Indexing Title:

DCHUA’s Medical Anecdotal Report [05-3]

 MAR Title:

Pandora’s abdominal cavity

 Date of Medical Observation: March 31, 2005

 Narration:

 I was called upon during one of my regular hospital duties to check out the innards of a 58 year-old patient being operated on by a group of gynecologists.  They had sought to remove an infected tumor from the reproductive tract.  What they found was a one centimeter cyst that could not explain the patient’s severe right lower abdominal pain, nor her massive weight loss during the previous couple of months.  They cleaned out the outdated reproductive tract anyway and then sought a surgeon to examine the rest of the abdomen.

 I started reviewing the chart to get an inkling of what sort of chocolate I would be fishing out of the box in front of me.  The data suggested a pelvic inflammatory disease process in spite of the fact that the patient had been menopausal and had had her last coitus over ten years ago.  It seemed that the patient had also been referred to a fellow surgeon during her previous admission.  She had no symptoms of gastrointestinal obstruction, urinary tract infection, or tuberculosis.  I was interrupted a few times during my chart review by the gynecologists and anesthesiologists who thought it best I skip the part and just dive in.

 On exploration, I noted that the beginning of the large intestine was indurated and adherent to some adjacent structures.  The terminal small intestine was not as involved and there were no peritoneal seedings that would suggest a tuberculous process.  Neither the liver nor the para-aortic lymph nodes seemed involved by any metastasizing malignant process.  The previously removed uterus and ovaries did not show any signs of inflammation that could have involved the adjacent bowels.

 I called upon the patient’s relatives and presented them with the options- remove the lesion which was probably cancer, or close the patient, do an endoscopy with biopsy later, and either reopen the patient or avoid another operation if the mass turned out to be due to TB.  I also sought out the advice of the Department Vice-Chair for Patient Services, with the consultant of the day being out of reach by phone.  He advised resection and the relatives consented after I explained the matter.

A member of the surgical team who saw the patient previously answered my call and agreed to help me do the task at hand.  We noted that the right colon was adherent to the left and had another round of discussions with our consultant and the patient’s relatives.  We decided on removing practically the entire large intestine, an extent my assist had not heard of being done during his tenure in our hospital.  Removing the lesion en bloc with adjacent involved structures would give our patient the best chance for cure.  One of my first colectomies and it had to be unusual.

 The procedure took quite some time to finish.  The lumen of the affected intestine was over ninety-five percent obliterated by the tumor, explaining the patient’s symptoms.  The mucosa of the adjacent colon was grossly uninvolved by the malignancy.  A colostomy was suggested but we decided it best to reconstruct the patient’s gastrointestinal tract in a single operation.

 I let the patient start on liquids the next day so that she could take in medications that would lessen the expected diarrhea together with controlling the post-operative pain.  The adaptive response of lessening the frequency of bowel movements was unexpectedly quick.  She went home after a week with just two bathroom visits a day.  She is scheduled to follow up the histopathological report soon so that we could start the needed chemotherapy.  There is still a hope for cure.