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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at The Nebraska Medical Center. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE at THE NEBRASKA MEDICAL CENTER
Spring | Summer 2008

Gift of Life

Ruth & Myron Gerdes

There’s nothing wrong with Ruth Gerdes’ hearing. But when an oncologist in Lincoln told her the carcinoid tumors in her liver were inoperable and that she had no hope for a cure, she refused to listen.

Instead of being overwhelmed, my gut reaction was that my husband and I and my family would figure out the best possible course of treatment, and I would be fine,” Ruth recalls. “My mother, Barb Marcy, had beat breast cancer, and my cousin Denise, who is an emergency room physician at St. Elizabeth’s in Lincoln, had beat non-Hodgkin’s lymphoma years before.

“The women in my family had cancer, but they all had beaten it. I had great role models.”

Less than 18 months after receiving that horrible prognosis, Ruth is tumor free, thanks to a unique surgical procedure performed for the first time in Nebraska by Jean Botha, MD, director of hepatobiliary surgery at The Nebraska Medical Center and assistant professor of surgery at the University of Nebraska Medical Center (UNMC).

Using procedures originally described in a medical paper by a group of French surgeons, Dr. Botha employed a two-staged approach to removing all of Ruth’s hepatic (liver) tumors.
“She had 22 tumors in her liver,” Dr. Botha recalls. “We took out all the tumors in the left lobe of her liver, then allowed the left lobe to grow, or regenerate, for six months before we removed the right lobe and some of the left lobe of her liver.”

The ground-breaking surgery is one example of the wide range of effective treatment options physicians at The Nebraska Medical Center are affording patients with cancers of the gastrointestinal (GI) tract.

Some of these advancements include:

  • Portal vein embolization. “The idea with portal vein embolization is, if you block the blood supply to one side of the liver, it encourages the other side to grow and regenerate, allowing larger portions of liver to be removed,” Dr. Botha says.
  • Laparoscopic surgery for liver resections is now being routinely performed, offering patients a less-invasive approach for these operations.
  • A multidisciplinary approach to all types of liver tumors, involving surgeons, hepatologists, radiologists and medical oncologists, enables the medical center to offer patients state-of-the-art therapy for a wide variety of liver tumors.
  • A greater use of laparoscopic surgery to treat pancreatic tumors that may not be as aggressive as pancreatic cancers, says Aaron R. Sasson, MD, surgical oncologist at The Nebraska Medical Center. “We have conducted one of the largest series of laparoscopic pancreatic surgeries that spare other organs like the spleen, which will be published in a leading surgical journal,” Dr. Sasson says.
  • Dr. Sasson and Surinder Batra, PhD, UNMC Professor of Biochemistry and Molecular Biology, have collaborated on research into the early detection of pancreatic cancer. “Dr. Batra has developed a blood test that may prove useful in screening pancreatic cancer in patients before they exhibit any symptoms,” Dr. Sasson says.
Aaron Sasson, MD

Dr. Sasson credits Michael A. “Tony” Hollingsworth, PhD, professor in the Department of Biochemistry and Molecular Biology and the Department of Pathology and Microbiology at UNMC, with being instrumental in maintaining pancreatic cancer treatment and research as a focus for the medical center.

“The ultimate goal is to increase the survival of patients with pancreatic cancer and to treat them more effectively,” he says.

The GI treatment team is a collaboration of doctors familiar with the cancers as well as surgeons, medical oncologists, gastroenterologists, radiologists, pathologists and radiation oncologists.

“We are fortunate to have experts here in all those areas,” Dr. Sasson says. “To offer more options that are effective, that is where hope translates into longer survival.”

Facing a frightening medical situation, Ruth Gerdes lost sleep. She lost time at her job as a crop insurance agent in Auburn, Neb., during the busiest season of the year. But she never lost hope.

Her battle began in December 2006 with a call from an insurance company. Ruth and her husband, Myron, a family farmer near Auburn, had begun putting together an estate plan. Myron had turned 50 and Ruth would hit that milestone the following May. Life insurance was part of their plan.

Jean Botha, MD

The insurance company representative asked why Ruth “didn’t get those liver lesions checked out?” “What liver lesions?” she asked. The rep explained that when Ruth had been hospitalized for an infection two months earlier, a magnetic resonance imaging (MRI) scan indicated several liver lesions. The doctor who examined the MRI, however, never told Ruth or her primary care physician in Auburn, Michael Zaruba, MD.

Dr. Zaruba immediately ordered a series of tests and an abdominal CT scan, but he found no answers. He continued the tests until, after still no clear-cut answer regarding the lesions, he asked that the earlier CT scan be checked again. It was and, for the first time, the word “tumors” entered the picture.

One tumor was evident in the small bowel and another in the mesentery portion of Ruth’s abdomen. On Dec. 28, she underwent bowel resection surgery at St. Elizabeth Regional Medical Center in Lincoln. It was performed by Greg Fitzke, MD, a UNMC graduate. While Dr. Fitzke found several tumors in Ruth’s liver, he took biopsies but chose not to remove them. The biopsies confirmed Ruth had carcinoid cancer, a rare, slow-growing cancer that usually starts in the lining of the digestive tract or in the lungs.

Ruth and Dr. Zaruba immediately began researching treatments, and she met with an oncologist in Lincoln.

“He told me I was inoperable, and there was nothing that could or should be done at that time,” she recalls. “He did offer to check into clinical trials. I had already looked at all kinds of treatments through my own research and knew that his opinion was out of date. Carcinoid cancer rarely responds to traditional chemotherapy and radiation. The best treatment is surgery.

Michael Zaruba, MD

“Leaving his office that day, I was as low as I ever got during this entire journey. I wanted to talk with Dr. Zaruba, so I called his office and left a message. He called me back within a few minutes. Dr. Zaruba’s willingness to communicate with me when I needed it was one of the many things I depended on through this fight, and he never let me down.”

Dr. Zaruba, also a UNMC graduate, suggested exploring the options for surgery at The Nebraska Medical Center’s renowned liver transplant program. Ruth’s cousin, Dr. Denise Capek, and her son, Karel, who at the time was a third-year medical student at UNMC, told her about a “liver transplant doctor believed to be one of the best liver surgeons in the world” – Dr. Jean Botha.

Appointments were made and Ruth met with Dr. Botha and Daniel Schafer, MD, associate professor of internal medicine and adult hepatologist who serves with the adult liver and small bowel transplantation team at The Nebraska Medical Center.

“Dr. Botha had gone through my medical records in detail,” Ruth says. “He was upbeat, encouraging and confident. He simply instilled a peaceful confidence in me from the first minute. He told us that he was considering a fairly radical and aggressive approach to my case.”

He detailed a two-staged surgical approach that had never previously been performed on carcinoid in Nebraska. Ruth consented – on the condition that Dr. Zaruba remain her primary physician regarding her overall health.

Although he had never met Dr. Zaruba, Dr. Botha agreed.

Ruth recalls leaving the medical center after meeting Dr. Botha and being almost euphoric. “This surgeon really got me,” she says. “He understood my personality and how to tailor a treatment plan that I could be comfortable with.

“I called Dr. Zaruba immediately. I explained that I had signed him up to stay in charge of my overall health. Talk about strong support; I got it in spades from him. I really believe that Dr. Zaruba’s attention to detail, his honesty and willingness to work with Dr. Botha was a gift. And Dr. Botha’s openness in working with a primary care physician was awesome.”

The first liver resection took place Feb. 8, 2007. Dr. Botha removed the left lobe of Ruth’s liver and a portion of the right lobe – about 65 percent of her entire liver. She left the hospital four days later and returned to Auburn, where Dr. Zaruba conducted weekly follow-up appointments and monitored Ruth’s bloodwork.

The second stage of the operation was performed on May 21 – which coincidentally would be Ruth’s 50th birthday. Dr. Botha removed the remaining affected portion of Ruth’s liver and resected a portion of the vena cava that also had been affected. It was risky – and successful.

“By employing portal vein embolization, we allowed the approximately 30 percent of Ruth’s liver that remained after the first operation to grow enough so we were able to go in and remove the portion with the remaining tumors,” Dr. Botha explains. “No one in the world had ever done this until a few years ago.”

Ruth spent six days in intensive care. On one of those days, Dr. Zaruba took the day off and came and sat with her. “Seeing him there, I knew I was going to make it through this.”

Once Ruth returned home to Auburn and later went back to work, Dr. Zaruba still kept an eye on her. “He’d drive by the insurance office, and if he saw my car parked here too long, he’d call and say, ‘You have to go home, Ruth.’”

Dr. Botha says the surgeries and accompanying research into gastrointestinal cancers taking place at UNMC and The Nebraska Medical Center are having a profound impact on patient outcomes.

“We are really pushing the boundaries of what we can offer patients,” he says. “We are performing surgeries for cancer now that, as few as five years ago, may have been considered inoperable. We’re doing liver resections on 70 and 80 year olds because we have perfected the ability to do this operation safely.”

The cause of Ruth’s carcinoid tumors isn’t precisely known, although her first symptom may have been an unexplained case of gastrointestinal bleeding in 2003. What is known is that, as of the end of February this year, she remained tumor-free.

“To say that Ruth Gerdes is a positive person is an understatement,” Dr. Botha comments. “Despite the amount of fear and anxiety . . . Ruth remained remarkably upbeat, never expressing anger or bitterness at what she had to go through.”

The fact that Ruth’s last liver surgery took place on her 50th birthday is more than ironic. She considers it a sign.

Dr. Zaruba says her case taught him many things.

“As a family practice physician, I have learned more about carcinoid than I ever thought I would need to know in my career,” he says. “This case also allowed me to realize how important it is for patients to be active participants in their health care. Ruth was as much a part of the medical team as any of her doctors.

“In my opinion, patient involvement is the single most important factor that leads to a patient receiving individualized, outstanding medical care.”

Since her surgeries, Ruth has become a cheerleader of sorts. She tells her story to everyone she thinks may benefit, and she has written a chapter for a book being compiled by a carcinoid patient who lives on the East Coast.

By telling others, she is spreading the word about what can be done to treat carcinoid cancer. So far, she has helped direct at least three other people to seek the opinions of Drs. Zaruba and Botha.

“To have the talent of a surgeon like Dr. Botha and the others at the medical center just 70 miles from home – people need to know how awesome this facility is,” Ruth says.

The fact that Ruth’s last liver surgery took place on her 50th birthday is more than ironic. She considers it a sign.

“The way I see it,” she says, “when I celebrate my original birthday, I can also celebrate the day that Dr. Botha gave me a second chance.”

That’s the story she wants everyone to hear.

Next article in the Spring | Summer 2008 issue of One Thousand And One:
Drawn to Medicine