Tuesday, August 31, 2010

Prostate Snatchers?

Interesting article in NY Times today from Dana Jennings reviewing a book called "Invasion of the Prostate Snatchers". (Yeah, that's really the title---I suspect publishers nowadays are contractually obligated to come up with the most outrageously sensationalistic titles possible prior to shipping them off to Borders.) Jennings is a prostate cancer survivor who underwent a radical prostatectomy. His particular tumor was a highly aggressive variant. Surgery probably added years to his life. But according to a recent NEJM study, only 1 out of 48 patients with early prostate cancer who undergo a prostatectomy realize any survival benefit compared to non-operative treatment.

Here's a line that jumped off the page at me:
“Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”

That quite an astounding proclamation. 80% of the prostatectomies done in this country are arguably unnecessary? Whatever are we going to do with the million dollar DaVinci robotic machines that every private hospital is clamoring to buy and market?

Admittedly, I'm a no expert in prostate cancer. I'd love to hear a rebuttal from any urologists and medical oncologists out there.

Here's a nice review on early stage prostate cancer from the NCI. It seems that men with prostate cancer younger than 65 years old probably benefit from a more aggressive surgical approach. The older patients don't see a statistically significant benefit from radical prostatectomy.

It's never easy....

The life of a general surgeon is one fraught with contingency, soul-crushing doubt, unexpected disaster, and overwhelming stress. I wouldn't wish it upon my worst enemy. Fortunately, I was brainwashed to a sufficient degree during residency such that I actually don't mind my job.

One of the reasons general surgery is so tough is that it is nearly impossible to map out your week according to a strict schedule. Maybe at some point in a career, when you're the established, Big Kahuna of the group, you can load up your work week with elective breast biopsies, hernia repairs and lap choles and leave the middle of the night disasters for your more junior partners. In general, however, most surgeons never reach this stage of "easy livin'". It's a lifetime of inconvenience and last minute alterations and ulcer inducing pressure. If you're worth anything as a surgeon, you figure out a way to make things work.

Beyond the scheduling squeeze, the actual business of doing surgery can get to be pretty nerve wracking, no matter how routine the procedure. Anatomic variants, sick patients, hostile abdomens, and the inexorably crushing statistical likelihood of complications (no matter how careful you are) all contribute to the inordinately tight sphincters of surgeons even during the seemingly routine elective gallbladder or breast biopsy.

A few weeks ago I had one of those cases that take a few years off your life. An older thin lady visiting from New Mexico presented to the ER with a partial large bowel obstruction. Her ileocecal valve was incompetent so we were able to decompress her with an NG and prep for colonoscopy. The scope showed a partially obstructing lesion in the hepatic flexure of the colon. She had had a Whipple procedure back in the 80's for benign disease so I planned to do a standard open right hemicolectomy.

The surgery went beautifully. She was one of those thin old ladies with very little intra-abdominal fat. Even her mesentery was an ochre yellow sheet of semi-translucent tissue, like a smudged window in the attic. You could see everything. The case took 45 minutes. The ileocolic anastomosis looked perfect. She then did well for the first three days. On the fourth morning, she looked like hell. She was diffusely tender and had developed an elevated white blood cell count. I'm thinking worst case scenarios----anastomotic leak, inadvertent bowel injury, ureteral transection, etc. So I take her back to the OR and encounter something entirely unexpected: 25 inches of dead distal small bowel. I resect frankly gangrenous bowel and start to investigate. First thing I notice is a lack of pulsatile flow in the area where one would normally be able to palpate the superior mesenteric artery (SMA). Then, as I start to mobilize the left colon for either a new anastomosis or a stoma, I discover a rope-like, pounding arterial branch in the sigmoid mesentery, arising from the IMA. I follow it to the transverse colonic mesentery. I think I know what's going on, but I scrub out at this point and open up the CAT scan on the OR computer and get on the phone with the radiologist. I always get a pre-op CT scan of the abdomen on patients with colon cancer. I ask the radiologist to reconstruct the images in a coronal fashion. He calls back in five minutes and confirms my worst fears.

The lady suffered from severe mesenteric arteriosclerosis. We depend on three main arteries to feed the bowels; the celiac, SMA, and IMA. Her celiac artery and SMA were both occluded by thrombus. Her IMA was open and there was a giant meandering mesenteric artery that had developed over the years to compensate for her lack of flow through the other main trunks. So when I performed an oncologic resection of her right colon cancer, I basically transected that lifeline of blood coming over from her IMA to feed her small bowel. When I scrubbed back in, her remaining intestine was starting to look worse. She didn't have a lot of time. She was about to infarct her entire intestinal tract.

While I waited for the vascular surgeon to arrive, I dissected out the SMA origin and harvested some saphenous vein. Then we revascularized the SMA via a saphenous graft coming off the IMA. The next day, her stoma looked awful and I took her back for a second look. I resected another 6 feet of small bowel. The graft had clotted on the SMA side so I did a quick throbectomy to re-establish flow. I heparinized her and said a little prayer. The graft stayed open. She ended up leaving the hospital. Her life will never be normal again. She will suffer from short bowel syndrome and severe fluid/electrolyte disturbances from the high output stoma. The graft could shut down again anytime. But she made it through this battle. I'll take it.

We wade into shark infested waters every time we press scalpel into flesh. Your eyes better be wide open and your head on a swivel. There's no such thing as routine in general surgery. If you have masochistic tendencies, then by all means come join our club. Otherwise you might be better off in dermatology.

Wednesday, August 18, 2010

First, Do Nothing

(From the New York Times)

The New England Journal Of Medicine has published an astounding randomized controlled trial this month. 151 patients with metastatic, terminal non-small cell lung cancer were randomized to either receiving experimental chemotherapy alone versus chemotherapy plus palliative care. The group introduced to a palliative care specialist early in the diagnosis experienced a higher overall quality of life as the clock ran down. This part of the study shouldn't be surprising. The benefits of early involvement of an end of life specialist have been known for a while. Patients get better pain control, feel more in control of their lives as the disease unfolds, and are able to address end of life issues more honestly and openly with a professional. The psychological and emotional benefits are simply incalcuable.

The surprising part of the study was that the patients in the chemo/palliative care group lived an average of3 months longer than the chemo alone group. This, despite the fact that the patients in the palliative care group often decided to forgo additional aggressive treaments as they deteriorated.

What does this mean? Can we attribute the small, but significant, benefit simply to the effectiveness of palliative care? Or can we extrapolate further? What if patients who deferred chemotherapy altogether or only underwent an abbreviated course of treament had a survival advantage? Wouldn't it be reasonable to conclude that the chemotherapy itself was the determining variable?

Let's be honest. The literature on salvage chemotherapy in stage IV cancers is pretty weak. Survival "benefits" are quoted in terms of weeks or months. This stuff is basically poison blasted into your veins, in the hope that maybe, possibly, hopefully you will live a couple months longer than the guy who buys a ticket to Costa Rica and sits on a beach drinking Pina Coladas until he dies.

I've always been uncomfortable with the entire rationale behind "medical oncology" in stage IV, terminal disease. Many of these guys are peddling pipedreams and exploiting a very vulnerable patient population for financial and academic gain. It's good to see an RCT paper like this one to help tilt the perception back toward a "less is more" mentality.

Tuesday, August 17, 2010

My Continued Anti-Percutaneous Drain Crusade in Appendicitis

A young kid comes into the ER with 36 hours of RLQ abdominal pain. The ER scans him. The scan shows an obvious 4cm abscess next to the appendix. What do you do?


Please. Just take the kid to the OR. Use your laparoscopic suction/irrigator to wash out the abscess. Remove the appendix. Leave a JP drain if you must. The kid goes home in 1-3 days. No more sitting in the hospital for a week with a foul smelling rubber tube hanging out his side. No more prolonged courses of expensive IV antibiotics. No more interval appendectomies. These patients don't need multi-staged management strategies with multiple invasive procedures. Just operate and be done with it.

Saturday, August 14, 2010

Between Cases

Nothing more awesome than spending a Saturday night waiting in the office for the OR room to turnover so you can start the second of three cases. It's hard to do anything real productive (like dictate charts or write a serious blog post) so I tend to screw around on YouTube. Here's Chet Baker tearing things up.

Thursday, August 12, 2010

Horseshoe Abscess

These cases are sometimes a little tricky. The patient had been suffering from severe butt pain for over a week. He couldn't even sit upright in a chair. He was feverish and had an elevated WBC count upon arrival in the ER. But on exam, you couldn't actually see any of the typical findings of perianal sepsis---no erythema, induration, or fluctuance. But it hurt him like hell when you tried to do a rectal exam. So we got the pelvic scan as seen above to help clarify the diagnosis.

What you see is a circumferential abscess/phlegmon, ringing the low rectum. You can't just lance these things at bedside like you can most abscesses. So I took him to the OR and made a couple of counter incisions to help effectuate complete drainage of the deeper pelvic sepsis. Then I like to leave a Penrose drain in situ, connecting the two incisions. It comes out in the office usually in a week.

Surgical Warranties

The mathematics and specific details of this article from Archives elude me to a certain (substantial) extent, but the main gist of it is this:
Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.

What that means, I think, is that those providers and hospitals that perform colon surgery with a lower overall incidence of complications set the bar in terms of bundled payment reimbursements. Those hospitals with higher complication rates, and therefore accrue higher costs, will find that much of the cost of this additional care and treatment will go un-reimbursed; thereby financially incentivizing them to either do a better job taking out colons or to get out of the colectomy business altogether.

I don't have much of a problem with this, to the exent that it is implemented fairly. A small hospital that recruits a colorectal surgeon isn't going to have the numbers to compete with the big tertiary care centers. As a result, complications that occur in the initial couple of years are going to statistically stand out as blaring clarion calls to cut reimbursements to that small hospital.

And the giant referral centers, teeming with surgical subspecialists clamoring for every square inch of operable human flesh will like that just fine.

Wednesday, August 11, 2010

Who Are the Torture Doctors?

JAMA this month has commentary piece on the ethical failure of physicians in the CIA Office of Medical Services (OMS) who helped organize, calibrate, and supervise the torture of unarmed, often innocent prisoners at Guantanamo. The principle of "do no harm" was abrogated by these lackey yahoos as they provided a professional cover to acts universally condemned throughout modern history as torture by all civilized nations.

My question is: Who are these doctors? What are their names? Are any of them practicing medicine in our country? When is anyone going to be held accountable for the despicable, embarassing, morally devastating era of American torture?

The American Psychological Association has already mounted an attempt to strip the license of a Texas pyschologist who participated in the "enhanced interrogation" of Abu Zubaydah:
If any psychologist who was a member of the APA were found to have committed the acts alleged against Mitchell, "he or she would be expelled from the APA membership," according to the letter, a copy of which was obtained by The Associated Press. APA spokeswoman Rhea Farberman confirmed its contents.

We know that Captain John Edmondson, the former Commander of the Gitmo Naval Hospital, is on record as admitting that he countenanced the forced feeding of inmates on hunger strike (an ethical lapse condemned by 262 signatories to a letter to the editor in Lancet).

What else can Captain Edmondson admit to? Is he practicing emergency medicine now as a civilian? How many of the other doctors at Gitmo are now enjoying lucrative private practice careers? Have they all done as well as former Navy Surgeon General Donald Arthur (who now commands a salary north of $400,000 working as the chief medical officer for MainLine health)?

Doctors or Technicians?

Interesting article recently from Health Affairs (via WSJ blog) about the clinical equivalence between the care provided by anesthesiologists and CRNAs. The article concludes by advocating that CRNAs be given permission to practice anethesiology without physician supervision. It's more cost effective. And there is no compromise to the quality of care delivered to patients.
We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.

A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by "friends and family and hired sycophants of Dr. Parks"). Also, the study admits that CRNA's tend to work on less complex cases than MD anesthesiologists.

The main thrust of papers like this is to delve into the essence of what it means to be a "doctor". Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialities according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?

In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that's all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?

The bottom line is, most of the time you don't need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.

The Increasingly Unacceptable Negative Appendectomy

When I was a medical student (really, not that long ago), we were taught on our surgical rotations that one can expect to take out a significant number of normal appendixes during a career. Specifically, a 15-20% negative appendectomy rate was considered appropriate, if not the standard of care. The rationale went like this: you don't want to miss appendicitis, delayed diagnosis leads to complicated outcomes, therefore, it's worth the morbidity of an operation to remove a few normal worms along the way.

This dogma dominated surgical thought right up until the Era of the Ubiquitous CT Scan came into being. Today's scanners are quick and highly sensitive for intra-abdominal pathology. An inflamed appendix rarely eludes its watchful eye. As a result, given the highly litigious environment of 21st century medicine, it's rare for a patient presenting to an ER with belly pain to go home without a scan. Personally, I like the CT scan, even in the so-called no-brainer cases (20 year old male with focal RLQ abdominal pain). For one thing, it helps me plan the surgery better--- is there an abscess in the pelvis needing drained, is it retrocecal, should I place my ports in a certain configuration, etc. For another, I'm a self-described ace when it comes to reading a scan for appendicitis. If I don't see the hallmarks of appendicitis while scrolling through the images, then I'm pretty hesitant to rush the patient to the OR. Finally, I just hate the concept of doing a surgery for no reason. Taking out a normal appendix is a highly unsatisfying endeavor. The only two truly negative appendectomies I've done in my career so far were on pregnant patients who chose not to undergo pre-operative CT scanning but had suggestive clinical histories.

It's funny, in the recent past, a surgeon with such a low negative appendectomy rate would raise suspicions from his local QA committee. It suggested that he/she was "not being aggressive enough" in treating ER patients in abdominal pain. The tide has turned however. A recent article from Radiology demonstrates a decrease in negative appies from 23% to 1.7% over the past 18 years, again directly attributable to the old CT scan. Also, from Surgery, a group at a New York hospital describes a decrease in negative appendectomy rates to around 5%. And that sounds about right to me.

Nowadays, a surgeon who regularly takes out normal appendices is going to come under fire. On one of my QA committees, we "keep an eye on" surgeons who have negative appy rates over 15%. With modern CT scanners, it's hard to justify the old dogma. Of course, someone will probably write up some groundbreaking finding about how all these CT scans lead irrevocably to a higher incidence of cancer---- which will reverse the tide again and we'll be once more teaching residents the value of "laying on of hands" and clinical judgement.