A Day of Surgery

Having a port for cancer treatments and blood draws makes life easier for me as I live with metastatic cancer. It even can be used for contrast dyes that are given during all the scans that come with MBC life. Whereas having the port is easy-breezy, getting one removed and replaced presented a few bumps. It took two procedures to remove it. You can read that story here if you missed it. It also took two surgeries to get a new one.

The procedure had already been rescheduled once due to what best can be described as communication glitches between departments that share patients from time to time. It was finally scheduled one day before treatment so I’d be good to go. Maybe I was supposed to feel some anxiety. I thought of it as a small deal in terms of hospital events. I could let my sister feel that stress. When she dropped me off, I told her I was psyched. Bring on my port!

I have been fortunate not to have had much surgery in my life. I had a couple of breast fibroids removed in my early thirties. I pushed for surgery when I was diagnosed with metastatic breast cancer but failed to get it and I was told it wouldn’t benefit me. The cancer had already spread. Getting my original port has been one of the only surgical experiences I’ve had.

The same surgeon who put in the first port was placing the new one. He took out the old one when it had leaked. He came into my room in pre-op and went over necessary details. He told me I was I difficult to sedate when he removed it weeks earlier. I do well with local sedation or general anesthesia. With conscious sedation I move around too much. I do well with general anesthesia and wake up pretty intelligently. Good to know even though I plan to be done with surgery for a long time. My spirits were up during our pre-op discussions. I announced to everyone I was going to rock it. Off I went.

I didn’t rock it.

I woke up fairly alert in recovery and learned a new port wasn’t placed. I hadn’t seen this coming and it hit me like a ton of bricks. The thought was the vein had become too narrow and scarred. From patient notes, I read an ultrasound was successful in accessing the right internal jugular vein. Multiple attempts were made to advance the catheter portion of the port, but there appeared to be a central stenosis (narrowing). Medical speak became too technical for me after this but I understood the gist.

Another surgeon from Interventional Radiology came for a consult. I would be handed over to him since I required more specialized attention. He was an overly cheerful sort who shared bad news with a smile. It was annoying and I said something to the effect I wasn’t as happy with this news as he seemed to be. He chuckled as he told me he was unsure if a port could be placed on the left side. Stenosis needed to be ruled out. Other impacting factors involved finding an available OR and more importantly a free anesthesiologist. These were all strikes against the likelihood of my getting a port that day no matter how badly I wanted one. What would I do long term if the left side couldn’t be used? I asked my new surgeon to please try to arrange it.

Yes, I wanted a new port that day. Thoughts ran through my head about rescheduling again. Maybe the third attempt would be the charm. Rescheduling would mean more fasting, another negative COVID nasal swab, and arranging a ride for another day. I’d need to do laundry the day beforehand to check off boxes for clean sheets and clean pajamas. I would need to shower at night and in the morning with special antimicrobial soap provided to me. I would have to emotionally decompress and then start from scratch another day with no assurances it was even going to work. I would need to do food prep ahead of time so I’d have good food when I got home. These are all hidden preparations that go unseen when someone pops in for a quick procedure. It’s work for the patient, too.

My surgeon returned rather pumped that it was my lucky day. His enthusiasm was remarkable and I was equally thrilled with his news. An OR was available and an anesthesiologist found. It turned out to be the same one I had in the morning. I was happy to see her for the afternoon session. She knew me and my history. Arrangements were made for something called a central venogram and left side line/port if central stenosis could be ruled out. The easiest way for me to explain a venography is imaging of veins. What I didn’t understand until moments before I went to surgery was I’d be under for this part. If a good vein was found they’d go straight into placing the port. I’d wake up not knowing if it was successful or not.

I hate not knowing. I hate not being aware of what’s happening to me. That happens too often with cancer. I hate waking up and discovering I had on a different gown. How did THAT happen? I already was the most underdressed there. I suspect this may be standard to help protect patients from infection and keep the environment sterile. It’s a bit of a mystery. I guess what happens in surgery, stays in surgery.

I loved waking up and finding out I had a shiny new port. It was on my left side which means I have symmetrical scars. It’s not the look I want, but it’s the one I need. Maybe it’s time for a tattoo. I’m entertaining a simple cross with the word hope or perhaps simply a heartfelt expression like Bite Me. One fits my personality better than the other.

Diagram of a PowerPort. Notice the three small bumps on top that are posing a problem in feeling them.

Cheerful surgeon returned to check in on me. I was more cheerful than he was in this instance. I exclaimed a hearty “Well done!” and adopted my pandemic gesture of hands in prayer to express gratitude. I often use it in greeting as well. It works for many things. I followed up with an air high five that he was happy to return. Shortly after this, I was able to leave, having arrived at 8 AM and finally leaving around 6 PM.

Living with cancer has taught me much about priorities with health care. There is a lot on my plate. I have found I need to identify and stay true to the biggest priority whenever I have an oncology visit, treatment, test, or something else related to my health. The day of surgery, my priority was getting a new port. My priority the next day was getting treatment. As it turned out, my cancer center couldn’t use the new port because their policy was to wait a week to use new ports unless needles had been left in ready for use. Hmmph. I was disappointed but knew I could still have treatment through an IV. Treatment was the priority.

My priority the day after treatment was ice cream.

My new port has been used once, and it wasn’t easy-breezy. It flushed easily yet a blood return was hard to get. It took three stabs and lots of pushing down on it and repositioning the needle while still stuck into me. Blood finally got flowing. On my next treatment, four people tried. Once it couldn’t even be flushed. Once it returned pink blood, not red enough to count. No one can feel the three bumps needed to access it well. It was another treatment day with an IV line.

I’ll have an x-ray early next week to see what information that provides. After all the hassle to replace it, it looks like a third surgery is a good possibility. Insane.

Figuring out what is going on with the new port is one of three big health priorities for next week. I hope it is an easy fix. My port business is even more important than ice cream. I can’t wait for my port to be fixed and ice cream can move up on the list again.

Cancer: Port Problems and Infections

As I’ve often said, there is always something when living with metastatic cancer. This post is about two of those somethings.

The National Cancer Institute defines a port-a-cath as follows:

A device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or drugs such as chemotherapy and antibiotics. The port is placed under the skin, usually in the right side of the chest. It is attached to a catheter (a thin, flexible tube) that is guided (threaded) into a large vein above the right side of the heart called the superior vena cava. A needle is inserted through the skin into the port to draw blood or give fluids and other treatments. A port-a-cath may stay in place for many weeks, months, or years.

Most refer to this as a port for short. I had my port for almost 9 years.

My port had always been comfortable. It was flush in my chest and didn’t stick out like a raised bump that I’ve seen in many photos. It was noticeable but not eye-catching or prominent. It was just there. Lately, I noticed mine felt tender and sore. The soreness stretched all the way up to my neck. I would feel sore for days after a treatment. It pulled and tugged at the port site and along the scar on my neck when I was both active and inactive. I chalked it all up to my port being used weekly. I’m receiving Taxol as my chemotherapy and thought it was more or less kicking my butt. I would recover and feel normal before the next treatment and the cycle would start over again.

One day I noticed the incision scar at the port site looked a little pinker. Again, it’s been used a lot more lately. It didn’t give a blood return regularly, which was accompanied with pushing, prodding, and all kinds of maneuvering to get it to work. The pinkish color was expected in my opinion. Still, I put my port at the top of my list to discuss with my oncologist. I wondered if it had moved a bit, had leaked, or was just plain worn out.

When I go to the cancer center, my schedule has a consistent order: labs, office visit with my oncologist, then treatment. The port is accessed for labs and then covered up until treatment is given. My oncologist never sees it. Due to some strange twist in scheduling, I was to see my oncologist two days before my labs and treatment. The port wouldn’t be covered. If not for this odd anomaly in scheduling, I’m not sure my issues would have been discovered. A higher power was intervening.

My oncologist agreed my scar looked pink and not quite right. She ordered my CBC panel early from the lab and also included blood cultures to check for infection. She also wanted me to check in with my surgeon to do a port check which would make sure the port still operated efficiently. She was doubtful that anything would turn up in the blood cultures or in the port check. All was precautionary.

My CBC blood panel was all fine. Even those absolute neutrophils were behaving, although they were a bit lower than I would have expected for Day 1 of a new infusion cycle.

The blood cultures were new for me. These are tests to check for infections in the blood (bacteria, yeast, fungi, other microorganisms). Knowing the kind of infection helps determine what the best antibiotic is to treat it. Blood is taken centrally from the port to see if only the port is infected. More blood is taken peripherally from the arm to test if an infection has gotten into the bloodstream. It takes 24-48 hours for an infection to grow and the test to come back positive.

My day suddenly became a lot longer. I headed from the cancer center to a building about ten minutes away to see the surgeon who had installed my port. He wanted to take it out immediately because it was so old. The discussion became one of multiple scenarios. I wouldn’t really need a port check done if he was removing the port the next day. There wasn’t much point if it was coming out regardless. On the other hand, we should wait for the blood cultures to come back before removing it. He was fairly confident they’d be negative, but to be safe we should wait. If he installed a new port to an infected area, the new port would need to be removed and we’d be starting from scratch. Then again, there also was no hurry. My port could come out at the next convenient gap in treatment. Now was an ideal time to remove the old and place a new port since my counts were all good. It went back and forth. I decided to be thorough, have the port check, and wait for the results to come in from the blood cultures. I’m glad I did.

The next morning, I headed out for my port check. The port check showed a leak in the catheter up near the neck. Little spurts of contrast dye leaked out and swirled like tiny puffs of smoke. This port was done. It could no longer be used in any circumstance for blood draws, injections, or treatments. I was to let no one near it. No one could touch it. I got the message. I’d wrestle anyone who tried to get at it, and I would win.

A leaking port explained a lot. I had experienced strange symptoms ever since I started a new treatment. An allergic reaction was first thought to be the issue. Then the position of the chin strap on the cold cap was thought to be the problem. You can read a past post about those experiences HERE. The swelling continued without knowing what caused it. No one but me seemed to notice. I finally connected that it was swelling in the areas where the port was located in my chest and neck. At last, my discomfort and pain made sense.

I returned home to begin a lot of rescheduling. It looked like I could get a new one placed the following morning. I would need to reschedule my chemo to the afternoon but that was possible. I had everything set up. I was ready to head out for my required COVID test.

Then came the calls that the blood cultures were positive. First one was positive. The port would not be replaced the next day. I didn’t know how chemo would be affected. Then came the call from my oncologist that both cultures had turned positive. No chemo. White blood counts would drop more. The infection had to be cleared before chemo could be resumed.

She wanted me to have IV antibiotics.

I was to stay overnight in the hospital for two nights. My port would be removed while I was there. To be clear, the leaking port and blood infection were two separate issues that just manifested at the same time.

Rats, shoot, darn, and fart up a tree. I hadn’t expected this, but it had to be done, and I could accept how events were playing out. Get it done quickly and get me back on track. Looking back, I am grateful for the quirk in scheduling that allowed this infection to be caught in very early stages before I showed any symptoms like fever, sweats, and chills.

I arrived at the hospital and settled in for my two-night getaway. I started receiving an antibiotic called vancomycin in my IV immediately. Later daptomycin and dalbavancin were added. Little did I know my adventure was just beginning.

Stay tuned for a special post tomorrow to read about relatively simple surgeries that aren’t that simple and other tests.