Dr. Ou said that the next couple days in surgery may not have much going on, but hopefully this is not true.  I would very much like to see a CABG before I leave.  Being back in the OR reminds me of my time at Tissue Banks International processing grafts, except now the tissue is of someone living not dead.  With this in mind, I am always awestruck by what modern surgery and anesthesiology is capable of doing.  Day 2 was comprised mainly of 3 surgeries and Day 3 was comprised of mostly outpatient.  I will elaborate exceptional cases from both days in the remainder of my blog entry. 

Throughout these days, I learned many things about the Taiwanese national health care system:

1.       All of the surgery residents are female (contrary to the states)

2.       All of the anesthesiologists are female (contrary to the states)

3.       The 5 least popular/most needed specialties are (in no order of importance and contrary to the states):

a.       OBGYN

b.       Surgery

c.        Internal Medicine

d.       Pediatrics

e.       Emergency Medicine

4.       Surgeons here have duties beyond just surgery:

a.       Handle all pre and post operation breast cancers that are not complicated

b.       Handle all pre operation GI cancers

c.        If cancer is complicated will refer to Heme-Onc dept.

d.       Some internal medicine complaints were brought to Dr. Ou in outpatient services

As for the Surgeries:

     The first notable surgery was a laparoscopic cholecystectomy.  First, air was pumped into the cavity to create space to work in as explained in my last blog.  Next, the Greater Ommentum was dissected to better expose the gall bladder.  Following, Dr. Ou drained the inflamed, pus filled gallbladder while suctioning out the fluid.  Though some residual pus remained inside the body cavity, we were told that a course of antibiotics would take care of the  empyema.  After stapling off and electrically cutting/cauterizing the celiac artery, Dr. Ou carefully dissected out the gallbladder making sure to cauterize all circulation that was bleeding.  Again, the specimen was placed in a bag before being taken out of the cavity, as to not risk exposing the incisions to the pus and bacteria of the infected gallbladder.  It was interesting to note the difference in level of skill between the residents and Dr. Ou, when handling the laparoscopic instruments.

     Following, we observed the excision of a lipoma inside the inferior aspect of the right arm of a patient.  I originally thought the patient was under general anesthesia but the patient was actually just put to sleep.  Local anesthetic was used on the surgical area.  After excising the approximately three inch diameter lipoma, Dr. Ou had to cut off extra skin before sutchering, for cosmetic purposes.

     The last surgery of the day was the most involved and was the one I learned the most from.  This patient was suffering from chronic peptic ulcers that lead to an obstruction at the stomach-duodenal junction.  There were a few of questions that needed to be answered.  The first was are the lesions benign or malignant.  The second was whether to bypass the stomach completely or do a partial gastrectomy (which is more physiological).  The third was whether to do the procedure laprascopically or through traditional open cavity method.  Regarding the later question, from the morning presentation of Day 3, I know that the laparoscopic method provides similar 5 year outcomes with a decreased time before being discharged and a decreased time before resuming ingestion, with only a ten minute longer procedure on average.  Nonetheless, this patient was very skinny and malnourished, so Dr. Ou decided to do the traditional open cavity gastrectomy. 

     After the opening of the cavity and dissection towards the stomach, Dr. Ou explained that we try to preserve as much of the Ommentum as possible because a lot of lymph tissue is located inside of it.  After finally having access to the lesion, Dr. Ou examined it for malignancy.  Although the outside looked like cancer, the inside of the lesion looked benign.  He explained that it was most likely due to chronic fibrosis, scarring, and build up.  Regardless, to err on the safe side he decided to resect it; however, since he thought it was likely not cancer, he did not decide to remove lymph nodes and he also preserved half of the stomach.  Thus, he tied off and stapled all of the vessels supplying the right side of the stomach, which was the side to be excised.  After excising part the stomach, the question was now whether to do a Bilroth I or Bilroth II anastomoses of the stomach to the intestinal system.   

The following is a figure explaining the differences: http://streamlyner.com/wp-content/uploads/2014/06/billroth-1stomaco-normale-stomaco-operato-e-gastropatie-ys112tcw.gif

Bilroth I anastomoses connects the partially resected stomach to the duodenum.  This is the more physiologic approach and will lead to a better appetite and better experience for the patient post operation; however, it also runs a higher risk of rupturing and leaking.  Because cancer was not completely out of the question, Billroth I route was not favored.  The Billroth II route takes a piece of the jejunum and connects the partially resected stomach to the jejunum itself.  The duodenum is kept but sealed with a GIA staple.  In this way, the pancreas can still excrete bile into the intestines.  This was the route that was chosen.  This is a safer route, though will lead to less appetite and more discomfort for the patient post operation.  We were unable to see the rest of the surgery, but when we left, the surgeons were in the process of excising parts of the jejunum.

      Today, we were not able to spend too much time in the outpatient clinic; however, what was most notable to me was a case of a 53 year old Male who had a history of a goiter.  He had a right thyroid lobectomy for cosmetic purposes; however upon pathological inspection, he had a follicular adenoma.  What was interesting about this case was that it was a well differentiated tumor, but it had invasive behavior.  Dr. Ou explained that the two options would either be to remove the left thyroid lobe as well (but this would mean lifetime hormone supplementation) or to leave it and observe.  Dr. Ou favored the later option.