Daniel 3:17-18

Daniel 3:17-18 "If it be so, our God whom we serve is able to deliver us from the burning fiery furnace, and he will deliver us out of thine hand, O king. But if not, be it known unto thee, O king, that we will not serve thy gods, nor worship the golden image which thou hast set up."

Sunday, January 9, 2011

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.

3 comments:

  1. Hi Steve
    Sorry to hear you have been on a down loop of the rollercoaster. Remember you can’t beat the laws of friction and kinetic energy so inevitably we will hit an upward curve again.
    Your explanatory post was perfect. Not overkill at all, just right for my level of understanding, and the illustrations helped enormously. It’s fascinating to read how different health systems treat different people.
    What sort of engineer are you. I’m married to a civil/structural one.
    The book club has been good in that it has made me read books I would never normally pick off the shelf. I haven’t liked many of them, but that’s not the point. The latest book is “The Book Thief” by Markus Zusak. If you haven’t read it, I recommend it (unless you have strong objections to reading about stories set in Nazi Germany). I’ve already read it but will dip into it again as I’ve forgotten some detail. Give me a bit of time and I’ll look back for some upbeat books I’ve enjoyed.
    The meeting started well . It’s good for me to do things that don’t revolve around cancer. I was managing to avoid answering the ‘how are you’s’ but then got into a tangle trying to satisfy questions without mentioning cancer or cirrhosis or hepatitis. The first can shock people and the last two suggest I must have been a ‘bad’ girl at some point in a murky past! In the end I had to be open and honest, but it got me quite upset as I hadn’t talked in front of a large group before, some of who don’t know me or didn’t have a clue I’d been ill. Since last May I’ve managed to be pretty upbeat and positive, by dumping the negative onto my blog, but I was feeling quite weepy when I got home and couldn’t sleep. Then I got an early morning wake-up call to say the clinic was running again after all and could I get there please.
    The consultant was very patient with me and took the time to explain exactly why he was doing what, and why it was taking a long time to get to certain decisions. He’s also promised to write it all down for me. I’ll be writing a blog post so won’t go into it here. Anyway I’m making progress along that low curve and given a bit of a push I’ll start to go up again. I really hope you do to, but don’t be surprised if things aren’t steady ever again. For a lot of years to come we are stuck on the rollercoaster of screening tests, waiting for test results, getting the all clear and then having a settled spell until the next set of screening tests. Some cancer patients have to go through the Kubler Ross ‘5 stages of grief’. However in answer to your question ‘how do I expect to get any better’, I’m afraid I don’t. For many cancer patients (you, Carole, ladies with breast cancer) there is no obvious ‘cause’, so once the tumour is out and the chemo complete I guess there is little you can do except eat well and wait for your next set of checks. For others, like me , and lung cancer patients who can quit smoking, there IS a cause, and in theory, if we stop doing the naughty stuff, we get better. If my cirrhosis was caused by drinking, I could quit drinking. But it’s caused by a virus that has gone but left behind its antigen embedded in my liver cells. They have been fooled into thinking they still need to defend themselves, and so the scarring continues. I can slow it down, through my diet, by not depleting my energy stores, by not drinking, by not taking any drugs (medication, not the bad stuff!) by trying to balance my fluids, by having regular tests to spot immediately any signs things are worse. It may take years but inevitably the liver will fail. Although it took many years (30) and many stages to get this bad, it’s now what is called ‘end stage’ and that needs no explanation. At some point I will need to decide if I want to go the transplant route, if a recurrence of the cancer doesn’t get me first!
    Well that was bloody miserable! I’d better go off and look for some good book recommendations and update my blog.
    With love,
    Fiona

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  2. Hey, Fiona. For some reason your comment got caught in my blog's auto spam filter so I didn't see it for awhile. It's a shame when cancer has to follow you to a book club meeting. You are the second one to mention "The Book Thief" to me. Time to chase that one down. As to my day job, I'm a software developer. Got it from my dad. Analysis and puzzle solving have always been fun for me. Attention to detail got added on during my time in the Navy after high school. All in all, I enjoy my work. That's a rotten deal with the virus and your liver. Are you sure you weren't just naughty at some point? I'm praying the 'end game' goes into overtime multiple times for you. Let's get many more years out of it. And I'd like you to know that I am a registered organ donor here in the United States. Not sure what's useful anymore given my cancer diagnosis, but maybe something. I'm looking forward to your upbeat book recommendations. Always fun to discover another great read.

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  3. Steve, You are an inspiration to many. Thank you for all you do and endure.

    Love, The Big Sister

    PS: To you other sufferers of cancer, May God Hold You in the Hallow of His Hand.

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