Surgial decision making

[Grurik]

So, I'm a medical student and I watched a procurement and the CT surgeon started dissecting. Walks away for about 10 min doing some phone calls. Coming back, telling everyone they're not going for the heart since there is some scar tissue and the OR did not have backup for bypass machine, ie he would f*ck for abdominal surgeons if something went wrong with cannulation and stuff.

I've had several encounters like this, where it seems that decisions are made quite quickly. I know I don't know anything about heart procurement but looking down, there weren't that much that had already been dissected. Of course he's about 1000x more skilled than me taking decisions when enough has been done to make a decision but anyways.

So my kind of general questions are:
- How often do you have to deal with the decision to really end the operation? I understand it varies a lot, but is it like 1%, 10% or 50% of the cases?
- Do you have like general rules of thumb for this kind of decision making or is it more like gut feeling? Things in surgery aren't straight forward I guess. Surgery can also be defensive I've heard many surgeons never wants a patient dying on their table, and that could mean "let just put him in the ICU and let him die there, I won't do that cut and have him die here on the table".

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[bannie22]

to be honest, it seems like if u asked the guy u would learn a lot more than the extrapolation that you will get here because you are providing the littlest of info

 

[Grurik]

Thanks It was just an example in this case, question being how often surgeon deal with decisions to end operation or not and a little bit about how these decisions are made.

 

[Pir8DeacDoc]

Reasonable question. It comes up infrequently. Mainly in my specialty is a cancer operation where things that looked resectable on CT aren't in real life. In practice so far I've backed out of one case. I was new. Big thyroid cancer. I underappreciated it's size. Needed another set of hands. None were available. So before trouble started I closed up. Shipped to tertiary facility a few weeks later for surgery. There is a lot of ongoing assessment in surgery and the plan changes rapidly. But in my experience rarely so dramatically as to cancel the case or back out.

 

[Dr.LeoSpaceman]

Doesn't come up that often. As mentioned, certainly more common in oncologic surgery. The "easy" ones are when you find previously unidentified metastatic disease..the so called "peak and shriek".

The fact that you noticed that "not much had been dissected" isn't surprising if he's an experienced guy. In those cases, the skill is actually knowing it won't be possible before you get "stuck". In other words, if you are fairly sure you won't be able to do the last 20% of the operation, better to realize at the beginning than when you are 75% done.

 

[evilbooyaa]

So, I'm a medical student and I watched a procurement and the CT surgeon started dissecting. Walks away for about 10 min doing some phone calls. Coming back, telling everyone they're not going for the heart since there is some scar tissue and the OR did not have backup for bypass machine, ie he would f*ck for abdominal surgeons if something went wrong with cannulation and stuff.

I've had several encounters like this, where it seems that decisions are made quite quickly. I know I don't know anything about heart procurement but looking down, there weren't that much that had already been dissected. Of course he's about 1000x more skilled than me taking decisions when enough has been done to make a decision but anyways.

So my kind of general questions are:
- How often do you have to deal with the decision to really end the operation? I understand it varies a lot, but is it like 1%, 10% or 50% of the cases?
- Do you have like general rules of thumb for this kind of decision making or is it more like gut feeling? Things in surgery aren't straight forward I guess. Surgery can also be defensive I've heard many surgeons never wants a patient dying on their table, and that could mean "let just put him in the ICU and let him die there, I won't do that cut and have him die here on the table".

Generally the transplant surgeons will be very, very picky with organs that they take. Generally the procurement physician sees something of concern at the surgery (like some scar tissue) and calls the head of the department (or whoever is ready to transplant the heart into the next patient), they decide whether it's worth it to take the risk with the organ (usually a combination of the procuring physician's story, their recent experiences with transplant, and secondary concerns like screwing up the abdominal organs like in your procedure) for the patient who does need the transplant.

Although I'm confused, as if it's a procurement, I figure heart would come out last (if at all), assuming it was still fully functional.

I personally admitted and subsequently discharged a share of pre-op transplant patients during my intern year (about 3 livers and 2-5 kidneys that were cancelled) because the procuring physician felt that the organ was not good enough for the patient it was to be transplanted.

But yes, otherwise 'peek and shrieks' for oncologic surgery, or catastrophic abdominal issues (like all of the intestine is necrotic, like I saw once or twice) are rare, but possible. Would probably be 1-5% as my best estimate.

 

[ThoracicGuy]

Generally the transplant surgeons will be very, very picky with organs that they take. Generally the procurement physician sees something of concern at the surgery (like some scar tissue) and calls the head of the department (or whoever is ready to transplant the heart into the next patient), they decide whether it's worth it to take the risk with the organ (usually a combination of the procuring physician's story, their recent experiences with transplant, and secondary concerns like screwing up the abdominal organs like in your procedure) for the patient who does need the transplant.

Although I'm confused, as if it's a procurement, I figure heart would come out last (if at all), assuming it was still fully functional.

I personally admitted and subsequently discharged a share of pre-op transplant patients during my intern year (about 3 livers and 2-5 kidneys that were cancelled) because the procuring physician felt that the organ was not good enough for the patient it was to be transplanted.

But yes, otherwise 'peek and shrieks' for oncologic surgery, or catastrophic abdominal issues (like all of the intestine is necrotic, like I saw once or twice) are rare, but possible. Would probably be 1-5% as my best estimate.

Hearts will usually come out first in procurement.

 

[evilbooyaa]

Hearts will usually come out first in procurement.

Interesting. My place only did abdominal transplants so no experience with cardiac transplants. Any specific reason for the rationale behind heart out first?

 

[surgonc2017]

It has the least tolerance of ischemic/cold time and has the most immediate "life saving" effects of a transplant. Once you go "cold" the priority is getting the heart out.

Sometimes you'll even delay starting the cold portion of the case so the receiving heart surgeon can start to take out the old heart/VAD so the timing lines up well. This is known as the dreaded "cross clamp delay", the mortal enemy of abdominal procuring surgeons.


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[vhawk]

Generally the transplant surgeons will be very, very picky with organs that they take. Generally the procurement physician sees something of concern at the surgery (like some scar tissue) and calls the head of the department (or whoever is ready to transplant the heart into the next patient), they decide whether it's worth it to take the risk with the organ (usually a combination of the procuring physician's story, their recent experiences with transplant, and secondary concerns like screwing up the abdominal organs like in your procedure) for the patient who does need the transplant.

Although I'm confused, as if it's a procurement, I figure heart would come out last (if at all), assuming it was still fully functional.

I personally admitted and subsequently discharged a share of pre-op transplant patients during my intern year (about 3 livers and 2-5 kidneys that were cancelled) because the procuring physician felt that the organ was not good enough for the patient it was to be transplanted.

But yes, otherwise 'peek and shrieks' for oncologic surgery, or catastrophic abdominal issues (like all of the intestine is necrotic, like I saw once or twice) are rare, but possible. Would probably be 1-5% as my best estimate.

The literature suggests about a 10% rate of detection of peritoneal Mets upon diagnostic laparoscopy for gastric cancer. Probably a little bit less for pancreatic and other GI cancers. Those numbers are decreasing with better imaging and more aggressive neoadjuvant regimens, but sadly I don't think I'd call it "rare." Probably peak and shriek once a month or so

 

[evilbooyaa]

The literature suggests about a 10% rate of detection of peritoneal Mets upon diagnostic laparoscopy for gastric cancer. Probably a little bit less for pancreatic and other GI cancers. Those numbers are decreasing with better imaging and more aggressive neoadjuvant regimens, but sadly I don't think I'd call it "rare." Probably peak and shriek once a month or so

I'd think gastric cancer was the most likely to develop peritoneal mets, so that makes sense. In that subgroup of resections (subtotal vs total gastrectomy), sure it might be 10%. I think OP was asking more for total percentage though of all a surgeon's cases. Obviously depends on a surgeon's practice, but I'd guess even the most hard core academic surg onc isn't doing gastric cancer (and maybe pancreatic cancer) resections only.

I guess to me, a 'peek and shriek' is more when you run into something completely unexpected (like after you've already done the laparotomy), although I suppose the technical definition would include diagnostic laparoscopy followed by aborting the procedure.

 

[vhawk]

I'd think gastric cancer was the most likely to develop peritoneal mets, so that makes sense. In that subgroup of resections (subtotal vs total gastrectomy), sure it might be 10%. I think OP was asking more for total percentage though of all a surgeon's cases. Obviously depends on a surgeon's practice, but I'd guess even the most hard core academic surg onc isn't doing gastric cancer (and maybe pancreatic cancer) resections only.

I guess to me, a 'peek and shriek' is more when you run into something completely unexpected (like after you've already done the laparotomy), although I suppose the technical definition would include diagnostic laparoscopy followed by aborting the procedure.

Seems like a distinction without a difference. Not everyone does laparoscopy prior to laparotomy for oncology cases. Obviously it does depend on your practice. If you define it narrowly enough it either happens fairly often or never. I'm sure in a pure trauma acs practice it's more rare. If you are doing thyroids all day it probably basically never happens.

For bread and butter general surgery the reasons to abort would basically be underestimated extent of disease, unanticipated hostile abdomen, some issue with the conduct of the operation such as significant bleeding or injury, or anesthetic related complications. I'd say based on nothing but my anecdotal experience this happens somewhere between 1-10% of cases depending on your practice.

I grant that my experience is a little biased and I'm at an extreme end of that spectrum, but i did also go through gen surg residency so I think I can't be that far off

 

[Smurfette]

I've aborted well less than 1% of all my cases.
The ones I have had to stop and close include:
1. lap choles where as soon as I'm in the belly, I find metastatic cancer (almost always pancreatic, but I also have found ovarian and gastric CAs this way). I generally take biopsies and GTFO.
2. Dead bowel where everything is dead and nothing can be done. If I suspect it's going to be truly awful in there, I will look laparoscopically first and make sure it isn't all dead before proceeding.
3. Had one patient with an allergic reaction to anesthesia, who coded just after making incision (patient survived but it was terrifying). Not malignant hyperthermia, although I have seen that occur immediately post op. Also terrifying.
4. Masses that are too involved to resect safely (i.e. at root of mesentery not evident on pre op work up, direct invasion into a structure requiring specialty help, etc.).
5. Findings that require consent to proceed due to the change of operative plans. i.e. classic "ovarian mass", colon mass/diverticulitis involving adnexa, or appendiceal cancer requiring right hemi. Usually I will break scrub and talk to family to see if I can proceed, but sometimes that's not appropriate or simply not an option.

These decisions are made based on training and experience. Gut feeling is part of it, but it's also simply knowing when the risks or drawbacks of proceeding outweigh the benefits to the patient.

If operating on a patient is futile, the kindest thing to do IMO is to say no to surgery, make the patient comfortable and let the family pay their respects. No one wants to die on the OR table after a prolonged code, get closed up postmortem and be left in that cold room alone until getting taken to the morgue. It also is very traumatizing and chaotic to have patients die in the OR; definitely not a peaceful way to go.

 

[dienekes88]

So, I'm a medical student and I watched a procurement and the CT surgeon started dissecting. Walks away for about 10 min doing some phone calls. Coming back, telling everyone they're not going for the heart since there is some scar tissue and the OR did not have backup for bypass machine, ie he would f*ck for abdominal surgeons if something went wrong with cannulation and stuff.

I've had several encounters like this, where it seems that decisions are made quite quickly. I know I don't know anything about heart procurement but looking down, there weren't that much that had already been dissected. Of course he's about 1000x more skilled than me taking decisions when enough has been done to make a decision but anyways.

So my kind of general questions are:
- How often do you have to deal with the decision to really end the operation? I understand it varies a lot, but is it like 1%, 10% or 50% of the cases?
- Do you have like general rules of thumb for this kind of decision making or is it more like gut feeling? Things in surgery aren't straight forward I guess. Surgery can also be defensive I've heard many surgeons never wants a patient dying on their table, and that could mean "let just put him in the ICU and let him die there, I won't do that cut and have him die here on the table".

Sounds like a strange situation. For there to be excessive adhesions in a donor is fairly unusual, and the need for extensive dissection prior to cross clamp can result in significant bleeding. It's worse if the dissection has to happen after cross clamp, because it means that you're going to have extended ischemic time.

These are tough decisions, and not everyone is built for it. Sometimes you're wrong. You just have to be able to live with yourself.