Magic's Surgery-Pre-op to Ready for Discharge

Continuing Magic surgery story up to discharge. Probably one more after this and then that'll be us all caught up. At the moment she is doing well from her diabetes point of view and hasn't required any insulin which is wonderful. Unfortunately, behaviourally things are not as settled which is hopefully just transient changes resulting from the neurotrauma and not permanent. In herself she is doing ok and we are managing so it is still hugely positive and the surgery was the right choice. Thank you to everyone for your lovely, kind and supportive messages.

Pre-Operatively

Magic was on a ridiculously high dose of 21units of glargine insulin (Lantus) which she was failing to respond to and she had a very high IGF-1 level of 2000. Ideally she'd have had her CT scan carried out in Glasgow with the rest of her pre-op screening. However, to limit cost and an unnecessary repeat dose of radiation, it was carried out on the Thursday at the RVC as their scanning equipment links to the Brainsight software which guides the surgeon intra-operatively during the hypophysectomy operation.

Her CT confirmed she had a 6mm tumour in her pituitary gland which is just within their threshold for surgery. I felt a little guilty and wondered if I had made the decision to go for surgery earlier would it have been smaller but I'll never know the answer to that. Unfortunately, she had a bit of a difficult post procedure reaction to the ketamine. This drug is safe and effective but it can cause hallucinations and excitement in both humans and animals so her vet let me sit quietly with her in a darkened consulting room until she eventually began settling and reorienting to her environment. He just kept popping in every half hour or so until Magic was back to normal. It was hard seeing her thrashing around in apparent distress although I knew it was just the drug but I was so glad to have to have been able to be there and to hold her through it.

I was offered a visit to the ITU which I gratefully accepted. Having an image of the ITU setting and understanding the systems and staff available routinely and in an emergency made me feel much more at ease. Clarity of reality rather than imagination, I suppose. Her critical care vet was fabulous. He was most engaged and genuinely interested in getting her optimised and home in as great a state of health as could be achieved. Our own vet from Glasgow Vet School has been wonderful and so supportive through this time too. 

 Her surgery was confirmed for the Monday and she was expected to be in ITU for a minimum of 5days and then some time in the cat ward. The plan was to optimise her over the weekend and allow her to acclimatise and settle into the hospital environment so that she was a calm and fit for surgery as possible.

 The mats in the consulting rooms looked perfectly clean and impressively hair free unlike my own carpets but obviously they had the most amazing scents

This one seemed to make her nearly faint and I think if Magic could have spoken she'd have asked me to roll it up and bring it home!

In addition to the abdominal ultrasound she'd had in Glasgow I was asked if I would give consent to her having a cardiac scan for research purposes. This is why she has a shaved tummy, legs and a bikini top! I was happy to do this and it was a lightbulb moment for me. When she became ill at first the presumed diagnosis was Hypertrophic Cardiomyopathy (HCM) and she has remained slightly cardiomegalic since. This research is looking into the link between these pituitary tumours and cardiac enlargement which certainly fitted with her clinical picture at diagnosis in June 2014. It is thought the effects of this on her heart might improve in time.

 Typical Magic, so long as she can explore the place she's happy and settled even if her dragging her IV line everywhere makes me wince.

Transphenoidal hypophysectomies are still a very novel intervention which with time I believe will become the gold standard of treatment as it has a high chance of offering a cure. It is a common enough intervention in humans with the condition but it is still relatively new in cats. Diabetes remission and treatment is a strong research interest at the RVC and this surgery is literally cutting edge. In turn it may have insights to offer human diabetes. This article from the Guardian discusses the surgery and showcases one of the early survivors.  Although I knew the positioning of the surgery to get through her mouth I actually found myself getting quite teary at the thought of this happening to my sweet Magic. 

 

Visiting her in the vet school each day and especially on the day I left was very bittersweet as you can imagine and one of the vets kindly took our picture together. She was only the 25th case to have been operated on in this manner and three cats did not survive. I had the strong sense that the way she would be managed and the expertise available was very much as a result of the learning the team have taken from each case so I offer my heartfelt gratitude to all the cats and brave owners who preceded us for the learning they left in their wake. 

 

We had gone down on the Wednesday and I'd arranged to stay till the Saturday so that I could be available for the scheduled appointments and also to give me time to rest if my knee became too painful or if it was fine then I could treat myself to a trip to Liberty's. As it was, I was so hyped with adrenaline and stress on the day of travel and the Thursday waiting on her CT results that I was surprised by how well I was coping and even managed a brief trip back into London to distract myself till the 5pm appointment. In fact I was even questioning whether I just hadn't been challenging my knee enough with exercise and thinking maybe I should get a new physio when I came home.

 Funnily I'd thought the Savoy would have had a larger entrance.

 I was really hungry and noodle and rice really hit the mark

Popping to the loo before I left lead to a rather forthright 'Too Much Information' moment

However, once after the appointment when the CT results were known and everything was confirmed and finalised for surgery the adrenaline began wearing off and on the next morning I just sort of crumpled into a sore heap. I recalled Samuel Johnson's quote that "If a man is tired of London, then he is tired of life". Well, I wasn't actually tired of London as I'd have loved to see more of it on the Friday but I simply could manage no more than the barest minimum of walking and the return train journey the next day was quite physically and emotionally taxing. Seeing this sculpture of Matthew Flinders and his faithful cat Trim while waiting for the train at Euston station made me feel it was a sort of sign that she'd be ok and I'd be back to collect my own close companion. 

On the Monday morning of her surgery I was at work and spoke with the neurosurgeon pre-operatively before spending the rest of the day on tenterhooks. The surgery lasted around three hours and then there was the time to stabilise her in ITU. The post-operative period for these cats is utterly critical particularly in the first five days as removing the pituitary gland causes a whole cascade of organ dysfunction and fluid management challenges which need closely monitored and corrected.

Her tumour and pituitary gland did not come out cleanly but required much dissection and this is possibly why she had a head tilt and was exhibiting circling behaviour to the right hand side post-operatively. Some residual effects remained when she came home, though they are now mainly resolved. Her renal values became problematic with her fluids and glucose needed close monitoring and management. On the up-side she was eating and drinking ravenously  very quickly post operatively as the rogue hormone from the tumour has a half-life of around five days after removal. She became anaemic at one point and apparently cats can haemolyse their own blood post-operatively particularly with certain anaesthetic agents so that caused a sleepless night.

 

In retrospect, I'd very much underestimated the stress of the whole venture even the sweet boy-cat seemed affected as he spent lots of time just needing to be in contact with me. He was less distressed than he had been the time she'd been hospitalised in June.

I am obsessive that both cats get equal time with me so that jealousy doesn't emerge. Magic by default had had a lot of necessary treatment and it was nice just to relax and give some concentrated time to Red as he'd been such a patient soul. 

Even de-hairing the vacuum became a joint venture 

He's actually sitting on my shoulder and upper arm here instead of on the top of the sofa as normal 

There were lots of ups and downs while Magic was in ITU and the ward post operatively but the most dangerous issues have resolved or are manageable. Eventually she was weaned off the insulin infusion and they tried to balance her new insulin regime which was significantly lower than she'd required pre-operatively.

What was hugely reassuring were the very clear telephone reports I was given twice a day by her critical care vet which I'd usually jot down so that I'd remember everything to let her own Glasgow vet know how she was doing. After ten tumultuous but ultimately healing and improving days she was deemed fit for the 400mile journey home and I joyously booked my train tickets and grabbed the wheelie carrier to go and collect my sweet cat.

I know I've taken a while to get this next part posted but I hope that I've done justice to her time in London.

Our Dick Whittington Trip

My proper laptop is finally home and I can now type away and post pictures to my hearts content. I'll try to get most of my recollections of Magic's surgery and recovery 'journey' into posts for you but I think I'll probably try to break her story into less lengthy chunks. This is our personal experience but I also want to share any information that I've gathered that might be of use to another owner possibly facing this same condition. Please just remember I am only an owner and not a vet so any information is based on my subjective understanding.

Before we start, as I know this is the most important news, is where we are at the moment. My darling Magic is now 1 month and 12days days post-op. She has had her first check up at our local vet school and is doing beautifully. We are so, so grateful to everyone who has left supportive comments and kept us in their prayers. A huge and very special thank you goes to darling Summer for her very kind mention. To date, it appears that everything is headed in the right direction and I am cautiously utterly delighted that her blood sugars are sitting in the non-diabetic region of 3.7-6.6 mmols/l pre-prandially. There are some renal and thyroid issues that need correction but these are in hand. As I write up our story Magic is curled up on the sofa beside me which makes my heart sing. So, onwards with what happened.

Planning the Journey to London

Knowing we were headed to the RVC for surgery in the New Year I booked my train tickets early. First class on the way down for Magic on the Wednesday as I hoped the extra room and table service might be helpful if needed as I'd never travelled this far with her. My return ticket was for bog standard 'cattle class' on the way back on the Saturday which shows where my priorities lie!

Pre-Assessment

Magic's pre-assessment, to make sure she was fit for surgery, was carried out two weeks before we left and she had a chest X-Ray, abdominal ultrasound and various bloods and urine tests. To distract me for the couple of hours while she was having these, and sleeping off the sedation, I sat crocheting and listening to an audiobook till it was time to go back and hear the results.

 

It did feel like ages to wait as it was still getting dark early 

 

Thankfully the news was mainly good. She had some renal impairment but that was felt to be as a result of her condition and unlikely to improve till after the tumour was removed.

I'd trialled her new harness which I wanted to use to link to her carrier and asked the vet to check it was applied correctly. Laughingly, she suggested giving it a bit more slack as it seemed it was more straightjacket than harness. Magic was pretty under impressed with it the first time I tried it on her and she did a very impressive Michael Jackson Moonwalk backwards. I failed to capture this on video as I was too busy laughing at her outrage.

Just before we left we were forecast quite a bit of snow. Poor Magic came to the door to greet me when I opened it after popping to the shops to make sure we had provisions in case the snow got worse and was quite mystified by this new white stuff.

Being a good owner I scooped her up and took her outside and let her see the falling snow while talking softly to her. Then being a bad owner, I gently plopped her down ONTO the snow and laughed as she gave me a filthy look and shot indoors! At this time I didn't know whether she was going to survive the surgery so her skinny little snow paw prints in this picture felt quite bittersweet. Luckily although it snowed around the trip, and a little while I was in London, it wasn't a problem.

For the trip I'd bought a new wheelie carrier as I could not have carried her. No matter what weight your cat is within minutes of carrying them in a box you think you might just have picked up a great dane by accident. I eventually chose the Trixie carrier on amazon and found it excellent for the car trip to the Glasgow Vet School and the long London RVC journey. I'll review it in another post in case this is of use to someone looking for a light wheeled pet carrier.   

 

Though I questioned myself frequently about whether I was doing the right thing and how would I cope if it went badly I could see she was just getting sicker and sicker as time went on.

 Often she was just so exhausted with constantly food seeking that when she slept she looked quite pitiful. Her coat was coarse and ill kempt and you could see the toll her illness was taking on her when you looked into her eyes. We were both exhausted as she was up multiple times over night and very unsettled from the effects of her disease. It was clear the neurosurgery was major but we were really out of viable options and I felt we had to go forward as positively as possible and try not to think what could go wrong.

 

Off to London

 

Our train journey on the way down turned out to be brilliant. Magic was a total star and charmed everyone we met.

 

The downside of the Trixie carrier is that I hadn't realised how much it looks like ordinary luggage.

In the lounge prior to boarding the train it tipped over, probably as I had my handbag over the handles and Magic was moving around. I apologised, told her to let me get up again to sort her out and made sure she was ok. I then sat back down to resume eating my fruit platter. About five minutes later an elderly lady opposite said in surprise to her hubby "Oh, look! there's a wee animal in there, oh its a CAT!". I was gobsmacked and said "Did you ACTUALLY think I was talking to my luggage...?" and she just replied "Weeellll, you know.....". So clearly I not only look like a crazy cat lady but I look like I talk to my luggage! It also says how resilient and accepting Glasgwegians are when people display unusual behaviour! Her hubby did go on to explain his wife talks to herself all the time as "she likes the answers she gets....!".

Travelling weekday first class was very nice as I was plied with a cooked breakfast, juices and coffee.

Pulling out of Glasgow Central Station and crossing the Clyde, relieved we are on our way but no turning back now.

 

Our booked seat was in a single facing a dour looking business man but the train steward found us a much better double seat in the next carriage.

I was able to pop her on the seat beside me. At first she was a bit concerned looking...

...but she quickly relaxed and was happy watching what was going on.

  Once she looked a bit more settled I opened the top of her carrier and let her decide to look out or not

She does not cope well if she is kept in the dark and is prevented from scoping out her environment. She has always been my wee protector and hates not being free to be beside me.  

 

 For this reason the harness clipped to a lanyard in the carrier was perfect.

Though she did test how far she could go as she quite fancied checking out the rest of the train

 As coincidence had it my friend and her mother had a carers respite week's break and had managed to book a last minute break to London. We were texting and realised she was on the train an hour behind! I'm glad we weren't on the same train as their's broke down in the Lake District! They had a lovely break and did some wonderful touristy trips including the London Eye and stayed in a lovely hotel. We didn't meet up as I was back and forwards to the RVC but it was very comforting knowing a close friend from home was nearby all the time I was there.

 

Arriving in London was ok and thanks to the guard at the Tube we were directed to an easier route avoiding the stairs to go via Kings Cross.

 to take us to Potters Bar

then onwards to the RVC by taxi.

If anyone is going out to the RVC and arriving via Potter's Bar then its worth remembering that there is a student shuttle bus that runs quite frequently during the week. Brookman's Park train station is actually closer to the RVC QMH but there is no taxi rank there so Potters Bar is the best place to arrive.

 All in all the journey from leaving home took about eight hours.

Magic was admitted and her first consultation and hand over of care took place with her critical care vet. Plans were made for her CT scan the next day and I was allowed to just spend some time cuddling her and saying goodbye for the evening. I headed off to get a taxi to the Day's Inn at South Mimms Service Station which was comfortable and had access to a mini Waitrose and fast food outlets next door. Note this is the room before I had all my junk strewn about!

It had been a very long day by dinner time and I enjoyed my Harry Ramsden's fish tea. However, I couldn't wait to get back to the hotel with some fresh milk for a coffee and the rose shortbread I'd picked up in the mini Waitrose.

I think they might have been in advance of Valentine's Day but I just love rose scented foods and milky coffee

I'd planned to get read for bed, take some painkillers for my protesting knee, watch a film on my tablet and do some crochet.

 Good use for a spare ball of wool

This kind of worked except I'd forgotten my nightie, so I had to repurpose one of my tunic tops as bed wear. Don't worry no piccies of this! I didn't last the length of the film and for the first time in months I was able to sleep undisturbed through the night. This was blissful and totally out of character as I can never normally settle somewhere new on the first night but I think exhaustion and the painkillers probably won the toss.

 

If you've lasted this long well done but I think this is a good place for a break. I'll write up the next instalment and get it posted soon. I'll also be able to pop round and not just read everyone's blogs but actually leave comments now my laptop is back. The tablet didn't seem to cope with different email accounts so was rather restrictive.



Feline Acromegaly Treatment

Feline acromegaly is a re-emerging area of interest for veterinary surgeons. It has had surges of interest over time for those cats who seem to tolerate very high doses of insulin with little apparent response. Recently the evidence base is still emerging but becoming stronger. Acromegaly is a tumour located in the pituitary gland of the brain which over-expresses growth hormone. This tumour is pulsatile which means the amount of the hormone it expresses can vary considerably.

Magic's condition has deteriorated to such an extent that on balance I feel my hand is forced and that neurosurgical intervention is the only realistic hope of curing or improving her diabetes and giving her a reasonable quality of life. Making this decision has been very hard. This surgery is fairly new and I am sharing our experience for anyone facing this situation.

Magic's illness became apparent on Friday the 13th in June 2014 when I realised she was non-specifically 'wasn't right' and took her to our own vet. She was so good/ill that I was able to get her to settle for an unsedated xray and the presumptive diagnosis was Hypertrophic Cardiomyopathy (HCM) and treated as such. Three more visits over the next few days saw her get sicker and sicker, stop eating and I was beside myself with worry.

By the Wednesday night I could hold my nerve no longer as she was clearly deteriorating. I took her to the Glasgow Veterinary School Small Animal Hospital at 2am with dreadful fear in my heart. I left her in the care of the emergency vet team and came home and sat in the dark of the garden with a coffee praying, contemplating and worrying. The call came two hours later and I shook uncontrollably with something akin to relief as I learnt they had diagnosed her with diabetes.

Compared to HCM, diabetes is a treatable lifelong condition. However, I was in no doubt how desperately ill she was and that her survival was perilous as she was in the throes of Diabetic Ketoacidosis (DKA). She remained in Intensive Care for five days, had respiratory problems, was being tube fed and there wasn't an organ that wasn't in dire straits including at one point the fear she was developing disseminated intravascular coagulopathy as she had problems clotting her blood. She was critically ill but she struggled through bravely and I was able to take her home.

This marked the beginning of a huge learning curve for me as her carer. At first she needed fed twice a day through an oesophageal tube, given an impressive schedule of drugs, blood glucose testing and given insulin injections.

She was amazing and all I could do was be there to support her recovery including frequently replacing the hated neck bandage she'd try to scratch off. She came up to me when it was time for the whole process, sat obediently (mostly) while I fed her 0.5ml every 30 seconds till the whole 52mls of food, drugs and additional flush were given and I'd stabbed her ear to test her blood.

Things improved, the tube was removed after a few weeks, her blood sugars settled, her organs began to improve and she needed less and less insulin. She also tolerated my little handmade neck warmer that stopped her scratching the tube wound on her neck.

We were on the road to remission and recovery and could put this whole distressing incident behind us. Summer looked sunny.

In a few weeks Magic was on a half unit of insulin which was so small I could barely see to draw it up in the morning but she was showing blood sugars and fructosamine results which were entirely in the non-diabetic range. Then within a fortnight her readings got higher and higher until she reached 30 on the 2nd of Sept which is a dangerously high level. This began our intense battle to gain any kind of control. Her insulin was switched from Caninsulin to the human Insulin Glargine also known as Lantus which has a reputation for a more even glycaemic control and less risk of hypoglycaemia. We explored the option of Magic as a candidate for the Diabetes Remission Trial at the Royal Veterinary College in London but the attendance schedule would have been prohibitive and not in her best interest.

As it became clear the insulin resistance was not a blip or phase we began further testing starting with an Insulin-like Growth Factor-1 (IGF-1) test for acromegaly test. After a nailbiting wait, as the test is only run in Cambridge weekly, her result came back at 2000. An IGF-1 result of 1000 is considered diagnostic of  acromegaly. This gave a reason for her insulin resistance but opened up some pretty scary treatment options including surgery and radiotherapy which I didn't even wish to have to contemplate.

This was my summary of the four main treatment options:
Escalating insulin therapy to achieve control-this is the most common route particularly as surgery has not been an option until very recently.
Drug therapy with human drugs-  this has a poor impact as there are issues regarding how well the drugs cross the blood/brain barrier. Some newer human drugs are apparently showing some promise.
Radiotherapy - This involves 20 sessions with an accompanying anaesthetic each time. This can have side effects post therapy and results can be variable. There are newer protocols with only 5 or 10 sessions.
Surgery- Transpenoidal Hypophysectomy, removal of the pituitary gland through an incision in the mouth to access the skull and the pituitary gland, is an emergent treatment option. It has shown good success in bringing about either complete remission or a return to insulin sensitive diabetes. For cats who survive the surgery the outcomes have been positive. Only a small number of cats have been treated in this manner, the surgery is not without risk and the recovery needs to be intensively managed.

I read every research article that I could find and had a number of long conversations with our own vet in Glasgow. My decision was to pursue the most common option of increasing insulin doses to try to get to a level where response occurs. This is what we've been doing and frankly it has barely shown an impact on her blood sugar level which I test at least twice a day. My sweet little cat was receiving 21units of insulin twice a day with a negligible effect as her blood sugar generally remained around the mid-twenties.

At the beginning of December 2014 she had a couple of nearly normal readings which would have been cause for celebration had they been sustained and related to her treatment. However, they were spurious and far more likely to be the result of the tumour activity varying. This finally made me realise I had to make the decision to go down the surgical route. The factors I decided it on were that she was getting no relief from increasing insulin doses, she was constantly hungry, thirsty and unsettled. In addition, and selfishly for me, I know that the likelihood of me administering her insulin is going to coincide with a dip from the tumour at some point and she is going to die of a hypoglycaemic event in which I effectively gave the fatal dose. I adore my little Magic and have always done everything to make her life good so I cannot imagine living with the guilt of having given her a treatment that is having little to no benefit with an increasing risk. So for me the surgery now moved from a 'high risk' to 'high risk/ high benefit' category for us.

Disclaimer: I am the owner/servant of my beloved cat, Magic, who has a diagnosis of insulin resistant diabetes due to acromegaly. I have no veterinary experience and share this series of posts purely as my personal experience of the condition and treatment and not as any kind of veterinary advice.