Ox Fall Down

Watching Maine come from 2 goals down against Harvard at the Moat tonight with Rodney Harrison. Patrons approach for his autograph but he just waves his beer and draft sheet and mouths, "Sorry."

"So you finally posted the surgeon's notes. Good for you. What took you so long?"

Just tired. No other reason.

"When do we hear from Delaney?"

Delaney's up next. He doesn't have much to say. By the time the bottle spins to Delaney there isn't much to do. Just point and shoot.

"Radiation in the middle of surgery? Why stop there?" Rodney Harrison gets a kick out of himself sometimes. He thinks he's laughing less than everyone else but he's actually laughing more. "Why didn't you get some of that intraoperative chemo? The trifecta."

Thankfully Maine scores their third in a row and I have an excuse to turn away.

The operative report:

DATE: 02/06/04


SURGEON: SAM S. YOON, MD
THOMAS DELANEY, MD

ASSISTANT: J. J. GONZALEZ, MD

PREOPERATIVE DIAGNOSIS: RECURRENT RETROPERITONEAL TUMOR ALONG CELIAC AXIS.

POSTOPERATIVE DIAGNOSIS: RECURRENT RETROPERITONEAL TUMOR ALONG CELIAC AXIS.

NAME OF OPERATION: EXPLORATORY LAPAROTOMY, RESECTION OF RECURRENT RETROPERITONEAL TUMOR ALONG CELIAC AXIS, IORT.

ANESTHESIA: GENERAL

INDICATIONS: The patient is a 33-year-old gentleman who initially presented with a retroperitoneal sarcoma in February 1992. This tumor was resected along with (a section of) the transverse colon by Dr. Jenkins at the New England Deaconess Hospital. The tumor measured 38 x 38 x 18 cm at that time and pathology was intermediate grade myxoid liposarcoma. The surgical margins were negative. The patient had a recurrence encompassing the celiac axis diagnosed in March 2000. The recurrence was 15 x 11 x 11 cm at that time and confirmed by biopsy (there was no biopsy and I can't find a report from DFCI that would give Yoon this idea.) He was treated with ET 743 and had a 95% regression (it was actually closer to 93%) but subsequent regrowth. He has more recently been treated with external beam radiation therapy by Dr. Thomas Delaney beginning in December 2003 and ending about three weeks ago. He is now brought to the operating room for resection and intraoperative radiation (funny how you present yourself for chemo, radiation, scans and meetings, but they bring you in for surgery.)

FINDINGS: The patient had a very soft necrotic appearing tumor which sat just above the celiac axis and adjacent to the common hepatic artery and splenic artery. It encompassed the left gastric artery. There was no evidence of other disease. This mass was resected in total. Frozen section analysis revealed 95% necrosis of this tumor. The patient was given intraoperative radiation therapy following resection.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. He underwent general anesthesia without event. The abdomen and right groin were prepped and draped in the usual sterile manner. We made a midline incision through his old laparotomy incision from the xiphoid (bottom of the sternum) to 2 cm below his umbilicus (navel). The incision was carried down through the subcutaneaous tissue and fascia. Near the inferior aspect of the incision, there was a small bowel loop that was densely adhered to the prior incision. Two serosal tears were made in the small bowel and this was repaired with interrupted 3-0 silk sutures. We performed some lysis of adhesions for approximately 20 minutes. We then placed the Omni retractor for exposure.

We began the dissection by dividing the gastrohepatic ligament laterally from the porta hepatis medially and superiorly along toward the GE junction. We identified the left gastric artery as it entered the lesser curve of the stomach and it was divided between ties. Once we had completely opened the gastrohepatic omentum, the tumor was clearly visible sitting just atop the celiac axis and closely abutting the anterior wall of the aorta. This tumor was soft and appeared to have a significant treatment effect from the prior radiation. We next exposed the common hepatic artery near its bifurcation into the gastroduodenal and proper hepatic arteries. The vessel was circumferentially dissected and the vessel loop was applied. We dissected anteriorly along the common hepatic artery to near the celiac axis origin. We next dissected along the superior border of the pancreas and identified the splenic artery. We dissected along the anterior portion of the splenic artery proximally toward the origin of the celiac axis. Next, the crus overlying the superceliac aorta was divided to gain exposure above the tumor. We then dissected along the wall of the aorta circumferentially and inferiorly. The tumor peeled off the anterior wall of the aorta along the adventitia layer quite easily.

The tumor spread along the sides of the aortic wall both to the left and to the right. We next dissected the tumor off the right lateral wall of the aorta in the adventitial plane.We took it off the soft tissues in this region as well as the inferior vena cava. We were able to peel the tumor from right to left and expose the celiac axis. We dissected the tumor off the celiac axis and its branches in the adventitial plane. There did not appear to be any invasion beyond this plane. The origin of the encased left gastric artery was divided between ties. The left gastric vein was also divided between ties both near the stomach wall and at its entrance into the portal vein. We continued to peel the tumor in a right to left fashion off the anterior wall of the aorta and proceeding toward the left wall of the aorta. We also took it off the superior aspect of the splenic artery. During this dissection, small blood vessels were taken between ties and divided. After some amount of meticulous dissection, the specimen was removed in its entirety. Stitches were placed to mark the margins posteriorly along the aorta as well as the lateral and superior margins. A frozen section was taken of the right lateral margin and left lateral margin during the dissection and both were negative for tumor. The entire pathologic specimen was taken to Pathology. Frozen section analysis revealed a largely necrotic tumor due to radiation effect with 95% necrosis. The tumor was consistent with a treated myxoid liposarcoma. There was an area of firmness along the left lateral aorta posteriorly immediately adjacent to where the tumor had been located. We dissected an approximately 1 x 2 cm firm nodule in this area and sent it for frozen section. Frozen section revealed a sympathetic ganglion.

We obtained adequate hemostasis and clearly demarcated the limits of the tumor bed. Dr. Delaney scrubbed in at this time and placed an intraoperative radiation therapy cone to encompass the radiation field along with a 1-2 cm margin. The intraoperative radiation procedure will be dictated by Dr. Delaney on a separate dictation.

Following intraoperative radiation therapy, we again checked for hemostasis. A Jackson-Pratt drain was placed within the resection bed given that we had dissected the tumor off the superior pancreas as well. This was brought out through a separate stab incision in the right mid abdomen. The abdominal contents were returned to their normal anatomic position. The fascia was closed using a running #1 PDS. The subcutaneous tissue was irrigated and the skin was closed with staples.

The patient tolerated the procedure well. There were no complications. The patient was transferred to the recovery room in good condition. The sponge and instrument counts were correct x 2.

Dr. Sam Yoon was present throughout the entire procedure.


SAM S. YOON, M.D.
DICTATING FOR:

Electronically Signed
Sam S. Yoon, M.D. 02/11/2004 09:50

-
___________________________
SAM S. YOON, M.D.

Bouldering tonight with Rodney Harrison up at Jack's barn. He works routes while I clutch the largest holds I can find. The boys ask for his autograph but he just waves his hands covered with chalk and mouths, Sorry. I tell him his arm looks good.

"The arm feels good. How's the stomach?"

Stomach's fine. Back's improving. Climbing stresses both but it's time. Yoon ok'd swimming. How am I going to swim in NH in March? Bouldering will have to suffice.

The snow is holding. I'm grateful for this valley, this barn, the Sopranos finally starting their season. Oh, yeah. If you take your Wyoming bride surfing in Mexico on your honeymoon...you win.

Drinking beers tonight with Rodney Harrison at The Waterfront. I nurse a Bud long neck and he double fists Bud Light 16 oz. snub noses. People ask for his autograph but he just raises both hands with bottles and mouths, Sorry. I ask about the arm.

"The arm'll be fine. How's the stomach?"

Getting there. It's less sensitive. Starting to eat more although I never know if I'm hungry. Dehydrated constantly.

"That's easy. Drink more water."

I'm drinking a lot of water. I've been drinking a lot of water since the radiation started at the beginning of December. I drank 5 to 6 liters a day and was still dehydrated.

"Are you doing radiation now?"

No.

"So stop complaining and start drinking more."

Rodney Harrison gets a touch touchy when he's on the 16 oz snub noses. Good thing I didn't mention my back.

Took a few runs today with Rodney Harrison. Late spring conditions. Sunny and high 30's. Visible snow loss from yesterday. Rain predicted for Friday and neither of us are happy about it.

In the lift lines people ask for autographs but he just waves his broken arm at them and says, Sorry. I ask about missing the parties and parade after the Super Bowl. He smiles and stares at the ground. "You know, for the first week I just wanted my arm off my body. When the pain subsided I was happy for the win and really glad I didn't get injured until the 4th quarter. But mostly, I was happy to be out of pain. Missing a parade and a few beers with the boys didn't seem such a sacrifice."

I nod. Graduation from high school was a huge ceremony followed by a week of parties. Graduating from college was quieter. Because of the first surgery and Paris I graduated in December and got my diploma in the mail. It was a huge relief. For weeks in the middle of conversations, walks or drives I would remember I never had to take another test, never had to write another paper. I didn't regret missing the ceremony or the parties because of the freedom.

Rodney Harrison smiles. "You know exactly what it's like to miss the Super Bowl parade. You couldn't care less. You're just relieved you didn't lose."