Thursday, 3 May 2007

Misguided

Today's story is a tale of guidelines and keyholes. This morning I saw a man in his mid-seventies who came to tell me about his recent laparoscopic cholecystectomy. I was relieved to hear that he had finally had the operation as he had suffered several attacks of acute cholecystitis during the three months he was waiting, and we had visited him several times during these attacks. But all had gone smoothly once the big day arrived. He told me that he had been put to sleep at 9.30, had awoken at 10.45 and was given some tea straight away, was dressed by 11.30 and home by 14.30 (though he was advised to go straight to bed). There were just two tiny scars on his abdomen. This contrasts markedly with what happened when I was a surgical houseman when the patient had a huge scar under their right ribs and were kept in hospital for ten days.

There was an unexpected finding when they sent the gall bladder for histology, as it contained an adenocarcinoma. However the cancer was small and appears not to have spread beyond the gall bladder itself. My patient who is rather timorous by nature has determined not to have any further treatment. He has not yet seen the oncologist but this sounds a sensible decision to me.

Later I saw an elderly lady in her early eighties who recently had a laparoscopic sigmoid colectomy. I didn't even know that this operation was possible, and was relieved when she said her surgeon had told her that few other surgeons are doing it. Once again she had made a swift recovery and been sent home. She is due to see the oncologist soon about chemotherapy, but I have not yet received details of the stage her cancer had reached.

But I feel uneasy about the way the diagnosis was made. She came to see me in November saying that she had seen some fresh blood in the bowl just once. Her bowel habit had remained regular, she had not lost any weight and felt well. Examination of her abdomen and rectum had been normal. The guidelines for urgent referral under the two-week wait scheme in patients over 60 are either persistent rectal bleeding or a change of bowel habit lasting longer than six weeks. So I told her to keep an eye on things and return if she continued to have bleeding. She saw my colleague three weeks later and told him that the bleeding had stopped.

She saw me again in January, two months after I had first seen her, and now the history was completely different. The bleeding had continued, her bowel habit had changed from being slightly constipated to frequent urges to go: a feeling of a pressure inside and then an explosion. Moreover she had been feeling weak and lacking energy for some time. A first year medical student would be able to make the diagnosis and I duly referred her to the two-week wait clinic.

In theory I have done things by the book, but of course her prognosis would have been better if I had referred her in November rather than January. I will be more inclined to refer elderly patients after a single rectal bleed in future, although this is not recommended by the guidelines.

Finally, although I was impressed by a local surgeon doing a laparoscopic sigmoid colectomy, I gather that the French have gone one better. Today the French medical press (www.quotimed.com) reports that a surgeon in Strasbourg has just carried out a vaginal cholecystectomy. “Professor Jacques Marescaux, one of the pioneers of endoscopic surgery in France, and his team have carried out a cholecystectomy by the transvaginal route in a young woman of 30. The operation required a flexible operating endoscope 1.5 metres long... The only break in the skin was produced by a 2mm needle to distend the abdominal cavity with carbon dioxide.” It seems that the technique is still experimental - c'est magnifique, mais ce n'est pas (encore) la chirurgie!

6 comments:

skinnyminny8 said...

Interesting post.. who knows, soon enough a future generation of med students will be looking back in horror at the cuts surgeons used to do to get out organs instead of operating through natural orifices.

Hey, does that mean there is an advantage to having a vagina after all?
http://www.kevinmd.com/blog/2007/04/minimally-invasive-surgery-via-vagina.html

Re: cancer.. where is the crystal ball when its needed eh?

I was under the impression lots of Gps overemphasise the severity of symptoms to get a 2 wk referral- doubt that is ethically sound.

Anyway.. aren't guidelines just that.. guidelines.. there to help to guide but not rules.

Its a tough job, but somebody has to do it. I commend you for your work.

Cal said...

Wow! Amazing! I never would have even thought a lap sig chole was possible!

I have to say, I do enjoy seeing lap choles... yeah, they're a bit routine and boring, but still.

A. said...

"a surgeon in Strasbourg has just carried out a vaginal cholecystectomy"
From a patient's point of view, and knowing nothing, why? I was sterilised in my late thirties (longer ago than I care to admit) and the scar is negligible. Indeed the only reason I can find it is that I know where it is. Why go through those contortions to avoid a minimal scar? La beauté avant tout, sans doute.

Ms-Ellisa said...

WOW again... I'm surprised though how they manage not to wound any other parts as they guide the endoscope

Dr Andrew Brown said...

Skinnyminny8: they issued crystal balls to everyone in my year at medical school, but I was away that day.
You're absolutely right that guidelines are not rigid rules. From your comment it sounds as though your consultants feel that GPs over-ride the guidelines too often when making two-week referrals. The trouble is that the guidelines will not pick up early cases.
Thanks for the compliment.

Cal/A/Ms-Ellisa: The advantages of endoscopic vaginal cholecystectomy quoted in the article are: cosmetic, very little post-op pain, easier access in obese patients, no injury to abdominal wall. But there were problems. In particular there was no binocular vision, it was easy for the operating surgeon to lose his sense of orientation, and there was almost no sense of contact with the tissues being operated on.
I can't see it becoming widespread.

A. said...

"it was easy for the operating surgeon to lose his sense of orientation"

I'm biting my tongue ...