Thursday, January 17, 2008

Double, "Bubble," Toil and Trouble

Double, double, toil and trouble; Fire burn, and cauldron bubble

I'll let you in on a little secret --- surgeons like to operate. I know that may not come as a great surprise, but when you stop and think about it ("Hmm, there are people out there who like to open other people up and fix what's inside"), it sounds a bit odd. And for some of you, what may be even more strange is that there are some operations that are generally kind of fun to do. One of those is a pancreatic cystgastrostomy.

Time out --- what the H E double hockey sticks is a pancreatic cystgastrostomy? Simply put, it's draining a fluid collection into the GI tract.

Okey dokey, now that's clear, why would there actually be fluid around the pancreas? The short answer is pancreatitis. The long answer is pancreatitis severe enough to cause a fair amount of tissue damage. As this resolves, a fluid collection in the surrounding area can form into a pseudocyst --- "pseudo" in the sense that because it is not a true cyst with a cyst lining, the walls of the cyst are formed by the inflammation and scarring in the surrounding tissues that result from pancreatitis. Because the pancreas lies behind the stomach, patients will have symptoms of extreme fullness when they try to eat. These things can become fairly large, tracking down the retroperitoneum, and occasionally get infected or can even be associated with significant hemorrhage. When large enough, they need to be drained --- and an elegant, simple method of draining them is into the GI tract, usually into the stomach with a cystgastrostomy.

This is a very satisfying operation, usually not very complicated, and usually not very time consuming --- and it can be described as a "double bubble," with one cavity being opened into another one. The front wall of the stomach is opened, exposing the posterior wall and the accompanying bulge of the pseudocyst behind it. It's not rocket science from here ---- the posterior stomach wall and wall of the cyst are opened, allowing the fluid to drain directly into the stomach and downstream. The only key to the operation is making sure that the two walls are sutured together to prevent bleeding.

I do not tend to see a large number of patients needing this procedure --- in fact, probably only a handful in the past dozen years --- so I have not had the opportunity to do this surgery with a minimally invasive approach. Basically, there is nothing about this procedure that precludes a laparoscopic approach, which minimizes discomfort and decreases recovery time.

So, getting back to our not so obscure literary reference, the three witches in Shakespeare's Macbeth (Act 4, Scene 1) chant the lines
Double, double, toil and trouble;
Fire burn, and cauldron bubble
as Macbeth approaches. In response to his questions, they conjure up three spirits with three warnings and prophecies, which tell him to "beware Macduff," that "none of woman born shall harm Macbeth," and that he will "never vanquish'd be until Great Birnam Wood to High Dunsinane Hill shall come against him." Assuming his safety based upon these prophecies, Macbeth has everyone in Macduff's castle put to death.

Ooops. Things didn't quite turn out for the young prince of Denmark.

Well, we can say that the three witches here are gallstones, alcohol, and more alcohol --- the three biggest causes of pancreatitis, which causes the "fire to burn" in the abdomen, and sometimes generates a pseudocyst -- the "cauldron bubble," so to speak, producing a "double bubble." The three prophecies that ensue would then be:
  • beware the damage that has been done --- pancreatitis can be a destructive force in the abdomen that rages for quite a while. Or, to quote Lady Macbeth, "What's done is done."
  • none of woman born can make it go away --- unless that child carries a sharp knife
  • the disease once vanquished can come against you once again --- for the patient afflicted with alcohol-induced pancreatitis, it's time to empty the tequila bottles or get ready to see the inside of the operating room again.......sort of like the mistake that Macbeth made
If the result of the "witches' brew" of acute pancreatitis is only a pseudocyst, instead of an all out destructive assault on the abdomen requiring pancreatic necrosectomy, the patient and surgeon should be very, very thankful. And not just because it's a fun operation.