CSI MEDBLOGS SUMMARY
Here's a one yard summary if you don't want to read it all...
- Although reported as a simple thing Bill Clinton is having a complex surical procedure for a severe problem
- His lung lining has filled with blood and complicated fluid, become rubbery, and caused the underlying lung to collapse
- Clinton's people claim this is a not unusual side effect of heart bypass surgery
This is not common and either the doctors missed this condition or they have been hiding it from the press for six months OR...there is something else entirely going on
NOW FOR THE WHOLE NINE YARDS...
As reported today, Bill Clinton needs new surgery to fix a complication of his coronary artery bypass. But is it really a complication, or is the cause something worse?
The news tells us that Clinton "will undergo a medical procedure" that could require a three to ten day hospital stay...WHOA...that's quite a range especially for something trivialized as a procedure?
To me, a procedure is a needle biopsy or an endoscopy; you know, in and out --overnight at best. But ten days?? There's more to that than meets the eye.
Here's what Clinton's people are saying:
The procedure, known as a decortication, will remove scar tissue that has developed as a result of fluid buildup and inflammation, causing compression and collapse of the lower lobe of the left lung
This is fairly serious stuff and decortication of the pleura of the lung is not a "procedure," it is an operation; so, let me spend a little time translating this condition so everyone can understand its severity.
Bill's Imprisoned Lung
What they are saying, in essence, is that Clinton has an intractable fluid collection separating the "leaves" of his thoracic pleura ( = a fibrous bag that surrounds the lungs).
Furthermore, they are telling us that the "fluid" between the leaves of pleura is, or has gotten, nasty -- either because of blood or infection making the normally resilient and pliable pleura hard and inelastic.
In this illustration, you are looking at one of the lungs. The lung is centrally located and the "pleural leaves" are outlined in color.
When the pleural leaves fill up with nasty fluid and become inelastic this causes the underlying lung to collapse ( called atelectasis).
So, although they may poo-poo Clinton's problem, it is no joke to have inflamed or bloody fluid surrounding your lung, creating a prison cell for your lung which then collapses under the pressure.
The Scope of It
<---- HERE IS what one sees in the pleural space, through the thorascope. Good luck to the surgeons, eh?
Briefly, what it seems that they are planning to do is called a VATS procedure (video-assisted thoracoscopy) during which surgeons insert a scope between the ribs and scrape out the pleura through the small incision. This is a fairly new approach for pleural decortication and one would assume these surgeons are comfortable with it...however...
Until very recently decortication would require open chest surgery -- and the leeway the surgeons are figuring into their estimate of the hospital stay likely includes the possibility that they may need to convert the VATS to an open decortication during the procedure.
There remains the question: Bill Clinton needs a pleural decortication to remediate a persistent pleural effusion. What are the chances this problem is related to his bypass surgery? If it is not related to bypass surgery than what could be the cause?
Clinton's office said the condition is an occasional consequence of open-heart surgery
Okay, I can buy a pleural effusion after bypass surgery. Not too uncommon. Especially when the surgeon uses the internal mammary arteries for the bypass, as was done in Bill Clinton's bypass.
But a persistent effusion causing "pleural inflammation" and lung collapse requiring surgery? Odds are getting a little more strained in this territory.
C'mon...Tell Us The Truth
Post-bypass effusions come in three flavors: immediate, delayed, and persistent. Immediate are just that: right after the bypass, resolving in days to weeks. Persistent effusions last more than days to Weeks but BOTH of these types of effusions usually go away by themselves. One study concerning the prevalence of these effusions stated:
Over the 12-month follow-up (after surgery), the effusions tended to resolve
Bill Clinton's surgery was six months ago. So either he has an unusually persistent post-operative effusion OR he has a delayed effusion.
Here's where a mystery starts to unfold. An important article in the Annals of Internal Medicine made a distinction between early and late occurring pleural effusions post bypass-graft:
EARLY effusions are generally the BLOODY COMPLICATED type (called exudative). Late effusions are non bloody and simple (called transudative). The early/bloody effusions are the ones that lead to pleural inelasticity. The delayed (late) effusions DON'T lead to the inelasticity.
So what are we left to conclude? A major study reported in the journal Chest had this to say about post-bypass pleural effusions (italics mine):
Pleural effusions after coronary artery bypass graft surgery should be treated conservatively. Other causes for these effusions should be sought only if the patient is febrile, the effusion is large, or if it fails to resolve in the appropriate time frame.
I DID NOT HAVE SEX WITH THAT WOMAN
If Clinton's pleural problem is secondary to his bypass surgery then either they failed to do appropriate follow-up and MISSED it for six months (unlikely); or, they have been hiding his problem while they exhaust all nonsurgical treatment options; OR ... Bill Clinton's exudative pleural effusion is from something else.
What are the possibilities?
- Cancer, including: lymphoma and leukemia and AIDS-related malignancy (he DID fool around a lot);
- Strange infections such as: Mycoplasma (TB), Rickettsiae, Chlamydia, and Legionella
- Liver disease and Pancreatic disease (not likely with left-sided problem)
There are others. But unless the Docs at Columbia let us in a little on some of the clinical history and pathology follow-up, as usual, we will probably be left speculating on the White House lawn.