I got a smattering of responses, all involving the same thoughts going thru my head while staring at this mess at about 10pm with a chief resident across the table staring questioningly at me--I,m sure thinking something like "OK, big shot, show me how to get out of this one!" Well, tubing the hole or patching it in some way and punting was not an option, otherwise I'd gladly have done it--you had to be there. Both John Kennedy and Bob Goldman hit the nail on the head with regard to the conclusions I came to and what had to be done.
We got the pathologist to come in to do some frozens--a couple of the big nodes showed nothing but hyperplasia, and a good pieces of the indurated mass-like area where the stomach was socked up to the liver was only chronic inflammation. As I dissected, it was obvious I couldn't resect en bloc if I wanted (thank God!) since the neck of the pancreas was glued right to the mesenteric vessels--so I decided to just digitally peel the adherent stomach off the attached body of the pancreas and the liver, figuring if this was cancer, leaving gross disease behind would make no difference to her given the local extent of disease--this completely freed up the stomach, showing about 3/4 of the circumference of antrum and body was gone, only having been sealed off by the liver and pancreas, but no mass or anything that looked like tumor--I was not going to sew it back up because of doubt as to whether cancer was in this, and it looked like we'd be left with nothing in the way of a lumen anyway--so with clearance ofnormal tissue of only about 1cm before the pylorus distally and esophagus proximally I found myself having to do a total gastrectomy to get this out. The pancreatic bed was smooth and fibrotic, just like the bed of a penetrating ulcer--same with the liver bed--but a suspicious tumor-like excrescence was arising in the middle of it, making me wonder if this was a pancreatic Ca invading the stomach--a generous biopsy of this again showed no malignancy, just chronic inflammation--the gastrectomy was just about complete by this time, so we finished it, did a Roux-Y esophagojejunostomy hand- sewn--also, our dissection had devascularized the densely adherent transverse colon, so that came out and I pulled out an end right colostomy--I didn't want another suture line at that point, and the colon was full of mushy stool, altho I guess we could have reanastomosed that. The stomach specimen also showed no evidence of cancer on frozen--finals pending.
In retrospect, this appears to have been one horrendous gastric ulcer which had penetrated posteriorly into the pancreas and superiorly into the liver, the treatment of which required just what we happened to have stumbled into--I am so glad we didn't go with my original instinct and have done that major en bloc resection, which is why it was so important to have the frozens done--altho it is the only time I have ever had to do a total gastrectomy for benign disease, but it was the only thing I was able to do to get rid of the immediate problem. Again, the stomach was full of mush--she must have just eaten a huge meal--and bypass in my mind would have accomplished less than nothing, as the contamination would have just continued.
Well, she's doing great on POD #3, with bowel function returned-- I'll get a hypaque swallow on day #5, then feed, and hope the final path shows no surprises. Maybe we'll have to deal with an abscess in a week or two, but I hope not.