The heist.
(WARNING: this blog post contains some detailed descriptions of anatomy that some may find disturbing. All the terms will be accurate and medically appropriate, but I understand if it's still not something you want to read about. If this applies to you - or even if it doesn't - I'd encourage you to check out my favourite web comic.
If you read on from here, you've been warned.)
Someone confessed to me last week that they were planning a brazen theft. They even explained how they were going to accomplish this bold heist.
They will cut a small hole in the front wall of the establishment they intend to rob. They've cased the joint thoroughly (to use the metaphorical vernacular); they know every detail of the establishment, inside and out, down to the smallest detail. Their entry would be precise and planned, they would grab the target of the heist and go back out through the same point of entry they made.
They would take their time. This would not be a quick "in and out" smash and grab. Oh no - they would be patient. Thorough.
Intentional.
Oh - one more thing. There will be witnesses. Lots of witnesses.
The mastermind of this heist is named Dr. Mark Samuels*, and the establishment he is robbing is my body.
He is going to steal my rectum.
Well, most of my rectum - the entire organ 5 cm above and below the level of my tumour (the second rectal valve), including all attached lymph nodes and a handful of others in the area, all its blood vessels and nerves. He has already explained that this is the surgical approach that is, as he put it, "the textbook response to colorectal cancer" and has the best cure rate in cases like mine - nearly 100%. I will have a Lower Anterior Resection (LAR), a procedure that has been performed and improved since the middle of the twentieth century. I've participated in the care of several patients that Mark Samuels has performed the procedure on before and they've all done well. That gives me a lot of confidence, but then Mark's calm, confident, and respectful approach with his patients would give me confidence if I didn't have this sort of insider information.
In my case, Dr. Samuels will use laparoscopy to improve my postoperative recovery. Several small (1-2 cm) slits or holes will be cut into my abdominal wall; one or more for a scope that he and any assistants that scrub in with him will use to view my rectum and the associated organs and connections to it, one or more for other special instruments they will use to cut away the tissue to be removed, one or more to flush my peritoneal cavity with saline, a drain, and even a tube to inflate my abdomen with gas so that they can more easily see and work in an area where there is normally no free gas.
It sounds weird to poke a bunch of holes in my belly to do this sort of surgery, but the other options for performing this procedure are to make a midline incision - cutting straight down from my umbilicus or belly button to my pubis - or a lateral (think of a cesarean section) incision from one hipbone to the other. Laparotomies or open procedures like this allow the surgeon to visualize and manipulate the area really well, but obviously cutting open someone's abdominal cavity comes at a definite cost in terms of postoperative complications and delayed recovery.
So... yeah. I'll take the laparoscopy please.
Of course, there is a chance that once Mark Samuels has me in the operating room, laparoscopy will prove to not be the right choice. Maybe my anatomy will be different than my MRI showed or maybe my rectum will be more fragile than he anticipated or maybe my diverticulitis will be flaring and cause problems or maybe there will be adhesions - kind of like scar tissue - that didn't show on my MRI that get in the way of his laparoscopic approach. He may have to proceed to an open approach anyway, but at least for now the plan is to use my tummy as a pincushion.
So what happens when he takes out my rectum?
Well, first and probably most important, the entire organ and all associated structures will be sent to pathology. A pathologist will prepare and dye and make ultra-thin slices of my rectum and look at the samples carefully - very carefully - to look for any other signs of cancer. He will look very very carefully at the lymph nodes that are associated with my rectum and very very VERY (you get the point) carefully at the 'suspicious' lymph node that showed up on my MRI. According to Mark Samuels, there is less than a 20% chance that pathology will find anything.
In other words, there is a four out of five chance that Mark will take out a perfectly healthy organ. In the immortal words of Glenn Frey (and Don Henley), every form of refuge has its price. If he doesn't take the entire rectum and the tumour that was removed during my initial colonoscopy left some cancerous cells behind, my colorectal cancer would recur or spread. Both of those would be bad, but the latter choice would be really bad.
I want to avoid bad.
But what if he didn't have to take the entire organ? What if he could just take a part of the rectum, the part around the tumour? Yeah; I asked him that.
"I could. If you were older or had other health problems I think it would be a good approach. But if we take that approach, there is a much higher chance of recurrence than with total resection. I'd have to talk about five year and ten year survival statistics, and you're too young for me to have that conversation."
He's right. Five years only gets me to sixty. Ten gets me to sixty-five. I had serious plans to be a crotchety old man of at least eighty-five before I cashed in my chips.
Total resection gives me the best chance for a cure. The procedure does have risks - every procedure does. Hell, life has risks. And I'm not that attached to my rectum.
Well, I'm obviously physically attached to it, but emotionally it's way down on my happy list.
So... balancing the risks of a total resection against the risk of recurrence of my cancer or of missing some residual tumour cells, I've consented to letting Mark steal my rectum.
I guess that makes me an accomplice?
*(that's not his real name but as I've said before I want to keep the actual names of my health providers protected)
If you read on from here, you've been warned.)
***
Someone confessed to me last week that they were planning a brazen theft. They even explained how they were going to accomplish this bold heist.
They will cut a small hole in the front wall of the establishment they intend to rob. They've cased the joint thoroughly (to use the metaphorical vernacular); they know every detail of the establishment, inside and out, down to the smallest detail. Their entry would be precise and planned, they would grab the target of the heist and go back out through the same point of entry they made.
They would take their time. This would not be a quick "in and out" smash and grab. Oh no - they would be patient. Thorough.
Intentional.
Oh - one more thing. There will be witnesses. Lots of witnesses.
The mastermind of this heist is named Dr. Mark Samuels*, and the establishment he is robbing is my body.
He is going to steal my rectum.
Well, most of my rectum - the entire organ 5 cm above and below the level of my tumour (the second rectal valve), including all attached lymph nodes and a handful of others in the area, all its blood vessels and nerves. He has already explained that this is the surgical approach that is, as he put it, "the textbook response to colorectal cancer" and has the best cure rate in cases like mine - nearly 100%. I will have a Lower Anterior Resection (LAR), a procedure that has been performed and improved since the middle of the twentieth century. I've participated in the care of several patients that Mark Samuels has performed the procedure on before and they've all done well. That gives me a lot of confidence, but then Mark's calm, confident, and respectful approach with his patients would give me confidence if I didn't have this sort of insider information.
In my case, Dr. Samuels will use laparoscopy to improve my postoperative recovery. Several small (1-2 cm) slits or holes will be cut into my abdominal wall; one or more for a scope that he and any assistants that scrub in with him will use to view my rectum and the associated organs and connections to it, one or more for other special instruments they will use to cut away the tissue to be removed, one or more to flush my peritoneal cavity with saline, a drain, and even a tube to inflate my abdomen with gas so that they can more easily see and work in an area where there is normally no free gas.
It sounds weird to poke a bunch of holes in my belly to do this sort of surgery, but the other options for performing this procedure are to make a midline incision - cutting straight down from my umbilicus or belly button to my pubis - or a lateral (think of a cesarean section) incision from one hipbone to the other. Laparotomies or open procedures like this allow the surgeon to visualize and manipulate the area really well, but obviously cutting open someone's abdominal cavity comes at a definite cost in terms of postoperative complications and delayed recovery.
So... yeah. I'll take the laparoscopy please.
Of course, there is a chance that once Mark Samuels has me in the operating room, laparoscopy will prove to not be the right choice. Maybe my anatomy will be different than my MRI showed or maybe my rectum will be more fragile than he anticipated or maybe my diverticulitis will be flaring and cause problems or maybe there will be adhesions - kind of like scar tissue - that didn't show on my MRI that get in the way of his laparoscopic approach. He may have to proceed to an open approach anyway, but at least for now the plan is to use my tummy as a pincushion.
So what happens when he takes out my rectum?
Well, first and probably most important, the entire organ and all associated structures will be sent to pathology. A pathologist will prepare and dye and make ultra-thin slices of my rectum and look at the samples carefully - very carefully - to look for any other signs of cancer. He will look very very carefully at the lymph nodes that are associated with my rectum and very very VERY (you get the point) carefully at the 'suspicious' lymph node that showed up on my MRI. According to Mark Samuels, there is less than a 20% chance that pathology will find anything.
In other words, there is a four out of five chance that Mark will take out a perfectly healthy organ. In the immortal words of Glenn Frey (and Don Henley), every form of refuge has its price. If he doesn't take the entire rectum and the tumour that was removed during my initial colonoscopy left some cancerous cells behind, my colorectal cancer would recur or spread. Both of those would be bad, but the latter choice would be really bad.
I want to avoid bad.
But what if he didn't have to take the entire organ? What if he could just take a part of the rectum, the part around the tumour? Yeah; I asked him that.
"I could. If you were older or had other health problems I think it would be a good approach. But if we take that approach, there is a much higher chance of recurrence than with total resection. I'd have to talk about five year and ten year survival statistics, and you're too young for me to have that conversation."
He's right. Five years only gets me to sixty. Ten gets me to sixty-five. I had serious plans to be a crotchety old man of at least eighty-five before I cashed in my chips.
Total resection gives me the best chance for a cure. The procedure does have risks - every procedure does. Hell, life has risks. And I'm not that attached to my rectum.
Well, I'm obviously physically attached to it, but emotionally it's way down on my happy list.
So... balancing the risks of a total resection against the risk of recurrence of my cancer or of missing some residual tumour cells, I've consented to letting Mark steal my rectum.
I guess that makes me an accomplice?
*(that's not his real name but as I've said before I want to keep the actual names of my health providers protected)
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