Nina’s Uninvited Guest

April 24 & 25 Nina, Zhora and I went to an agility trial for the first time since last August. It was great, they did great, I went into the weekend thinking if Nina told me she was ready to retire then I’d just scratch her and that would be that. Well, she ran and loved it and was Nina, older and slower for sure, but Nina nonetheless. This was less than a month before her 14th birthday.

Over the last year or so a couple of her liver values on her bloodwork had been elevated. Not concerningly high by any means, but above normal. Her liver function tests were always normal. She’s been on Denamarin (a liver supplement) for a while and she’d been acting just fine, like the extremely young-for-her-age senior citizen she is. But the last urinalysis we did showed a lower than normal concentration (USG), which was repeatable on subsequent testing. So now we had a concern about her kidneys (older animals can have kidney failure, not great but also not terrible since there’s a lot we can do to manage it). So I booked her an ultrasound with our usual radiologist Dr Homco, who I usually take my dogs to once a year or so for a screening, but thanks to COVID, we hadn’t been since January 2020.

That was the Thursday before Memorial Day weekend, and I came into work on Tuesday after Memorial Day to Dr Homco’s report on the fax machine.

Nina had a mass in her liver. Approximately 6 cm.

In her voicemail to Dr Stein, she said she couldn’t determine malignant vs benign (and she often can), which I guess is better than “it’s malignant”, but either way a mass on your liver isn’t something you want. Dr Stein (who is the best veterinarian I have ever known) sat down with me and had a long discussion about what our options were. Number one was do nothing, ultrasound her again in 4-6 weeks and see what it looked like then. Number two was get a CT or MRI done to learn more about it (operable or not). Number three was explore her, either him or a boarded surgeon.

I called around out of interest and we were looking at several weeks to months before a CT, MRI or surgical specialist consult were available. And aside from anything else, while Nina is a vibrant and very young 14, she’s still 14 and has age-related heart valve disease and kidneys that aren’t 100%, in addition to whatever was up with her liver. Plus we’d done a dental on her a few weeks before and her blood pressure was hard to manage during that procedure. I am fortunate that Dr Stein has a special interest in anesthesia and analgesia, and our anesthetic protocol and management where I work is second to none (he runs a website for other vets to help them perform better anesthesia, and he’s lectured internationally about anesthesia and pain management). I wasn’t sure I trusted the anesthesia anywhere else for a dog with her anesthetic challenges, plus Dr Stein had extensive post-doc surgical training and is an excellent surgeon, and I absolutely trust his skill in the OR.

Jim and I talked about it, and I went into work the next day and said we wanted surgery. Dr Stein said “here?” and I said “yes” and he said “putting the surgeon to the test huh?”. We’d done a liver surgery on an 11 year old Golden Retriever in March (his mass was benign), and I absolutely trust Dr Stein and the amazing staff I work with, so I felt this was our best shot. He said we’d better do it soon if we were going to do it (especially because he had some time off coming up). So we did a chest x-ray right away to be sure there weren’t any lung metastases (she has an old lady chest and an enlarged heart, which we already knew, but nothing obviously ominous per the radiology consultant). And so then last Tuesday (June 8), was the day. I knew she might not make it, but I needed to know what that mass was, and far better to do the surgery while she was feeling great, full of energy and not showing any symptoms. The weekend before we spoiled her rotten, took her for nice walks, made a fuss of her (even more than normal, because she’s Nina), called Ulla (Nina’s breeder) and had a long talk and a good cry (Nina’s great grandmother Cranberi had a 7 cm liver tumor and lived for 2 years afterward as an old lady). All “just in case”.

The techs and Dr Stein had a meeting on Monday to discuss the surgery (we do this with any complex case), Linda had mentioned after the dental that maybe we should do Total Intravenous Anesthesia (TIVA) for her next procedure so we could manage her blood pressure and heart rate better. So that was the plan.

I brought her in Tuesday morning and cried (I’ve cried a lot over the last couple of weeks). I wasn’t second guessing the decision at all but I knew it was a risky surgery. Dr Stein was already there when I arrived (and I get there at 6:30 or earlier), I buzzed up and said good morning and “how are you feeling?” and he said “ready to take on the liver!”.

She was first on the schedule that day (to leave all the rest of the day for monitoring her for complications). And in addition, that was the day I was scheduled to get my Invisalign fitted (my teeth have moved and are very crowded now and are chipping each other because they’re hitting each other). Not a relaxing day! Bekka buzzed down to me and said they were going to poke her (that means give her her pre-anesthetic sedative injection) and did I want to come hold her for it (I usually do hold my dogs for this, and you can bet I wanted to hold Nina).

The mass was significantly bigger than Dr Homco thought it was (which either means it had grown, or just that she wasn’t able to completely visualize it). Dr Stein got the best margins he could get. Fortunately it was on the left lobe of her liver, which is the lobe that can be completely removed, so he took the entire lobe and as much as he safely could get. There was at least a small amount of apparently healthy liver that he took, so we will have to hope it’s enough.

She was up and BAR (which means Bright Alert and Responsive) pretty quickly after the procedure, and started the usual spinning around that she always does post-anesthesia (which makes running an IV and CRI (constant rate infusion) difficult to impossible). I went up to see her and Bekka said “that’s a healthy dog”, meaning that for a 14 year old dog to be that bright that soon after surgery she was in good shape. Her packed cell volume (PCV) was 38-40 throughout (normal is over 38, we get worried the lower it gets, since lower than that is anemic). Bekka texted me pictures of her looking comfortable and alert while I was at the orthodontist.

I took her home Tuesday night since she was way too active for an overnight CRI (I’d planned to sleep at the clinic with her) and we didn’t want to give her too much additional sedation. I gave her oral meds that night and she had a good and quiet night Tuesday and looked great on Wednesday.

Thursday she started out the day OK (I was bringing her to work every day for monitoring), but then mid morning she suddenly got pale (her gums were pale) and very weak and droopy. Her PCV was down to 33 and all of a sudden things looked bad. We were worried she might die. Dr Stein was very stressed. He said “we do not, NOT, want to put her through another surgery”. We talked through what might be going on: it didn’t seem likely that she was septic since her temperature was normal; it didn’t seem likely that she was hemorrhaging since her PCV wasn’t continuing to drop. We took x-rays and they looked unremarkable for a post-op dog (also another confirmation that there were no obvious chest mets), and you’d expect to see something on an x-ray if she was septic or bleeding. The hopeful sign was that she didn’t continue to get worse, she went down in a valley but then started to climb back up.

Bekka came and told me she thought she was looking a bit better. Then Linda buzzed me and put me on speaker so I could hear that Nina was barking and complaining about being in jail (she was upstairs in case they needed to act fast if she crashed). I carried her downstairs and took her for a short walk and she urinated and then tried to drag me over to the car so we could go home. She was pretty much back to where she’d been first thing that morning (you’d never know she’d had major surgery).

Bekka and I discussed what might have happened (after she and Dr Stein had been discussing it). It could have been a vagal issue (the vagus nerve is in that area and they had to do a lot of pulling and pushing to get access to the part of the liver Dr Stein wanted to remove), it could have been some kind of transient delayed shock (losing half your liver a huge insult to the remaining liver), it could have been her spleen reacting to the whole thing. We don’t really know.

What I do know is that her PCV was up to 40 on Friday and she thinks cage rest is bullshit. She is strong, she is eating, she is taking her meds well, she tries to drag me around when I take her out into the back garden for potty walks on a lead. She is sleeping comfortably when she’s not angry about being in jail.

As best we understand it, dogs only really care about their quality of life, we’re the ones who care about quantity of life. But I have always believed that it’s well worth putting a dog through short term reduction in quality of life if there’s a reasonable chance for a return to a good or better quality and quantity of life. And selfishly, I’m just not ready to lose Nina, especially when she’s so full of life and joy. She’s sassy, she plays, she runs, she wrestles with the other dogs, she’s happy. Many people wouldn’t perform a major surgery on a dog of her age, but her lines tend to be very long-lived (well over 16 usually, and some 18 or even 19), and she’s lean, fit and very young for her age. I am fortunate that I work with some amazing and knowledgeable professionals, who have shepherded her through the first part of this with so much skill.

I love all my dogs but we say “but only Nina is Nina”. I have never had a dog like Nina and I probably never will again. The bond she and I have is something so precious and rare, she is my heart.

We don’t have the pathology results from the mass yet (it was big and smooth and pink), we don’t know what the future holds. But we do know that Nina is a tough cookie, and after all, you miss 100% of the shots you don’t take.

The haircut is pretty punk, and cage rest is bullshit

Update June 13: Biopsy is back already: BENIGN adenoma with narrow clean margins. The best possible news!!!!

Leave a Reply