An Incurable Disease?

pancreas-and-kidneys

Surender wasn’t the typical patient suffering from cancer. A healthy north Indian male with a voracious appetite and a waist circumference substantiating it, he depicted no signs and symptoms of the ‘crab’ growing inside his pancreas. His only complaint was an unbearable desire to itch.

Physical examination revealed a deep yellowing of his eyes. This coupled with the unbearable itch convinced us to admit him to the wards, to investigate the cause further. Not only were his eyes yellow, but his skin also wore a golden tinge, the color of pusillanimity and inadvertent cowardice. The culprit being that tumor, inconspicuously growing in the seat of the endocrine system (a system which produces and distributes hormones to the body), the pancreas, an organ hidden away in the upper abdominal cavity behind the stomach and intestines, beneath the liver and in close proximity to the spleen. So complex is the location of this organ, that any surgical therapy requires removal of not only the tumor mass, but even parts of the intestines, the stomach and the tract carrying juices from the liver to the intestines (billiary tract).

So abysmal is the survival rate amongst patients with such a tumor, that some ‘humane’ surgeons even go to the extent of leaving patients to their fate. The aggressive nature of the tumor coupled with an equally bellicose surgery reduces the chances of survival.

Falling amongst the healthier cohort of cancer patients, Surender demonstrated a strong resolve to take on the challenge. His work-up for surgery was effortless, and within a week Surender lay on the operating table in the OR.

“Doctor, come what may, please do not prolong my misery if things don’t go well. But leave no stone unturned to make things go well,” Surender told us just before he went ‘under’ (a colloquially used term amongst anesthetists to describe a patient who has been anesthetized)

The surgery commenced as the clock in the OR struck ten. Bit by bit, the insignificant organs were reflected carefully so as to reach the organ of interest. So deep and conspicuous is the pancreas, that exposing the organ alone takes up a significant amount of time during surgery.

The duodenum (part of the intestines running from the stomach to the small bowel) was mobilized around the pancreas and cut out right from the stomach to the upper part of the small intestines, the bile duct entering the pancreas from the liver was dissected and cut open and finally the pancreas was transected, removing the culprit.This was the easy part. Cutting things out took little skill and precision, the real challenge lay ahead. The small bowel was meticulously juxtaposed against the stomach, the cut end of the bile duct and the cut end of the pancreas.

Using all the skill garnered over the uncompromising years training as a surgeon, the lead surgeon skillfully sewed the small bowel to the cut ends to maintain continuity in the digestive system.

Notwithstanding the skill required and the mammoth proportion of this surgery, the survival rates after surgery were also abysmal. But, human beings are hopeful creatures. They repose faith in even the remotest of chances working out for them.

Surender woke up to the sound of his wife reciting the Gita as she ensconced herself onto a  small chair that lay beside his ICU bed. The recovery was quick and painless.

Surender bid adieu to us ten days after surgery.

2 weeks after an uneventful and unforeseen recovery, Surender reported to us again, complaining of a foul smelling discharge from the operative wound. Concerned and anxious, we whisked him off to the radiology suite and performed a plethora of imaging tests. None were conclusive. Baffled at this idiosyncratic development, he was admitted to the wards once again to monitor his progress.

Copious amounts of discharge warranted us to innovate a different method of dressing to prevent his clothes from soiling. The wound was surrounded by an adhesive paste sprinkled with granules of activated charcoal, with a bag placed over the adhesive to collect the fluid. The bag drained the fluid and the charcoal adsorbed the gases responsible for the foul smell.

Four weeks passed by and the amount of discharge hadn’t decreased. It was by then established that a tract had formed from the pancreas to the skin and the pancreatic juices found an alternate escape route. However, our team wasn’t convinced.

On a whim, a week later, the senior resident decided to open up the wound to explore the problem further.

“The smell,” he said, “isn’t that of pancreatic juices.”

Relying solely on his keen sense of smell, we took the patient into the operating room again. The wound, which had mostly healed by now at all places barring the discharging portion, was injected with a local anesthetic and incised.

A horrific smell engulfed the operating room, strong enough to weaken even the strong hearted. There lay the culprit. The fat in the subcutaneous space had liquified and formed a roundish structure, no larger than the size of a fist. Pus emanated from the structure and was well contained by the thick walls formed around it. This surprised us. The initial CAT scans didn’t reveal the abscess, and it continued to grow in size.

For every major surgery, surgeons always expect major complications, sometimes ignoring the smallest ones. Look no deeper, if you haven’t looked superficially.

There was an immediate improvement. Surender was sanitized of all the bacteria breeding in his wound and was soon discharged to go home. The real challenge was his subsequent survival. Such patients usually survived for no longer than a year post surgery.

Chemotherapy was given to Surender, as a part of his treatment course, taking care of not only the tumor site, but also the small fragments that tried to enter the bloodstream and seed themselves elsewhere.

6 months later, Surender was actually gaining weight and showed no signs of spread of the tumor to other parts of the body. He was eating well, exercised daily and even went for long trips to the Himalayas.

“I feel better now than I have ever felt,” Surender said.

We still warned him that a sudden deterioration would not be wholly unexpected. Surender brushed us off, saying, “If I live with the fear of dying everyday, I will not live life the way I should. Don’t worry doc, I still have plenty of time.”

His optimism was encouraging, but we all knew that the end would come. Sooner rather than later. What were the odds of him beating the odds!

Surender went incognito after that day. It was assumed that the worst had befallen him. That the disease won the battle. Cancer had once again reigned supreme and brought a premature end to a jolly good life.

Our myth was shattered three years later when Surender re-emerged. He had taken a trip to his hometown and went on to reside there uneventfully for the three years that we hadn’t seen him. It didn’t seem like a tumor had once swallowed a part of his pancreas. That he had undergone a surgery so mutilating and challenging, that people often succumbed to complications arising from surgery before cancer stepped in.

A momentous occasion to celebrate survival of a patient with a tumor in the pancreas, a tumor so indolent and debilitating that sufferers actually welcomed death when it came to their doorstep.

The Defiant Destitute- I

    pancreas-and-kidneys

Photo Credit: ADAM

No Surgical resident wants to admit a destitute in their unit. Admitting a destitute in the unit implies that he will be taken care of by the residents of the unit, not only medically, but even otherwise. Its the job of the resident to arrange for clothes, food and accommodation after discharge

I hadn’t admitted too many destitute’s in the units I’d worked in. But Ganesh was an exception!

Wheeled into the emergency ward with an accident on the roads nearby, Ganesh on primary inspection seemed to be, primarily an orthopedic case. His right limb was almost split into two parts by the impact of the accident. Fortunately he wasn’t bleeding as much.

A quick secondary survey revealed some bruises on his abdomen, a tell-tale sign of a blunt injury to the abdomen. Under the influence of alcohol, his partially conscious state made it impossible to extract any details of the accident. Ganesh would have to be cleared from the surgical end before he landed in the orthopedic OR. A CT scan was arranged for Ganesh, while his limb was immobilized and the routine blood work was done.

All the resources are stretched to the maximum when any trauma patient is admitted to the emergency ward. A destitute trauma patient would impose the maximal strain. There were no relatives, friends or policemen, just the doctors, nurses and ward boys.

A quick review of the CT images revealed nothing of great significance in the brain or the abdomen. Ganesh was cleared for a transfer to the orthopedic ward.

As an exercise to test their skills, the senior registrars in the unit reviewed the CT images. Taking a closer look and getting an unbiased opinion always helped. The review of the images revealed a fracture at the tail of the pancreas, an organ sitting in the abdomen just behind the stomach and responsible for regulating the sugar levels in the body and digesting proteins in the gut. A duct (just like a plumbing pipeline) runs through the organ, dispensing the digestive juices into the gut. Fractures of the pancreas disrupt the duct and cause the juices to leak into the surrounding space. These juices are highly active and can digest the proteins in the normal tissue as well, hence causing inflammation and destruction of the surrounding structures, including the stomach and the colon. The spleen is closely related to the tail of the pancreas and in a fraction of patients, the tail is embedded in the spleen.

These findings led to a knee jerk reaction and Ganesh was transferred back to the surgical side.

Ganesh’s problem was picked up relatively early and operating him to remove the fractured part and oversew the duct would probably save him from the consequences of a damaged pancreas. Ganesh was planned for a ‘Spleen preserving Distal Pancreatectomy’, a prolonged and complicated procedure in the emergency setting and was shifted to the operating room.

On opening his abdomen, we realized that we had gone in relatively early. There was minimal inflammation with a very minor leak. However, on inspecting the pancreas it was badly fractured, with the duct completely transected, as predicted on the CT images. The procedure was underway in the operating room, while another procedure was going on in the adjoining room. I was assisting the Assistant Professor, who was performing the surgery. While dissecting the pancreas for a resection, the team on the other table ran into some difficulties. The Assistant Professor had to scrub in for that surgery and permitted me to carry on with the procedure.

Ganesh was a part of the unfortunate fraction, who had the pancreatic tail embedded in the spleen, which made it mandatory for us to remove the spleen. The inability to preserve the spleen actually made the surgery a little easier and faster. After completing the procedure and placing a drainage tube close to the pancreas, the orthopedic team fixed his fractured leg with an external fixator.

Ganesh was shifted to the surgical ICU after the procedure on ventilatory support. Two days after the procedure, he had made a remarkable recovery and was removed from the ventilatory support. Three days after that, Ganesh was shifted to the ward.

This remarkable recovery surprised us, as did the arrival of his mother and two wives, the day after he was operated. Ganesh wasn’t a destitute after all. No doubt that his family reeled in poverty, but he did have a family, albeit a very dysfunctional one.

His mother came in drunk every morning and would pick up a fight with everyone. His two wives publicly quarreled to assert their rights over him. Ganesh, who had been an alcoholic, progressed to a state of alcohol withdrawal. Disoriented and confused, he added to the drama created by his family in the hospital. Ganesh, his mother and his two wives made a living out of selling flowers form a roadside stall. The money generated form sales was used to fund their addiction to cheap country-made liquor and tobacco. How he had managed to shelter two wives in the same house was beyond me. But it didn’t matter. We just wanted him to get better and move out of the wards.

On one such Sunday, immediately after my morning rounds, I was paged by the nurses in the ward. Ganesh’s mother in one of her drunken stupors, had fed his son some food lying by his bedside. Ganesh, who was still in a state of alcohol withdrawal was unable to swallow the food and aspirated the food particles in the respiratory tract.

There was an immediate response to the food particles stuck in the respiratory tract. Ganesh became breathless and blue and vomited large quantities of gastric secretions. Our worst nightmare had just been realized….

 

To  be continued…………..