The Gory Details From My Operative & Pathology Reports

[tex]

Hi All,

As I mentioned in another post, I picked up a copy of my operative report, and my pathology report, from my GP yesterday, and I found the operative report, especially, to be rather interesting reading. For one thing, I had a hernia, around my existing colostomy, that I wasn't even aware of.

The most troubling part, though, is the description of all the work that went into freeing my small intestine from all the adhesions. They barely got inside, when they noted this:

Immediately upon entering the subfascial plane, small bowel was encountered, which was densely adherent to the undersurface of the linea alba. The bowel was quite friable, and simple traction on the intestine resulted in a full-thickness tear of an isolated segment of the ileum which was repaired transversely using an inner row of continuous3-0 chromic catgut and an outer row of interrupted Lembert stitches of 3-0 silk.

It got worse:

Some 2-1/2 to 3 hours was then consumed carefully mobilizing the entire length of small intestine from the ligament of Treitz down to the ileocecal vlve. Several small, superficial, serosal tears were made with traction on this patient's friable intestines, and these were repaired using interrupted sutures of 3-0 silk.

The ligament of Treitz is located just below the stomach, (IOW, it attaches the duodenum to the diaphram), and the ileocecal valve, of course, is located between the small intestine and the colon, and it prevents the contents of the colon, (including colonic bacteria), from backing up into the ileum. The serosa is the outer layer of the intestine. IOW, separating my small intestine from all the adhesions, resulted in a number of tears, that required a bunch of tedious repair work. (I'm amazed that I didn't have any leaks). Apparently, all this time, my colon continued to bleed:

As the dissection carried out to mobilize the small bowel, it was apparent that bleeding into the colon proper was continuing although no point source or obvious pathologic lesion was visible to account for the bleed, and the colonic distention involved the entire length of the colon with what was apparently a competent ileocecal valve and a diffuse bloody distention of the residual colon. Once mobilization of the small bowel had been completed, a total abdominal colectomy was undertaken.

The colonic resection was completed and the specimen submitted for pathologic evaluation. The abdominal cavity was irrigated with copious amounts of saline solution. The bowel was re-run 5 or 6 times during the course of the procedure to assure that no enterotomies had been missed and no sites of focal obstruction were present.

An enterotomy is a surgical incision into the intestine.

The case was terminated and the patient remanded to the intensive care unit in guarded condition.

Okay, here's the pathology report:

Gross:

Labeled colon is a 65.0 cm in length x up to 11.5 cm in circumference segment of colon with attached cecum, attached 2.0 cm in length x up to 0.6 cm in diameter pink-tan vermiform appendix and an attached 6.0 cm in length x up to 3.5 cm in circumference segment of terminal ileum. There is an attached mesocolon over the length of the specimen. The serosa is grossly unremarkable, the proximal end is closed with a row of metal staples and the distal end has a 3.0 x 1.6 cm area of exposed tan mucosa closed with black suture material and surrounded by a thin rim of pale tan skin all grossly consistent with colostomy stoma. Opening the specimen reveals a few scattered shallow diverticulae approximately 10 cm distal of the ileocecal valve, a 0.3 cm sessile polyp 18 cm distal of the ileocecal valve slightly dilated lumen 12 cm from the distal of the palm and the remaining mucosa appears slightly edematous up to the stoma. There are no grossly recognized ulcerations, perforations or mass lesions. Sectioning does reveal the cecal mucosa to be slightly edematous and there are some additional widely scattered diverticulae in the mid portion to more distal areas. Representatives are submitted as follows: 1A - proximal margin, 1B-diverticulum, 1C-sessile polyp, 1D-1I-mucosa taken at approximately 10 cm intervals in sequentially submitted proximal to distal, 1J-stoma 1K-appendix, 1L-six lymph nodes from the dissected mesocolon measuring up to 0.3 cm.

Microscopic Diagnosis:

Colon and ileum and colostomy site, resection: Diverticular disease, with diverticulitis and serosal inflammation, adjacent to large vessel with clot, viable margins of resection.

Stomal area with inflammtion and mucosal denudation.

Benign appendix.

Six reactive lymph nodes.

"Edematous" means swollen, with an excessive accumulation of fluid.

My impression is that my guts were/are in such bad shape, that I'm surprised that they didn't just remove all of them, while they were at it.

Tex

[Mars]

My goodness...........I'm just glad you are ALIVE after all of that. It seems that you have answers to some of your belly problems these last few years. The diverticulitis and inflamation should have been enough to have you bedridden at times.

You need to take care of yourself and not return to work too soon no matter how anxious you are to do so!

Love and gentle hugs,
Mars

[tex]

Mars,

The weird thing is, I never had any pain that I could attribute to diverticulitis. The only time I had pain, camps, etc., was when I had MC symptoms, and the diet finally resolved that. The doctors kept telling me that I should have pain in my lower left quadrant, but that never happened. Just before I had the previous surgery, (when they removed my Sigmoid colon), the only pain that I had, was on the opposite side, (my lower right quadrant), and it wasn't anywhere near severe enough to be connected with diverticulitis.

Yep, I'm mighty glad to be alive, too.

Love,
Tex

[Gabes-Apg]

Tex
the report is not gross..... well not to us in the MC family.
As mars said, we are so very glad you are alive and well.

for me, as someone with adhesions it reiterates my mission to do whatever is necessary for good health (follow the diet and minimise MC flares) and avoid surgery for as long as possible.

Thank you for trusting us with your reports. in the pathology report what does the comment six reactive lymph nodes mean?

[Rosie]

My goodness, Tex, you were worse off than you realized. It's a testament to your strength and determination that you pulled through! And I second Mar's gentle suggestion that you take plenty of time to heal and recover.

Rosie

[tex]

Gabes,

Reactive lymph nodes are lymph nodes that are actively fighting an infection of some type. The pathologist concluded that this was consistent with diverticulitis, mostly because that's what the surgical team assumed to be the cause of the bleed, so he merely concurred with them, rather than to actually analyze the colon objectively.

I'm pretty sure that those lymph nodes had to come from the mesentary, which is external to the colon. I wish I know of some place interested in researching MAP, where I could request another opinion on those samples. I have a hunch that those lymph nodes were fighting MAP, not a diverticulitis infection. After all, why would diverticulitis cause the serosa to be inflamed? Diverticulitis infections occur inside the lumen, not external to the colon. I could be all wet, of course, but I think that something else was/is going on. Doctors are almost always fixated on horses, and they wouldn't acknowledge a zebra if it stepped on their foot. (IOW, they always look for common causes for problems, and they assume that they will never encounter any rare diseases - at least that's what they're taught in med school).

Tex

[Gabes-Apg]

interesting - which is why i asked.....

mmmm I will do some 'natural' research via my acupuncturist and see what he says.
it reiterates the point that the digestion cycle is the core of the body and there are web links to every part of our body.

if digestion is not working to its optimum, then that is why we get symptoms in feet, hands, skin etc

mmmm lots to ponder

Get some rest! it must be close to midnight there

[tex]

Rosie,

I'm probably going to follow Mars' advice, and not overdo it for a while. Lifting weights can cause hernias, and since I had a hernia with the previous stoma, (and didn't even realize it), I sure don't want to tempt fate, right off the bat. (Part of my work involves stacking bags of corn on pallets, and that's sorta like lifting weights for hours at a time). One of the doctors that I saw today, warned me not to lift more than ten pounds, for two more weeks, but after that, there's no limit. Really? That might be what the medical texts say, but I have a problem believing it. It's interesting how so many doctors don't believe in the existence of any "gray" areas.

Thanks,
Tex

[tex]

Get some rest! it must be close to midnight there

You're right - I didn't realize it was that late. Time flies when you're having fun.

I reckon I'd better take that advice and get some shuteye.

G'nite,
Tex

[ant]

Dear Tex

Wow, thank goodness you pulled through that! You are one tough guy.

Sounds like the surgeons and team also did well under difficult circumstances. Not so sure about the pathologists. IMHO I think you may be right about MAP. And, as discussed elsewhere, it could be a key to understanding MC. Did they keep the colon for more possible tests?

I tried to understand the report, but cannot work out if they ever actually found the source of the bleeding in the colon?

I agree, take it easy, do you have any heavy lifting help on the farm ?

Love, Ant

[starfire]

Wow Tex,
You never cease to amaze me with the way you continue to research and TEACH in any and all circumstances. I feel like I have learned so much from reading your posts the last few years.

I'm rather glad you got all the information about your case because apparently it made you realize that you do need to "pamper" yourself for a while to let your body totally recover from all the trama. That has to be a good thing although I know it will be hard for you.

Love, Shirley

[MaggieRedwings]

Morning Tex,

Well my opinion is that you are a very, very LUCKY MAN! Please take care of yourself, get a lot of rest and do not overdo. Those reports scared the heck out of me. Amazing what goes on when you are under anesthesia.

Love, Maggie

[Polly]

Very interesting, Tex.

A few thoughts:

1. Why was the small intestine so friable (damaged) everywhere? Gluten damage would likely be limited to the terminal ileum only, wouldn't it? And rarely are diverticla found throughout the small bowel - they are mainly a large bowel problem, so that's probably not the answer.

2. They are pinning all of the problems on diverticulitis, but on the path report, they describe the number of diverticula as "a few shallow diverticula" in one place and then "some additional widely-scattered diverticulae" in another location. Hardly what we might expect to cause the chronic and life-threatening problems that you encountered.

3. AHA! No wonder your body was working madly to increase the number of platelets, with all of those extra "nicks" that needed to heal after surgery.

4. I didn't see any mention of the length of your small bowel, but apparently they thought it was remarkable enough to mention to your brother, who mentioned it to me. Wasn't it something like one third longer than normal?

Am so happy and relieved to hear about your continued progress. You REALLY scared us, you know!

Love,

Polly

[tex]

Ant,

They keep the samples noted in the report, (for a while, at least), but I'm sure the rest was discarded. Hmmmmmm. As greedy for money as that hospital is getting, I wonder if they dispose of body parts properly, (as biological waste, or whatever they call it), or they sell them to a company that makes livestock or pet chow. LOL. The reason for that cruel comment, is because when I requested a copy of all the records from the duration of my hospital stay, they demanded payment of $340.40, before they would release the records. Just a few years ago, that information was available free, to the patient. It's still available free of charge, to my GP, so I just got a copy of the reports that I was interested in, from him. Also, when a patient goes to see a doctor in the clinic, a hospital charge is automatically tacked onto their bill, even though they never set foot in the hospital. That rankles a lot of people, but apparently the hospital has figured out a way to get the insurance companies and medicare to agree to that charge. They provide good service, but they're not bashful about creative and aggressive billing techniques.

I assume the part highlighted in red, below, is supposed to address the source of the bleed, but I could be wrong:

Colon and ileum and colostomy site, resection: Diverticular disease, with diverticulitis and serosal inflammation, adjacent to large vessel with clot, viable margins of resection.

That's so ambiguously written, that it's difficult to pin down any specifics. Serosal inflammation, adjacent to large vessel with clot, doesn't specify whether the vessel/clot was adjacent to the serosa, (IOW, external to the colon), or inside the lumen, (adjacent to a diverticulum). Of course, a diverticulum is actually a herniation of the mucosal layer of the colon, through the muscular wall of the colon, so for all I know, the pathologist's statement here may indeed correctly specify a bleed inside a diverticulum. This is kind of puzzling, since the colonoscopy exam/s failed to detect that "large vessel with clot", prior to the colectomy, and the operative report notes that:

it was apparent that bleeding into the colon proper was continuing although no point source or obvious pathologic lesion was visible to account for the bleed, and the colonic distention involved the entire length of the colon with what was apparently a competent ileocecal valve and a diffuse bloody distention of the residual colon

Yes, I do have help available for heavy lifting, if/when I need it.


Shirley,

I seem to have a habit of "thinking out loud", in many of my posts, FWIW.

Yes, I do plan to be cautious about resuming work. When I get to that point, I'll probably follow the plan that we often fall back on - I'll take it one day at a time.


Maggie,

That's probably the main reason why they use anesthesia, (even more important than pain control, and immobility) - if we were able to see what was actually going on, it would surely scare us to death.


Polly,

1. Why was the small intestine so friable (damaged) everywhere? Gluten damage would likely be limited to the terminal ileum only, wouldn't it? And rarely are diverticla found throughout the small bowel - they are mainly a large bowel problem, so that's probably not the answer.

That's exactly what I asked one of the doctors, yesterday, at my checkup. She was present during the surgery, and she actually dictated the operative report, even though it has the surgeon's name on it. (And all this time, I thought that the surgeon actually wrote the operative report - silly me, ). Anyway, she hemmed and hawed, and claimed that my intestines weren't/aren't unusually weak/damaged, but that such issues are typical, after a previous surgical procedure.

After I continued to press the issue, she looked up a lab report, and pointed out that my blood protein level was below range, and this would cause intestinal damage, and delay/prevent proper healing. She told me that I didn't eat enough protein. Well, duh! My blood protein wasn't low, until the bleeding started. I went to the hospital because I was bleeding to death. Massive bleeding probably doesn't do much to enhance blood protein levels. And, what were they feeding me, when that lab test was made? Salad. With a side order of salad. If anyone eats plenty of protein, it's me. I'm someone who considers a well-balanced meal to consist of meat, with a side order of another type of meat, and maybe some nuts for desert. My blood protein level usually runs in the upper half of the "normal" reference range. (She never asked what my normal blood protein level was). This was what led me to believe that she didn't know what was causing my issues, (which is not surprising), but she didn't want to admit that she didn't know.

I was under the impression that the entire small intestine is vulnerable to inflammation damage caused by gluten, since most nutrient absorption takes place in the duodenum, and the jejunum, and that's where villus damage is most significant. (Isn't it, or does that just happen to be where they usually check it, because that's the most easily accessible part of the small intestine?)

I agree - I doubt that any diverticula are present in my small intestine. I get the impression that my small intestine simply tore, whenever they applied too much force, trying to pull it free of the adhesions. I asked several different ways, why it was so easily torn, but she insisted that the tearing was due to damage resulting from the previous surgery, and inadequate protein in my diet , and not from any unusual cause, (IOW, she wouldn't admit any possibility of a MAP infection, in the mesentary). My GP, bless his heart, will admit in a heartbeat, if he doesn't know something, but this lady doctor, (presumably an intern), would never admit to not knowing anything. Soooooo, I'm guessing that she/they just don't know why, but she was unwilling to admit that fact.

2. They are pinning all of the problems on diverticulitis, but on the path report, they describe the number of diverticula as "a few shallow diverticula" in one place and then "some additional widely-scattered diverticulae" in another location. Hardly what we might expect to cause the chronic and life-threatening problems that you encountered.

Exactly what I was thinking. I believe that my Sigmoid colon, (which was removed over 4 years ago), did indeed contain a fair number of diverticula, (and that's where they are usually concentrated), but this report certainly doesn't mention enough of them in the descending, transverse, and ascending colon, to get excited about. Obviously, it was a far cry from being "eat up", (as they say), with diverticula. I get the impression that my intestines, (including both the small intestine and colon), were significantly damaged by something, and I'm not convinced that diverticulitis is the "something" that is primarily responsible for the damage.

3. AHA! No wonder your body was working madly to increase the number of platelets, with all of those extra "nicks" that needed to heal after surgery.

I never thought about that, but I'm sure you're right - there was a lot more going on than I realized. I'm still amazed that I didn't have any infections, anywhere. My immune system must be pretty "capable".

4. I didn't see any mention of the length of your small bowel, but apparently they thought it was remarkable enough to mention to your brother, who mentioned it to me. Wasn't it something like one third longer than normal?

I have to apologize. I left out a few comments from the report, that didn't seem "sensational" enough to be worth mentioning. After the report noted, "Several small, superficial, serosal tears were made with traction on this patient's friable intestines, and these were repaired using interrupted sutures of 3-0 silk.", it noted:

The stomach was mildly to moderately distended, but an NG tube had been placed by our anesthesia colleagues and was initially found to be at the junction of the esophagus and stomach but was advanced with direction of the operative surgeons into the distal body of the stomach where suction was applied and the stomach decompressed. The small bowel was found to be abnormally long length apparently but contained no obvious blood and was deflated along its entire length.

There are additional remarks that I omitted, but these mostly pertain to "taking down/removing/closing" the existing colostomy, (reversing a Hartman procedure), and "installing/creating" the new ileostomy, (Brooke procedure). If you want, I'll be happy to e-mail you the original copies of both these reports - just let me know. That applies to anyone else who might be interested in seeing them - just let me know.

Love,
Tex

[Stanz]

You truly are a walking miracle, Tex. I cannot imagine how you could NOT have been in a great deal of pain 24/7 before your bleed/surgery.

Your mention of MAP triggered a memory from my last surgery in '02, which was to remove scar tissue from my right wrist. The surgeon ordered an acid fast bacilli smear, which was monitored for 6 weeks for bacterial growth, as well as a fungal/yeast smear that was also monitored for 6 weeks. I wonder if they did the same with you?? I had no idea this was ever done until I got the copies of my medical records.

Surely they would have kept tissue for further testing, and it sure seems likely that the lady doctor, who wasn't very forthcoming with you in your direct questions, wouldn't have mentioned this. My assumption when I learned about the tests they did on my tissues, was that they were watching for MRSA, but maybe not...

I haven't had much time for research the past 2 months, but I am convinced my GF died of MAP or Johnnes.

Please do take care of you, I wouldn't be too hasty to get back to hefting bags of corn.