Intended for healthcare professionals

Bmj Usa A memorable patient

A memorable patient

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7521.E386 (Published 13 October 2005) Cite this as: BMJ 2005;331:E386
  1. M. Gerard Baggot, adjunct professor (Accbizsvc{at}aol.com)
  1. Department of Anesthesia St. Louis University, School of Medicine St. Louis, Missouri

    The war bride was born about 1920 and raised in Rumania or thereabouts. When she was 3 years old, she swallowed lye, which scarred her esophagus, making deglutition almost impossible. Fortunately, a master surgeon took her case and devised an extraordinary practical solution.

    At that time, an Irishman, Dr Ivor Magill and his British associates working in London were introducing endotracheal anesthesia for plastic surgery. Their work would eventually advance surgery and critical care therapies, but it did not reach continental Europe until much later.

    Meanwhile, for endothoracic operations, German surgeons were experimenting with “negative pressure chambers.” These were never really practical nor widely available. The problem was that when the chest was opened, one lung or both collapsed. Either way, respiration would seriously be affected or impossible. At the same time, inhalation anesthesia, the only kind available then, would become unworkable, so elective endothoracic surgery was not attempted. Furthermore, since antibiotics were still far in the future, the possibility of infection constituted a serious risk.

    That master surgeon could not let his little patient slowly starve to death, so he entered her abdomen and excised a length of bowel. One end of this he attached to the stomach. Since invading the chest was verboten, he tunneled the free end of gut subcutaneously up along the anterior surface of the sternum into the neck. There he anastomosed the other end to the pharynx. This gave her a functioning conduit for nutrients to reach the stomach.

    The maiden grew up and found her knight in shining GI uniform who rescued her from cruel dictators and brought her to America, where they lived happily and raised a family. Unfortunately, when I saw her, she had developed an inoperable cancer at the junction of the graft and the pharynx.

    Despite the advances in anesthesia, surgery, and antibiotics that had occurred in the intervening 40-odd years, I, her American surgeon, had no solution.

    How did that master surgeon know the length the intestinal graft should be, in a growing child? How did he preserve the bowel's nerve and blood supply? How did he arrange that the transplant would have peristalsis?

    Presumably, when he excised that stretch of gut, he removed it with its mesentery attached so that it retained nerves and vessels. Did the bowel develop a new blood supply from the skin above and/or the subjacent sternum, which enabled the graft to grow as the child did? For peristalsis I imagine he attached the distal end of the graft to the stomach and the upper end to the pharynx. Anyway, he did provide his little moribund patient with a future and about 35 years of normal happy life.

    Lloyd Nyhus tells us that Amza Jianu, a Romanian surgeon, was keenly interested in this problem, so perhaps he or one of his neophytes saved the little girl.1

    References

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