Fiona's Question

In my last post, Fiona realized that based on my scar I must have had open surgery. This lead to the following comment:

"I'm following your story, Carole's story and another story of rectal cancer by a poster on Cancer UK called Graham. (Carole will know who I mean). All 3 of you have had surgery, though I think you are the only 1 of the 3 with a temporary ileostomy.

I think, (Carole will probably remember better, as you know rectal isn’t my speciality area!) that you are Stage 1, Carole a Stage 3a and Graham hasn’t had his pathology results yet.

Please explain, how come that with a Stage 1 tumour you had open surgery (judging by your impressive scar) and Carole with a Stage 3a had keyhole/laparoscopic. Graham also had keyhole/laparoscopic surgery and he too now has a permanent stoma.

Is the different surgical technique to do with the location of the tumour?"

The answer lies buried among my earlier posts plus a few things I haven't shared. I thought a new post would serve to summarize all of the information and answer Fiona's question. (Oh, and thanks for the complement on my "impressive" scar, Fiona.)

When I was first told I had cancer the doctors had found a 2 inch (5 cm) tumor located about 2 inches inside my rectum. It was reachable by finger which, you'll remember, four people did. My diagnosis was stage II rectal cancer (T3N0M0). It was a large, invasive tumor with no lymph nodes involved and no metastasis.

My tumor as discovered during the colonoscopy

After being examined by my colorectal surgeon, Dr. Sklow, his first response was that he was positive he could save my sphincter, but that it would be very close. If radiation and chemo therapy shrunk the tumor first, there would be a larger margin. This meant that he would use surgery to remove the tumor and most of my rectum with enough rectal tissue left over to reattach the colon from above, leaving me with a working anus. While I had a low rectal tumor, Carole's was even lower, leaving little or no chance for saving her sphincter.

I asked Dr. Sklow at the time if he would do open or laparoscopic surgery. His training and preference was open surgery, so I accepted that. He did explain that a male pelvis does not expand like a female pelvis since men are not designed to give birth. A low rectal tumor meant that he would be working down in my lower pelvis, which is like working at the bottom of a cone. There is not much room and plenty of other things in the area to be avoided, particularly various nerves controlling urinary continence and sexual functionality, two things which I heartily agreed were important for quality of life after surgery. Open surgery gave him the most room to work and better visibility.

Six weeks of radiation and chemo therapy not only beat me up, but it kicked my tumor's butt. When Dr. Sklow examined me after this treatment, he was pleased to report that my tumor had shrunk, looking more like an ulcer the size of a dime. Surgery was scheduled for two weeks later giving the residual radiation and chemo more time to work. By the time I was in the operating room all he could find of the tumor was a small scar. The pathologist later confirmed this, and my diagnosis was changed to stage I rectal cancer (T1N0M0).

Another reason for the open surgery is that Dr. Sklow hoped to construct a colonic J-pouch if I had enough room in my lower pelvis. This would give me a new storage tank since my rectum was being removed. Again this had more to do with quality of life after surgery. Click here and scroll down to see a sketch of what this is and how it is created. It seems to me a J-pouch would be difficult to construct laparoscopically.

I am now the proud owner of a new colonic J-pouch, which leads me to the temporary ileostomy. I am not allowed to use my new storage tank yet. Diverting bowel traffic at the end of the small intestines gives all the new plumbing below that point time to heal.  Once the doctor tests everything under pressure, making sure there are no leaks into my abdomen, the ileostomy will be reversed. Not sure I am looking forward to the pressure test, but better to find a leak with harmless fluids than with toxic bowel stuff.

In the end (Did you catch the rectal cancer humor?), Carole and I had two different surgical procedures. Hers was an abdominoperineal resection (APR) while mine was a low anterior resection (LAR). The following two illustrations show the difference.

Steve's procedure

A, Low anterior resection; B,C, coloanal anastomosis; D, j pouch construction creating a reservoir.

Carole's procedure

Abdominoperineal resection with colostomy.

Now having hopefully explained my reasoning, I would have to say that the short answer to Fiona's question is, "Yes, tumor location made all the difference in our scars." Thanks for reading the longer version.