Life and Times; L.A. Medical. Dr. Michael Zinner

<v Dr. Michael Zinner>Today should be pretty straightforward, except for what we don't know is going to be. <v Dr. Michael Zinner>I suspect we'll go about six or so hours and then we can send messages to you from the operating room. <v Dr. Michael Zinner>Let me have a Richardson, let me look around. <v Dr. Michael Zinner>Plan for today is to removeall of the stomach and then hook you back up, essentially make you a new stomach out of your small intestines. <v Paul Hsieh>The surgery probably is easy for me, but it's difficult for my family. It's equivalent to like a heart surgery in terms of the death rate. <v Dr. Michael Zinner>He's a very knowledgeable patient. He's very aware of the issues involved, one with the kind of cancer he has and to the fact that it's come back a second time. <v Narrator>Next on Life and Times, a profile of surgeon Michael Zinner and his fight to save a patient suffering from stomach cancer. <v Narrator>Major funding for Life and Times is provided by the James Irvine Foundation, which is dedicated to the development of an informed California citizenry with additional support from GTE- a company committed to telecommunications excellence and an open dialog among all people. This episode of Life and Times offers a profile of a surgeon, it contains timely and important information about the medical battle against stomach cancer. The program includes scenes of actual stomach surgery that some viewers may find disturbing. Viewer discretion is advised.

<v Dr. Michael Zinner>Let me go over a couple of things that are going to happen soon. They'll come get you, put you on the gurney, take you downstairs. The anesthesiologist will meet you down there and plug in the I.V. And that hopefully is the last thing you're going to remember. Then I expect you to get a good night's sleep and then we'll talk some more tomorrow when we look at all the results. Anything else I can tell you? <v Paul Hsieh>Thank you so much, I'm ready.

<v Dr. Michael Zinner>All right. We're ready too. We'll see you in just a few minutes, All right. <v Dr. Michael Zinner>Mr. Hsieh came to me as a referral from an oncologist. He had been seen on routine follow up from his previous cancer surgery to have another focus of cancer in his stomach. Like most cancers, this one is the survivability is related to the time of diagnosis for many of the gastrointestinal tumors and malignancies. We don't see them or know about them until later on in the course. And because of that, the survivability is not as good as some of the other tumors that can be easily seen or easily felt as lumps or changes in in symptoms. <v Dr. Michael Zinner>OK, Mr. Hsieh, I hope for you things are as advertised. <v Paul Hsieh>When they give me the anesthesia before that, I'll be praying and then I'll wake up. So very little to do on my side. So my mind, one way or the other, it's, you know, doctor's in his hand, you know, it's his responsibility to get me through here. <v Dr. Michael Zinner>You got a bovie scraper? Why don't you lay it down.

<v Dr. Michael Zinner>The hope is that he's only going to have a very small area of cancer, which is going to be easily removable. <v Dr. Michael Zinner>Cautery, why don't you cut across here. <v Dr. Michael Zinner>There is a concern that we'll get in there and discover two things, one, that he's got tumor spread all over his abdomen and that it's little tiny bits of tumor everywhere. If that's the case, there's nothing we can do, not much we can offer him or that the tumor is the kind of tumor we can't see on X-ray, but is in fact continuing to grow. And it grows in the areas that we can't remove, like the major blood vessels in the abdomen or those kinds of areas. <v Dr. Michael Zinner>That's not as advertised

<v Narrator>When Paul Shur first had stomach pain, he and his doctor thought it was caused by stress. An engineer in the aerospace industry, he feared being laid off. Mr. Hsieh was shocked to learn that his pain was actually due to cancer. In November of 1991, part of his stomach was removed. <v Paul Hsieh>You know, it's probably better to have AIDS than stomach cancer because AIDS patients in some ways a little while longer than I do. It's better to be behind bars and sent to death row than having cancer because they will they will live longer than I do. And so those are the thought processes you go through. And and in probably my life now is like living in fast forward, like we see our fast forward and you must compress so much time in a short period to, let's say, to accomplish a living trust, take care of your financial situation, uh, things that you want to communicate to your kids and so on, so forth. And that takes a long time to do that. And then just never seem to be enough time. But time like this, you know, being a Christian, you know, it gives me a lot of strength. And without that, I don't know what I would be doing. <v Dr. Michael Zinner>Pickups, please. All right, we've got more tumor than we'd planned on. Can you hold that up. Here's his old, uh, here's his old hookup. You see the suture line stomach coming down to his small intestines. It's like they did a Hoffmeister. It's like they took it all the way up. But this this thing this worries me. That's much more tumor than we thought we were going to come up with. I didn't expect to see any tumor at all. We were told on a CT scan and on the upper series that he didn't have any. But he does. Could be scar. Could be scar. But the worry my concern is that he's got a tumor growing outside of his stomach. We won't know that till we get a little further along here. The other side looks OK and going up higher, way up high. And it looks OK, too. All right. Well, OK, let's go to work.

<v Paul Hsieh>How do I feel when I discover cancer. it's a disappointment. It really play havoc on your life. And right now I'm looking forward to retirement and I can't move, OK? I don't know what the my life is going to be like a month, two months or five months from now.

<v Dr. Michael Zinner>In terms of how alarming it is, it's a very serious cancer. It's a cancer that when all things are considered, is a difficult one to cure. Unless we can get to it early, often by the time we get to the tumor or the the, uh, the cancer to either remove it or do something to it, it will have spread to the lymph glands. And once it's begun to spread, then it's very much harder to cure. <v Narrator>Michael Zinner has been chairman of the Department of Surgery at UCLA and chief of surgery at the UCLA Medical Center since 1988. He began his academic career at Johns Hopkins after growing up in Florida. <v Dr. Michael Zinner>There was a lot of academic things going on in the house, my father was a professor of microbiology at the University of Miami. I suspect that had an influence on me. I entered a science fair projects and did things like that as a kid growing up, I played sports and did fair- fairly well as as a student in high school and then went off to college where I didn't do as well. Actually, I did terribly and had to leave in the middle of college because I was doing a lot of other things that had nothing to do with academics. I was playing sports, I was involved in plays. And so I had to spend some time away from college getting that sort of back in order so I could get back in and graduate. And then I did and then went off to medical school.

<v Dr. Michael Zinner>Oof. That's all tumor. All right, reassess. Colon, we've got his tumor growing through the transverse mesocolon coming out the bottom, the only way to get that out is to is to take part of the colon with us, which is not what we planned to do, but it's the only way we're going to rid him of that disease that part will come out, then go after the the old anastomosis. Disconnect that tumor up to here tumor. We were able to disconnect from the pancreas, it wasn't anywhere near the pancreas portion. You see the pancreas, this that's clean and healthy and no tumor, there tumor growing up here, the lesser [curve] we'll disconnect it from the blood supply there and that should do it. If we can do all that, then we'll take the spleen with us. <v Narrator>In his first cancer operation 14 months earlier, the lower part of Mr. Hsieh's Stomach was removed. Today, Dr. Zinner Had intended to take out the rest of the stomach and the spleen. Now he will have to remove part of the colon as well. Dr. Zinner will attach the small intestine directly to the esophagus.

<v Dr. Michael Zinner>This is the normal location of the esophagus as it comes down and meets the stomach. And this is the normal location of the stomach. And this is where it meets the small intestines. This is where the normal position of the spleen is. And these around the edge are the lymph glands. This is not routine at all. If I put it in, put it in perspective, this is significantly more complicated than having your hernia done or your gallbladder taken out or even having a colon removed, <v Narrator>Paul Hsieh recognizes that stomach cancer is anything but routine. He has become a student of the particulars of his own case and talks regularly to medical experts in England, Japan and this country. <v Paul Hsieh>I have a friend who is a pathologist, and when I had cancer, I talk to him about it. And so we kind of talked and he told me that, you know, you, Paul, you must take charge, charge of your your your situation. And so he says, I'll be your coach. So it's almost like a sporting events to me, OK, that I have a coach and I'm able to talk to other people. I'm able to talk to other people who have stomach cancer and they tell me what they're doing kind of OK. And so that networking is very important.

<v Narrator>The night before his surgery, Mr. Hsieh brought Dr. Zinner In or into his network, insisting that he consult with a stomach cancer surgeon in Japan before proceeding with the operation. <v Dr. Michael Zinner>I spoke to the surgeon from Japan, and in reality. In reality he and I both have a very similar approach to the disease and a very similar approach to the tumor. And we had an opportunity to compare notes. And I think that greatly relieved the patient's anxiety. It's very common for patients to be concerned and it's very common for patients to be involved with their disease and to be knowledgeable about it. It's a little unusual for them to pursue it, uh, as much as Mr. Hsieh <v Narrator>For the patient, surgery may be a matter of life and death, but the others in the operating room, though surgery is often also a matter of education. UCLA is a teaching hospital and surgeons like Dr. Zinner usually operate with residents and medical students in attendance. Diedre Fisher is a third year medical student.

<v Dr. Michael Zinner>Diedre. Welcome. Why don't you to replace Andrews up there. This patient's a 55 year old man who who about 14 months ago had a resection for gastric carcinoma um free margins, as they're reported to us, but he had several positive lymph nodes, at least seven or eight positive lymph nodes. He then was treated. He did well. His CEA, his marker levels remain low and then his marker levels began to go up. And as his marker levels went up, they began to restage him, reevaluate him. First thing they did was a CAT scan and a CAT scan showed really nothing, no, no evidence of recurrent tumor. And then they endoscoped him. And what they did was see no tumor on his lumen, no tumor inside. So they did some blind biopsies around the area of a previous anastomosis where they'd remove the distal part of the stomach. And although they didn't see any tumor, one of them came back positive for cancer. So he sent in today to see whether we can evaluate him with respect to removing the remainder of his stomach, anticipating that there's going to be more tumor there. What we found today a little bit a little bit more than we'd been led to believe was that he's got a tumor in a couple of places. Here's his stomach. Let me just pull this down. Here's his stomach. And you can see the sutures here from his old anastomosis where they took the rest of his stomach out sewed his old stomach to his intestines. And there's the suture line. Pick-ups. I can show you where the tumor is. The tumor. This is the tumor sitting right here. This hard, this hard this rock hard thing right there. Right. <v Dr. Michael Zinner>That's not too surprising. I guess we'd expect that that could be there. And I suspected that they biopsy that right in this region, being in that region, they probably were able to get a tumor that's gone through the wall that part is OK, we're prepared to do that. What we did not expect, though, was that he has evidence of the tumor growing down into the into here. This is his large. What I'm holding in my left hand is a large intestines and and the arteries and veins, the large intestine come this way and the tumor is growing into the base of that. The only way to remove all that tumor is to remove a segment now of his large intestine. So we're going to have to take part of his large intestine and the stomach and probably the spleen. We're lucky in one recentre. He's lucky in one sense that what I was afraid of was that he was going to have this tumor growing into this organ here, which is the pancreas, but it's clean and free and there's no evidence of tumor there. So we're lucky because if it had grown into there, I don't think we could have done anything. So what we've got now, stomach, we're going to be removing that.

<v Dr. Michael Zinner>Some of his small intestines. And now we're just about to go across across his his large intestine and take that out now. Deidra this part you're going to like, this is a machine that will divide the intestine, staple both sides and divide it for this one. We're just doing to keep it.

<v Diedre Fisher>We're going to be sewing the colon-. <v Dr. Michael Zinner>Right. These were invented by the Russians. Have you figured out what you want to be yet? <v Diedre Fisher>Yes. <v Dr. Michael Zinner>What. <v Diedre Fisher>I want to go into surgery. <v Dr. Michael Zinner>Surgery? Diedra. <v Dr. Althoff>Do you know what that means? <v Dr. Michael Zinner>Do you have any idea what you're talking about? <v Diedre Fisher>Maybe not very much sleep. [inaudible] <v Dr. Michael Zinner>Dr. Althoff is in her seventh year. Yes, seventh year from medical school. <v Diedre Fisher>Really? <v Dr. Althoff>Yeah they keep us around a long time here. <v Dr. Michael Zinner>Well, keep till they get it right.

<v Diedre Fisher>Did you decide in your third year to go into surgery. <v Dr. Althoff>Actually when I went into medical school, I wanted to go into surgery <v Dr. Michael Zinner>During most operations, there are parts that are very routine and very easy to do, and there are parts which are complex and require an enormous amount of attention and concentration in a very, very small area, often no more than an inch square. And your- you- I end up being riveted, literally riveted to that one or two square inches. And I suppose bombs could be blowing up in the room and I wouldn't be paying any attention to them <v Paul Hsieh>That's the first question that I will be asking when I come out of surgery. Did they remove the stomach? And if they didn't, I would feel sad. And if they do. I'll be very happy because there's hope there. <v Dr. Michael Zinner>All right, specimens coming out, we need a big bucket. I want to take this up for frozen and make sure we got it marked for for frozen section. Come right across right across in here. Score score before you come through. Section. We're going to need- There's EG junction, right at EG junction.

<v Dr. Michael Zinner>See the difference in the necrosis? OK, [inaudible] OK. This is stomach. This is spleen off next to it. This is where the old, uh, your old anastomosis was, the old connection was, and this is the part of the colon where the tumor was growing into it right there. So we had to remove that. OK, um. <v Diedre Fisher>Irrigation.

<v Dr. Michael Zinner>Irrigation. I want to take this up for for frozen section. Take that out, just let me see what the bed looks like. Yeah. You got the sheet. Ok. <v Dr. Michael Zinner>Specimen frozen section. Let me orient you. <v Narrator>Though a complete pathology report will not be ready for four or five days. Dr. Zinner needs a quick reading on whether the outer edges of the tissue he has removed are free of cancer cells. <v Dr. Michael Zinner>Oh. Let's see what we've got. <v Pathlogist>This is a frozen section of the proximal margin of the risk section, I do not see any atypical cells to suggest the involvement of this proximal margin of resection. This is right at the gastroesophagealjunction. <v Dr. Michael Zinner>Good, good, good, good news.

<v Dr. Michael Zinner>OK, thanks. <v Pathlogist>Thank you. <v Dr. Michael Zinner>All right, this is a little bit of what's standing on your head. Show me the back row, we'll parachute it in, OK? This is a sometimes difficult anastomosis, one, because it's high, it's not looking at you right in the face, and in two, because the esophagus is an organ which has a higher propensity for leakage and sewing them together and most of the other GI organs. We essentially can make a new stomach out of their small intestines and the stomachs really main purpose in life is to serve as a reservoir for food so the patients can continue to eat. They just have a smaller reservoir than when they had their stomach in place. And the small intestine takes over the function of being the reservoir. Let's just cut these and see what they look like. <v Dr. Michael Zinner>OK, Hand out. See what it looks like. Here's the NG tube coming through. Good.

<v Dr. Michael Zinner>Esophagus and this is his new stomach. OK. OK, so, uh, let me take a stitch. Actually, I'm really satisfied with that anastomosis, scissors. We've got to sew the small bowel back together, which is where things will go together downstream from what we just did, and and then just sew up the openings that we've made in various parts of the intestine and then close. <v Narrator>On a Saturday morning, 10 days following Mr. Hsieh's Surgery, two surgical residents and medical student Deidre Fisher on rounds with Dr. Zinner to review the status of his patients.

<v Dr. Michael Zinner>Mr. Hsieh How are you? <v Paul Hsieh>Good to see you. <v Dr. Michael Zinner>Good to see you, too. How you feelin'? <v Paul Hsieh>I feel so good, let me move up here. <v Dr. Michael Zinner>OK. You're, uh. You're pretty close to going home. <v Paul Hsieh>I know it's exciting. <v Dr. Michael Zinner>What'd you eat today. <v Paul Hsieh>Well, breakfast had some eggs and had the- had cereal. I felt today the breakfast went down the best. <v Dr. Michael Zinner>Good. Good. <v Paul Hsieh>I would like to make sure I have a full day in terms of eating if I don't, because last night I did experience some cough and that was very painful. <v Dr. Michael Zinner>Any incision? <v Paul Hsieh>No, it's just that I still you know, my coke was my favorite, so I decided to drink you know about two, about a couple, swallows of coke and then kind of-.

<v Dr. Michael Zinner>Coke? <v Paul Hsieh>Well it was some soda it went up and down- and it made me cough. <v Dr. Michael Zinner>You may have a little trouble with carbonated beverages. <v Paul Hsieh>I know I'm learning that. So I-. <v Dr. Michael Zinner>You may want to hold off on carbonated beverages, at least until that the plumbing gets reorganized in there. <v Narrator>Though Mr. Hsieh suffered no serious complications following his surgery. His problems aren't over. The pathologist reported that 13 of the 21 lymph nodes removed during his surgery were positive for cancer. Mr. Hsieh is still hoping for a cure, expects to follow his surgery with chemotherapy. <v Dr. Michael Zinner>OK, you have no Groat's disease. So all that's out, right? And the next step will be to be evaluated by our oncologist and decide what the next step is. Good. See you. <v Paul Hsieh>Thank you. <v Dr. Michael Zinner>Bye. I've seen patients who had relatively minor tumors or neoplasms or cancer been diagnosed where they're eminently treatable with very minor types of therapy, surgery or something else that have been just devastated by the having the term cancer applied to them. And others who have really serious cancers, who've gone through lots and lots do as well as Mr. Hsieh is doing. That's very hard to predict, and I think it has a lot to do with the person more than the illness. <v Narrator>Paul Hsieh knew that although surgery in his case was a gamble, it held out his only chance of survival. The outcome would depend on the aggressiveness of his cancer. He gambled and he lost. His cancer returned quickly, and Paul Hsieh died on June 3rd, 1993, only three months after his surgery.

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