The Perplexing, and Sometimes Perilous, Polyp

Until last weekend, quite a few Americans had probably never heard of polyps. But now that the small growths have made history by causing a temporary transfer of presidential powers, their name has become part of the popular lexicon. Polyps are small growths that generally appear on epithelial tissues, like those that line the intestines. Intestinal polyps are quite common, especially in people over 50, and if detected early they can be treated with minor surgery, usually by being cauterized or snipped off. When the polyps are allowed to grow, however, they not only are more difficult to remove but can interfere with body functions and even become cancerous.

President Reagan first learned that he might be susceptible to developing polyps in May 1984, when doctors discovered a growth in his intestine during a routine physical examination. The discovery was made with a device called a sigmoidoscope, a tube containing a light source. Inserted into the colon, it enables doctors to examine the walls of the lower part of the intestine visually.

Because the President's polyp was so small and a biopsy showed no sign of malignancy, his physicians decided not to remove the remainder of the growth. During another routine examination last March, doctors found no evidence of the first polyp but discovered a second small growth, attached to the intestinal wall by a stalk, and found traces of blood in two samples of the President's stool. Although this finding suggested that bleeding was occurring in the intestine which could signal the presence of a malignancy, doctors were not immediately alarmed; eating red meat also sometimes leads to traces of blood in stool. Indeed, after Reagan was placed on a restricted diet, the blood traces disappeared. Still, to be on the safe side, the President's doctors decided to remove the polyp, asked Reagan to pick the earliest convenient time, and scheduled what was to be a minor operation on July 12.

For this procedure, performed under light sedation, doctors used a colonoscope, a flexible hollow tube with fiber-optic threads, that can be inserted to the full length of the large intestine. Inside the tube is a wire snare that emerges in a loop at the far end. Maneuvering the colonoscope, they placed the loop around the suspect polyp and passed an electric current through the wire which cauterized the polyp, freeing it from the intestinal wall. Held to the end of the colonoscope by suction, the polyp was withdrawn. Using the same instrument, the doctors visually scanned the rest of the President's colon. It was during this examination that the larger polyp was discovered in the cecum, at the juncture of the large and small intestines.

Doctors quickly determined that they could not remove the polyp with the colonoscope because of both the size and nature of the growth. Unlike Friday's polyp, which rose on a stalk, this one was attached to the wall by a broad base. Instead, they merely scraped tissue from the periphery of the growth and removed it for a biopsy. Although the tissue samples proved benign, doctors concluded the polyp was a villous adenoma, so called because of the villi, or finger-like projections visible under a microscope. While only from 2% to 5% of adenomatous polyps (the kind excised from Reagan on Friday) eventually become malignant, about half of villous adenomas turn out to harbor some cancerous cells. Furthermore, even without the threat of cancer, a large polyp can cause digestive troubles. It was clear that major surgery was necessary to remove the polyp, the sooner the better, and the operation was scheduled for the following day.

On Saturday, a team of surgeons headed by Navy Captain Dale Oller placed President Reagan under general anesthesia and performed a right hemicolectomy. They threaded a tube through his nose and into his stomach to remove any gas and fluids that would accumulate until the intestines regained their peristaltic movement. With the President lying on his back, the surgeons made a 6-in. incision through the right side of his abdomen and exposed his colon. Then, using what Oller described as a "no touch" procedure, they excised a 2-ft. section, including the cecum, a portion of the small intestine and some surrounding lymph nodes. No touch involved taking care not to open the section as they removed it, in order to reduce the risk of infection and to keep the polyp intact so that any possibly cancerous cells would not spill into the abdomen, where they could take root and begin to multiply. After sewing the severed ends of the bowel together, the surgeons made a careful visual inspection of the liver and the rest of the abdominal cavity for signs of malignancy. None were evident, and the surgeons closed the incision, completing the operation in 2 hr. 53 min.

The President's polyp proved to be quite large, about 2 in. across, and Oller did not rule out the possibility that it might be malignant. The intestinal segment was promptly placed in Formalin, a preservative in which it was "fixed" for 24 hours, then sectioned and stained, and the sections mounted on slides. Early this week the sections were to be examined by pathologists, who would determine if any malignant cells were present and where they were located in the polyp. Even if cancerous cells were discovered, Oller stressed, the President would probably need no further treatment. "The strong likelihood," he said, "is that [the segment's] removal has dealt with any problem."

Reagan's doctors conceded at the Saturday press conference that the size of the polyp suggests it has been growing for a long time, perhaps years or decades. Even before the conference, however, other physicians were questioning why it had not been detected earlier either by a colonoscopic inspection or a barium enema. Said Dr. Stephen Hanauer, a gastroenterologist at the University of Chicago: "The bottom line was, if he had either blood in his stool or a polyp last year, then our way of dealing with that is to recommend examination of the entire colon for polyps." The President's doctors stood fast, explaining that they had decided against a scan of the entire bowel after the discovery of the first polyp because it was in fact merely a "pseudopolyp," more an inflammation than an actual growth. In following the course they did, insisted Dr. Edward Cattau, chief of gastroenterology at the naval hospital, the doctors were adhering to the screening guidelines established by the American Cancer Society.

Still, knowing what he knows now, Cattau admitted, he will recommend that the President undergo more frequent colon examinations. It is now clear, he said, that the President is prone to polyps. In fact, the tendency may run in the President's family. Oller disclosed that the President's brother Neil, 76, a retired California ad executive, was recently diagnosed as having cancer of the colon. Said Oller: "I would recommend that Reagan have a repeat colonoscopy in six months."

As President Reagan recovers during his seven to ten-day stay in the hospital, he will be living with tubes: the one inserted through his nose into his stomach at the beginning of the operation, and an in travenous tube in his left arm through which he will receive nourishment in the form of dextrose, a sugar, and Ringer's lactate, a buffer solution. Both tubes will remain in place for several days until he resumes normal bowel movements, after which he can begin eating solid food again. The President is also receiving antibiotics to guard against the possibility of infection, which occurs in 2% or 3% of those who undergo the operation. To relieve the President's postoperative pain, which is expected after such surgery, doctors used a special technique called intrathecal injection of morphine. They delivered the opiate through a needle inserted in the sheath of Reagan's spinal cord, where it blocks nerve pathways through which pain signals are relayed to the brain. Even with the array of medical paraphernalia leading in and out of his body, Reagan should be able to carry out most of his important presidential duties. Said Dr. Oller: "One can conduct business even with a nasogastric tube in place."