Thursday, September 3, 2015

CHOP surgeon says Rachel's cancer operation went "beautifully"

Hi, my name is John Dormans, and I am Rachel's orthopedic surgeon. I was asked by Rachel to write a brief update on her surgery and her postoperative recovery so far.

CHOP surgeon says Rachel's cancer operation went "beautifully"

Hi, my name is John Dormans, and I am Rachel’s orthopedic surgeon. I was asked by Rachel to write a brief update on her surgery and her postoperative recovery so far.

Rachel’s surgery went beautifully and without any complications. While the entire process was 7-8 hours long (including operating room set up and “take down” time), the actual operation lasted 4 hours and resulted in relatively low blood loss (600 cc).

In addition to general anesthesia, an epidural catheter – which puts pain medicine into the space around the spinal cord -- was placed to further reduce postoperative pain. Before and during surgery, Rachel was given antibiotics to reduce her risk of developing an infection.

Her procedure consisted of three stages. The first stage was to resect, or remove, the bone and soft tissue in which the Ewing sarcoma tumor was visible on her MRIs, plus a margin of healthy tissue. I removed two-thirds of the femur, from the hip to the mid-thigh. At no point during the procedure did I actually see any tumor, indicating that chemotherapy had been effective at reducing the tumor burden in her soft tissue. The excised portions of bone and tissue were sent as frozen sections to our pathology department while surgery was underway; analysis of these sections confirmed that we had “clean margins” – no cancer cells in tissue from the margins.

The second stage involved the reconstruction of Rachel’s leg using a femoral endoprosthesis, a device implanted to replace the missing bone. The device was secured to the remainder of her femur, as shown in her X-rays, with bone cement, and now it forms a joint with the socket of her pelvis.

The final stage required the transfer and re-attachment of Rachel’s muscles to preserve adequate hip function. Then, drains were placed under the skin to remove blood and fluid that may build up post-operatively. Once her wound was closed with nearly 100 absorbable sutures, X-rays were taken to confirm the stability and position of the endoprosthesis. These images also confirmed that the device avoided the major growth plates located below the femur, so her leg will continue to lengthen as she grows.

I visited Rachel in her hospital room Tuesday night at 7:00 pm. As expected, she was a little groggy. To my surprise, she said she had zero pain. She was very interested in the details of her surgery. As expected, she had some muscle spasms and pain issues around 2:00 am, but they resolved after Rachel was given muscle relaxers and more pain medication. Today, her epidural is still in place, and an intravenous line has been inserted to deliver pain medication and fluids. She will remain on bed rest and a clear liquid diet for the next few days.

To prevent the formation of blood clots that can result from extended periods of inactivity, Rachel’s legs have been placed in specialized inflatable garments called sequential compression devices. These will help the circulation of blood throughout her legs. To ensure adequate lung function during bed rest, Rachel will breathe every hour that she is awake into a device called an incentive spirometer.

Please join me in sending Rachel best wishes for a speedy recovery and a long, happy, healthy life!



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About this blog
Rachel Kovach, 12, is a seventh-grader at Mother Theresa Regional School in Atlantic Highlands, N.J. She lives in Highlands, N.J., near the Sandy Hook national seashore, with her parents, Mari and Kurt Kovach.

Since first grade, Rachel has been swimming with the Monmouth Barracudas, a year-round competitive United States Swimming Club program. She hopes to continue competitive swimming after her cancer treatment; if not, she envisions coaching someday or maybe a career in medicine. Figure skating and jazz dancing have been big parts of her life. One of the things she hates about being in the hospital is missing her dog Cocoa and her many friends.

Rachel's doctors

These are the key physicians overseeing Rachel’s care at Children’s Hospital of Philadelphia:

Naomi BalamuthNaomi Balamuth, pediatric oncologist, specializes in treating pediatric sarcomas, a subset of solid tumors.



Richard B. WomerRichard B. Womer, pediatric oncologist, led studies of the latest chemotherapy treatment protocol for Ewing’s sarcoma.



John P. DormansJohn P. Dormans, M.D., chief of orthopaedic surgery, is an international expert in the surgical treatment of musculoskeletal tumors.


Timeline of Rachel Kovach’s Treatment

Dec. 3, 2010: Pain in Rachel's right knee is initially diagnosed as tendinitis.

Jan. 20: An MRI reveals a tumor in right leg.

Jan 24: Rachel sees John Dormans, chief of orthopedic surgery at Children's Hospital of Philadelphia.

Jan. 27: A biopsy confirms Ewing's sarcoma.

February to mid-April: Regimens of chemotherapy alternate every other week. The three-drug regimen is given over two days; the two-drug regimen is given over five days.

May 3: Surgery replaces most of the right femur with a prosthesis.

May 5: A Children's Hospital team will help Rachel get out of bed.

May 10 to September: Alternating regimens of chemotherapy are to resume.

Around May 10: Physical therapy will begin in the hospital and continue for at least several months after Rachel goes home.

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