We scheduled Ian’s operation and went to see him and his family in the pediatric ward. While we talked, Ian stood in his crib, sucking his pacifier.
We did our best to assuage the parents’ fears, but this was a lot of surgery for a little person, and it involved a great deal of risk. Whether or not we found a malignancy, the outcome might be bad.
After a night of little sleep for me, and most likely less for Ian’s parents, the morning of the surgery arrived. In the operating room, nurses carefully inserted a breathing tube into Ian’s narrowed airway. He was then anesthetized, positioned with his right side up, and cleaned with an antiseptic solution. Drapes covered his tiny body, exposing only the operative field.
We made an incision in his chest and placed retractors to make room between his ribs. The mass was immediately evident. It was oval-shaped, with an irregular contour, like the surface of a reddish-tan rock. We both felt it. “It’s fixed and firm,” said Kelsey, not needing to mention that this was consistent with a cancerous tumor. We began by working our way around the mass with surgical scissors to the back wall of the esophagus. It was a struggle.
“It’s definitely involving the esophagus,” I said. “Let’s try the trachea.” Kelsey was a skilled young surgeon, but using a variety of tools, including an electric scalpel, we could not free the mass from either structure. It was too firmly attached. While working around the mass, we spotted an enlarged lymph node nearby. “That’s not a good sign,” I murmured. “Might have spread there.”
We worked without speaking—four adult hands in a small space. A sense of foreboding was accumulating in the room around us like fog.
Finally, I made a desperate suggestion. “Let’s divide the mass,” I said. “Maybe we can see from another perspective how it’s attached to the trachea and esophagus separately—we aren’t making progress.”
This was something we preferred not to do. When removing a tumor, an “en masse” approach is best, meaning the entire tumor is extracted intact with any surrounding tissues attached, which gives surgeons the best chance to leave no cancerous tissue behind.
“Agreed,” Kelsey replied. “Maybe we can save some of the trachea that way, make the repair easier.”
I took a scalpel and carefully incised the mass. After a couple of passes, it cracked open. Ian’s heartbeat, a beep on the anesthesia monitor, registered five times before either of us spoke.
There was something dark and linear at the center. It looked horrifyingly like a slug. “What is that?” Kelsey asked.
I reached down and grasped it with a pair of forceps. “It’s firm,” I said. Kelsey adjusted the light overhead—there was a glint of reflection. “Metal?” I asked. I carefully pulled the object free. It was dark gray, oval, and covered in a layer of mucus.
I held it up in the light between us.
It was a leaf.
“A leaf?” Kelsey asked. “A leaf?” Her eyes were squinting above her mask, and her forehead wrinkled in disbelief. Suddenly it was clear. The mass formed to protect Ian’s body from the leaf and had taken on a life of its own. We both started laughing. The nurses clapped. There was no cancer; Ian was going to survive.
During the rest of the operation, we found that the leaf was nestled in a place where the normally cylindrical esophageal wall bulged out—a diverticulum in medical jargon. It all added up. Ian had swallowed an oak leaf months before, and it had lodged in the diverticulum, unable to pass. The leaf’s tip had eroded into the trachea and eventually, after white blood cells homed in on the region to heal the lesion, a scar formed around both the inflamed tissue and the leaf.
The young mother and father were incredibly relieved at the news, which Kelsey and I delivered immediately following the operation. They hugged each other, and after several moments, Kelsey and I left the room quietly, the two of them still embracing. Ian left the hospital after a few days. He was going to be fine.
The fact that the mass was not a malignant tumor didn’t change the urgency behind the operation. If Ian’s diagnosis of stridor and the surgery had been delayed, the mass could have led to the complete obstruction of the airway and sudden suffocation, or a leakage of esophageal contents, laden with bacteria from the mouth. If leaked into the trachea, these contents could have led to pneumonia, or if into the mediastinum, to sepsis and vascular collapse. We were relieved to find that the mass was not cancer, but left untreated, a simple leaf could very well have ended Ian’s life.