Thursday, July 5, 2012

Tough Case 1

This post conforms to the blog rules.
I met "Lisa" right before her surgery. She is not much older than I am. She was surrounded by her parents, her sister, and her young husband.

Her physician had seen something suspicious on an ultrasound, and so the procedure she was scheduled for was a "ovarian cystectomy, possible myomectomy, possible RSO." In other words, she could be in for a 45-minute removal of a cyst, a several-hour removal of a fibroid, or the loss of an ovary at a very young age.

In pre-op, the surgeon promised her that "in somebody so young" the ovary would only be taken out if it was absolutely necessary.

Once Lisa was moved to the OR, anesthetized, and prepped, the surgeon asked me to feel her mysterious mass. To my surprise, I could feel it (medical students usually aren't good at that). I didn't feel how large it was, but it was as hard as an uncooked potato.

The procedure began, and once the camera was placed in its trocar, the assistant raised Lisa's uterus and, with it, the mass. It was a fibroid, almost as big as the uterus itself, and attached at the uterotubal junction. The surgeon began making shallow cuts into it, and called for methyline blue, a dye.

A fibroid at the uterotubal junction is very bad news for a young woman. Fibroids are bad enough: they're painful and recur throughout life. But Lisa's fibroid was growing where her fallopian tube met her uterus, so it was possible that that tube was blocked, and very likely that this would be difficult surgery. I pictured her young husband and wondered whether they were planning a family. The surgeon was calling for dye to inject it into Lisa's uterus and see whether the affected tube was patent.

The surgeon kept cutting, and I mentally cried out, "Stop! Wait until the dye arrives."

I didn't speak because of the difference in status and personality between me and the surgeon. By the time the dye arrived, there was a decent-sized cauterized area. The dye entered Lisa's uterus and turned it a bright blue. But dye dribbled out of the cauterized area, indicating that the surgeon had cut into the uterotubal cavity while waiting for the dye. Beyond the fibroid, the affected tube was pink, indicating that it was not receiving any dye (either because it was blocked, or because dye was flowing out of the cauterized area before it reached the ampulla of the tube).

Worse, the opposite tube was likewise pink, indicating that it was also blocked.

Lisa was infertile, unless the diseased tube was still patent at some point along its length and was reattached to the uterus at the open uterotubal junction. This would be a time-consuming and technically demanding procedure. I expected (correctly) that this procedure would not be performed.

Thus, Lisa was infertile. The suddenness of the discovery shocked me. Infertility is something that people usually have time to become aware of. Here, in an instantaneous and unceremonious way (a glance at a picture, an absence of color) Lisa's condition was announced to a roomful of relative strangers. She would probably be the last to know. My heart broke for her and her husband. And I wondered: would the dye result have been different if the surgeon had waited? Did this surgeon just cost Lisa her fertility?

If the tube had never been patent, then there was only the tragic discovery of infertility for this young woman. There was nothing lost by the surgeon's too-early cauterization. Perhaps because of this, the surgeon began to voice aloud what I knew was impossible as she continued to dissect the fibroid away from the uterus. "Strangest anatomy I've ever seen...the tube connected to the fibroid and not to the uterus." Lisa, said the surgeon, was probably born like that. (That is highly unlikely, according to what I know about embryology and fibroids.)

This denial made me more certain, in an irrational way, that this surgeon just lost the patient her only patent tube. Admittedly, there was no clear evidence of destruction of a tube which was patent along its entire length; there was only evidence that the surgeon diminished the validity of the dye study by opening the uterine cavity and making it possible for a patent tube to remain pink even when dye was injected into the uterus.

The fibroid and tube, assumed to be useless, were removed. The ovary (which was to be protected "in a woman so young") stayed behind; nevertheless, it lost its most exalted purpose.

To the surgeon's credit: later in the surgery we spoke more about the patient's anatomy and (after some mention of embryological orgins) the surgeon said that the tube must have emerged from the uterotubal junction and the tube was originally connected. The surgeon told the Lisa's family that the fibroid "dissected the tube away from the uterus" as it grew, an explanation that I think is likely.

If I had been operating, things might have been different. I would have waited to cut so that the dye study could show for certain whether both tubes were blocked. And regardless of the result of the dye studies, I would have attempted to save Lisa's fallopian tube, since tubes can be reopened. Perhaps this surgeon assumed that the tube was blocked and ordered the dye as an insurance policy for the removal of the tube. Or, perhaps the surgeon was not bothered by an inconclusive dye study. Or, perhaps the surgeon didn't see any reason to save a tube for recanalization when the patient would probably just get IVF.

But what if the patient (or her husband) were Catholic? What if they were too poor for IVF?

I left the OR feeling sad for Lisa and her family, and sad for this surgeon.

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