Wednesday, September 19, 2007

Dr. Phibes meets the Pancreas

There are times when surgery is elegant --- cases move smoothly, every suture is placed with a minimum of effort, anastomoses look like they belong in a textbook. Every song played on the iPod is a staff favorite. The anesthesiologist is happy to be there, and no administrator darkens the door. Life is good.
And then, there are other days.

Those are the days when, despite everyone's best attempts, everything is just a bit out of sync. Anatomy may be severely distorted. Tissues may ooze almost continuously. A few bon mots are uttered, not always politely. The operation takes longer than anticipated, and so does the next one, and then an emergency case "bumps" the room to make everybody hopelessly behind schedule. But we get through these days, and move on to another, more elegant day of surgery later in the week.

Except, of course, when we don't.

The honest truth is that at times abdominal surgery can appear to the uninitiated as a violent assault on sound surgical principles --- when the operation is performed with a minimum of delicacy and a maximum of expediency. The patient is sick, extra time spent in the OR can be deleterious, and what needs to be done is, to be blunt, dirty work. In my opinion, the "dirtiest" of these dirty jobs is dealing with necrotizing pancreatitis.

Pancreatitis occurs when a sleeping beast is disturbed. The nice, pleasant pancreas sits is the back of the upper abdomen, minding its own business, quietly going about the job of producing insulin as well as enzymes that pass into the upper GI tract and help break down fats and protein. This smooth operation is thrown into chaos when something (passage of gallstones or excess alcohol intake, to name a few) causes injury to the pancreas, creating a situation where the gland leaks those same enzymes into surrounding tissues....which is a pretty expensive piece of real estate made up of, you guessed it, fat and protein. In mild cases, this causes inflammation and pain. When severe, this causes tissue destruction on a pretty big scale --- pancreatic necrosis.

When necrotizing pancreatitis develops, patients get pretty ill --- "low sick," as some would put it. A whole cascade of what can only be termed bad things may ensue, such as shock, ARDS, SIRS, hemorrhage, hypocalcemia, and renal failure, to name a few. Treatment is in large measure supportive --- large volumes of fluid, pain control, transfusion as needed, nutritional support (which, in my opinion, is very critical), sometimes mechanical ventilation, etc. The use of antibiotics in necrotizing pancreatitis has been debated for some time, with the most recent large study suggesting it offers no benefits in the absence of proven infection.

Surgeons are frequently involved with the care of these critically ill patients, with many of them eventually requiring surgery. When tissue destruction (necrosis), that dead tissue not only makes patients sick but it may become secondarily infected. The role of the surgeon in that instance may entail one --- but frequently many --- trips to the operating room for debridement of the necrotic, infected tissue. This procedure is a search and destroy mission undertaken with trepidation and care, as we attempt to leave what is viable while removing what is dead and infected, all the while trying to avoid vascular or bowel injury. When patients require repeated trips to the OR, risks for complications increase.

This is not what I can in any sense describe as elegant surgery. In a tip of the hat to Dr. Phibes. it is frequently termed pancreatic necrosectomy --- a rather oblique term that hardly describes a challenging and frequently bloody operation. These patients are in for a prolonged hospitalization, requiring every resource at our disposal, and some do not survive. The role of nutritional support cannot be overstated; similar to patients with large burns, these critically ill patients burn up their caloric reserve in the blink of an eye. The safest way to provide nutrition is via the gut, so every patient I operate on with this process gets (along with a zillion other things) a feeding tube inserted into the jejunum. This will serve to provide the patient with adequate nutrition throughout their hospital stay, and is vastly superior to parenteral nutrition (more on that in some other post).

Hospital stays are long, complications are frequent, and the one thing required above all else in the patient with necrotizing pancreatitis is found in very short supply in our pharmacy: patience. But it is with a hefty dose of patience on the part of the surgeon, patient, and family that we manage to get the majority of these folks back on their feet. And then, it's Hammer time for all!