A Life Without Limits
It was October 2009, and inflammation continued to ravage Julie Stierer’s colon. Medications prescribed to control it had stopped working months earlier, turning the cheerful life of a 9-year-old into one of frequent diarrhea, fatigue, anemia, and dehydration. More and more mornings came when she’d be too sick to go to school. Dance and other activities she once enjoyed were out of the question.
“Everything stopped,” says her mother, Kari Stierer. “She was lucky to get through the day.”
Although medications had failed, a surgical option to relieve Julie’s condition remained. Children’s Hospital of Pittsburgh of UPMC surgeon R. Cartland Burns, MD, explained to the family that in a series of operations he could remove Julie’s chronically inflamed colon and reconstruct her small intestine so she would feel better and have normal bowel function.
As difficult as it was to accept the idea that Julie needed major surgery, her parents found some comfort in the fact the operations would be performed as minimally invasive procedures, rather than conventional open surgeries. That meant much smaller incisions — the longest being less than two inches long — and an easier, much quicker recovery.
A few days after her colon was removed, Julie was back home. “She felt better instantly,” says her mother. One week later, Julie was back in school telling her teacher and classmates all about her operation.
A Better Way of Doing Surgery
Children’s Hospital is a national leader in minimally invasive procedures. Nearly half the hospital’s 13 surgical suites are equipped with state-of-the-art minimally invasive technologies. Children’s Hospital surgeons are also among the nation’s most experienced in minimally invasive surgery. Today, they are performing an increasing number of these procedures, which range from more common operations such as appendectomies to complex neonatal, abdominal, and chest surgeries.
The term “minimally invasive” describes the key reason patients like Julie benefit from this type of surgery. In conventional, “open” surgery, surgeons usually make a large incision to create an opening big enough to see what they are doing and to perform the operation with conventional surgical tools.
But minimally invasive surgery requires much smaller incisions. That’s because surgeons perform the operation using tiny surgical instruments that can be threaded through very small openings. Surgeons also insert a small tube-like telescope — either a laparoscope or a thoracoscope — and a camera through the same small incisions. These imaging technologies allow them to see inside the patient’s body and send highly detailed images to a series of movable television screens in the operating suite.
For surgeons, using a laparoscope has certain advantages over conventional open surgery. “There are certain parts of the body that are hard to reach because they are under the ribs or way toward the back of the body or down near in the pelvis where you can’t see easily,” says Dr. Burns, associate professor of surgery at the University of Pittsburgh School of Medicine and co-director of the Intestinal Care and Rehabilitation Center at Children’s. “With the laparoscope, you have the ability to drive up into those areas and look around. In some of these operations, you see so much more than you ever saw before. a lot of the things we used to do by feel, we now do by seeing.”
For patients, the much smaller incisions used in minimally invasive surgery usually means less time spent under anesthesia, less pain, less time on narcotics to control pain, much less scar tissue, shorter, easier recovery, and a much shorter time between their operation and when they can return to full activity, including sports.
“Minimally invasive surgery isn’t a deviation from the gold standard,” says Dr. Burns. “It’s an improvement above it for those reasons.”
Tiny Instruments, Big Benefits
Symptoms of the disease that required Julie Stierer to have minimally invasive surgery surfaced in late 2008, when she and her parents began to notice blood in her stool. At first, it was believed she had Crohn’s disease, an inflammatory bowel disease without a known cure that causes inflammation of the lining of the digestive track and leads to abdominal pain, severe diarrhea, and other problems.
Medications prescribed to keep it under control worked at first. But by May of last year, her symptoms had returned, including the discomfort, blood in her stool, frequent diarrhea that kept her up most of the night, anemia from blood loss, and the constant risk of dehydration.
Out of options, her parents agreed to a series of three minimally invasive operations to be performed by Dr. Burns at Children’s Hospital. During the first, which was done in October, Julie’s inflamed colon was removed and her small intestine attached to the wall of her abdomen, in a procedure called an ileostomy. The ileostomy allows digestive waste to exit the body through a small hole in the abdomen called a stoma and into a bag that can be emptied. In Julie’s case, this was done as a temporary solution.
After the tissue of Julie’s colon was examined, it was determined that she had ulcerative colitis, another kind of inflammatory bowel disease. Unlike Crohn’s disease, ulcerative colitis usually attacks only the colon. That meant that once Julie’s inflamed colon was removed, she was unlikely to ever again experience the symptoms of the disease.
As part of the process, Children’s staff made sure Julie and her parents were educated about her condition, how her body has changed, and the care she needed. This included teaching them how to live with and care for her ileostomy during the few months she needed to use the external bag. In fact, she was given a special doll that helped explain it.
Had Julie had conventional surgery to remove her colon, she probably wouldn’t have been able to return to full activity for six weeks and would likely have needed narcotics to manage pain for up to a week after returning home.
But after her minimally invasive operation, Julie experienced minimal pain and only needed one or two doses of pain medicine, her parents say. She had the operation on a Wednesday and was home on Saturday. “She was back in school a week later with her ileostomy doll, explaining everything to her class,” says her father, Ray Stierer. “That shows you how quickly she was feeling better and that she was at peace with everything.”
A second minimally invasive operation was performed in December so that Julie wouldn’t have to live with the ileostomy bag for much longer. Using the same tiny instruments that required only small incisions, Dr. Burns created a pouch in part of her small intestine and attached it to the cuff of the rectum during a two-hour operation called an ileoanal anastomosis, or ileoanal pull-through. The pouch acts as a reservoir that allows a patient to pass waste normally and not wear an ileostomy bag.
Patients such as Julie receive long-term observation at Children’s Hospital. Three months after her final surgery, Dr. Burns described her prognosis for living life free of the symptoms of her disease as excellent. “Now she’s back to being a kid,” says her mother. “She’s playing softball for the first time, she goes to school, she rides her bike — everything.”
Read more in Promises.