Tuesday, January 29, 2019

The Laparoscopic Cholecystectomy





I had a laparoscopic cholecystectomy done on January 28.  The indication was possible biliary colic and atypical symptoms of gallstone disease and a gallstone and polyp in the gallbladder noted on abdominal ultrasound.  That scan was done to determine a possible cause of 2 years of bloating and tachycardia.  There was no right upper quadrant pain or colic following fatty foods.  The confounder there is that I hardly eat any fatty foods.  All of my dairy products are fat free.  I have not eaten beef in over 30 years and the only time I eat bacon is as a condiment.  I know the cultural swing in medicine is that fat and cholesterol are now supposed to be "good" for you but I don't buy that and the proof is my fasting lipid profile. I also recently learned that two of my cousins had cholecystectomies at a young age for gallbladder disease so there may be a genetic factor.  The diagnosis did take me by surprise and might illustrate the value of retrospective analysis.

When I presented to my internist with symptoms of abdominal bloating and postprandial tachycardia in the absence of any blood test abnormalities it suggested to him that it was more of a dumping syndrome except there were not associated symptoms or diseases. He set up the ultrasound and called me with the results.  Surgical referral was next. The surgeon suggested that while I did not have "classic" symptoms of gallbladder disease that he had seen varied presentations over the years including the symptoms set that I came in with.  He  suggested cholecystectomy as on option but didn't oversell it: "You may find that those symptoms are not changed after the surgery." He did tell me about a patient who did not want the surgery and managed her illness by diet alone for 20 years until the laparoscopic approach was widely applied.  I thought about it for a few minutes and decided to go with it.

Several factors went into my decision.  First, when I was a freshman in college I had severe appendicitis and had a gangrenous appendix excised and a Penrose drain hanging out of my side for a week that drained the residual tarry remnants of my appendix.  It was the only time in my life I thought I might be better off dead.  Friends visiting me at the time thought I was joking.  So my first thought was that I dodged a bullet at age 18 and I did not want to take that chance again. And then there was my medical school experience. One of my first patients on surgery was an 85 year old man with an ED diagnosis of acute cholecystitis.  He died postoperatively and at autopsy no cause of death was determined.  Could I really afford to try to manage this with diet for the rest of my life and take that kind of chance?  The other patient was a 45 year old woman who presented with an acute abdomen.  In those days imaging not widely applied and the clinical examination was the key determinant. My surgical attending at the time found out that I was considering psychiatry and went out of the way to berate me.  He challenged me to tell him the diagnosis on the patient. He was certain it was acute appendicitis.  I went with the odds and said she had acute cholecystitis.  The surgical team dissected out a normal appendix and he said: "Looks like the medical student was right" and proceeded to make another incision and remove the gallbladder.  I put more weight on the imaging, but from my discussion with the surgeon there is still a fair degree of uncertainty. If I am an old man some day with abdominal pain it might be useful to tell the physician: "I don't have an appendix or a gallbladder".

The surgery itself seemed like a breeze.  I had a brief pre-op discussion the surgeon and the anesthesiologist.  My basic concerns were that I do not get any antibiotic or anesthetic agent that interacts with my existing medication - especially the one that affects cardiac conduction.  They assured me that would not be a problem.  I also told the anesthesiologist that I had never been intubated before or had either inhaled anesthetics or neuromuscular blockade.  I had several minor surgeries where the agents used were fentanyl and midazolam and that seemed to work fine.  I also let him know that I have significant arthritis in the neck and he checked it for range of motion.  They gave me the intravenous pre-anesthetic, wheeled me into the OR and I was out before I could remember anything.  Totally unconscious without a single dream.

In the recovery area I was stoned for about 2 hours. I remember the anesthesiologist coming in and asking me if I had shoulder pain.  Sure enough I had significant right should pain. Two milligrams of Dilaudid (hydromorphone) not only cleared that up but it never returned gain.  I had both fentanyl and hydromorphone on board and the nurse kept telling me to "take deep breaths" because my oxygen saturations were dropping.  Eventually I woke up completely, got out of bed and started walking around.  I reflected back on my gangrenous appendix experience.  The day after that surgery, it took two nurses to stand me up next to the bed and then my doctor pushed my chest in order to straighten me up. Every step resulted in severe abdominal pain.  That was not the case with this surgery. I had 4 puncture wounds in my abdominal wall but I did not have peritonitis. I was not only moving with ease, but I could also flex my abdominal muscles to get out of bed.  The discharge pain medication was oxycodone 5 my every 4 hours as needed.  I get headaches and mild nausea from it and stopped it and switched to acetaminophen.

Post op day #1 - I felt progressively worse getting home.  It was a general flu-like syndrome with mild nausea.  Whenever I think about flu-like illness I think cytokines. There has been a lot of work on that specifically to cholecystectomies, but none of it seems very specific.  I was also having difficulty voiding despite having to void as a requirement before being discharged form the hospital.  I did not figure out until the next morning that it was probably all part of the physiological changes that occur with abdominal surgery.  That was the most interesting chapter in my undergrad surgery text.  I also wondered about the oxycodone and the intraoperative cephalospoin (cefazolin) given for antibacterial prophylaxis.  I prefer cephalosporins if I need antibiotics and had a similar reaction to cephalexin. With that flu like syndrome I started to get mild tachycardia and blood pressure elevation that I attributed to anxiety about the flu-like symptoms and continued problems with voiding.  All of my temps were normal.  A final significant symptom was episodes of hiccups, a result of the pneumoperitineum  induced to perform abdominal surgery.

Post op day #2 - The voiding problem cleared entirely.  Negligible pain.  I was contacted in follow up by the hospital. They seemed impressed with the lack of pain, especially shoulder pain and advised me to get active and eat foods that might be beneficial for constipation.  The flu-like syndrome seems to be nearly resolved with the exception of some mild facial flushing. At this point it seems like I am on the way to recovery but will post if anything of further interest develops.

I post this experience here to highlight how individual conscious states impact medical decision making - even surgical procedures.  I encountered a number of physicians in this process but the core physicians were my primary care internist, the physician who did the pre-op assessment, and the surgeon.  My primary care internist has know me for about 30 years. He was highly recommend to me by a psychiatrist who worked in the same clinic.  He performed the most thorough examination and gave me a good differential diagnosis at the beginning before ordering the ultrasound.  He knows me well enough to know that I am neurotic but when I have a problem it is usually significant.  I know that I can expect a very thoughtful analysis of the problems and that he will always call me in follow up. The physician doing the pre-op physical has done two other pre-op physicals on me in the past year. He is also thorough and notes my concerns on the pre-op history and physical - but the problem is that nobody seems to read them after that.  The surgeon in this case did a cursory exam but provided me with key information about what to expect up to and including no resolution of symptoms.  He didn't have to tell me about the bad outcomes - I was almost a bad outcome myself.

Everything I read about evidence-based medicine and the corporate standardization of medicine minimizes all of the subjective elements that I have listed above.  I could have seen different physicians at any step in the above sequence and the outcome may have been different.  I could have been a guy who did not have a near death experience with acute appendicitis.  I could have had an internist who told me to try simethicone for gas and not ordered the ultrasound. There is also a level of uncertainty that a lot of people seem unaware of. It is certainly possible that I would die from something else and the gallbladder finding was totally incidental.  UpToDate suggests that is the course for most incidental gallstones 15-25% become symptomatic in 10-15 years of follow up (1).  But was I already symptomatic? Whether it works for the presenting symptoms is still undecided.

There is always room for personal experience and subjectivity in medicine - on the side of the patient as well as the side of the physician.  People often refer to this as the art of medicine. The only parallel with art is the apparent creativity that occurs when unique conscious states are all focused on trying to solve the same problem. Informed consent is often seen as a medico-legal procedure but it also acknowledges the subjective experience of both people in the room. There are probably multiple paths to address a problem - but the usual debates I see suggest that there is only one right one.


George Dawson, MD, DFAPA


Reference:

1.  Salam F Zakko, MD Section Editor:Sanjiv Chopra, MD Deputy Editor: Shilpa Grover, MD.  Overview of gallstone disease in adults.  UpToDate.  Accessed on January 29, 2019.

Graphics Credit:

The above graphic was downloaded from Shutterstock per their standard agreement.




 

3 comments:

  1. Interesting post, hope things are going smoothly into the weekend now. Was waiting for you to tell us you had to have a psych consult since you work in mental health...

    But, the take home for me, if we have "universal" health care forced on us by the next 4-6 years per the sociopaths masquerading as representatives for the public, will procedures like this be offered in a timely and responsible manner, or, per my belief, force people to wait until they are truly at death's door with complications, and then politicians can decide who lives and dies per access to interventions...

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    1. Thanks - doing OK in that I am pain free but still have the flu like feeling and general malaise. Interestingly that is treated very well by acetaminophen but not at all by oxycodone. I did warn my former colleagues that if they got a consult on an agitated old man claiming he used to work there as a psychiatrist - that it was just me and that I did not need to be on a hold. They all know I am somewhat agitated at baseline.

      On the issue "universal" health care - I think it is doable in that practically all European countries have it. The Swiss and Japanese systems could be implemented at huge savings, the same or more access, and better quality. The "single payer" arguments frequently come down to freedom arguments to those hard core Republicans who think all issues except abortion are about freedom.

      That rhetoric always seems to miss the point to me and that is - health care companies and the government currently run health care and they do a poor job of it. The entire system maximizes clerical work for physicians and keeps us from doing out jobs. It makes medications - even insulin impossible for out patients to afford.

      At some point the Republicans need to recognize that the "free market" they think they are endorsing is really a recipe for the health care monopoly to make trillions and keep all of the physicians in this country under their thumb.

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    2. There is a sensible solution to this since it is a given that we are not going to turn away patients in a crisis if they have no money. A return to some form of lemon socialism that we had in the 1970s.

      Emergency services ought to be on the fire/police model and paid for by Medicare, or preferably a state or local tax system.

      Most maintenance and elective services should be paid by cash or the insurance system, but there should be more competition. One of the problems with ACA is that it created a five way oligopoly with insane volumes of regs that no one has read or understands, except by the cottage industries those regs have spawned.

      EHR and HIPAA need severe deregulation since compliance costs make it impossible for smaller offices and hospitals to compete. FDA approval is way too expensive but on the other hand patents are way to precious. All the intellectual property law related to drugs and devices needs to be updated. An obvious fix that would prevent gouging would be to deregulate manufacturing licenses on off-patent drugs.

      There are a myriad of pragmatic solutions that can never happen under Medicare for all. Besides, we can't afford the Medicare we already have. Doctors will drown in that system since it is a given that we are the weakest and most ineffective actors in our own and patients' best interest.

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