’t you help Dr. Jones remove the gallbladder from Mrs. Thomas?” This depersonalization of patients continued throughout my surgical residency, surgical oncology fellowship, and into the early years of my academic career. As a senior and chief resident I drove the younger residents mad by insisting they identify patients by their name, not by a diseased or damaged organ like “the bleeding esophagus,” “the pancreatic cancer,” or “the cirrhotic liver.” However, it took me a few years to attain a level of seniority as an academic surgeon before I felt comfortable addressing this vexation with my peers and colleagues. Now when I politely correct them after they refer to a patient as “the stomach” or some other anatomical site, I am invariably met with frosty glares, lack of comprehension, or a shake of the head.

  That’s right, I’m at it again.

  An important reality of modern cancer care is the still-crucial role surgical treatment plays in improving patients’ probability of long-term survival. For many organ-based solid cancers, surgical removal of the primary tumor, affected regional lymph nodes, and (in specific cancer types and instances), metastatic deposits of tumor continues to provide patients the best chance of beating their disease. This in no way is meant to minimize the role of chemotherapy, radiation therapy, immunotherapy, targeted therapies, or other multidisciplinary approaches. The team approach to treating cancer is clearly beneficial to patients and improves their odds of survival. Surgery is still dominant, however, when it comes to removing large or aggressive cancers.

  This reality leads to another misdirected euphemism among surgical trainees and staff surgeons: their wonderment over an unusual, difficult, or particularly grueling and technically demanding operation. Residents or fellows will regale others in their program with a remark like “Wow, the liver I did yesterday was a great case!” or “I’m doing a tough bile duct with a vein resection with Curley today. It’s going to be a great case!” Most surgeons like doing challenging, big operations. Frankly, for me, the advanced, exacting surgical methods and the variety of sites involved was a major draw to a career in surgical oncology. Performing routine, mundane procedures is fine, but surgeons get a little amped up at the prospect of a “great case.” However, I fear we forget too commonly the great case is a really big, frightening prospect for the patient who is unknowingly being dehumanized.

  Early in my career after completing my surgical oncology–fellowship training, a patient was referred to me because he had a large right-colon cancer. His tumor was easily palpable through the abdominal wall. The patient was a thin gentleman in his mid-forties who had lost almost twenty pounds over the preceding three months. He had not intended to lose weight and had not been dieting. The gastroenterologist who referred the patient to me had performed a colonoscopy and a CT scan that revealed a large mass in the colon just beneath the liver.

  Usually, if a colon cancer is related to weight loss it is advanced or metastatic to other organs. I looked at this gentleman’s CT scan and saw there was no evidence of enlarged lymph nodes or any tumors in the liver, peritoneal cavity, or lungs. I also noticed the tumor was larger than a cantaloupe and was abutting the duodenum (the first part of the small intestine) and the head of his pancreas. The small intestine is critical to absorb nutrients from the food we eat while the colon is involved in conserving water and storing and excreting waste products. I asked the patient if he was having pain related to the cancer and he replied he was not. But when I asked if he was having trouble eating he admitted he felt full after only a few bites of food. He paused, and as an afterthought reported he avoided eating because with even a small meal or snack he felt queasy, and on several occasions had vomited food and some blood.

  Vomiting blood was a red flag. Patients with colon cancer may notice blood in their bowel movements, but bloody emesis is not common. I asked one of my gastroenterology colleagues to perform an upper-gastrointestinal endoscopy to look into his esophagus, stomach, and duodenum. This revealed his colon cancer had grown into a portion of the duodenum. A biopsy confirmed colon cancer was present near the ampulla of Vater, the location where the bile duct and pancreatic duct drain from the liver and pancreas, respectively, into the duodenum.

  As I looked at the images from the endoscope, I exhaled with a low-volume whistle. This was going to be a big operation, the proverbial great case. I met with the patient and his family and explained that his colon cancer had grown into the first part of his small intestine and was also involving the head of his pancreas. With anatomical diagrams and drawings I described the operation I proposed. This would involve a surgical tour de force, an en bloc (everything taken out together in one large specimen) extended right hemicolectomy and pancreaticoduodenectomy. All told, the operation would remove a few inches of the terminal ileum (the last part of the small intestine where it joins into the right colon), the entire right colon and most of the transverse colon, the distal (last) portion of the stomach, the entire duodenum, the head of the pancreas, the gallbladder and a portion of the common bile duct, and the proximal jejunum for a few inches past where the duodenum joins the jejunum at the ligament of Treitz. (Sorry for all the anatomy terminology.)

  I took a good thirty minutes detailing the operation and I emphasized the implications of four anastomoses, or surgical connections, I would perform. The remaining pancreas and the common bile duct would each need to be reattached to the small intestine, the stomach would need to be sutured to the small intestine so ingested food could exit from the stomach into the intestine to be absorbed, and the transected end of the ileum would need to be attached to the remaining colon.

  The surgical resident and fellow in the clinic room with me were as wide-eyed as the patient and his family. I explained that the operation would be a large-magnitude procedure, but I believed it provided him the best chance to remove the malignant tumor completely and give him hope for a reasonable period of survival.

  Everyone knows the saying about hindsight, and my remarks to the patient were more than prophetic. Despite his weight loss, the gentleman was nutritionally still in good condition. The next week we performed the operation, which required more than seven hours from incision to final skin suture. The patient was stable throughout the procedure and the morning after his operation he was alert and optimistic. He had a drain tube protruding from his abdomen to watch for a leak from the pancreatic anastomosis to the small intestine. And because I was concerned about his nutritional status with the combination of weight loss and a complex, major resection a second tube was placed directly into his small intestine (a procedure called a feeding jejunostomy) to allow us to begin feedings. Surprisingly, we never had to use it. His bowel function returned within forty-eight hours, and we allowed him to begin drinking small amounts of fluids gingerly. He breezed through a liquid diet and by day four was eating solid food, wolfing it down, and asking for more. M
y suspicion that his family was providing him with contraband fast food was confirmed when I walked into his hospital room on day six to find hamburgers and french fries being held or chewed and swallowed rapidly by all. Guilty facial expressions were replaced by smiles and laughter when I said, “What the hell—you didn’t bring me one?”

  My patient remained hospitalized for an additional two days, frankly more as treatment for my anxiety rather than as medical necessity, and before he was discharged, both his drain and feeding tube were removed. He was eating well, and his bowels were functioning well. I saw him back in the office the following week. He had gained three pounds and was pleased with the surgical results. I reviewed his extensive pathology report with the entire family. The examining pathologist had indicated that the large cancer arising from his colon had indeed invaded directly into the duodenum and the head of his pancreas. More than sixty lymph nodes had been removed during the operation, and remarkably there had been no evidence of cancer in any of them. All resection margins were negative by several centimeters. The final analysis: he had a locally advanced cancer invading into adjacent organs but that had not metastasized to lymph nodes or to any other organ.

  The following week I presented my patient’s findings at a multidisciplinary tumor conference. As I walked in, I overheard my fellow talking to other surgical fellows and residents. He exclaimed, “What a great case. The colon-Whipple did great!” At that moment, he caught my eye and quickly corrected course knowing what remark I would make otherwise. He amended his comments and told his colleagues the patient with a right-colon cancer locally invading adjacent organs had recovered very well from his right colon resection-pancreaticoduodenectomy (Whipple) procedure.

  Uh-huh. A close call for the fellow. Don’t make me come over there and talk to you about referring to patients by their body parts.

  My colleagues in medical oncology could not find a data-based reason to administer chemotherapy treatment to improve this gentleman’s prognosis. Admittedly, at the time we did not have many of the drugs we now have available for locally advanced or invasive colorectal cancer. These days, the patient would likely receive preoperative chemotherapy to try to reduce the size of the tumor. But at the time, I called my patient with the recommendation we simply follow him closely and we would intervene with additional therapies if and when his cancer recurred.

  I had that conversation with my patient twenty-three years ago. He is alive, vibrant, and active, and his cancer has never recurred. He exemplifies the importance of being committed to surgical-technique excellence when operating on patients with cancer. Complete surgical removal with negative margins is a goal we strive for in every patient. However, negative margins are not always possible because we may discover during an operation that cancer is invading vital sites we cannot remove without doing irreparable or life-threatening damage to the patient. This is why we frequently decide not to perform an operation when preoperative scans reveal tumor growing into or abutting critical structures we cannot remove or replace. In those situations our colleagues often give preoperative chemotherapy or a combination of chemotherapy and radiation therapy to shrink the tumor so we can hopefully perform a complete resection at a subsequent date.

  My patient’s success story is not unique. It is well known that some types of cancer tend to invade locally into structures or organs around them, and in a subset of patients when complete surgical removal of all cancer is possible, long-term survival may result. However, a major surgical procedure has implications on a patient’s lifestyle, functions, body image, and nutrition. The patient may have a successful cancer operation but be forced to live with stomas, deformities, or other disabilities. Every now and then, we encounter a patient like mine who underwent an extensive operation and recovered well. He is thriving, and except for a long scar on his abdomen, you would never know he was a cancer survivor.

  This represents a great result after a great case. I’m still working on the objectification problem, however. A couple of years ago I was planning to remove a malignant tumor in the left liver lobe of a very amiable gentleman. During the operation, I recognized that the malignant tumor was invading into the diaphragm. The surgical resident and I opened the diaphragm, planning to remove a small piece of this muscle attached to the tumor and then close the defect. I had encountered this situation dozens of times previously. Instead, we found the tumor had grown through the diaphragm and was attached to the right ventricle of the heart. That was a novel situation; I hadn’t seen this problem before.

  I am fortunate to work now at an institution with a renowned cardiothoracic-surgery center. I called over to the heart operating rooms, had two cardiothoracic surgeons come join me, and within twenty minutes my patient was on full cardiopulmonary bypass. The cardiac surgeons removed a piece of the apex of the right ventricle stuck to the liver tumor, I completed the liver resection, they closed the hole in his heart, and the patient came off the bypass smoothly. All of our margins, including the heart, were tumor-free, and the patient walked out of the hospital the following week.

  A few days after this remarkable procedure, I encountered one of the cardiac surgeons who had assisted me. He was sitting in the surgeons’ lounge waiting for his next operation to begin. I remarked, “You know, Mr. So and So is recovering really well. Amazing! Thanks for your help.”

  He looked at me with a puzzled expression, and suddenly, the light bulb went on.

  “Oh, the liver-heart guy. Yeah, great case.”

  Long sigh. Change is usually not easy or fast.

  My mission continues.

  28

  Surf’s Up

  “Contentment is the only real wealth.”

  Alfred Nobel

  Contentment: A state of happiness and satisfaction

  At the pinnacle of its power and influence, the Roman Empire extended across large portions of Europe, Western Asia, and Northern Africa. To maintain peace and to display authority and prosperity, the leaders of Rome designated many days as celebrations or “holy days” to give thanks to a variety of gods in the pre-Christian era. Holy days became holidays in modern parlance. There were almost 140 identified days or periods for feasting and festival in the Julian calendar. The Roman population apparently liked a good party, causing the Emperors of Rome to go to the trouble and expense of sponsoring bloody battles at the Colosseum, chariot races at the Circus Maximus, and festive parades and performances.

  Assigning more than one-third of the calendar year for feast and folly may be one factor that led to the decline of the Roman Empire. The lack of productive and useful work by celebrating citizens certainly could not have helped maintain the empire. Political corruption, abuse of power, declining moral values, expansion into far-reaching territories, and excessive spending on public works and military campaigns also contributed to the end of the empire.

  Doesn’t history repeat itself? One thing can be said about the modern United States; we are not to be outdone by the Roman Empire. We have more than 2,300 recognized or declared holidays or observances. These special celebrations may last a day, a few days, a week, or a month. In fairness, very few of our sanctioned holidays actually are a day off from usual work and other banal duties. Like our ancient Roman brethren, though, we do expect a spectacle on a few special days. What would the Fourth of July be without rousing marching bands or extravagant, brilliant, exploding fireworks? What is Thanksgiving without turkey-based (or basted turkey) gluttony, parades, and televised football games? Why observe Labor Day if we don’t relax from our labors with a barbecue and a gathering of family and friends? Memorial Day would not be memorable without speeches, parades, and American flags displayed on the graves of American soldiers during somber ceremonies across the nation.

  Paradoxically, the majority of special days, weeks, or months in America pass without fanfare or much notice. Did you save your unwanted, untouched, hardened holiday fruitcake and fling it across your yard on January 3 to commemorate National Fruitcake Toss Da
y? Or heave it over the backyard fence as a special Happy New Year gift for your neighbors? You know, the folks with the teenagers who like to play really loud music. At 2:30 a.m. On week nights. How much money did you spend hosting an exhilarating festival at your home on July 19 for National Hot Dog Day, and did you double down with an even bigger party on September 9 for National Weiner Schnitzel Day? Tell me you displayed red, white, and green decorations and made a nice marinara sauce on February 13 for National Tortellini Day. Was your family driven into a sugar-fueled frenzy on May 19 after eating all of the chocolate cake they wanted to honor National Devil’s Food Cake Day?

  What are your plans for the entire month of October, appointed as National Toilet Tank Repair Month? Should we be concerned that toilet-tank repair requires an entire month for adequate homage? Does excessive flushing during the summer months lead to tired tanks in need of service to prepare for the winter holiday season? And what happens if the toilet bowl breaks? Must we wait for a special month to seal or replace a cracked and leaking crapper? My grandfather, my father’s father, was a union plumber his entire adult life. Is the plumbing lobby in Washington, D.C., responsible for acquiring official recognition for an entire month to extol the virtues of a properly functioning toilet tank? I must wonder if money is being privately passed under the bowl in the privy.

  If you play your cards right, you can spend any given week in daily blissful celebration. I’ll give you an example of how to make big plans for the first week of June. On June 1, as an important public-safety exercise, you can teach a class at your place of employment in honor of National Heimlich Maneuver Day. It’s critical for people to know the proper administration of the Heimlich maneuver. Convince your boss to take the entire office out to lunch, just in case an actual food-induced airway obstruction occurs. Parenthetically, you will be sock- and shoeless during your Heimlich demonstrations because June 1 is also National Go Barefoot Day. No worries if you exhaust yourself teaching the maneuver because June 2 is National Leave the Office Early Day. Thankfully, there is no official code stating how early one can leave, so why not take off after a 9:30 a.m. coffee break? The week just keeps getting better; June 3 is National Repeat Day, so you’ll leave work early again. Well-rested and invigorated by the holiday mood, identify an older unmarried woman on June 4 and ask her to join you at a local pub to enjoy a fine brandy to celebrate both National Old Maids’ Day and National Cognac Day. In high spirits after a few snifters of brandy, you may not get much accomplished at your job on June 5 as you enjoy National Moonshine Day. You know moonshine is illegal, right? But it still has its own official national day. Is America great or what? The moonshine will have you relaxed, loose, and ready to demonstrate manual dexterity on June 6 for National Yo-Yo Day. The week will end on a high note, especially if you are a card-carrying chocoholic, because on June 7 you can pound down your own half gallon to revel on National Chocolate Ice Cream Day. Great week! And it works for every other week, too, if you apply your sanctioned and recognized holidays to full advantage.