Me and my pump

So this, I believe, is a picture of a pump much like the one that’s now inside me. It’s a clever device: one compartment holds the chemotherapy, while the other holds freon, and my body heat causes the freon to expand and push the chemo in the other compartment out via a catheter to the vein serving my liver.

It’s also, as the picture suggests, surprisingly big! I think the true size is about 4 inches in diameter, probably a couple in depth. You might ask – I certainly wondered – how can this thing fit? I mean, wasn’t all the space inside my abdomen already in use? The answer, however, is that it fits in with no trouble at all. The surgeon makes a horizontal incision, to the left of and just a little higher than my navel, and pops the pump in. All right, he probably doesn’t do anything that should be called “popping.” But he (my surgeon was a man) inserts the pump, and evidently everything else in the area shifts around a bit and the pump is in! Then he closes up the incision and glues it shut (yes, literally, glues it shut; the glue on mine is slowly wearing away now, which is fine since my own healing process has taken over), and if all goes well it remains there for the rest of my life.

Just to be clear, inserting the pump isn’t the whole surgery. It’s also necessary to connect the catheter from the pump to the vein serving the liver; this catheter is probably 8 – 12 inches long because that vein is actually some ways away from the pump’s resting place in my lower left abdomen. And to make sure that the chemo that will flow through the pump actually reaches the whole liver, the surgeon had to redesign my liver circulatory system somewhat – cutting off, as I understand it, a vein that used to serve part of the liver but which branched off the main liver vein too early to receive the chemo from the catheter a bit downstream. They also took out a couple of lymph nodes, as part of this redesign. And they took out my gall bladder: that’s a cholecystectomy, in case you were wondering, and is necessary because the chemo to the liver is likely to cause the gall bladder to die. The gall bladder is almost as useless as the appendix, but like the appendix you don’t want it dying inside you.

Doing all this other stuff required a second incision, straight down the middle of my abdomen from a little below the breastbone down to the navel. The incision actually bends around the navel; I thanked the surgeon for keeping my navel intact and he told me it’s “bad form” to cut through it. This is the incision that I had staples in – but they’re now long gone, and the incision itself is a straight and narrow line down my abdomen. I wouldn’t say I’m going to look great on the beach, but the fault won’t be with this incision. The only remaining problem is that one small part of the incision opened up – leaving me with a hole maybe a centimeter and a half long, and part of a centimeter wide and deep. I found this completely creepy, but the surgeon and his nurse were unfazed, and instructed Teresa on how to dress this small wound with gauze twice a day. She’s been doing that as if she’d been dressing wounds all her life, and just as the doctor said, the wound is filling itself in – from the inside out!

Meanwhile, a wonderful thing is happening. The most lasting effect of the surgery on my overall condition was that it robbed me of energy. Walks that I’d have thought as a month ago as very short now left me clammy with sweat. But all of a sudden – I’ve felt it over the past three or four days – my energy has begun to return. I’m not at 100 per cent by any means, but I feel much more like myself. And that’s even though I’m now 10 days into the first round of chemotherapy delivered via the pump; precisely because this chemo goes directly to the liver, and evidently is almost entirely absorbed there, the side effects on my body as a whole are likely to be modest. They watch the liver carefully, though, to make sure it’s not being overwhelmed by the medicine it’s receiving. So: so far, so good.

Surgery's done

Just a quick update (more details about the past weeks to come in future posts):

So I went in for the surgery on Friday, August 12 – and it went fine. I came home the following Tuesday, August 16, several days earlier than we’d anticipated, and on Wednesday, August 24, they removed the row of surgical staples that they’d sealed me up with. (Staples – pretty weird.) None of this meant that I was feeling great – it turns out abdominal surgery is just plain a big deal -- but I was (and am) making pretty steady progress.

Then, this past Wednesday, August 31, I received the first dose of chemotherapy into the pump that was installed in the surgery. The pump is now doing its work, sending the chemo bit by bit to my liver over a 2 week period. At the end of that period, they’ll reload the pump with a combination of saline solution and heparin (to prevent blood clotting), and I’ll have two weeks off from the pump treatment.

Meanwhile they’ll re-start the intravenous chemo (which aims to guard against cancer throughout my body, not just in the liver itself). They’ll use just one drug, gemcitabine, for this intravenous treatment rather than the two-drug combination I’ve had up till now; that means I won’t get another drug, cisplatin, which can be tough on the blood vessels it travels through, so this should be relatively easy too. From then on the plan is that I’ll get the intravenous chemo every two weeks, while every 4^th week I get a new dose of chemotherapy via the pump.

Meanwhile, my incision continues to heal, and I’m feeling reasonably well though quite tired. It’s startling to think that all this surgery did was to install a delivery system to send chemotherapy to the right spot in the right way – but I’m hopeful the results will be good!

Next step: surgery

It’s been some time since I wrote about my impending CT scan, and what it might mean for my treatment. Teresa and I got the results of the scan at the end of July, and now I’m about to take the next step: surgery two days from now, Friday, August 12.

What the CT scan showed was that my tumors were no longer shrinking. If they had continued to shrink, as they had done over the first six months of my chemotherapy, we might have answered the question of what to do next quite differently. But the fact that the tumors were no longer shrinking was a sign that the next stage would be that they would begin to grow again. Even though we don’t know when that next stage might arrive, it might well be soon, and our oncologist made clear that she felt it would be better to undertake this clinical trial before the tumors began to grow. That’s probably partly because I’m stronger now than I would be then, but it’s also because the surgery itself requires a break from chemotherapy, and it’s better to take that break while the tumors are still in check.

Meanwhile the CT scan also showed that the cancer still seems to be confined to my liver. They won’t know for sure if that’s so until they actually start the surgery and look, but assuming it is so that means I’m still eligible for this clinical trial, which is designed for cancer that is, like mine, only in the liver.

The surgery does not remove any tumors; with my cancer that approach, called “resection,” isn’t feasible. Instead, it makes possible a targeted assault on the tumors by chemotherapy sent directly to the liver. The surgery will implant a pump, about 4 inches wide, on the left side of my abdomen, positioned if possible so as not to bump against my ribs on the top side or against my belt on the bottom. It turns out there is room in one’s abdomen to insert an object this big – and once it’s inserted they’ll be able to see where it is beneath my skin, and insert a needle into it to load the chemotherapy. The pump is cleverly designed: it apparently uses my body heat to cause freon gas in one compartment to expand, and that in turn pushes the chemo in a second compartment out into a tube, which is connected to the artery leading to my liver and so can deliver the chemo directly into the liver. 

There's a bit more to it as well. As part of putting all this in place they also take out my gall bladder; I gather the gall bladder is almost as useless as the appendix, but the chemotherapy that’s going to be hitting my liver can destroy the gall bladder inside me, and that wouldn’t be good. They also have to do some reworking of my abdominal blood vessels, to make sure that the only artery bringing blood to the liver is the one that the tube from the pump is connected to; that way they can be sure that all the blood in the liver is delivering chemotherapy with it.  

Doing all this requires about three hours of surgery, and also involves cutting through the abdominal wall – and so after the surgery itself I’ll probably be in the hospital for a week. Then I’ll be recovering at home for about two months, though I’m certainly hoping to be back on the computer long before that.

Meanwhile, two weeks after the surgery, we’ll go back to Sloan Kettering and they will load the pump with a two-week dose of chemotherapy, and the pump will start sending it to my liver. I gather that the drug they’ll be using, called FUDR, can be less fun than the two I’ve been on till now, but I’m hoping that I will not have too much trouble with it. Sloan Kettering, meanwhile, will be carefully monitoring my liver to make sure it’s not too stressed by all this medicine coming at it. Once this is all underway, I’ll have two weeks on this chemotherapy and then two weeks off.

About the same time that my first pump dose is finished, and four weeks after the surgery, they’ll restart the intravenous chemotherapy I’ve been having up till now. Probably they’ll modify the drugs I get this way: I was getting two, gemcitabine and cisplatin, and it looks like they’ll continue the gemcitabine but drop the cisplatin, which is an irritant and has in fact irritated a vein in my left arm. What the intravenous chemo does that the pump chemo doesn’t is to reach the whole body, and therefore to guard against any spread outside the liver. The net result is that I’ll be getting a two-punch approach, which is exactly what I like about this trial.

Will it work? There’s no guarantee; this is, after all, a clinical trial. But the results Sloan Kettering has gotten so far – this technique has been used in trials for some time – are encouraging. If it works, even imperfectly, it gets me that much more time to enjoy my life, and meanwhile improves the odds that I’ll get to take advantage of the wave of research on other treatments that’s now underway. And if it doesn’t work, there are other possibilities right now as well. So I’m quite optimistic.

And that's what we'll be involved with for the next month or two!