Ash the Rad

Fellow student, demonstrating both professionalism and honesty

A good chunk of teaching during clinical years happens on the ward & off the hoof. I often found myself just nodding along blissfully while it’s happening. Recall percentage maybe an hour later? Quite low… 

So I carry a small notebook & pen around with me most of the time. I jot down important teaching bullets, but a lot of my notes are reminder-to-selfs to look things up later that have been mentioned on the fly. I think it’s way easier than trying to furiously scribble down everything happening on a busy ward. I keep a to-do list on post-it notes stuck to the inside cover, which is handy. 

Simply:

Write down the few key things your consultant has told you

Pop a to-do on your post-it to look it up at home. I also put any assignments/deadlines there as well.

Once home, review your day’s notes. Mine usually look a senseless mess. 

RN: why can’t they just take his (pt with recurrent pancreatitis whose pancreas is basically dead at this point) pancreas out? Me: Honestly, I don’t know. I know it’s an evil organ, and the third rule of surgery is not to fuck with it. But I’m not a surgeon.

tl;dr: the juice is usually not worth the squeeze.

to a surgeon, it’s less about being able to survive without a pancreas and more about the operation itself, and the relatively high complication rates.

think about the anatomy and the physiology. the pancreas sits in the retroperitoneum, so even just to get to it isn’t exactly a walk in the park. you have to make a monster chevron incision, get mr. colon out of the way, get all the small bowel out of the way, get into the lesser sac, kocherize the duodenum… and who else important lives in the neighborhood? mr. IVC with his super thin walls, sir portal vein, the biliary tree… best case scenario, you don’t have any aberrant anatomy, but think about the most common hepatic arterial variant (absite question!) - the replaced right hepatic artery, which has a quoted prevalence of up to 20%. that’s 1 in 5, which is huge!

so if you’re lucky and you get to the pancreas, now what? let’s say you’re doing a whipple for a pancreatic head mass. the head and neck of the pancreas are something they don’t really emphasize in the books: cancer causes inflammation. inflammation makes everything stick to each other. even if there’s technically a plane, it’s often hella tough to dissect it out without hurting something. and what about the pancreas itself? think about what it does. yes, it has an endocrine and exocrine function and all that, but what does that MEAN when you’re staring it in the face? it’s a bag of enzymes. and those enzymes’ job is to stay inside the ducts and go into the duodenum when called. and when you make holes in the bag, even microscopic holes that you can’t see with your eyes in the operating room, those enzymes leak out into the peritoneum and eat up everything they touch. (why is that bad? again, think about our vessel friends in the neighborhood - their walls have no defense against a persistent duct leak. and this isn’t something that happens in the OR. this happens to the patient after the incision is closed and they’ve recovered and they’re at home with a clinically silent leak and then all of a sudden they’re hypotensive, in shock, because the splenic artery was eroded through by the enzymes that were just doing their job). 

and, even if you’re nowhere near the business end at the pancreatic head, operating on the tail is not so simple either. because who is the tail intimately involved with? mr. spleen. and mr. spleen doesn’t like to be touched. mr. spleen bleeds if you just look at him. 

going back to the whipple - even if you manage to avoid disaster in the OR, you still have to reconnect all the plumbing. you have to make 3 anastomoses. why don’t surgeons sleep at night? because they’re worried about anastomotic leaks. even with 1 anastomosis. here you have THREE: PJ, HJ, and GJ. (pancreatico-jej, hepatico-jej, gastro-jej) that’s 3 times as many chances to leak. 

if you ever see a patient with a bad persistent pancreatic duct leak, you’ll never want to touch a pancreas again. they can’t eat by mouth (they have to be tube-fed distal to the leak, otherwise the leak gets worse). they get collections that, at best, have to be drained by IR (at worst, they have to go back to the OR). they lose weight and have all the other problems that go along with malnutrition, like immunocompromise and vitamin deficiencies and all that. it is horrible. and the tragedy is, the only thing more horrible than that, arguably, is dying from pancreatic cancer, which is why you take that risk, and if you’re a good doctor, you have a long conversation with the patient and their family BEFORE the operation about realistically what might happen, because if you’re lucky you’ll be seeing them for a long time after.

on a philosophical level, it is just not a super satisfying operation, in my opinion. kind of like transplant. when you win, you win big, but those wins are so infrequent, and more often, you do your best and the patient still has problems.

it’s the same reason why you transplant a kidney into the right lower quadrant of the abdomen and not in the retroperitoneum where it “belongs”, and you leave the dead kidney in the retroperitoneum. the dead kidney’s not hurting anyone, and to take it out could create a world of hurt. (basically, the retroperitoneum is a bad neighborhood. just don’t go there, unless you have to! at least for general surgeons. urologists may be more comfortable back there.)

it’s also the same reason why we don’t take out appendixes willy-nilly on everyone. even though the operation itself is relatively low risk. just because you CAN, doesn’t mean you SHOULD!

There is an awkward pause as her student stares back at her. “No” he agrees, “this isn’t rocket science. That I can do. This is some sadistic step designed specifically to torture rocket scientists.”