SURGEON'S DIARY: Determined not to lose her beloved father before she was born

My patient, his dear wife and I suffered the wrong diagnosis until the pathologist put us all on the right track. ILLUSTRATION| JOHN NYAGA

What you need to know:

  • It started with Robin Ouko coming to see me with his wife Hilder and carrying a letter from his family doctor and a bulky large envelope containing his X-rays.
  • I warmly welcomed them, put the anxious looking couple at ease and then read the letter from Dr. Juma.

To set the record straight for my professional colleagues, who were repeatedly attacked in the popular press, I wrote in the Daily Nation of March 3 this year and I quote: “Medicine, unlike mathematics, is not a pure science and, in spite of phenomenal progress in diagnostic and treatment techniques, misdiagnosis and mismanagement do creep in despite the most competent and highly ethical effort by a health professional.”

After making that statement, it was natural for me to look back on my own record to see how many close brushes of similar nature I have had. Naturally, there were a few where I initially missed the diagnosis but I want to reminisce about this case where an erroneous diagnosis was fatal and the correct one was indeed life saving.

My patient, his dear wife and I suffered the wrong diagnosis until the pathologist put us all on the right track. It started with Robin Ouko coming to see me with his wife Hilder and carrying a letter from his family doctor and a bulky large envelope containing his X-rays. I warmly welcomed them, put the anxious looking couple at ease and then read the letter from Dr. Juma.

It said, “Ouko saw me a week back with dysphagia. Physical examination: negative. Barium Swallow: suspicious. For your expert opinion and further management.”  By dysphagia, Dr Juma meant difficulty in swallowing and Barium Swallow is an X-ray of the food-pipe, while the patient is drinking barium.

This telegraphic message was typical of Dr Juma, going by previous referral letters from him. For my readers born after the computers arrived and telegrams went out, in the good old days, urgent messages were dispatched telegraphically. The cost and time taken depended on the number of words, so a serious attempt was made by the sender to make the message as brief as possible without distorting the substance. After reading the letter, my first question was. “Where do you come from?”

“Kisumu,” replied Robin.” I work for a bank and they recently transferred me to their Nairobi branch.”

I inquired about where he hailed from because dysphagia caused by cancer of the food-pipe was and is still common in people who live by Lake Victoria.

 “Is the swallowing difficulty progressive and does it apply more to solids than liquids?” I asked next.

VARYING DIFFICULTY

“The difficulty varies but I have more difficulty with fluids rather than food items.” Robin was very clear on the two significant points.

I asked various other questions and came to his family history. “How long married?” I inquired looking at Hilder.

“Five years,” Hilder readily replied while Robin had a temporary amnesia, which men usually get when confronted with that question.

“Any children?”

“No, but one on the way.” By now Robin had regained both his memory and speech.

Not seeing any overt signs of pregnancy, I asked Hilder. “How many months?”

“Two.”

I then asked Robin to get on the couch. While he was doing so in slow motion, I fleetingly recalled an incident in England when I was training as a surgeon there.

Notices had just gone up on the London double-decker buses to give seats to pregnant women, disabled people and senior citizens.

A young lady boarded a bus in which I was travelling to the Royal College of Surgeons to attend my lectures and brazenly asked a man dressed in a three piece striped suit, a bowler hat and carrying a walking stick to vacate his seat for her, pointing at the new notice. Flabbergasted and not seeing any obvious signs of pregnancy, neither wanting to be taken for a ride, he asked the woman, “How long pregnant?”    

“A couple of hours!” she replied, her face crimson with sinful guilt.

My examination of Robin did not yield any positive findings either. I put his X-rays on my viewing box and saw the barium held up at the lower end of his food-pipe which tapered into what is described in surgical text-books as rat tail appearance, so typical of cancer of the gullet.

“I am sure your doctor has told you what he is suspecting,” I said trying to get out of giving them the sad news. Without waiting for a reply, I added: “I feel the same and suggest that we do an oesophagoscopy, look inside the food-pipe and take tissue sample for microscopic verification.”

COUPLE HAD BEEN COUNSELLED

Obviously the couple had been counselled and we booked the procedure for early next week. At oesophagoscopy, I could clearly see the food-pipe narrowing and tightening at its lower end but did not see a growth or an ulcer, neither could I push the scope without forcing it.

Having made a clinical diagnosis of a malignant growth, I did not want to do that and presumed that it was further down where my illuminated instrument could not reach. I took a few bites of the tissue for microscopic examination.

I knew that Hilder was anxiously waiting outside the operation theatre to get information about what I found, so I popped my head out of the theatre door between operations and said to her “I am afraid I did not see a growth or a malignant ulcer, which is a good sign, but let us wait and see what our pathologist has to say after she has examined the tissues I have sent her.”

As I drove home that evening, I made a wish that the material I sent for histology would be reported negative for malignancy. A happy thought passed through my mind to the effect that against all odds, it could be a case of cardio-spasm, where the muscles of the lower end of the oesophagus get hypertrophied and go into spasm, causing a functional obstruction in contrast to a mechanical one. The former is supremely curable by a straight-forward piece of surgery, while the latter is more or less like a death warrant.

 The surgical axiom that common things occur commonly and Robin hailing from Kisumu went against my wishful thinking. The disease, as mentioned before, is common around the lake and, though we don’t know the cause for sure, various theories abound.

Drinking local brew, excessive smoking, inhaling fumes from open fires used to combat cold in confined spaces like huts the local people live in, eating dried fish processed with strong chemicals have all been incriminated. On the other hand, the history of greater resistance to liquids rather than solids and the periodic appearance of obstruction greatly favoured the unlikely diagnosis.

What a joy it would for me to announce to this couple expecting their first child after five years of marriage that Robin’s condition was benign and what a relief to them. There was also another reason for my wishful thinking. The disease was common in Japan and a lot of research on the disease was coming out in the journals there, duly translated in British surgical magazines.

The Japanese surgeons recommended using a triple approach making oesophagectomy operation  a long laborious procedure involving opening three cavities, abdomen, chest and neck, so as to comfortably remove the cancer with two inches of the normal oesophagus above and below the growth to get a good clearance.

HAZARDOUS PROCESS

This surgery was fraught with many complications. Also oesophagus is deeply placed inside the chest and is close to the largest artery, the aorta, and the largest vein, the vena cava, making operation on it a very hazardous process. A slip of the knife can literally result in rivers of blood and death on the operation table.

For these reasons, the first oesophagectomy I carried out at the Aga Khan Hospital took me a good eight hours. At the end of the marathon, as we were closing the chest, to lighten the tense atmosphere which accompanied our maiden effort, I asked the Sister who had scrubbed with me: “If God granted you one wish, what would it be?”

“Feeding tube,” she replied instantly. “I am thirsty and hungry.” Reciprocating my concern for her, she asked: “What about you?”

“A catheter,” I replied. “My bladder is bursting!”

Anyway, Robin Ouko did not put us through that ordeal. The report on his biopsy was: “No malignant cells seen in the specimen sent. However, in view of the history and where he comes from, a repeat biopsy is recommended.” The disclaimer was typical of the lady pathologist and commensurate with my views.

As I usually did with difficult cases, I had given her lot more information than could be physically included in the request form and had discussed Robin’s case with her.  I went one stage further and requested our chest surgeon to carry out repeat oesophagoscopy and take another biopsy. To everybody’s delight, the pathologist, late Dr Rana, gave the same benign report.

The diagnosis of cardio-spasm had been properly established and I carried out Heller’s operation, split the hypertrophied muscle at the bottom end of Robin’s food-pipe and relieved his symptoms for good.

A few months later, Helder delivered a lovely baby girl. Carrying the little girl in a baby cot, she accompanied Robin, who came to see me on his follow-up visit. She thanked me for taking the trouble to come to the correct diagnosis on her husband. While I was glowing with pride, pointing to the baby, she added: “This daughter of mine is responsible for the switch in her father’s diagnosis. She was determined not to lose him before she was born!”

I was not offended in the least. We surgeons are used to getting the blame when things go wrong. God usually gets the credit when things go right. I was happy to see the credit this time going to someone else!