Biliary Stricture

     It's mid-September and we find ourselves back in Minnesota. It was a crisp thirty-nine degrees this morning and these Texans are cold! We flew into Rochester Wednesday evening and settled in for a few days of labs, scans, consults, and diagnostic procedures. As I mentioned in our last update, Co's been struggling with some liver infections on and off over the past couple of months. We've been in close contact with his team at Mayo, and after the most recent labs and scan they decided we needed to head north for further testing and a possible procedure. We try to stay local for as much monitoring as we can, but when Mayo says it's time to return to the Motherland, we go. People are constantly asking us "why don't you get treated in Texas", and the answer is quite simple for us; we go to the best and the best is Mayo. 

    Since arriving Wednesday, Cody has completed a COVID test, labs, MRCP scan, three consults (Hepatobiliary Surgery, Interventional Radiology, and Hepatology), and an ERCP. Woof. He's always such a trooper through these weeks and I can tell he is working extra hard to not be too much of a cranky bear, even though he has every right to be the grumpiest of bears; I know I would be.

    What we've learned this week is that Co has stricture (narrowing) of the bile ducts at the site of his anastomosis from his liver resection. This narrowing is causing an obstruction that is preventing bile from leaving the liver. In order for your intestines to absorb fat (this is needed to sustain life, fat is not the enemy here, people), the liver has to produce bile and allow it to leave and travel onward to the intestines where it lives a happy life digesting fats before passing along. Cody's liver is functioning great, creating bile just as it should, however, the bile isn't able to leave the liver and is causing his crummy symptoms.

    Symptoms of biliary obstruction: increased liver enzymes, jaundice (you can see the yellowing in his eyes), fatigue, lethargy, decreased appetite, weight loss due to inability to absorb fats (okay, but can I get a smidge of this?), itchiness due to the build-up of bile salts, tea-colored urine, clay-colored stools, and an increased chance of infections...Unfortunately, all of this checks out with what Co has been experiencing for the last several weeks.

    This type of narrowing is not entirely uncommon after the surgery Cody underwent last summer; couple that with the 5 weeks of radiation and you have a recipe for some bile-blocking scar tissue. One of the methods for relieving this type of narrowing is called an ERCP. This procedure involves a person being placed under anesthesia and a long scope/camera placed down the throat, through the stomach, into the small intestines, gaining access to the bile ducts. At this point, a balloon is placed and filled with air to dilate and expand the vessel. A stent can then be inserted to keep the duct open and allow bile to be freed from the liver and travel to the intestines as nature intended. The scope is then removed and there are no external drains/tubes needed.

    Yesterday, this procedure was attempted with Cody. His team was adamant about trying this method first because it is the least invasive method. However, since his surgery required a bit of rewiring to remove the tumor (but also keep his GI tract functional) his anatomy is a bit wonky. Thusly, the scope used for these procedures was never meant to function in wonky anatomy and was ultimately too short to make it to the biles ducts.

Normal Anatomy vs. Coco's Anatomy

    To be honest, we were both saddened that this procedure didn't take. I suppose we have been out of the direct cancer world for too long and momentarily forgot that things are never easy or straightforward. The first words out of Cody's mouth after waking up were "did it work" followed by a redundancy of "I wish it had worked" until the anesthesia had worn off. 

Waking up in PACU after his scope 

All tucked in and napping

    Regardless, we have to keep going because there is no other option. On Monday, Co will go under for a percutaneous drain placement. Medical jargon for: they'll be putting him to sleep to insert a wire in his side and access the liver and bile ducts externally. Some of y'all might remember when he had the tube in his side, and it's likely that he will have that again for some time until the vessels are dilated enough to stay open on their own. It is also likely that we will be returning to Mayo every six to twelve weeks to repeat this process several times before the end goal is achieved.

    So. That's where we are at. There are no signs of malignancy at this time; we could not be more grateful for this news. The stricture is frustrating, Co feels like junk, and we miss our puppy babies, but we are content that this is the problem we are facing compared to the alternatives. We will keep everyone updated as the week progresses. For now, we are enjoying some cooler weather and taking in the gorgeous color change of the leaves as Autumn settles in. We will continue to look for the happy moments and celebrate even the smallest of victories as we continue the good fight; Cody's fight.