The Knife’s Edge. Stephen Westaby

from the surgery showed a very high white blood cell count, which suggested an abscess. Rather than passing through the gut as most bones do, this one had clearly penetrated through the wall of the oesophagus.

      Nick’s team was surrounded by medical students and radiologists as the CT scans came through. There was an abscess the size of an orange wedged between oesophagus and aorta in the back of her chest. Worryingly, there were bubbles of gas in the pus. Gas-forming organisms are among the most dangerous, so it was no surprise that she felt dreadful. The pus needed to be drained away urgently before the bugs entered her blood stream and caused septicaemia. Otherwise it could be fit to fatal within days.

The oesophagus and aorta descend side by side in the chest, nestled behind the heart and in front of the spine – oesophagus on the right, aorta to the left. Tiger country. Under high-dose antibiotic cover, Nick planned to open the right side of the chest through the ribs and locate the abscess behind the lung. Then, by opening the abscess cavity, the pus could be washed out and drains left in place for a few days until the antibiotics clobbered the infection. Nick thought that the small perforation through the muscular wall of the oesophagus would seal itself. While awfully simple in theory, it was destined to be simply awful.

      Through the glass door of Theatre 2, I could see Nick, sweating profusely with his face covered in blood, and both arms up to the elbows in the woman’s chest. Blood was slopping out of the chest cavity and down his blue gown, while anaesthetists were squeezing in bags of blood. It transpired that all had gone according to plan until he swept an index finger around the abscess cavity to clear the infected debris. First came the noxious odour of anaerobic bacteria and rotting flesh. Then, whoosh! Blood hit the operating lights. The abscess had eroded through the wall of the aorta. Behind the heart lay an infected swamp. All Nick could do was to stick his fist into the fountain and press hard. Big problem. They had already lost more than a litre of blood and if his fist moved she would bleed out in seconds.

Groaning deeply under the burden of the day, I gave Nick a resigned look and thought for a moment. The bleeding was still not under control and there was no prospect of repairing the hole while her heart kept on pumping. She would simply bleed to death. The only potential route out of the predicament – I called it ‘deep shit’ at the time – was to get onto cardiopulmonary bypass, cool her down to 16°C, then stop the circulation altogether. Deep cooling of the brain would give us a safe thirty- to forty-minute window without blood flow to identify and deal with the damage.

      Given the morning’s conflict, I very politely asked anyone not immediately engaged in the frantic resuscitation to ask one of my perfusionists to bring in and prepare a heart–lung machine. And for a couple of my own scrub nurses and a specialist cardiac anaesthetist to come across. Nick just had to keep on pressing. His anaesthetists kept on squeezing.

      Once I’d scrubbed up and joined the team around the body, I couldn’t even see the heart. I needed a much bigger hole in the chest to work around my colleague’s ‘finger in the dyke’. There was no time for finesse. With the scalpel and cautery I virtually split her in half as she lay there, right side uppermost on the operating table. The metal retractor cranked the chest wide apart with a crack that told me that one of her ribs had just broken. This was not unusual. Chest surgery is a brutal business.

Now I could see the pale, empty heart beating rapidly in its fibrous sac. I needed to cut this open and insert two cannulas to connect to the bypass machine. The first went into the aorta as it left the left ventricle carrying cherry-red oxygenated blood. The second was pushed into the empty right atrium, where blue blood from the veins of the body re-entered the heart to be pumped to the lungs. This venous blood, low in oxygen, would now pass through a heat exchanger and mechanical oxygenator before re-entering the aorta. Then we could cool and protect the brain and other vital organs. The heart is rarely approached through the right chest, but I had done it on a number of occasions for complex reoperations on the mitral valve. With a daunting challenge like this, every ounce of experience counted.

      Thinking ahead, I told one of the watching cardiac registrars to go in person to the homograft bank and ask for a tube of antibiotic-treated aorta from the supply of spare parts we obtained from dead donors at autopsy with the relatives’ permission. Human tissue is more resistant to infection than synthetic vascular grafts made from Dacron fabric. I often used donated heart valves, patches of aorta or segments of blood vessels from the dead to repair the living. This is recycling. God’s stuff is still better than man-made.

      At 2 pm the registrar from Theatre 5 came in to announce that he had put in pacemaker wires and chest drains, and had closed the baby’s chest. All was well.

      It took us around thirty minutes to cool down for the next stage of the operation. While his hands grew colder and colder, I congratulated Nick for saving the woman’s life. I told him not to risk moving and that cold was good as it meant the woman’s brain was cooling too. Then I asked the enthusiastic registrar to scrub up and babysit the bypass circuit so I could duck out for coffee and a piss. What I really wanted to do was to phone Gemma, but when I did there was no answer. She was still in a seminar. Although time was passing relentlessly, I remained hopeful that I would be in Cambridge by the evening.

At 18°C I was too impatient to wait any longer. Gowned and gloved for the third time that day, I told the perfusionist to stop the pump and empty the lady’s circulation into the blood reservoir. Nick could finally withdraw his cold, stiff arms from her chest after having had them in there for more than an hour, while I took the first operator’s position. In turn, Nick moved the registrar out of the way, eager to get a look at the damage for himself.

      With no blood flowing around the body, we were working against the clock. The infected tissues had the consistency of wet blotting paper and the stench of rotten cabbage. We could not repair the damaged oesophagus, and Nick agreed it had to go. I chopped through the precious muscular tube above and below the abscess, and dissected it away from the aorta. Nick passed a wide-bore suction tube down into the stomach to prevent it from spewing acid and bile over my aortic repair.

Now we had a clear view of the ragged hole, which really should have been a fatal problem. I reluctantly decided to replace the whole infected segment of aorta with the homograft tube rather than risk just a patch. No time to debate this. I trimmed the donor tube to the correct length, then sewed at top speed using blue polyester thread on a fine stainless-steel needle, held in a long titanium needle holder; deep bites into healthy tissue – aesthetically pleasing, bordering on the erotic. Throwing the final knot left-handed, I told Richard the perfusionist to ‘go back on’ and rewarm. Cold blood from the machine expanded the flaccid graft and air fizzed through the needle holes. It needed a couple of extra stitches to make the whole repair blood tight, but we restored blood flow to the brain after thirty-two minutes. Happy days. Though not so happy in my own case.

      I really didn’t have time to loiter and admire my needlework. Between us we agreed that Nick would divert the upper end of the oesophagus out of the left side of the poor lady’s neck to drain saliva and enable her to swallow liquids for comfort. The lower end would then be closed off and an entrance to the stomach fashioned through the abdominal wall through which she would now be fed. We call this a gastrostomy. Months down the line Nick would restore her swallowing with a new gullet made by transposing a length of large bowel between her neck and stomach. But for now she was safe. In life, and for that matter death, timing is everything. Heart surgeon close at hand. Heart–lung machine and perfusionist available between cases. Spare parts on the shelf. Otherwise she was dead, killed by a fish.

      Nick’s gastro team were happy to close the chest, put in the drains and finish off. Stepping backwards from the table into a pool of slippery blood clot, I skidded gracelessly onto my backside, hard down on the tiled floor with a crack – retribution perhaps for leaving Nick for so long with his cold hands in the chest. Now with a soggy red patch on my trousers and the suspense of a near-death drama lifted, it gave the nurses something to laugh at. Some proffered concern for the integrity of my coccyx. But, pain apart, I was content to have dispelled the gloom.

The levity was short-lived as no fewer than four messages with my name attached were taped to the door. First, the lady waiting