Settling in to Wait for Surgery

I / we have now met with all the major players in my treatment at Beth Israel: Drs. Schlechter (hematology, oncology), Kent (pancreatic surgery), & Levine (Multiple Myeloma).  My hope that there was a “Whipple light” or immunotherapy that could spare me the big operation turned out to be baseless, as there is no alternative to the “full” Whipple.  The internal bits in the area of the Ampulla of Vater (where my tumor is located) are too closely packed in and inter-connected to do anything less than full removal.  Perhaps if the growth had been on the surface (intestine side) of the Ampulla of Vater, I could have been spared the big surgery.  But it is on the hinge of the flap, and who knows how much further up the various ducts, so an isolated extraction is not in the cards.  I must have completely misunderstood the relevance of immunotherapy.  Apparently, that is an option for post-operative treatment, not an alternative to the operation itself. 

So, I am all prepped for surgery first thing on Wednesday, 6/28.  They were going to remove the tube that currently is keeping my liver duct open on 6/20, but the surgical team for 6/28 can do that just as well, so I continue to have a capped tube sticking out of my right side, preventing swimming and complete showers.  I have resumed the treatments for Multiple Myeloma.  I have taken Ninlaro pill #2 and will take #3 this coming Friday.  To take the full course of Revlimid would take me to Monday, 6/26.  But Revlimid interferes with healing and lowers crucial blood counts, so Dr. Levine recommends stopping those treatments the weekend before the surgery.  Yes, the free lambda reading is alarming, but Dr. Levine says Multiple Myeloma is not going to kill me in the next few weeks.  Interfering with healing from the Whipple surgery could have disastrous results. 

Dr. Kent explained exactly what is involved with a Whipple procedure.  Here is a picture of the relevant pieces before the surgery. 

My growth is on the Ampulla of Vater, which is the flap covering where the bile duct and the pancreatic duct empty into the duodenum.  The parts that are circled by the pen on the diagram are the parts that are coming out. The picture makes the pieces all look quite independent and separate.  But another picture, which shows the blood vessels, gives a better impression of how interconnected they all are.  The pen drawing to the upper left is the liver.

Cutting into any one of the blood vessels in that area could be fatal, and they don’t have a way of taking out just parts of the complex.  So, they end up taking out the head of the pancreas, the gall bladder, much of the bile duct, and the duodenum.  Major surgery.

Then they stitch it back up as shown below.  

What is left of the bile duct is attached to the lower intestine, as is the pancreatic duct.  The stomach is sewn into the jejunum, a part of the lower intestine below the duodenum.  The gall bladder acts as a storage area for the juices the liver produces, but apparently the liver can store its juices on its own well enough for normal digestion to occur.  The tail of the pancreas can generally produce the hormones and digestive juices it is responsible for in the absence of the head.  Sometimes there is insufficient insulin, in which case insulin injections are required.

There are lots of risks.  Infection is always a risk in such a large, long surgery.  The places where organs are reconnected may leak.  Someone with my history of pulmonary embolisms will certainly have the risk of a blood clot.  Generally, they monitor these risks and have specific antidotes.  They will have drains next to the 3 areas where the organs are reconnected.  I will wear special socks and have compression booties to keep the blood circulating in my lower legs to minimize the chance of blood clot.  Presumably all sorts of disinfection efforts are standard for this type of surgery.  Then we fall back upon close observation of how the recovery is going and speedy analysis of whatever is going wrong.  Beth Israel has an excellent history of performing these operations, and does more annually than any of the other major hospitals in the Boston area, and apparently I am a good candidate for it.  In the past, they had to resort to the Whipple more frequently than they do today, as not many alternative treatments existed.  Now they only do these operations on patients that are likely to survive and benefit.  Let’s hope I fall into that category.

They acknowledged that this period of pre-op waiting can be stressful, but recommended we head to Cow Island for a few relaxing days during which I am to eat as many good nutritional meals as possible, and avoid any sort of risky behavior: no broken legs, hips, etc., no major cuts….given my track record, this will be a challenge as well.

Thank you all for your good thoughts and concern.  Modern medicine is indeed amazing, but I would prefer to learn about it third hand, not first hand.