One of the wonderful, and at the same time vexing, aspects of veterinary surgery is that it is predictably unpredictable. That may sound unsettling, and oftentimes it is, but it means that unexpectedly poor outcomes, and all of the heartbreak that they bring will be, at times, balanced by surprisingly good ones.
Max is a 14-year-old, domestic short-haired cat, who has literally never been sick. That is until now. His signs crept in so slowly that they were hardly noticeable at first. A little vomit here, some diarrhea and looking just a touch thin. He remained happy and behaved normally otherwise.
But it seemed to dawn on his owners all at once that something was wrong. He was definitely thinner, his appetite had dwindled to near anorexia and the vomiting, or regurgitating, had gone on for days in a row.
Their family veterinarian, who has known Max since he was a kitten, grimaced as he examined him. He palpated a large, firm mass in the abdomen. It was up under the ribs, which made it harder to detect, and indicated that it was probably involving the liver or the stomach, but he could not be sure.
What he knew was that in most cases, a palpable mass, which would require surgical removal and was likely cancerous, would spell the end of the line. He explained his findings and his deep concerns that the mass was so large that removal may not be possible. And if it were cancer, just removing it may not cure the problem.
As tears welled in the owners' eyes, he explained that an abdominal ultrasound, or CT scan, would be necessary to evaluate if surgery were even an option, but he was not really thinking that they would give these options serious consideration. To his surprise, the owners opted to pursue his suggestion for further diagnostics, and a specialist was called to perform an ultrasound. The findings indicated that removal may be possible, because it was not clear that the mass was invading adjacent important structures, like the major bile duct, pancreas, blood vessels, stomach or intestines.
The next step was a consultation with me (Henri Bianucci). I reviewed the ultrasonographer's report and other relevant medical data, and my assessment boiled down to this: I agreed that it may be difficult, but it was possible that the mass could be removed.
Of course, I explained the risks of surgery and anesthesia on a debilitated patient of a certain age, but more importantly, I told them that there are still two unknowns beyond the surgical considerations. We still did not know whether this was a benign or malignant mass, which means that it may not be cured by surgery alone or at all.
We also could not be certain that this mass, as described by the ultrasound was even responsible for the signs we were seeing. Yes, it seemed large, but in that location, large masses can be present and cause no noticeable problems at all.
Could the patient survive anesthesia and surgery? Could the mass be excised? Is the mass a malignant cancer? And is this mass really causing the problems Max was exhibiting? It’s amazing, and disconcerting, that with all of the technology we have at our disposal, there can still be so many hanging questions that may only be answered after the surgery is complete and the biopsy is done. In spite of all the uncertainty, the owners were squarely in the camp of “not going down without a fight.” So to the operating room we went.
As soon as I opened the abdomen, one question was answered. The mass appeared larger than what was described by the ultrasound. It was pressing on the outflow tract of the stomach, and could easily explain the regurgitation and vomiting. Given its size and extent, it took a little work to answer whether it could be removed, but fortunately this, too, was answered in the affirmative.
Max sailed through anesthesia and surgery, despite his age, without a hitch, and his recovery was remarkably smooth. Within a day, he was eating, and not vomiting. Three days later came the answer to the most important question: Had we cured the problem? The biopsy indicated a low grade cancer, which was excised completely and not likely to spread.
The answers to any of these questions could have gone against us. The decision to put Max to sleep without trying would be accepted, by almost anyone, as reasonable and humane. But without trying, sometimes we don’t know what’s possible.
We always want to balance the risks we are willing to take, with what the patient must endure and the odds of success. The truth is, most outcomes, good or bad, are not completely predictable.
So, sometimes we have to push the boundaries to see what’s possible. It’s the willingness to do so that can, at times, yield surprisingly good results in certain cases and is what drives progress in the medical profession in general.