Infra-popliteal bypass – longest case by far

Below is a short and sweet version of the longest surgical case thus far in my short and sweet medical career:

Patient is a 47 years old Caucasian male with IDDM, past stroke, past DVT, PVD, and HTN. He has a dry gangrenous ulcer in the plantar aspect of his right first metatarsal, and occlusion of anterior tibial artery. He is scheduled to undergo femoral to peroneal artery bypass with great saphenous vein.

Image result for popliteal to peroneal bypass

Common femoral artery cut down was performed first for pre-op angiogram; this was partially due to the uncertainty of where exactly the occlusion is and patient’s vascular anatomy. We saw completely occlusion of the anterior tibial artery and distal portion of the posterior tibial artery after the takeoff of peroneal artery. The popliteal artery and peroneal artery were patent. Next, the deep compartment of the mid calf was dissected from the medial leg to skeletonize the peroneal artery. We also skeletonized the popliteal artery because we decided convert the procedure to popliteal to peroneal bypass. Afterwards, we proceeded to looko for the GSV in the medial malleolus, but the vein was too small (lower threshold is 3mm in diameter, but ours was much less). Therefore, we retrieved the GSV from up to, following the sephaneous-femoral-junction. Finally, we heparinized, dilated and anastomosed the venous conduit. Due to the difficult, delicate dissection of the deep compartment of the leg, difficulty exposing the GSV, the changing of procedural planning intra-op, and not having the imaging study pre-op made the whole case around 10 hours. Luckily, the goal of re-perfusing the foot as accomplished, with biphasic pulse on doppler post-op.

The take away from this case is for me is the importance of being prepared before diving in. The fascinating part about vascular surgery for me is the options of choosing your strategies for the battle – like a tactician – may it be open, endovascular, medical, or expectant management. The choices branch out further with each category of treatment. However, in this case since we didn’t have a strong plan going in, we were not able to change our plan smoothly on the fly. The result? 10 hours of anesthesia for patient instead of 6. On a good note, there were lots of dissections and anatomy structures that I learned, rather serendipitously I would say though…

Finally, I learned the luxury of having a stool in a marathon case.

Looking for the Zebras

When I started third year of medical school, I was a zebra whisperer. I think it’s the result of studying so much for Step 1, and reading First Aid trying to memorize the rare diseases. Oh, she has slightly low platelet count and elevated creatinine, we must think about TTP. When in fact AKI was enough to explain her clinical presentation. However, this mentality of painstakingly turning over every stone has helped me in one very memorable instance…

A zebra ^_^

A manic patient from the psych floor in her 40s was transferred to my inpatient internal med unit when I was doing medicine rotation. She (fortuitously you may say) fell on my lap as one of 4 patients I am responsible of following. She experienced syncope and was found to have bradycardia thereafter. She also complained of persistent pain in her left foot. Her HR was normalized by atropine and bedrest, but her foot pain was unabated. My team thought she was malingering because the beds in the psych wards were infamously uncomfortable, but I was unconvinced. I performed the Ottawa Foot rule on her and she was positive at two spots and in addition she was unable to bear weight. I asked for a foot Xray and it was granted. To my dismay, it came back negative. Still skeptical, I meticulously looked at the images myself. I was able to locate a cortical discontinuity on head of first metatarsal on the oblique view. I ran it down to the radiologist’s office for a curbside consult (my favorite type of consult), and he blamed this oversight on his wife’s mistake of making decaf that morning. A noncontrast CT revealed nondisplaced fracture on the first, second and third metatarsal head, and ortho came back and put her in a walking boot the next day.

To the exhilaration of my team, they put this encounter in my final evaluation at the end of my clerkship. Frankly, it was just the way she grimaced and flinched in pain that made me go above and beyond to find the cause. You may say what’s most common is a simple sprain or malingering, but I didn’t want to stop there given how she presented to me. I also think in this case being a psych patient did not help her problem. It’s definitely ideal keep the prejudice out of patient care, and base decision on clinical presentation and patient’s well-being. I am getting better at focusing what’s common these days, but still keeping the zebras in a glass cage so it can be viewed when needed.

Radical Approach and Surgical Menopause – What’s Best for the Patient?

I met a patient during GYN surgery rotation, a 33 years old with stage 4 endometriosis. I watched and assisted her trans-abdominal hysterectomy, bilateral salpingoophorectomy, adhesion lysis and intra-op bilateral ureteral stenting. She had chronic pelvic pain and menorrhagia for years that were refractory to many conservative management such as OCP, progesterone depot shot and D+C. Patient experienced prolonged ileus post-op so she has been a hot topic during our discussion in sign-out (not that she needed it).

Sketch of Radical Abdominal Hysterectomy

Several points about her management were discussed. First and foremost, was trans-abdominal approach the best or could it have been done less invasively via robot. The surgeons who performed her case were concerned about the overabundance of adhesion bands and the extensive resection that was needed, so the invasive approach was chosen. However, a consultant physician who specialize in minimal invasive GYN surgery advocated for the robotic approach when we discussed her post-op status in sign-out. I think there is also a third option of doing a robotic assisted exploratory laparoscopy first, and back out when the adhesions, anatomical distortion, etc pose too much of an obstacle. Of course, you have to be absolutely frank with the patient before the procedure, but this would grant us an opportunity for attempt a much less invasive route with less chance of intra- and post-op complications.

The second dilemma was whether oophorectomy was needed for this 33 years young female. We all know the pathogenesis of endometriosis is estrogen driven, but was removal of both ovaries, creating a surgical menopause, and having the patient be on hormone replacement therapy for 10+ years indicated? From what I found, patient was tired of her dysmenorrhea and had no wish for future childbearing, but I did not think she had a full grasp of predicament of menopause at 33 years old and long duration of hormonal therapy when I talked to her before and after the surgery. Besides, the clinical presentation of endometriosis has absolutely no correlation with severity of lesions grossly (especially when we did not find any ovarian cyst), and less radical approach might have resulted in similar clinical outcome.

I believe I can extrapolate the ethical dilemmas encountered in this case and broaden them to all areas of medicine. It is paramount to go over all treatment options with a patient before reaching a decision. It is also necessary to work towards a goal of patient’s best interest. In this case, perhaps more exploration of treatment alternatives would have changed the course, and perhaps a thorough education about the gravity of early surgical menopause and long term hormonal replacement therapy would have changed her mind and management. I also wonder if more extensive discussion and collaboration among the surgeons would have changed the course of treatment for this woman.