Surgeon performs controversial cancer surgery named after him

November 25, 2012

Paul Sugarbaker takes an even breath, leans over the left side of his patient and slices her iodine-coated abdomen from pelvis to ribs.

The air of the red-and-pink-tiled Operating Room 1 of MedStar Washington Hospital Center is chilly and smells of antiseptic; the only sound comes from the beep-beep-beep of the heart monitor as a digital clock on the wall flips silently from 11:09 to 11:10 a.m. In just five seconds, the surgeon completes the 12-inch incision, beginning what will be a marathon operation that he hopes will rid his patient of cancer.

After 15 minutes of slicing with his No. 10 blade and of searing flesh with his cauterizer, the surgeon confronts the enemy — a grape-sized tumor lodged in scar tissue from previous operations. With his left thumb and index finger, Sugarbaker peels back tissue and peers at the mucinous wartlike blob. He excises it with one clean swipe of the scalpel and plops it onto a steel tray. The swift act feels good, but only for a moment. The gray-haired surgeon, clad from head to toe in blue surgical garb, knows what lies ahead.

The high-stakes surgery will last 10 hours and involves cutting open the patient’s abdomen, removing her organs and hundreds of tumors, and then soaking her belly in a toxic elixir of chemotherapy drugs for 90 minutes. If everything works well, Sugarbaker says, the patient has about a 33 percent chance of living another five years and a 25 percent chance of being cured. Without it, he says, “her chances of survival are near zero.”

This is the Sugarbaker procedure — a controversial operation that is seen as the last hope for those suffering from advanced stages of some cancers. It is performed about 1,000 times a year at more than 100 medical centers across the country and is named after this 71-year-old blue-eyed surgeon, who has dedicated an entire career to pioneering, honing and promoting this treatment, which has left him with a permanent stoop from having spent so much time hunched over patients. He performs about 70 such operations each year on cancers that have spread into the abdomen from places such as the appendix and colon.

Whether he’s jetting across the globe to preach his procedure’s benefits at medical conferences or conducting back-to-back marathon operations, Sugarbaker is racing against time, hoping to outlast his critics and establish a legacy that he believes will save many more lives. His determination is not unique to medicine, but in Sugarbaker’s world, the stakes could not be higher. He is often his patient’s “last hope,” the surgeon who will operate when others have declined to take the chance.

Like many doctors treating those with potentially deadly illnesses, Sugarbaker faces countless questions — some of the same ones raised by his detractors — that will only grow more sharp as the country begins to focus intensely on reducing health-care costs: Does he turn away a patient who is too sick? Does he continue an operation even when hope seems lost? Is it worth the time? Will the surgery and subsequent hospital stay be worth the estimated $120,000 cost?

There are no easy answers, as will prove true in the case of this 58-year-old patient with metastasized colon cancer, Laurie King — not on the day of the operation earlier this year and not months later.

Perhaps the only thing approaching an answer is a quotation on tattered paper that the surgeon has taped to his office’s filing cabinets, which contain the records of every patient he has treated over his long career:

“You never know how far you can go until you have gone too far.”

Making the call

It is 30 minutes into the operation, and the rhythmic beep of the heart monitor has been overtaken by the roaring of four vacuum tubes that suck away smoke generated by the cauterizer; the room now smells like burning tires, blood and bile. Sugarbaker is being assisted by two nurses and another surgeon who crowd the operating table. He has already fully opened the abdomen, removed several tumors and is inspecting tissue and organs to determine whether the cancer has spread too far to continue.

Despite advances in radiology, cancer can still surprise a surgeon, and Sugarbaker has stopped countless procedures because it would be too difficult to remove enough cancer to make a difference in the patient’s long-term survival.

First, he studies King’s gall bladder, spleen, greater and lesser omentums, uterus and ovaries: All are all infested. King’s peritoneum, a thin layer of tissue the consistency of plastic wrap that encases the abdomen and individual organs, is teeming with tumors. The surgeon next studies the liver and sees that its peritoneum is affected, but the liver itself seems fine. That is a good sign. He can remove the peritoneum, but if he had felt a tumor inside the liver, he would have to halt the operation. The other organs are a different matter — King can survive without them.

Next he inspects the woman’s small intestine, the Achilles’ heel of the surgery. Through his double-gloved hand, he feels the twisting coils and then leans down to get a closer look. He counts small nodules and stops when he tops 500; most of them are the size of an eraser-head or the period at the end of this sentence. This is bad and good – more cancer than he had hoped but no large growths. He turns to his right and tells the nurse manning the anesthesia machines that it’s “time to reserve a berth” in the post-operative intensive-care unit. The meaning is plain: He is moving ahead.

Evaluating ‘a fighter’

Just a day earlier, Sugarbaker hadn’t been so sure there would be an operation. He was sitting knee to knee with King in a drab examination room. To his left was King’s 21-year-old daughter, Michele, and King’s best friend, Susan Shandler. All three had spent the night in a motel after having driven up from their homes in the Roanoke area. King, bundled in a thick gray sweater and a purple scarf and winter hat, sat in a wheelchair because she was too weak to walk.

It was King’s second meeting with Sugarbaker in a matter of weeks, and now the surgeon, wearing a white lab coat and green surgical scrubs, was growing increasingly grim as he shuffled through scans that had been taken of King that morning.

“That’s undoubtedly cancer,” he told King, pointing to what looked like an orange peel covering her liver on a scan.

“There is a lot more here than I would like to see, based on what [the last surgeon] reported seeing and what the last scan revealed,” he said in a nasally twang that betrayed his upbringing in rural Missouri.

“I think,” he said, pausing. “I’m going to find a radiologist to help me look at these. I don’t want to do a surgery on you tomorrow if it is not going to help you, you know what I mean?”

King stared at the wall, then blinked. Looking into her eyes, Sugarbaker could tell that she had not considered the possibility of being turned away. He did not know that two other surgeons had declined to perform this very procedure on King; one had even told her that she was “a lost cause.” But he was impressed with her determination — “I’m a fighter,” she had said more than once — and her biography. The single mother was an emergency room physician who knew the risks and was desperate to win more time with her daughter.

“You are eager to go ahead with this, aren’t you?” Sugarbaker said. King nodded. “Let me go find a radiologist.”

After consulting with the other doctor, who reviewed the scans and convinced Sugarbaker that the operation might be helpful, the surgeon returned to the examination room, sat down and said, “I think we can try. But I wish you were a little more of a straightforward case.”

“If anyone can do it,” King replied, “it’s you.”

The operation

Sugarbaker and Lana Bijelic, an attending physician who often assists in his surgeries, retract more of King’s skin to get better access to the abdomen and continue to scrape and zap cancer nodules.

The surgeon turns to the greater omentum, an organ that helps the body’s immune system. It is covered in tumors, one the size of a plum. The omentum is fed by about 40 arteries and veins, and each must be dissected to allow him to remove the organ. It is a tedious process. Sugarbaker first clears scar tissue in the area — King had two previous operations to treat the colon cancer and a bowel obstruction — then ties knots an inch apart on each vessel before snipping between the knots.

So far, Sugarbaker and Bijelic have exchanged a total of only a dozen or so words — they have worked together so often that she knows what he is going to do before he does it.

Sugarbaker has long believed that surgery should never become too tedious, because that is when mistakes are made. So after separating the 26th artery, he turns his attention to another part of the peritoneum, where he spots a fist-sized tumor in what he calls the “gutter.” It takes him about 15 minutes to wrestle it loose. Then he scours the liver’s peritoneum with his cauterizer, turning the pink surface gray.

He shifts focus back to the greater omentum, and after 30 minutes of cutting and searing, he removes it, the gall bladder and the spleen in one big cancerous clump. The ovaries, uterus and a large chunk of the peritoneum go next.

Five hours into the operation, King’s temperature has dropped to 94 degrees, and Sugarbaker tells a nurse to pour warm saline into the abdomen. For the next 20 minutes, Sugarbaker washes away blood and tissue so he can better remove tumors and stitch shut bleeding vessels.

By 5 p.m., it is time to start the chemotherapy “bath,” and the nurses hook up the lines and probes to supply and monitor the toxic liquid. One flips on the machine that will pump chemotherapy into the body; it hums to life, and in about 10 minutes fills the belly with orange poison.

Sugarbaker excuses himself from for the first time and shuffles to the doctor’s lounge to nibble on an egg-salad sandwich prepared by his wife, Ilse, who happens to be his office manager (one of his three daughters is a nurse in the office, too). The break doesn’t last long.

At 6:15 p.m., a nurse pokes her head into the room to say that Bijelic is on the phone.

An ‘old-time surgeon’

Sugarbaker lives a fairly spartan life — his house in Northwest Washington has no ostentatious furniture or works of art and is heated by a wood stove that he fuels from trees chopped down on a relative’s property. Except for refurbishing trunks, snowboarding and sailing, his downtime is spent thinking about work — his living room coffee table is stacked with medical journals, not picture books.

To those who know him, this is no surprise because if anyone was destined to be a surgeon, it was Paul Sugarbaker. The second of 10 children born to Everett Sugarbaker, a renowned surgical oncologist, and Geneva, an education advocate who turned 100 in October, in Jefferson City, Mo., Sugarbaker was expected to become a doctor, just like his other siblings.

Sugarbaker excelled in school, eventually making his way through Wheaton College and then Cornell University Medical School. By 1976, he had joined the staff at the National Institutes of Health, where he learned about other doctors combining surgery and chemotherapy during an operation — known officially as “cytoreduction and heated intraperitoneal chemotherapy.” The premise was that the surgeon would remove as much cancer as he or she could see and then fill the patient’s abdomen with chemo drugs that would kill whatever remained.

“The whole thing just made common sense to me,” he said.

He and other doctors launched an intense effort to test and refine the procedure. In 1986, he left NIH for Emory University’s hospital, which he would leave after just three years. “They thought I was overly aggressive,” Sugarbaker said.

He joined the staff of MedStar Washington Hospital Center, where he is now director of the peritoneal surface oncology program. Within a few years, he was being criticized again — a top surgeon wanted to push him out because patients were suffering from too many post-operative complications. Oncologists and others rallied to Sugarbaker’s defense, noting that his patients were all doomed to die without his help, said James Jelinek, a friend and chairman of radiology at the hospital.

Sugarbaker won over doubters by reducing complication rates — about 1 percent die during or shortly after the operation, and about 12 percent experience serious post-operative problems — and by deploying his easygoing nature and working so assiduously, Jelinek said.

In that same way, he has handled his more recent critics, who do not doubt Sugarbaker’s skills as a surgeon but say that there are few, if any, studies that show the procedure actually works, especially in the case of colon cancer.

The procedure, which has grown in popularity in recent years, has generated debates at medical conferences and has been detailed in national medical journals and general interest publications, such as the New York Times.

The Sugarbaker procedure “isn’t like dispensing aspirin,” said David Ryan, clinical director of the Massachusetts General Hospital Cancer Center. “This is potentially harmful therapy.”

Despite their differences, Ryan said he respects Sugarbaker, calling him “the quintessential old-time surgeon. He’s a super-nice guy, hardworking. He’s kind to his patients. He’s very straightforward.”

Sugarbaker, who has founded a nonprofit group that funds cancer research and recently published a massive textbook on his technique, says the debate was settled long ago about his procedure’s effectiveness in battling appendiceal cancer that has spread to the abdomen and peritoneal mesothelioma, a rare cancer linked to asbestos exposure. Survival rates for patients suffering from those cancers are 50 percent for at least five years if they undergo his procedure, Sugarbaker said.

The surgeon said he would welcome a randomized study — in which some patients get the treatment while others do not — to prove it is effective in treating colon cancer, which spreads to the abdomen in about 10,000 patients each year.

The problem with setting up such a study, he says, is how to find participants for a truly randomized trial.

“How do you tell someone that you won’t treat them, operate, remove the cancer and then give them [heated chemotherapy], which you believe is their only chance at survival, and they are then certain to die?” he said.

Complications

Sugarbaker scrubs his hands in a sink outside of OR 1 and backs through the double doors. “What, where are we?” he asks Bijelic as a nurse puts on his surgical gown and gloves.

Bijelic reiterates what she had told him by telephone: The patient is bleeding at an unacceptable rate. Sugarbaker peers into her abdomen and sees that the normally orangish elixir is bright red from blood.

This is not good; Sugarbaker orders transfusions to make up for the blood loss.

“I think we have to cut this short; we’ll do it for 60 minutes, not the full 90,” he says.

It takes about 10 minutes for the chemo to drain. And after 10 more minutes of searching, Sugarbaker finds the “bleeder” and stitches it shut. Then he fixes four more while excising dozens of small tumors. After about an hour, he and Bijelic are ready to “close” the patient, meaning it’s time to sew her back together. While some surgeons leave this tedious part of the operation to underlings, Sugarbaker says his father taught him a valuable lesson as a youngster: “Cleanup is part of the job.”

By 9:10 p.m., King is being wheeled to intensive care and Sugarbaker is negotiating a warren of hallways to find King’s daughter, Michele; King’s close friend Shandler; and Shandler’s husband in the waiting room. With his surgical mask dangling around his neck, Sugarbaker escorts them to an oblong windowless office and explains that there were not a great many surprises, except for a large amount of tumor in the scar tissue from previous surgery.

“We got caught there for a long time,” he says. “We moved very, very slowly.”

After a typical back-and-forth between relatives and a surgeon about King’s bleeding and hospital stay, Shandler asks a more profound question: “Did you save her life?”

Sugarbaker is quiet, gathering his thoughts as he jots a note on a pink hospital record. “Let’s be conservative,” he says. “Let’s just say we got a good start on it, and we did what we set out to do.”

The surgeon awkwardly accepts a big hug from a teary-eyed Michele, excuses himself and heads toward the elevator, his step a beat slower than when the day had started. It is just after 10 p.m., and he still is not done — he is heading back to his third-floor office to dictate his notes while they are still fresh in his mind. In just a few hours, he will be back at work, checking on King, other patients and then launching another 10-hour surgery.

After the surgery

King, whose insurance company picked up the tab for the procedure and its related treatments, had a rough hospital stay of five weeks — three beyond what was expected — because she suffered from a lack of nutrition, a breathing problem, a thyroid issue and pain. When she was finally discharged, Sugarbaker was optimistic, however — her cancer seemed to be in retreat.

But then the patient was rehospitalized in Roanoke for pain, and a feeding tube was inserted in her bowel to help her gain weight. In August and September, Sugarbaker heard disturbing reports from King’s doctors in Roanoke that her cancer levels had risen, she was not eating enough and was still experiencing extreme pain. The surgeon was beginning to wonder whether he had made the right call in operating on her.

Sugarbaker often does not examine patients after they leave MedStar Washington Hospital Center and tracks their progress through updates from oncologists and from the thank-you notes — from the living — he receives during the holidays.

But he would see King again, shortly after her Roanoke doctors detected what they thought might be an abscess or cancer in her bowel. When Sugarbaker walked into King’s second-floor hospital room in October, he expected to see a woman clinging to life.

Instead he discovered that King had put on some weight and had color in her face. She was even walking. He ran tests and determined that the growth was benign inflammation. Blood tests revealed her cancer was actually in remission — the surgery and chemotherapy cocktails delivered by her doctors in Roanoke were working. Sugarbaker felt pleased when King left the hospital after just two days, a huge smile on her face.

For now, it seems, the surgeon didn’t go too far.

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