Surgical Surprise

It began in the middle of America when two years ago God told her, let’s pretend her name is Mary, that she must “seek medical care.”  Mary had just finishing packing her groceries into the car when out of nowhere she heard a voice that she recognized as God. The voice told her that she needed medical attention. God didn’t tell her why, but only that she needed it. Mary had faith in her creator, so she moved across the country with her daughter to her sister’s apartment to find the best medicine that she could afford.

Mary saw several doctors, none of whom could find evidence of disease. After exhausting the outpatient circuit, she made regular visits to the Emergency Department near her sister’s apartment, never bringing specific complaints, but more so a general concern that something was wrong. The work-up was consistently negative so she was referred to follow-up with the many local clinics.

When Mary told me her story, I could tell this was an extremely difficult time for her. The expert doctors, whom she respected greatly, did not seem to agree with her God.

That all changed last month when she developed abdominal discomfort. Her friends at the emergency room performed an ultrasound, which was within normal limits, and a subsequent CT scan, which showed an appendiceal mass.

She was referred to the General Surgery clinic where she was further evaluated and scheduled for an appendectomy. The pre/post-operative course was uneventful. The procedure went smoothly and the recovery was steady. Mary believed she had been cured.

I met Mary in the pre-operative holding area for her 2nd surgery. She was back in the hospital because the histopathology from the the appendectomy showed mucinous adenocarcinoma of the appendix. The neoplastic mass was greater than 2cm, an indication for right hemicolectomy.

Mary told me her story between IV placement, blood draws, a physical exam, and the ritual informed consent. It didn’t matter to her the reason for surgery or the possible risks. She sang, quite beautifully, about being in her Lord’s hands, so all was well from her perspective.

We took a laparoscopic approach to the hemicolectomy. A 12-mm blunt Hasson trocar was inserted through the umbilicus and two additional trocars were placed: one superiorly and one inferiorly. Once we were able to visualize the abdominal cavity with full attention, we realized something was wrong. There were mucinous implants littered throughout the abdomen.

The surgeons and residents were talking across the operating table about these implants until I interrupted and asked, “What’s an implant?” One of them told me they were cancerous growths that had sprouted from the original tumor. Some were tiny and others were large like the one shown to the left. When the implants invade the abdomen like in our patient, the condition is called Pseudomyxoma Peritonei. 

When this happens, surgery is no longer sufficient. It needs to be paired with chemotherapy called Hyperthermic Intraperitoneal Chemotherapy (HIPEC).  First the chemotherapeutic agents are heated to above body temperature, then the surgical team physically rocks the patient back and forth on the operating table for 90-120 minutes making sure all of the abdominal contents are coated in the chemotherapy. Patients who receive this treatment are generally very sick, and rely on a feeding tube or IV nutrition for approximately 2 weeks until the gut recovers from the treatment.

Mary was never consented for HIPEC, only a hemicolectomy, so nothing more could be done for her in the operating room. The chief surgeon made the executive decision to collect biopsies, snap a few photos, and close the abdomen.

Mary woke up 15 minutes later lethargic and disoriented, like all post-operative patients. Hours later she had returned to her cheery, faithful self. The chief resident and a fellow medical student explained to her that we found cancer beyond the intestines and needed to discuss a new therapeutic strategy.

But this was no concern for her, she just sang a song about her Lord, and told us, “Do what needs to be done, He will take care of the rest.”