A happy little case

[Note: The following is based on an aggregation of multiple patients. It does not represent any single patient's case.]

It was a little case.

I know, I know, I've said in the past that there's no such thing as a little operation, at least not when it's happening to you, and that's true. Nonetheless this case was as close to "minor surgery" as you could get while still actually having to wield a scalpel to cut through skin. As I spoke to her before the operation to get informed consent, the patient ran her fingers across her short hair, only now starting to grow back after her having completed her chemotherapy a few weeks ago. As I've found with many women whose hair is just starting to reappear, like the soft coat of a short-haired puppy, she looked good--better than I remembered her with hair. Indeed, it never ceases to amaze me how many women can look so good at this point in their course, where they have what looks like a Marine-style buzzcut. Maybe it's just me, or maybe it's because women who reach this stage almost invariably seem so full of life; they've faced down death and their worst fears, and come out intact, if not unscathed. And this time, the patient was elated at having this procedure. Indeed, she was practically giddy, happier than I had ever seen her. She had a glow that, if I believed in Reiki, might have interpreted as a her life energy becoming visible. I knew why she was so happy.

I was going to remove her port.

Vascular access is considered very unsexy as surgical procedures go. For dialysis patients, the goal is to create a high flow connection between an artery and a vein that can be accessed with needles to provide adequate flow for dialysis to finish in a reasonable amount of time. This can involve either a direct connection, where the surgeon sews a vein directly to an artery in the forearm. When this can't be accomplished, then a small artificial tube (graft) is used to connect an artery and vein higher up in the forearm. The problem with these procedures is that they tend to have a fixed lifespan. They tend to clot off (often at night), requiring revision or replacement, and the replacement is nearly always on another limb or higher up on the same limb. Over time, dialysis patients start running out of locations, and sometimes it becomes a battle to keep fistulas and grafts open as long as possible, so that the patient doesn't run out of sites before he or she runs out of life expectancy.

In cancer, the goal is different. It's shorter term, and the tools used are less permanent. The goal is to give the patient durable vascular access that allows chemotherapy to be given, usually over a few months. Some chemotherapeutic agents are very harsh on the veins, and because of that it's highly useful to place a catheter in a large central vein with high flow. There are basically four kinds of these devices: First, there's your basic central venous catheter, which is not designed to remain in place for more than a couple of weeks. It's basically inserted into either the subclavian or internal jugular vein, sutured in place, a dressing placed over it, and its end left hanging. There are PICC lines, which are placed in a vein in the arm and threaded to the central circulation under fluoroscopy. They're much like central lines in that they also leave a tube hanging out, but they avoid the necessity of sticking needles in large central veins, are narrower, and can be left in longer. There are tunneled catheters (Broviacs and Hickmans being the two most common), which are like the central line, except that they are tunneled under the skin and have a cuff that's designed to induce scar tissue to make the catheter "stick" in the tunnel. These have the same disadvantage as PICC lines and central lines of also leaving a tube hanging out, but they can be left in place for many weeks, or even months. Finally, there are totally implanted ports (like the Port-a-Cath), where the entire assembly is implanted under the skin, and the port is accessed through a resealable diaphragm using a special needle inserted through the skin. These can be left in place for months or even years and tend to be the first choice for chemotherapy. Unless a patient is thin enough that it's possible to see the outline of the metal part of the port sticking up under the skin, they're basically invisible.

If you're a cancer patient who needs a prolonged course of chemotherapy, your port is your friend. Your blood can be drawn through it (and you will need frequent blood draws). You can get your chemotherapy through it without painful needlesticks and burning out of veins. As I said before, injecting chemotherapy in to peripheral veins can be quite painful for some drugs, and a port will eliminate that problem. These two things alone can go a long way in improving a cancer patient's quality of life. It is true that ports aren't without their complications. They can become infected and require urgent removal. They can clot, necessitating treatment with clot busting drugs. Sometimes they can cause a clot in the large blood vessel in which they are placed, leading to arm swelling and even facial edema, not to mention urgent removal of the port. There can be rare misadventures where the port catheter breaks and goes flowing off in the bloodstream, requiring angiography to fish it out. However, on the whole, ports do far more good than harm, and, before radiologists started doing these procedures (which they are doing more and more) general surgeons were the ones who put most of them in.

And took most of them out.

I'll betray a surgeon's bias in thinking that most of the time it's better for a surgeon to put them in. This is not because radiologists can't do it well or that they have more complications (like a pneumothorax), but rather because when surgeons put these ports in, it can be done in the operating room, which allows better anaesthesia to be given. When radiologists put these in, it's usually under straight local anaesthesia, with maybe a little sedation but often not; when surgeons put them in, there's an anaesthesiologist who can provide much better sedation. It's generally a better experience for the patient in my opinion. Sometimes getting these ports in can take multiple sticks and a fair amount of digging around.

This particular woman had had a rough time of things. Diagnosed with 2 cm. breast cancer around eight months ago. Having a history of depression, she was devasted by the diagnosis, and it didn't help that, when I operated on her, she had multiple positive lymph nodes. She was at high risk for a recurrence and a definite candidate for chemotherapy, a prolonged course lasting around 5 months, followed by radiation. It was actually not too difficult, given that fact, to talk her into a port, and the procedure went smoothly. At this point, their surgical therapy being complete, breast cancer patients like this usually disappear into the black box of medical oncology and radiation oncology and I don't see them again for several months unless there are surgical issues. This time around, the surgical issue was a call from the medical oncologist asking me if I'd remove the port, because the patient was finished with her chemotherapy.

It's easy for a surgeon to forget that the insertion and removal of a port represent two major milestones in the course of a patient's cancer treatment. The insertion of a port often represents, even more than the scars from surgery, a daily reminder of the patient's disease, and the insertion of that port represents a long-term alteration of the body necessitated by her disease. It's a constant reminder that life is not normal, a cold, metallic foreign body implanted in her body. Every time a woman feels that quarter-sized metal port under the skin, it's telling her that her life is not what it was; she is not the same as she was; she is not "normal." Even though the implanted port may not even be noticeable even if she wears a wide-necked shirt, other than the small scar left from its implantation, the patient knows its there. Sometimes this provokes complaints that one wouldn't have expected. I've had patients complain that they felt the port while trying to golf, to ride a bike, or even do yoga, and it bothered them. I've had patients who normally sleep on their stomachs complain that they can't do so anymore because they end up lying on the port.

Of course, putting in a port is not particularly difficult (well, most of the time, anyway, when port insertions go bad they can be among the most difficult and frustrating "little" cases there are, particularly because the surgeon gets to sweat under lead shielding as he wields the fluoroscope). However, it is still considerably more difficult than removing one. Removing a port involves making an incision in the skin; carrying it down to the port while avoiding the plastic catheter, which can be inadvertently cut, leaving the end to retract into the vein, where it's difficult to get out; dissecting it free from the capsule of scar that forms around it; and then closing the skin. It usually doesn't take me more than 15 minutes, even if I'm taking my time. (If I'm doing it with an intern, make that a half hour.) This time was no exception. I made the usual incision, did a little cutting to free the port from the filmy embrace of the surrounding tissue, and delivered the port into the wound triumphantly. The incision was closed and a dressing placed. Done. Nice and easy. As I often do, I showed the patient the port, although I was a little embarrassed that there was a piece of tissue still attached to it that was stubbornly resistant to removal. I usually like the port to be a bit cleaner before I show it to the patient.

Indeed, removing a port is so easy that it's equally easy to forget what this means to the patient. It means an end to the chemotherapy. It means that the most intense, painful stage of treatment is over. It means reversal of at least one bodily alteration. it promises the hope of a return of what was taken away by the cancer. To us surgeons, it's a simple procedure, even a nuisance sometimes when things are busy and we're being asked to do a dozen procedures and being pulled in a million different directions.

After the procedure was done, the postoperative instructions given, and pleasantries exchanged, I had to move on to the next case. I could only pause briefly to think of what lay ahead. She still had five years of Tamoxifen therapy to look forward to. Worse, given the stage of her tumor at the time of diagnosis, there was still a significant chance that the monster that is her disease was not entirely vanquished, that somewhere, somehow, a few cells lurked, having weathered onslaught of chemotherapy and radiation, everything that modern medicine could throw at them, dormant but not dead, ready to return, even years later. Even so, whatever happens, whatever the future holds in store for her, removal of her port was still an important milestone.

It gave her her life back.

A happy little case indeed.