I visited my surgical oncologist today. We began with a final physical exam, including a DRE that revealed precisely nothing...that's good news. In fact, when I asked the surgeon about the DRE, he said there was nothing, he had expected nothing, and that the rectal tumour was probably now little more than an ulcer, not something a DRE would detect. Even my own descriptions of the diameter of stool is not too significant at this point.
Then it was time for Q&A. I had already received instructions for bowel preparation from the surgeon's executive assistant, forms for the pre-surgical clinic and questions to answer for the anethesiologist, so those questions were unnecessary.
I asked about pre-surgical medical imaging. No more images are necessary, as I expected. The surgical procedure is called a low anterior resection and will proceed according to the pre-surgical staging diagnosis. Part of the sigmoid colon will be removed as well as all but 8 cm of the rectum. Then, as long as the remaining tissues have healed and appear to be able to hold the anastomosis staples, the ends of the colon and rectum will be resectioned.
The incision in the abdomen will be a long vertical one starting at the pubic bone and going northward as far as is necessary to accommodate the surgeon. The mesorectum will be removed entirely. During that part of the operation, the pathologist will be present so that documentation of a clear margin can be done immediately. Then the pathologist will take the specimen and begin slicing, dicing and evaluating lymph node involvement, the grade of cancer still present, etc. The pathology report will be delivered about 8-10 days after surgery.
About 10 lymph nodes will be examined very carefully as part of the pathology report. The results are important for the medical oncologist in a way that I don't yet understand but which will help him determine the exact combination of chemotherapy drugs and the delivery mechanism for my third stage of treatment.
The operating room is booked for 4 hours. There will be another 2-3 hours before I am conscious after surgery. At that point, after seeing my wife and sons, I will be looking to my right side to see if I have a device attached to my abdomen. If so, then it will be because I have had a temporary ileostomy .
My surgeon explained that I will most likely not have a colostomy, but approximately 15% of patients will require a second surgery because of a determination of the surgical team that the resected tissues are problematic in some way. If that determination is made, then part of the colon will be used for something called a J-pouch which is like a replacement rectum. Then, at the bottom of the small intestine and start of the large intestine is something called the ileum. That will be pulled as a loop outside the abdomen through a surgically created stoma. All effluent created by the digestive system will leave the body through that stoma into a device attached to the abdomen.
The temporary ileostomy allows what remains of the rectum, the J-pouch, and the colon to heal. Then, after a period of 3-6 months, a second surgery will be scheduled to reverse the stoma, reconnect the ilium to the large intestine, and allow the body to defecate in a normal manner. Normal? Well, I guess I'll just have to wait and see what kind of quality of life there will be, whether there is a temporary ileostomy or not. I expect there to be some problems, but I'll do whatever I can to promote healing and improve my chances for good quality of life.
After surgery, I'll remain in hospital for about 8 days, followed by recovery of another 5-10 weeks at home. Just 3 weeks after surgery, I'll be meeting with the medical oncologist to discuss the chemotherapy protocol we'll be following. This third and, I hope, final stage of treatment will take up to 6 months.
This all assumes there are no complications, the most common of which is thrombosis in the legs. I will be given blood thinners prior to surgery to help prevent that eventuality. But I have this covered ;>)
I asked the surgeon to humour me for a minute. Then, I explained how research has shown that patients under anesthesia, when given a verbal suggestion by the surgeon that they will recover more quickly than normal, do just that. So, smiling, he assured me that as soon as I was completely under, he will come around the surgical table to tell me that I will recover quickly, then he'll start his real job.
But my job, between now and then, is to enjoy myself, eat well, do those progressive relaxation exercises, think positively, imagine good outcomes, exercise, and prepare for my recovery.