A Surgical Error Leads to a Regional Crisis that Continues to Evolve

On October 29, 1956 Israel attacked Egypt. Nine days later England and France landed troops along the Suez Canal under the pretense of separating Israeli troops from Egyptian troops, saving the Suez Canal and Egypt.  This was a ruse;  England, France, and Israel had colluded to put on this charade under the leadership of the British Prime Minister, Anthony Eden.  The Suez Canal Crisis had profound regional and world-wide implications that are still playing out.  How did this happen?

On July 26, 1956, Gamal Abdel Nasser, President of Egypt, assumed control of the Suez Canal.  Almost 100 years before, the Suez Canal was built by the French and English with the proviso that it be returned to Egypt 99 years later.  Egypt was entitled to it, although Nasser should have followed internationally accepted protocol instead of marching troops in to seize it.  Also, there was the issue of all the bonds that originally paid for the construction of the canal, and were owned by French, English, and other European citizens that needed to be compensated, but were simply ignored by Nasser.

The Prime Minister of England, Anthony Eden, was incensed by the audacity of Gamal Abdel Nasser.  Eden’s response of invading Egypt was uncharacteristically undiplomatic. How is it possible that such a world class diplomat, who served under and learned from Churchill, and who had helped format the United Nations, now completely kept them out of the loop?  He used secrecy and deceit to hide the pretense of saving Egypt from Israeli aggression, in order to send in his troops. He ignored President Eisenhower’s advice, and failed to fully inform his own Monarch, Queen Elizabeth II.

To understand what was in Eden’s mind, we must go back in history.  There have been several canals connecting the Mediterranean and Red Sea, going back thousands of years.  Napoleon’s armies discovered traces of canals that had been dug by Darius and by the Ptolemies.  The current effort was made by the French builder Ferdinand de Leseps, starting in 1859, and opening ten years later, on November 17, 1869. The Suez Canal shortened the trip from England to India by 5,000 miles.  Eden saw the Canal as a necessity to provide a route from Iran and the oil rich Emirates, to the West, including England.

Churchill had been increasingly weakened by several strokes, and finally in April 1955, he stepped down as Prime Minister.  Had Eden, the only person deemed qualified to step into Churchill’s shoes, not also been beleaguered by illness, this would have happened sooner.

Eden had bouts of severe abdominal pain that was misdiagnosed as an ulcer.  In April of 1953, an X-ray showed gall stones and the correct diagnosis of cholecystitis was made. He was given the choice of three top surgeons in England at the time, but Eden instead chose John Basil Hume, a surgeon that had done Eden’s appendectomy when he was young.

On April 12, 1953 Eden’s life would change forever.  He underwent a cholecystectomy.  The operative report did not describe what had actually happened.  The surgeon was heard saying that Anthony Eden had two cystic ducts.     That is an impossibility.  What happened was that portions of the common bile duct and common hepatic duct were resected along with the gallbladder, as seen in the drawing above.

If the common bile duct is divided and the common hepatic duct is resected, the optical illusion is that there are two cystic ducts.  Additionally, the right hepatic artery was also injured, which eventually resulted in the shriveling up of the right side of the liver.

It so happened that one of the world authorities on bile duct injuries, Dr. Richard Cattell, was in London and consulted.  He wanted to take Anthony Eden to his hospital in Boston.  Despite objections from Winston Churchill, Cattell operated on Anthony Eden at the Lahey Clinic soon thereafter.  He was well enough by October 1953 to resume his job in London. Cattell did an end to side hepatico-jejunostomy over a Y tube, implanting the remnants of the right and left bile ducts into a loop of jejunum and then creating an jejuno-jejunal connection to allow the food stream to by-pass distally.

He was well for over two years.  Late in 1955 Eden starts having fevers again.  As fate would have it, in the summer of 1956, Gamal Abdel Nasser takes over the Suez Canal by marching his troops into the Canal Zone and seizing it by military force, unhappily coinciding with Eden’ recurrent biliary problems.  In early October of that year Eden took a turn for the worse with rigors, and a fever of 106℉.  Up to that time he was living on pain medications: Demerol and a “mild stimulant” (he was told), Benzedrine 1:1 combination of dextro and levo amphetamine and Drinamyl – a combination of amphetamines and amobarbital.  In several weeks he was well enough to travel to Paris for a top secret meeting with Israel, and France.  A secret deal is made called the Protocoles de Sèvres, which would have Israel attack Egypt, then England and France would send in troops to ostensibly save Egypt and the Canal by taking control.  During this time Eden was still taking the pain and stimulant medication, mostly by intravenous self-medication.  Eden was very agitated unable to sleep, and his staff, even his private secretary, found him irritable and “not himself”.

At the end of October 1956, the Protocoles de Sèvres was placed into action and Israel attacked Egypt.

Eden sent in ground forces with air support and France joined in, a full-fledged invasion.  The world reaction was swift and very negative on Eden’s decision to invade Egypt.  The United Nations held emergency meetings and called for an immediate cease fire.  This is one of the few times the US and the USSR were in agreement.  Eisenhower threatened to put economic sanctions on England.  And on November 6,1956, Eden capitulated and called a cease fire.  Nasser won!

Anthony Eden was racked with cholangitis, narcotic and amphetamine use, likely addicted to both, sleep deprivation and now world-wide condemnation.  Even his old boss, Winston Churchill, although publicly supportive, privately was livid about the invasion.  Eden escaped to Jamaica to recuperate and think things over.  He happened to have a very good friend that had a spectacular estate there, Ian Fleming, author of the James Bond books. Three weeks later, not much better, he returned to England and within a month turned in his resignation to the Queen.

His health saga continued to plague him.   In mid-1957 he has to return to Boston.  Cattell operates on him again.  The fact that his right hepatic artery was injured and likely completely transected, led to the recurrent strictures of the right hepatic duct.  Cattell would probably have been better off to just resect that lobe of the liver.  But that was not such an easy task especially, in 1957 on an old sick man.  He opted to just dilate the right hepatic duct.  Eden kept having cholangitis, and he had yet another operation in 1970, this time by John W. Braash as Cattell had passed away.  This time the right lobe of the liver had an abscess that was drained.  He died in 1977, of cancer, involving the liver (there is disagreement as to whether it was cholangio-carcinoma or metastatic prostate cancer).

Did Eden have substandard surgical care?  It is easy to second guess and use the proverbial retro-spectroscope to say, “Yes, his common bile duct should not have been cut!” But this happens everyday to competent surgeons, with the average injury rate in the US being 1500 injuries a year! It is said that most surgeons will transect at least one common bile duct in their surgical career.  In fact, ironically, this was the career ending event for the renown surgeon that had done the reparative operations on Anthony Eden, Dr. Richard Cattell.  Mortality of common bile duct injury is quoted to be 10-20%, depending on whether short term or long term is considered.  The cost of repair is at least $40,000 per case, and the average law suit settlement is $500,000.

There are a variety of contributing factors in causation of CBI’s (Common Bile-duct Injury).  The main cause is inability to identify the correct anatomy.  Infection, scaring, aberrant anatomy, failure to dissect and identify all structures are all contributing factors.  One factor that needs to be mentioned is confirmation bias.  That is a state of mind when the surgeon has developed a mental image that is incorrect, but the surgeon so affected rejects all evidence that disputes his/her view, and only accepts evidence that supports his/her theory, leading him/her down the primrose path to make a disastrous mistake.  Along with this principle is the reluctance of junior surgeons to challenge a more senior surgeon.

Example of a normal Intraoperative Cholangiogram, the roadmap for the bile-duct anatomy.

The role of Intraoperative Cholangiography in preventing Common Bile-duct Injury is debated with no clear resolution as to whose statistics are correct.  Many surgeons are on the side of “No IOC (intraoperative cholangiogram)” because it takes time, increases costs, can have its own complications, and the statistics are not clear as to a benefit.  Yet there is no question in my mind that if an injury occurs it is discovered much sooner if an IOC is done.  And the sooner the correct diagnosis is made the better the eventual outcome.  Showing a normal IOC to the jury, when faced by a jaundiced patient who claims damages for surgical error, is also quite helpful.  Regardless of the statistics, driving with a roadmap does give one an advantage in my humble opinion.  The IOC is such a roadmap. There are situations where even the nay- sayers will agree that an IOC is indicated, and certainly in a teaching institution IOC should be done for its educational benefit for the surgeons in training.  Finally, the so-called Critical View of Safety, although acknowledged as useful by most surgeons, is not practiced, as described by Steven Strasberg MD in 2010, making it only marginally helpful.

A minimum of the lower third of the gall bladder needs to be lifted off the liver bed to see across to the other side, for a truly Critical View of Safety to be useful.  Only two structures can be seen entering the gall bladder.

The next question I pose is, “Did the mental state of Anthony Eden affect his decision process to cause the Suez Canal Crisis?”  A man of his stature, training, and background should not have acted alone, keeping his superiors, advisers, and fellow leaders out of the picture in a decision that needed their input.  His personal hatred of Nasser was quite obvious when he called for the murder of Nasser on an open telephone line.  A fully rational diplomat would never have done that.  On the other hand, we know that “speed”, opioids and sleep deprivation have strange effects on the human brain, making it have paranoid ideations and even hallucinations.  I believe Eden was not in full control of himself at that time.  Most historians agree with that assumption.

My final question is, “What effect did the Suez Canal Crisis have on subsequent events in the Middle East and the world?”

During the Suez Crisis with the world mandating the withdrawal of English troops,  England loses its stature as a world power. It was the first of many events that followed which placed the Middle East  on notice. The natural response was an increase in Arab Nationalism that raised the level of animosity towards the West and Israel. Russia now became a player in the Middle East.  Russia gained a foothold, and this gave her the springboard to eventually invade Afghanistan.  The stage was set, and the motivations crystalized to clear the land from foreign “devils”.  Religion became a great unifier that drew a clear line between Muslims and infidels (everyone else).  The Mujahidin had been in existence and fighting the British as early as 1857, in the first Indian war of independence.  Other para-military groups were a natural extension of unhappy people under foreign rule.  The Taliban, Al-Qaeda, and the Muslim Brotherhood had plenty of subjects from which to recruit.  And we all know what the result of that was.  It is the gift that keeps on giving, and it is still not over!