Thursday, December 03, 2009

close call

i have already spoken about the hazards of doing favours, but recently i was reminded of another example when i was still a registrar where i only just escaped the proverbial falling anvil.

it was not an unusual case but still fairly challenging for a registrar like myself. the old man presented with an acutely tender abdomen and free air revealed on x-rays. if you ignore the outside horses for a while, this is either a perforated peptic ulcer or complicated diverticulitis (some people would throw complicated appendicitis into the mix, but i'm going to leave it in the stable with the outside horses if there are no objections). the patient needed an operation and soon. so with the sun shining happily over australia somewhere, i took him to theater.

it turned out to be diverticulitis, but what a mess. the entire abdomen was full of pus and there was a big inflammatory mass in the region of the sigmoid colon. i knew what to do. i whipped out the offending sigmoid colon and, because the risk of reattaching the bowel in that level of sepsis was too high and because the patient couldn't afford a further complication, i pulled out a colostomy. after the surgery the patient started recovering at an acceptable rate. the plan was to reverse the colostomy in the future.

now usually, this sort of colostomy would be left in place for quite a while (in the order of six months) to give the abdomen time to recover fully from the severe inflammation that accompanies free pus throughout the abdomen. inflamed bowel is very friable and difficult to work with. thereafter it would be closed in a second operation. however there was a private consultant with sessions at the university who strongly advocated for what he called early closure of colostomy. he said that as soon as the sepsis had cleared up, long before the inflammation had settled, you could re operate and reverse the colostomy. he advised that the second operation be done before the patient even leaves the hospital, even within a week of the first procedure. he actually approached me about this patient specifically and told me i should try it. i started contemplating the idea.

then something happened that i should have seen as a big warning sign; an old friend asked me for a favour.

you see this friend was related to my patient in some way. apparently he had visited him in hospital and discovered i was the one who had done the operation. as can be expected from someone who wakes up from surgery with an unexpected colostomy, the patient was bemoaning his lot in life. in the end he asked my friend to ask me for a favour. the friend asked me to close the colostomy, sooner rather than later. i should have seen warning lights. i didn't.

so i decided this would be the case where i listen to the often contentious advice of this specific private surgeon. i took the patient back to theater to close the colostomy about a week after the first operation.

quite soon i was in trouble. everything was adhered to everything. over and above this, because the inflammation was far from resolved, everything was oozing blood at somewhat more than an acceptable rate. but it was too late. i was elbow deep in the abdomen. i had no choice but to continue. the other catch was that i was doing the operation at the advice of the outside consultant and not with the consent of my own consultant. this essentially meant i would experience a severe loss of cool if i asked my consultant to come in to help me *read bail me out*.

the details need not be dwelled upon (truth be told i have filed them deep in the forget folder in the darkest archives of my mind) but suffice to say it was an almost impossible dissection to get the two ends of the colon together to reattach them. finally, almost miraculously, i approximated the two ends in a somewhat acceptable manner and attached them.

during the postoperative period i almost expected a leak. day after day i'd check the patient out and be surprised to see there was no leak. finally i discharged him in good health. but not before i swore to myself never ever to attempt an early closure of colostomy again. also i reminded myself of the dangers of doing favours.

p.s many years later i ran into this friend and was pleasantly surprised to hear the old man was still going strong.


Jabulani said...

Recently I was chatting with a friend who said of operating, "If I am asked, I will not say no."
I was reminded of this as I read the post, because if I am asked to do a favour, if I can do it, I will not say no...which tends to make me very busy doing other people's stuff with not so much time for my own. I doubt I shall ever learn the lesson not to do favours.

rlbates said...

Hard learned lessons.

sammy said...

what do you think of these surgeons who do Hemicolectomies and anterior resections or whatever by laparoscope? this guy came to the ward the other day after having a laprascopic bowel resection and yes he felt fine! by that evening he was up in a chair, sipping high protein drinks and swallowing paracetamol. however next day after a walk around the ward and everything was fine: then his HB dropped to 4. he didnt even have a drain. Also how low would you let your HB go if you needed a blood transfusion in Africa?
MR boerwors: i am glad you are having such a lovely holiday: steak, sex, beer and broganvillia and the singing of birds...............meanwhile back in uk: swine flu pandemic and lots of rain.

Bongi said...

sammy, laparoscopic colectomies are the way to go. in this case, because of the generalised peritonitis it was not an option.

bleeding can happen in any operation and is not so much a result of laparoscopic surgery as a result of surgery. it is one of the things you need to be able to deal with as a surgeon. complications happen. do enough operations and you'll get one.

drains is a whole other topic. i don't think it is wrong not to put in a drain after a lap colectomy. obviously in retrospect in this case it looks like it might have been helpful but retrospecively everything is easy. there is even evidence that drains increase anastomotic leakage, so your surgeon was well within present conventional thinking.

transfusion is also not cut and dried. standard thinking is that hb under 7,4 needs transfusion, but if surgery is going to happen something much closer to 10 is acceptable. but the actual point it the case you describe is he probably needs reoperation rather than transfusion. blood is not going to stop bleeding.

Anonymous said...

thanks Bonji..........nothing like an artery in spasm to make surgeons think everything is o.k!!!!

Bongi said...

point of order. my name is both spelled and pronounced bongi and not bonji.

Mary said...

Yeah, favors are tricky things. I am fond of doing favors for people, but they're mostly people who I am close to and trust. The good thing about favors for certain people is that you can then ask for a favor in return! They "owe you one" in a sense. Which may or may not come in handy in the future.

StorytellERdoc said...

Hey Bongi

Great post. A learning point in there for all of us. Always stick with what you believe, although an open ear to listen to other ways is commendable. I'm glad the surgery turned out well and you walked away all the better a person.

By the way, I liked your use of horses outside the stable. Here in the US where I live, we say "don't overlook the horses for a zebra." Same thing...

Thanks again.

Albinoblackbear said...

When in doubt go with your gut (double entèndre intended).