“You can’t just let me bleed like this, Doc. I need to get out of here.” So said John, a man in his seventies, with kidney cancer spread to his Ampulla of Vater. Renal cell cancer is among those that sometimes behave in very strange ways. John had had his removed, along with his left kidney, about nine months earlier. At the time, it was thought likely to be a curative procedure. Now, he’d been admitted anemic, weak, with evidence of blood in his stools. Workup, including endoscopy, had shown a friable bloody tumor right at the ampulla, and biopsy had shown it to be the kidney cancer, now spread to this ultra-highly unusual place. It didn’t seem to be anywhere else. He wasn’t bleeding much, as these things go: about a pint a day. Easy to keep up with; hard to send him home.
Ordinarily, the operation for a tumor at this location is a choice between two options: local excision (done by opening the duodenum and carving the tumor out), or a Whipple procedure — the biggest of the bigs. For a diminutive tumor, the former may suffice. Its main limitation is that you can’t carve very deep without getting into the pancreas or going through the back wall of the duodenum. So it’s pretty much reserved for those small tumors, preferably mild-mannered ones. If you’re serious about cure, you go for the Whipple. I talked about a Whipple in my book: it’s every surgical resident’s dream: the full-meal deal, the three-ring circus, the Superbowl of surgery. It involves about every trick up the sleeve of a general surgeon: removing some stomach, some bowel, some bile duct, some pancreas, the gallbladder. Hooking things back together using — because the organs are so structurally different — every type of sewing technique you know. As challenging and fun as it is, it’s also risky for the patient (mostly because of the possibility of leak of digestive enzymes from where you sew the pancreas to bowel, which begins a process of auto-digestion …) So doing it on a patient with metastatic — and therefore statistically incurable — cancer just ain’t hardly done.