The Rubber Factory Manager

– A Tale Of Two Tumours
case-studies-the_rubber_factory_manager-01
Rubber is collected from trees like this.

 

It all began innocently enough.

“Can you take a look at father? He has a lump under his left armpit that’s causing some discomfort”
Mr Lee’s son smiled anxiously at me. He had brought his father along with his sister.

Sure.
Small lump in the skin of the armpit. No problem at all.
Mr Lee peered at me, explaining that the lump kept catching on his clothes.
An affable man of 92 years, he used to be a rubber factory manager.
He was remarkably lucid and looked more like someone in his mid eighties.
His previous doctors had done a good job.
He had a stent put in for blocked arteries in his heart 16 years ago and he’d survived a major operation for bowel cancer 8 years ago during which the gall bladder was also removed.

“Best to take this lump out just to make sure it’s not a recurrence of the bowel cancer.” I concluded, having had a good look at it.
“We can do this with local anaesthetic. We should avoid a general anaesthetic at his age.”

The lump proved to be a benign tumour of the sweat glands.
Problem solved.

Black stools!

So, it was with surprise that I found them back in my clinic 2 months later.
“Father is passing black stools…”
“Are you sure it’s really black?” I asked, eyebrows raised, pointing to my trousers.
“Yes, we think so… and he has some pain in the upper part of his tummy.”
Truly black stools mean one thing – bleeding in the upper gut, usually the stomach.
We call that melena stools.
Ever so often, I see patients claiming to pass black stools which just turn out to be merely “very dark brown”.

Hmmmm…..
I was not keen on doing a scope on someone in his nineties unless it was really necessary.
“Let’s do some Faecal Occult Blood tests,” I said, hoping they’d come back negative.

 

Faecal Occult Blood test

This test (also known as a FOB) looks for the presence of tiny traces of blood concealed in the stool.
If the test is positive, it means there is bleeding somewhere in the gut. The patient therefore has to have an endoscopy (both gastroscopy & colonoscopy) to determine the source of the bleeding.
It is used as a cheap, painless and effective way to screen for bowel and stomach cancer.
However, bleeding could be intermittent so a single negative result may not mean that the patient is OK.
The FOB test is best done 3 times on different days. If all 3 are negative, one could say with some confidence that the patient is OK but if one or more are positive, the patient needs endoscopy.

All three of Mr Lee’s FOBs came back positive!

Aiyo!!!
I’m going to have to scope him, I thought.

His scope of the large bowel (colonoscopy) was normal. Which was great as there was no recurrence of his previous bowel cancer.

To my dismay, the scope of his stomach (gastroscopy) showed a stomach ulcer.
An ugly looking ulcer with raised edges.
There was little doubt this was causing his black stools. The raised edges suggested the possibility of stomach cancer.

A few days later, my fears were confirmed. The biopsies of the ulcer showed stomach (gastric) cancer.
A CT scan did not show any evidence of spread elsewhere.
To be honest, we couldn’t even make out the outline of the gastric cancer on the CT scan.

 

Mr Lee's gastric ulcer at gastroscopy
Mr Lee’s gastric ulcer at gastroscopy
To operate, or Not to operate – that is the question ……

We now had a dilemma – to operate or not to operate.

On the one hand, here was an early gastric cancer, definitely operable, potentially curable.
Yet, one cannot underestimate the risks of major gastric resection in a 93 year old. Especially one with previous heart trouble, previous bowel cancer and some impaired kidney function as well.
If he made it, we would have controlled the gastric cancer and if he lived for another say 5 years, I would consider that a success.
BUT if complications set in, he could die as a result….

On the other hand, to do nothing would lead to the cancer growing, then spreading and eventually leading to his death.
Gastric cancer is aggressive, tends to spread early and causes lots of problems like weight loss, vomiting, inability to eat, anaemia and jaundice at the later stages. Not to mention the possibility of pain if the nerves are involved.
At 93 years, he would not tolerate chemotherapy.
Once the cancer progresses, curative surgery would no longer be possible but bypass surgery might still be needed if his stomach became obstructed or the tumour continued to bleed.
Of course, by then he’d be older, more frail and surgery could be even more risky.
Further still down the road, bypass surgery might not even be possible so we’d have to look at stenting the tumour to relieve obstruction.
In the final stages, it would have to be supportive care, pain relief & TLC (tender loving care).
In other words, not doing anything at this stage would mean that as the cancer progresses, the treatment options available to him would get less and less till all we are left with is TLC.

We consulted his Cardiologist Dr L & his Renal Physician Dr C to assess if he was fit enough for major surgery.

Wow!

His cardiac function was great!
His previous stent was patent even though he had not been taking blood thinning medication like he was supposed to.

His kidney function was impaired however. Though not bad enough to require dialysis, some care was clearly needed. However, Dr C was confident he could make it through surgery and I had great faith in Dr C & Dr L.
What was very clear to me was that his surgery had to be as perfect and faultless as possible because at his age, he would not tolerate any complications that might require repeat surgery.

This is one of those times where the decision is not clear cut or easy. I could put forward a case for operating, and also a good case for not operating. Some of my colleagues would advocate leaving well alone, and they could be right. They would certainly sleep better at night!
However I did not train as a surgeon just to treat easy cases or fit young patients. I trained as a surgeon with a commitment to do my best for all my patients at all times. If there was a life to be saved, I was up for it.

So I put all of this before Mr Lee and his children.
I would have been entirely OK about it if they had decided not to operate.
After much detailed discussion, they decided we should go for it.

Adhesions !

And that was how I found myself looking at Mr Lee’s stomach cancer.
Yes, it was relatively early cancer and yes, there was indeed no evidence of spread.
There was even no recurrence of his previous colon cancer.
But his previous operation had left his abdomen full of adhesions!
Adhesions are scars left in the abdomen after surgery. Sometimes it is not too bad but Mr Lee’s adhesions were pretty awful.
Just about all of his small bowel was stuck down and I needed to free all of it up to do the operation and make sure I was joining the stomach remnant back to the correct part of small bowel.
There was no way of doing this quickly and it ended up adding a good few hours to the operation.
That was before I could even get going with removing his stomach cancer!

I think I ended up just as exhausted as Mr Lee, albeit with less pain…..

Mr Lee’s family anxiously awaited me, bursting with questions.
“It’s OK, the cancer has been removed but the coming week we have to be very careful …..”

Well, his progress was slow that following week, which was hardly surprising, considering his age. There was some fever due to a chest infection to fight off.
Every night, I went through in my head all the possible things that could go wrong and how I’d avert them. The worst would be a leak from one of the multiple joins in the bowel and stomach.
Mr Lee’s devoted family were by his bedside throughout and for his part he displayed a tenacious fighting spirit.
Finally, on the 8th day after his operation we did a special X-ray called a contrast study and I was able to announce that he was healing well with no sign of a leak at any of the joins in the bowel and stomach.

The day eventually came when we were able to declare him fit to go home.
His 2 sons and daughter looked at me with relief.
It was a strange feeling – the hazardous journey we had just undertaken had somehow brought us closer together, as if we were one.
We had emerged from a dark place into the light, unscathed.
And this was in no small part helped by invaluable support from my two medical colleagues.

Mr Lee's gastric cancer. Note the ulcer with raised edges (green arrow). The report showed an early cancer with clear margins and no lymph node spread.
Mr Lee’s gastric cancer. Note the ulcer with raised edges (green arrow).
The report showed an early cancer with clear margins and no lymph node spread.

 

Unsung Heroes ….

From time to time I read stories of heroes and extraordinary rare acts of bravery.
Yet, I am surrounded by heroes all the time – my patients who bravely place their lives in our hands and courageously battle through surgery and cancer.
These are the unsung heroes of our time, facing adversity with grit and determination.

I do not know if Mr Lee will get a recurrence of his cancer or not.
I do not know to which ripe age Mr Lee will live to.
But I do know this –
That we had made the right decision and that we had done our very best.
And that is the most that I can humbly expect of myself.

UPDATE – Mr Lee has now returned to his daily routine of shopping at Tesco’s and driving his car. I don’t think any of the shoppers there know of the journey Mr Lee had to take to get there.