17th August 1997

Near miracle indeed

The Healing Cut - 6

By Roshan Peiris

It was a surgical miracle, performed on a 47-year-old farmer from Kottawa. For three months the unsuspecting man had found he could not swallow, had no appetite and naturally lost weight.

Finally he came to the Sri Jayewardenepura hospital and was diagnosed as having cancer of the oesophagus, the thoracic part. So the surgeon, doctor Gamini Goonetilleke operated on him.

It was a marvel of intricate surgery by a surgeon who with unassuming skill and ease successfully performed a six-hour operation.

All the patient's abdominal organs lay exposed and I must confess it was an unseemly sight putting it mildly. Awe stricken I asked the doctor whether he prayed before the operation. He, a Christian said, "No but I do ask for God's grace to carry out the operation successfully. My belief is that it is the job of the medical profession to relieve the suffering of humanity.''

To go back to the patient, after he was brought to the hospital he was first administered an enema and made fit for this long and intricate operation.

In this operation the lower part of the oesophagus together with a part of the stomach is removed.

A tube like contraption is extended from the stomach and is pulled upto the neck. The stomach is virtually pulled up to the neck. This part is sutured to the upper part of the oesophagus, the cervical part which did not show signs of cancer, into the neck.

This neatly sewn tube from the stomach will replace the cancerous oesophagus and will function as a conduit for food to go down from it to the intestine.

All the sutures looked like neat top stitches which could put a competent seamstress to shame.

The spleen too was removed to give the stomach area more space.

One need not pull the stomach to the neck. By cutting the chest it could be done, but this puts the patient to tremendous disadvantage and recovery is slow.

Dr. Goonetilleke the surgeon explained that the only way to save the life of the man and cure him was to remove the diseased part. In consultation with the anaesthetist Dr. Mrs. Suriyakanthi Amarasekera he began the operation following adequate pre-operative treatment.

After the general anaesthesia, a tube is inserted into the oesophagus and a drip given to the peripheral vein. A large cannule is inserted into the neck vein to monitor the pressure at the central vein and infuse blood rapidly if the need arises. A catheter is also inserted into the urinal bladder to measure the urine output.

Dr. Goonetilleke then made an incision first into the abdomen, identified the tumour and gently detached the stomach from its moorings except from those parts required to keep the blood supply flowing. The supply is carefully monitored to ensure a continuous flow.

Next the tumour is removed and the cut end is sutured to make a part of the stomach into a tube.

After that an incision is made at the roof of the neck on the left side and by careful direction the remaining area of the oesophagus is identified, and is separated from the rest. Finally the surgeon separates the oesophagus in the chest and when it is free pulls it into the neck. A tube is passed from the neck to the abdomen through the chest. The stomach is connected to this and is pulled up into the neck. The upper part of the oesophagus is sutured to the stomach to restore the continuity of function of the alimentary tract.

With neat stitches, the neck wounds and the abdominal wounds are sutured.

The patient remains for twenty-four to forty-eight hours in the intensive care unit for careful observation.

By the seventh day he will be able to drink and hopefully between ten to fourteen days he will be back at his home.

It is, mused the surgeon, "a satisfaction that no money can buy."

'The Sunday Times' thanks Dr. Gamini Goonetilleke, consultant surgeon of Sri Jayewardenepura hospital for this wonderful opportunity afforded to watch an operation which is nothing less than a near- miracle.

Juan Appu's example

My uncle Lakshman used to have a favourite story about Juan Appu and the dog.

The dog in this story used to be a terrible disturbance to Juan Appu by regularly howling outside his window in the early hours of the morning - which, needless to say, played havoc with Juan Appu's sleep and peace of mind. Although he would grumble about it to his wife (which disturbed her sleep as well) and then go on hoping and praying and wishing that the dog would cease this cacophony, the canine pest persisted in making a nuisance of itself.

One night, during a particularly long spell of howling, Juan Appu decided that he had had enough. He crept out of the house, picked up a large stone, and flung it with unerring accuracy at the dog. The howling ended with an abrupt yelp of pain - but the dog got the message. Ever since then, Juan Appu was able to sleep in peace.

When it comes to illness, most of us are a bit like Juan Appu. Taking steps to change the situation and treat the ailment is easy but the ailment has to become unbearable enough for us to want to take the necessary steps.

The fact is, a patient's attitude to his or her symptoms can have an enormous impact on the outcome and duration of the illness.

Many of us have symptoms perhaps a nagging cough, or some breathlessness when we walk up the stairs or even the need to get up four times during the night to go to the bathroom. Generally we put up with these symptoms or even inflict those willing to listen to us with a painstaking description of these ailments but we don't make the effort to consult a doctor about them.

Like Juan Appu, the howling has to reach a certain threshold before we get out of bed to do something about it.

Take one of my old class teachers for example. He had been getting these episodes of loss of vision in one eye for the past six months. Suddenly, out of the blue as it were, he would get the feeling that a curtain was being drawn across one eye. This would last for a minute or so and then the feeling would pass off.

He did nothing about these episodes - except occasionally complain about them to his wife. They were not serious enough, he felt, to warrant a visit to his doctor - which was a pity because several of his old pupils were now doctors, who would have been only too glad to see and advise their old master.

What the old gentleman did not realise was that these transient episodes were really TIAs or Transient Ischaemic Attacks. Such episodes of blindness are caused by temporary blockage of a blood vessel supplying a part of the eye and are an indication that sooner or later a major blood vessel would get blocked, causing a devastating stroke. It is now known that about 25% of people who suffer a stroke have had a TIA prior to the stroke. TIAs therefore are important warning signs that will alert a doctor to take measures (such as prescribing medicines to prevent clotting) to try and avoid a stroke taking place.

Unlike Juan Appu who put up with the disturbance for quite a while before he did something about it, we should take note of any unusual symptoms we experience and at least run the story past our doctor. Better to ask and (perhaps after a test or two) be reassured that the symptoms are nothing serious - rather than stoically put up with them until one drops down dead from a condition that could have been prevented.

Now I am not for one moment suggesting that one should start throwing stones at every dog which makes a noise.

But simply hoping and praying that one's ailment will go away is not enough - one has to go out and do something about it.

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