Surgery is a specialty that creates a unique bond between the patient and the doctor. The surgeon uses various cutting devices to enter spaces in the body that were not designed to be entered. This opens the door to unforeseen and unexpected results, not always good. Complications are always a risk, and more so with invasive procedures. Such a complication happened to a patient on whom I was removing a colon polyp. These growths usually start off being benign but often become cancerous when they get bigger and therefore are best removed when they are still small. The flexible colonoscope is the instrument used for most such procedures. A thin wire loop ensnares the polyp at its base where it is attached to the colon wall. Using an electric current, it cuts off the polyp. The risk is cutting too deep and making a hole in the colon wall that is only 2-3 mm thick. I have done hundreds of such procedures, and it only happened twice in my career. One I immediately recognized as I could see abdominal organs through the hole. That patient got an operation right away to close the hole. However, another time I was not so fortunate to recognize this complication. As the days went by, stool leaked through the hole and the patient developed peritonitis, an infection within the abdomen that manifests itself with pain and fever. When the patient presented himself at the hospital, I immediately operated. Usually, the only practical solution is to divert the colon and bring it out as a colostomy. That then allows immediate prevention of further leaking. It also allows the abdominal cavity to be washed out of any contamination. Along with antibiotics, peritonitis subsides. Later, the colon can be reconnected. My patient was very ill in the early phases. I kept him in the ICU for over a week. His son was very upset with me. The nurses informed me that the son was waiting to speak with me in the hall. He was a tall and, overall, a big man. He didn’t really want to talk. He tried to threaten me. He pushed me against the wall, lifting my shoes off the floor. “If my father dies, I will kill you!” he said.  I had planned a vacation with my family, which I cancelled to stay with the patient. I also thought, under the circumstances, I should transfer the patient to another surgeon’s care. I spoke with my patient about allowing another surgeon to care for him. His response was that he didn’t want that. He said to me, “You did this, and you will fix it!” I was pleased with his response, but then I brought up his son’s threat. He said, “Don’t pay any attention to him, he’s crazy!” Not much of a reassurance to me, however. But I continued his care. He fully recovered, and I later reversed his colostomy.

A case that still haunts me and gives me nightmares was a young woman who was barrel racing. This is where the arena has two barrels at each end, and the rider and horse race around them, using the barrels as turning points. She fell off the horse and hit the right side of her abdomen on the barrel. She arrived in the ER in deep shock with a distended abdomen full of blood! I took her to the operating room immediately. On opening the abdomen, I was not pleased to see that amount of blood. She had torn her liver off the vena cava, the largest vein in the body, leaving two holes in it where the hepatic veins inserted. Every time I pulled the liver down to see what I could do to control the bleeding, I was met with audible bleeding; you could hear the blood rushing out of the giant vein. I had never encountered this injury before, but I had read a paper that described a way to fix it, written by a UCSF professor of Surgery, Theodore Schrock. I followed his technique for bypassing the torn vena cava by placing a plastic tube from the right atrium into the vena cava below the hepatic vein entry. This injury has a 90% mortality rate. And unfortunately, it claimed this woman’s life as well. The word on the atrio-caval shunt is that more papers have been written about it than there are survivors of the procedure.  To make the incident even more tragic, she was to be married a couple of weeks later. Barrel racing can be fatal!

On a happier note, one very memorable patient came to me with rectal bleeding, a common complaint that she attributed to hemorrhoids for several months, but it was not! It was from the big “C” despite the fact that she was very young. At the time of her surgery, I found that the cancer had already spread to the lymph nodes and the liver. It was only one spot that I could see, and I saw no reason not to remove it along with the cancer in her colon. She had a reasonably quick recovery and underwent prophylactic chemotherapy. It is now several decades later, and we still see her well and very much alive. About a year later, I danced at her wedding. I was seated with a distant relative of hers, a prominent colon surgeon in Santa Barbara who had actually been one of my teachers in my residency. He was not a happy camper because he was not pleased that I did her surgery, as colon surgery was his specialty, but I even assumed the responsibility of removing part of her liver, something that is usually done in tertiary referral centers. But you can’t argue with success!