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Jessica: Hey guys. Welcome back to The Absite SmackDown podcast. I'm your host, Jessica. And with me is Dr. David Kashmer. Hi Dr. David, thanks for being on today. As you can see, we are doing our Halloween special.

 

Dr. Kashmer: Yes Jessica, I looked forward to this one. I think when you were talking to me about, it sounded like a great idea. So here we are to talk about kind of a Halloween theme Absite Smackdown podcast.

 

Jessica: I actually asked Dr. David to wear a costume today and he indulged me. And so for those of you watching, not just listening, I am a cow, my ears keep disappearing from the video in Zoom, but it's a fun costume. And Dr. David, I love your costume, Dodgeball, right?

 

Dr. Kashmer: Yeah. It's a favorite movie. It's my go to custom every year. It's the Average Joe's dodgeball costume. Yeah, easy to do and really comfortable. And so, easy to wear on the show while we talk about the top five darkest surgical facts.

 

Jessica: Right. As Dr. David said, that is our podcast this week, “Top Five Darkest Surgical Facts”. So how we came to this is if you're a regular listener to our show, you'll remember a previous episode where we were talking about surgical mistakes and Dr. David told us about schadenfreude, which is dark joy and how you can get dark joy from other people's mistakes. And I just really loved that word and thought about what it meant and how appropriate it is for Halloween.

 

Dr. Kashmer: And I think you picking up on it with wanting to talk about the top five darkest surgical facts was kind of a really great idea. There are plenty of interesting sort of dark or sort of, I mean, sometimes people who aren't in the surgical field may even say creepy, surgical facts. And so bringing those together today, I think will be really fun.

 

Jessica: Yeah, I'm excited. So let's go ahead and get into it.

 

Dr. Kashmer: So number five, one of the things that's always been most interesting to me is how quickly that a liver remnant can regrow after major liver resections, especially obviously non-cirrhotic patients. It's really interesting, you know, hepatocytes to begin with are interesting. They have multiple nuclei often, and you see a lot of phosphate used in this process. There's a DNA replication that's going on, and that really is sort of a phosphate sink as cells come back. So it's sort of this really interesting, unusual fact to me that the remnant could regrow and things like trans arterial catheter embolization (TACE) takes advantage of a similar thing. And it's just so interesting to me. So that's number five today for us, this rapid regrowth of the hepatic remnant after major liver resection.

 

Jessica: Okay. Well, that's interesting to you, but kind of creepy to me.  Especially, you know, when you think about the fact that the liver regrows itself, and it definitely ties in with this slide choice of mythology and having the liver eaten out and regrowing over and over for ultimate punishment. It's super interesting.

 

Dr. Kashmer: Yeah, that's the classic Prometheus's punishment where he stole fire from the gods. And this is all my memory. So, you know, pardon me, I don't have it spot on, it's been long time, but I'll tell you what a punishment!  To have a liver constantly consumed only to regrow. And it turns out liver really does that. So like you said, this is number five on our list, rapid liver regrowth of the remnant. And I know, like you said, Jessica, you find it kind of creepy!

 

Jessica: I do. I do. It reminds me a little bit of The Silence of the Lambs where Lechter is like, “I ate his liver with a side of beans and a nice Chianti.”

 

Dr. Kashmer: So then on to number four!  Jessica, take it away.

 

Jessica: Okay. Well this one, I wouldn't say this is creepy, but it's super interesting:  incomplete gut rotation.

 

Dr. Kashmer: It's just like you were saying before. and, as we go through embryology, the gut actually forms and herniates out through the umbilicus early in gestation about week six. So just to clarify, because I know we talked about it a little bit ahead of time and, I know you'll have plenty more to say about it, but what's super interesting is the gut herniates out, rotates 270 degrees (at least it's supposed to) and then returns to the abdomen and through that umbilicus and in the area close out, closes out, except when it doesn't, when patients get on fallacy or something similar, or the rotation is incomplete, even though the gut returns and they're left with a nonrotation or incomplete rotation or “malrotation”.  Some can be obvious and symptomatic. And they end up with a Ladd's procedure.  That's all covered in the review book of course, in the book.

 

Interestingly, I've seen two patients who made it to adulthood with this, and that caused me to read all about it again.  It turns out approximately 1% of adults have some type of nonrotation.  So it's super fascinating and super interesting to me that there are people walking around who never even come to the hospital, but a percentage of the population has this non-rotation of their gut. So I just was really excited to share. It didn't mean to jump in there.

 

Jessica: I mean, it's okay. So what, just as a side note, what happens when an adult comes in and they were unknowing of this and they have this issue, what do you do?

 

Dr. Kashmer: Well, interestingly, I've seen this in two patients and one patient of mine was 70 years old…seven zero years old.  He came in with a partial small bowel obstruction. And originally two other surgeons were working on him and he'd had previous surgical procedures at a very large famous institution. And they placed a tubes in him, including a gastrostomy and a jejunostomy tube. And despite that they either didn't recognize, or for some reason didn't correct, his non rotation. (Maybe they didn't think it was the cause of anything important in that case.)  After all, usually if you make it 70 with malrotation you don’t have symptoms.  He had these Ladd’s bands overlying the duodenum and a mesenteric twist just like people get with this condition and this 70 year old required correction of everything because no particular adhesion seemed to be obstructing. So during his complete lysis of adhesions everything was already freed up and so the team went on to complete a Ladd's procedure, even though he was older. And that's so unusual. I say that, but as I get closer to 70, it's really not that old anymore! 

 

I'll tell you though that, he, underwent this because there was no clear partial, small bowel obstruction from adhesions. And so the team opted to correct his non rotation at 70 years old, actually 72. During his recovery, he explained he’d had bowel issues his whole life and now felt better with food than he ever had before.  Who knows whether that was a mild, subclinical effect of his non-rotation since birth!

 

Jessica:  So interesting. So fascinating. So sort of dark and creepy that there are people walking around that have this!  Just walking around, not knowing they're all twisted up!

 

Dr. Kashmer: Yeah, super interesting.

 

Jessica: Which brings us to number three.

 

I had a bit of a reaction to this picture again, because I'm not a surgeon and I don't have the smooth demeanor you guys have. So number three, and again, if you're not watching the slides and you're listening let me tell you this is significant!  Will you pronounce this for me David to make sure I do not say it incorrectly?

 

Dr. Kashmer: No problem. It's gingival hyperplasia. And so the photo is of someone's teeth and gums with the gums sort of winning the war against the teeth, sort of taking over the spots where teeth would normally be. So kind of dramatic if you've never seen it before. And that gingival hyperplasia is a known side effect of cyclosporin.  Not every solid organ transplant recipient gets cyclosporin nowadays. And the ones who do get cyclosporin do not usually develop gingival hyperplasia.  Jessica, if you had to pick one of the words that we've been using today to describe things, these different entities, which word would you use to describe this one?

 

Jessica: Honestly, I don't even know. I look at it and to me, they look like bubble gum bubbles. Not an appropriate word. I'm sure you have an appropriate word, but it just, you know, it makes me a little unsettled.

 

Dr. Kashmer: “Unsettling”…I can see that. So yes, gingival hyperplasia.  Number three on our list today. Now number two, Jessica is the umbilical hernia in the cirrhotic. And the reason this makes our top five darkest most unsettling facts is that this is like a trap. Think of the umbilical hernia in the cirrhotic, whether for the Absite or your oral boards:  it's a trap.

 

This is like that the Halloween movie where the killer is clearly in the house, you know, the killers in the house waiting to kill someone and people are wandering into the house.  You'll watch junior residents or faculty kind of wander into the house.

 

And the next thing, you know, bam!  Chainsaw gets them.  That's number two on the list. That's the umbilical hernia in the cirrhotic. And here's why. Cirrhotics have often ascites and umbilical hernias. When you make a surgical incision to repair it, you are very much more likely to get an ascites leak out of the wound. And with that fluid leak comes fluid shifts and imbalances, and their liver can be compensate. Clearly if they have cirrhosis with ascites they have decompensated already, I mean, their liver function is compromised. They are in a bad way. if they have ascites, their MELD is at least 14, that's just how it works (because a MELD of 14 is decompensated cirrhosis) but they will often get an ascites leak via this incision. They'll get kind of a wound infection, ascites leak, and then they'll spiral downward and can die. Whether their kidneys shut down or something else happens, it's a nightmare.

 

So like a Admiral Ackbar in Star Wars says, it's a trap.  Like the killer in the house waiting with a chainsaw. It's a trap. There are ways around this. You can close the hernia after you place a drain into the belly that exits away from the surgical incision to get a controlled ascites leak.  So it doesn't leak from the wound, but it leaks from where you bring your drain out. That's an option. Why would you ever do something like that?  Why would you ever operate on an umbilical hernia in a cirrhotic at all?

 

Well, Jessica, the reason you would ever do anything to an umbilical hernia in the cirrhotic is really, if you have to, if the skin is dead over the area, if there's a piece of incarcerated bowel and that bowel is dead, or, more commonly, there's already an leak. The skin has died and there's fluid leaking out already. Well, cat's out of the bag.  But in general, number two in our list is the trap.

 

It's the killer in the house. It's Admiral Ackbar saying it's a trap. And from a Halloween perspective, that's what makes me think of this one as number two.

 

Jessica:  What’s the name of the simulation in Star Trek that they can't win no matter what?

 

Dr. Kashmer:  Yeah. That's a scar Kobayashi Maru. That's the name. I just totally gave away my SciFi nerdiness. Yeah. This is exactly like that. There's no way you can win. What's the best you can do in a losing situation.  There are actually lots of situations like that in surgery, but this one, I think you nailed it.

 

Which brings us to number one. Number one is inflammatory breast cancer, and here's why it's scary.  Inflammatory breast cancer, Jessica, can look like a lot of other stuff.  In the picture onscreen (for the people who are just listening) it looks like just a rash. That's the inferior medial portion of a breast and it just seems to have a rash on it. Guess what?  It was breast cancer. You may see a breast lesion and you think it's just an abscess. People come to the ER with breast abscesses all the time. Well, another breast abscess. It may have MRSA in it. Methicillin resistant staph aureus, you know, it looks like an abscess. Well guess what?  It may not be.  It may be cancer. And you always have to have that in the back of your mind when you see these people.

 

Typically there are different approaches. One common one is antibiotics for a couple of weeks, seeing back in the office very quickly, impress upon the patient that they need to go to the office. There is a cancer risk and they need to be followed for that. And then after a certain set time, a brief set time, if there is not complete resolution the area needs a punch biopsy to check for invasion of the dermal lymphatics by cancer cells. And the hint here is it doesn't resolve with antibiotics.

 

You have to be thinking of it. This is a scary one because of what it looks like, which is just such a common thing, a breast abscess or skin rash. So number one, the reminder that inflammatory breast cancer masquerades like a lot of things, and you have to be sure close followup with a punch biopsy is done if there's any question?  So what do you think Jessica?

 

Jessica: Well, I think breast cancer is just scary regardless, and it could have taken more than one spot just for the fact that it doesn't metastasize the way that most cancers do. Like it doesn't go straight to the nodes. It can just go elsewhere. And so for me, that is a super creepy, scary part of just breast cancer period. Let alone, “Oh, I have a rash on my chest. Oh no. That's cancer girl.”

 

Just number one all around.

 

Alright guys. So that was our top five darkest surgical facts. If you have any questions or any comments, you can always email us info@thehealthcarelab.org. And just to go back over them really quick, Dr. David.  Hit us with those top five.

 

Dr. Kashmer: Sure. Number five:  the liver remnant regrows, and just how interesting it is. The liver can regrow and the history of some of the punishments that included having the liver eaten by a large bird and it regrows are kind of dark.  Number four:  incomplete gut rotation.  About 1% of people are out there walking around with their bowels returned to their abdomen, but improperly rotated, and that can manifest late. Although usually it’s symptomatic, which is how they made it that long. Number three, gingival hyperplasia from cyclosporin. And Jessica called this one creepy. And it is creepy. I encourage you to watch the video version of the podcast (if you haven't) just to see how impressive this gingival hyperplasia from cyclosporin can be.  Number two:  umbilical hernia in the cirrhotic. This one is a trap. This is the killer in the house.

 

The answer there is don't repair it unless there's a leak from the area already, or the skin's already dead, or there's a piece of bowel that you're very sure is dead. And the reason why is cirrhotics will decompensate often post repair. If you do have to do a repair, options include placing a drain so that you get a control. This gives a controlled ascites leak rather than one via your wound. And then last, as Jessica said, breast cancer could have taken up more than just the first spot!  Number one on the list, inflammatory breast cancer.  And the reason it's so scary is that inflammatory breast cancer looks just like a breast rash or abscess. And I can't say enough about how this one is really kind of like a masquerade ball, how it's people wearing a mask, but that distracts from the underlying truth that you have breast cancer here, not an abscess. They ultimately get a biopsy of the area if there’s any question of something other than routine infection. So those are the top five darkest surgical facts for this Halloween!

 

Jessica: Thanks Dr. David, thanks for being on the show. And again, guys, if you want more info or just want to follow us, go to AbsiteSmackdown.com.  On Insta, you can find us at daily.Absite.fact.  On Facebook, we’re @AbsiteSmackDown, Twitter is @AbsiteSmackDown, LinkedIn is @AbsiteSmackDown.  YouTube is the Absite SmackDown channel, and, starting this week, we're going to be on Tick-Tock @ AbsiteSmackDown.  Follow us on our podcast on iTunes, Spotify, Stitcher, SoundCloud…anywhere you want you can find us and guys remember…#AbsiteSmackdown!