Personal experience with Retroperitoneoscopic pancreatectomy with Dr.Walz in Germany, Ivan, Aug.2016

[Olga]

Thank you everyone for the best wishes. We are in Germany (Essen, close to Dusseldorf). The surgery is scheduled for tomorrow morning, we've met Dr.Walz and other drs today. New scans are done and they all are very confident they can do it in an organs saving way, although as they say the real location of this met is only going to be revealed during the surgery and that will determine the extend of the surgery. Hoping for the best - that it will be easily accessible and resectable. I will let you all know tomorrow how it went.

[Bonni Hess]

Dear Olga, Thank you for your very thoughtful update in the midst of what I know must be great physical exhaustion from your long flight and busy scans and doctors' appointments schedule, and the immense emotional exhaustion of all of the pre-op anxiety and stress that you and Ivan are going through as you await tomorrow's surgery. I am so grateful that you arrived safely, have already been able to meet with Dr. Walz and his associates, and that they are confident about the surgery. I deeply share your Hope for the very best surgical outcome and easiest and most successful surgery, and my every most caring and positive thoughts will be sitting right there beside you during Ivan's surgery tomorrow. In the meantime, I Hope that you and Ivan will be able to rest, relax, and enjoy some good German food, and that tomorrow will bring very good news of the successful organ saving removal of the pancreatic area met and dear Ivan resting comfortably with post op pain well controlled and on his way to a speedy and full recovery.
With gentle hugs for dear Ivan and you, most special caring thoughts, healing wishes, much love, and continued Hope,
Bonni

[ntran727]

Best of luck on the surgery Ivan! I will be praying for him to have a successful surgery with quick recovery.

[jenhy168]

Good luck with the surgery Ivan and hope everything goes well, my thoughts are with u.

[Kathy]

Tom and I are thinking of you both and sending our love.

[Olga]

The surgery is done now - Dr.Walz in Essen, Germany, the most experienced VATS surgeon in the specific retroperitoneoscopic (from the back) approach done it. We expected it to be about 2 hours, but it was more than 5 hours, because there was lots of scar tissue from the previous cryoablation of the adrenal met last year - the new tumor was right past that cryoabalted met and to get there they had to cut and evacuate the scar tissue first. After they cut the debris, they finally found that this met is located - unfortunately - IN the pancreas. The good thing was that it was located very close to the tail of pancreas so they just had to cut the end of the tail, separating the blood vessels and preserving most of the pancreas and the spleen. All of it was done trough the 3 small incisions in the back because the tumor was located in the back side of the pancreas. I was very worried that they had to convert the VATS surgery into the open one when the time of the surgery was going for so long - it would have been a pretty hard for Ivan as the converted surgeries are the worst - they are done without the epidural and are the full size open abdominal surgeries, very painful and hard to recover, lots of adhesion too. But fortunately it was not the case, it just took very long with all the scars and saving the blood vessels that were attached to the tumor but the surgery was finished as planned - VATS (laparoscopic) from the back, under the general anesthesia. Dr.Walz said that VATS is for the very patient surgeons - they cut very small pieces and move very small steps so they have to be ready to spend hours to move few cm... Ivan feels ok but he is still VERY dizzy, they probably have given him more narcotics because they needed him to lie still for 5+ hours without the epidural.
So in short - the surgery is done and I am glad this tumor is gone in a less possible traumatic way (Dr.Walz gets 5 stars rating), but it went harder than I hoped for and there might be short and long term problems from the pancreatic resection that I am going to start to worry tomorrow about - but today I am just happy.

[Bonni Hess]

Dearest Olga, WOW!! What a very thoughtful and detailed update in the aftermath of your emotionally exhausting and very stressful day!! You and dear Ivan have been in my every thought today and I have been anxiously and constantly checking the Board for your update so am deeply grateful that you somehow found the time and energy to write. I am SO VERY grateful and relieved that the long, extended, and more complicated surgery is now over and that it went well considering the location of the met inside the tail of the pancreas. I am very grateful too for Dr. Walz's great expertise and 5 star surgical performance. I know that you must be completely physically and emotionally exhausted right now so I will close with thoughts of deepest caring, full and speedy recovery wishes for your dear courageous Ivan, gentle hugs for both of you, all of my love, and continued Hope, Bonni

[D.ap]

Olga and Ivan and family

I share your relief, as well as the readiness to move towards and forward, with any possible challenges.

My hopes and prayers for good healing and good rest for yourself and Ivan for today and tonight.

Its truly great to hear of a particial removal today. The fact that the doctor began with just that particial removal is very encouraging.

Much love
Debbie

[arojussi]

Very glad to hear that all went well.

[MartinBube]

Olga, I'm very glad that you passed through this surgery and Dr.Walz managed to get it done without an open surgery.

I understand your concerns and hope that that Ivan recovers very soon and everything will be OK.

Maybe there is an option that there will be a doctor back home that could help in case of need.

send my regards to Ivan, and wish him to stay strong as always

[Olga]

Martin - in case there are delayed complications when we get back home they will HAVE to help him - they have no choice under Canadian rules, he has provincial health insurance coverage and has to be treated at any place where he goes if something happen. In some sense it is even funny - people can go out of country to have any unproven treatments and the doctors at home have to deal with the complications free for the patient. The problem is to get safely home - two long 5-6 hour flights with the few hours stop in between. And also the problem that now he has a drain from the operation size that we have to keep and the fluid has to be analyzed to see if there is a pancreatic juice in it - as soon as the cut end of the pancreatic duct heals and there is no panc fluid in the drain it can be taken out. Pancreas surgery is a big deal because this organ produces few very important enzymes and hormones that have to be replaced if they leak out - especially insulin. If there is no drain and they leak inside of the abdominal cavity, they will burn it so they have to be evacuated if there is a leak. So to manage it properly he would need to be admitted to the hospital right after he arrives to Canada - or to heal here before we go, so we will probably stay as long as it is needed although it is expensive.
Today was a pretty bad day for Ivan, he is not feeling well - despite the surgery being minimal from the access point of view, there is still a big surgical work done inside.

[Olga]

To report on a progress:
Ivan's recovery goes well. The pain level has decreased a lot since yesterday. All the vein access ports are removed now and he does not get any infusions, only oral drugs and 2 types of injections - a blood thinner and the other one to suppress the enzymes production in the pancreas to reduce the inside pressure on the stitches. The pathology report came back from the independent lab, the margins are clear from the tumor cells (they are negative i.e. no tumor found on the resection borders means it was done clean) but they are paper thin in some areas. The pancreas end by the spleen attached to it at the tail end and the splenic vein runs on on side of the pancreas and its artery runs on the other side of the pancreas. The objective of the surgery was to have the met resected from the tail but to keep the spleen and its blood supply. So they had to dissect the vessels from the spleen first to lift them while they remain attached in place to the spleen. Then to resect the end of the pancreas tail and to suture the open end of the pancreatic duct - in runs inside of pancreas along all of it, if you cut the tail it creates and opening at the end, it needs to be closed as the pancreatic liquids would flow out of it. The drain is inserted before the end of the surgery to collect the amounts that go out between the stitches. The collected output is measured and analyzed to see if the % of the panc. juice is decreasing in it - means the stump is healing and the duct is sealing. So far it looks like the process goes as planned - the overall amount is decreasing and the % of the panc. juice in it is decreasing, but it is till there - the drain is in the left back on the kidneys' level. They said that this is another advantage of having the surgery in this area done from the back - there is no naturally occurring volume space in the back, they create it during the surgery by inflating it with the CO2 but when the surgery is done it is deflated and the space is tight - kidney/adrenal/panc middle and tail/spleen are all in the contact and if there is anything that is coming out of the resection stump, it is forced to go out trough the drain - as opposed to having this type of surgery from the front of the abdomen when anything that is coming out from the resection sites can move around in the abdomen space so sometimes the drains do not work as it collects somewhere else versus where it was planned. So we are reasonably optimistic with the progress. It seems unlikely that the drain is going to be removed before we go home, as we want to make sure there is no panc juice is collecting inside - it is an acid and can damage the surgical site, incl. one very precious detail that is there to take a special care about - to peel off the splenic vein from the tumor they had to cut its wall a little to create at list the paper thin negative tumor margins. Then it was sutured so now it needs to heal - to feed the spleen. We are going to remain here for the few days at least to watch for it and then we will fly to Vancouver - with or without the drain, I have already changed the tickets for 3 days later than the original date. I am already imagining the conversations at the ER in Vancouver - oh, doctor, can you please take a look at my son's drain coming out of his back after the panc surgery in Germany? I bet they have never seen a drain coming out in this particular area there.

Ivan feels pretty good and physically he is recovering very fast after this type of surgery, the difference versus the open surgery is striking.
We walked around the block outside of the hospital grounds first time yesterday, it felt as a trip. The food is very good at the hospital especially the afternoon pastries they bring in every day - two types of cake on a level of the best bakeries in Vancouver, they are different everyday and are excellent. I am going to gain weight for sure. Very attentive stuff with no shortage of nurses, doctors rounds twice a day, big clean and modern room with the huge shower, small park with the trees on the grounds, balconies from the rooms, good food - alacarte for the lunch and an open buffet for the breakfast and dinner - all of it makes for a very good the experience so far. I realize that all of it only makes sense if the surgery outcome is good. I will link or repost it into the panc metastases later when we are back home and the drain is (hopefully) out.

[Jorge]

Olga,
Thanks for the detailed update. I'm sooo glad Ivan is recovering quickly.
It's really amzing this complicated surgery is done successfully with laparoscope. Still, sounds there is a lot of cutting around/on the pancreas. I hope Ivan will have a sufficient recovery before flying home. How many days is the flight date after the surgery?
Wish Ivan a speedy recovery day by day.
Lynette

[MartinBube]

Great news Olga,

I'm very happy that Ivan is back on his feet and recovering well. As you described this has been a very detailed surgery that they made. very thankful that we have such people and doctors.

I hope the recovery will continue well and you will travel safely home.

[Olga]

It is planned for this Friday - Aug.12th, the surgery was done on Aug.4th so basically on the 8th post-op day. We started to walk outside since the day 3 and today we walked for about 2 km in the area of the hospital.
Dr.Walz is very skilled with this type of posterior access laparoscopic surgery, he is way ahead of other places in the numbers of the surgeries done. They improved the procedure a lot after discovering that they can inflate twice of the CO2 from the back versus from the front because it does not suppress the artery which is a limiting factor for the front abdominal laparoscopy. Gives them more space and also they say the inside bleeding stops very quickly as the blood vessel are quickly closed by the pressure. But I realize that the pancreas is a very delicate and strange organ to work with and needs to be protected by all means. This is why Ivan is actually very reluctant to even plan to remove the drain here - we might be better to keep it in place for few more days or even a week to reliably evacuate all the discharge to outside so there is no abscess/damage to pancreas and vein from the juices. Although having a drain for to long may be a risk factor for the pancreatic hardening as well.
Lynette - I am super grateful to you for clarifying the situation with the proposed cryo in China. After the surgery is done and the real location of this met is revealed, I realize very well that no complete cryo would be possible and the damage would be very devastating - the vessels were lying right on the outside wall of the met (they say it was encapsulated which is not true as this is a pseudo capsula - dense wall of the normal epithelium caused by the pressure of the slow growing tumor), so to cryo the tumor they would have to cryo the vessels completely, there would be either an incomplete ablation or a bleeding, and also the blood supply to the spleen would be damaged and a very extensive pacreatic fibrosis in the area. Which is a life threatening condition by itself and is only treatable by the open surgery. I am even thinking now that we should not have been done a cryo a year ago for the left adrenal, going back I would go for the adrenal surgery here as well, less damages in that area and to pancreas. They do kidney/adrenals/spleen/pancreas here in the areas accessible from the back.