Dear Editor,
For over 10 days, I have seen a GPHC patient’s husband looking very sad in the ward. His wife was diagnosed with obstructive jaundice. A CT Scan was done, and referred that there was a tumor at the head of the pancreas.
She was waiting for surgery for almost 10 days. During these days she felt more pain, and the jaundice became more severe due to bad medical conditions in Guyana.
The first case of nerve blocking in end stage pancreatic cancer to treat pain at Georgetown Public Hospital Corporation (GPHC)
I have arranged a team to come to GPHC because it is the best hospital in Guyana. However, if my team is on call the same day as we are operating, emergency cases take precedence over the patients for elective surgery, and attending to them is delayed and pushed back to another date.
I researched this case and found that it was very complicated due to the location of the tumor, and that the tumor has invaded the common bile duct and mesenteric vein. Her jaundice was worsening, and protein levels were low. Her pain was so severe we could not sufficiently treat it with only medication. Due to the lack of resources, such as MRI, contrast CT, albumin and plasma, we are unable to assess the patient preoperatively; and postoperatively, we are unable to give sufficient nutrients to aid in the duration of treatment. I did not want to operate due to the high risk; however, because of the patient’s pain and her family’s hopefulness in the doctors, we proceeded.
The night before the operation, my team and I planned and read articles in preparation for surgery. We discussed all the possible outcomes that may happen during the operation. I even got advice from my teacher back in China.
On July 19, 2018, we began operating. We found that the situation was much worse than anticipated. The tumor was bigger, and had invaded the common bile duct and the mesenteric vein. Multiple lymph nodes were present, and organs were edematous; the liver had changed colour due to over-storage of bile. The decision was made to put in T-tube drainage and block the abdominal nerve with 95% pure alcohol, which has never been done in this hospital.
It is dangerous to block this nerve because of its location. It is located next to the inferior vena cava and close to the aorta, which are the biggest vein and artery respectively. Also, if the alcohol goes into the patient’s blood stream, she could die immediately. Before injecting the alcohol, anesthesia was told to pay special attention to the patient’s vital signs. We located the correct point for injection of the alcohol, and proceeded. At first there was a complication with the injection, the nerve was then compressed and position readjusted. I advised anesthesia once more, and at last the operation was finished.
Anesthesia told us that the vital signs were all normal. I knew I had succeeded. After I was finished, I found that my scrubs were wet from sweat.
The next morning, even though it was only one day post-op, the patient told us she was feeling much better, and we knew the surgery was a success. All the doctors described the outcome as “Amazing!”
My colleague, Dr. Motilall, told us there are many patients in similar condition, and this operation would be very useful for those patients. An operation like this had never previously been done in Guyana.
Even though I was smiling at the time, I regretted in my heart that we could only relieve her symptoms and not cure her. Only thing we can do is to relieve her pain and help her live the rest of her life with respect. If these patients came to hospital earlier, and the medical condition is much better so that we can assess the patient’s situation correctly, we would have a chance to resect the tumor completely; and after operation, the patient can receive sufficient nutrition to sustain their life.
It was perfect, and the smiling of the patient and her family will be with me forever. That’s all we want as doctors.
