Like a knife through hot butter

So I saw my surgeon this morning who advised me that 18th March is the big day for surgery. “That’s all very well and good”, I hear you say, “but what are they actually going to do to you?”. Well, read on and find out. I apologise in advance as there will be some measure of detail, some diagrams, and maybe even a picture of a rectum or two just for shits and giggles.

The official name of my operation is a Total Mesorectal Excision (TME) performed by Low Anterior Resection (LAR). Sounds fancy eh. For some time now it has been the gold standard of curative surgical intervention for advanced (read lymph nodes involved, not metastatic) rectal cancer, and when combined with neoadjuvant chemoradiation, reduces the incidence of local recurrence (i.e. the cancer coming back in my ass) to <5%. That’s a good thing, because my pelvis is already irradiated to buggery and as much fun as I had with Zeus, I’d like to never see him again.

Unfortunately, because my tumour is ‘bulky’, and notwithstanding that it has shrunk and will likely continue to shrink, my surgery will be a combination of ‘open’ and ‘laparoscopic’. The diagram below shows the difference in terms of the incisions and ultimate scars. At best it’ll look like a snake going down to my man bits, and at worst it’ll look like I have an ass crack on my stomach. Anyways, better to have two asses than be dead. On a positive, I’ll be sure to shave the pubes:

Wounds

A quick anatomy lesson

The image below shows the large intestine, or colon. You can see that it is made up of various parts, with the rectum being the poo warehouse before dispatch, and the anus being the turd-cutter.

The colon’s principle job is to remove water from waste, and to move the turd along until it’s time to drop the kids off at the pool. The large intestine is pretty big, measuring about 5ft long, but is dwarfed by the small intestine, which measures on average, 20ft long.

The dark shaded part is what is removed in a LAR, although, as is the case in every instance, the actual bits removed will vary:

LAR.png

My tumour is more towards the top of my rectum and so they may not remove as much of my poo warehouse. The trade-off is that the surgeon will probably take a little bit more of my sigmoid/descending colon just to be on the safe side.

Because it looks like some lymph nodes have been compromised, they will also take out a large portion of surrounding tissue (read: fat) called the mesorectum. The image below shows the approximate plane of tissue that will be removed:

TME

The final part of the operation is to take a medieval looking torture implement and staple the healthy part of my colon, to the healthy part of my rectum, a procedure called ‘anastomosis’. The device itself looks like some sort of demonic dildo that has double rows of staples within it which creates a double seal, reducing the risk of a leak. They then flood my abdomen with water and pump CO2 up my ass like a reverse fart, to test for leaks, just as you would when repairing a bike inner tube.

Below is the ass stapler:

Ass-Stapler

Hopefully, my surgeon can read Japanese(?) and he knows that the bit on the left goes up the date and not the handle. The cap on the far left is stitched into the healthy part of my colon and the rod part from it marries up with a bracket in the long bendy part. Once they are paired up, the handle is pulled and a double row of staples are fired, creating a perfect (hopefully) seal.

Unfortunately, the fact that I will have an open wound in my sewer canal means that I will have to have a stoma while the anastomosis heals. Fortunately, it will only be temporary, and will be reversed after I finish my post-surgery chemotherapy. After that I’ll be able to poo again, albeit a little bit differently.

What is a stoma

A stoma is basically an opening of an internal organ to the outside world. The most common, and relevant ones in terms of this type of surgery, are colostomy’s and ileostomy’s. A colostomy comes from the colon itself and is more often than not permanent. The waste it removes is more like the turds you are used to seeing when you check to see whether you did a phantom or a floater.

I will be having what is called a ‘loop ileostomy’ which is where they remove the final part of my small intestine, the ‘ileum’ out through my stomach and sew it to my stomach creating an opening through which liquid waste can be expelled into my ‘bag’. I will have to have it for at least 3 months but in light of the fact that my chemo will go for at least 4 months, and my surgeon isn’t keen on digging around in my insides while there is poison in there…I know, what a pussy right, I will have my bag for c 6 months.

Below are two images. The first is roughly what a stoma looks like and the second shows what I will look like with my bag:

Stoma1

Stoma3

I am trying to think of a name for my stoma/ileostomy bag. At this stage I am leaning towards naming it after a defence solicitor who, given he is full of shit, lends his name quite well. I will refrain from naming him here but those who know and work with me will have a pretty good idea who I’m talking about.

Will I ever be able to poo normally again?

The short answer is ‘sort of’, the long answer is ‘probably not really’. As explained, the large intestine’s main job is remove water from the stool, making it more solid. It then travels through to the rectum where it is stacked and stored until it is time to ship out.

The result of losing a portion of both my colon and rectum is that there will be less water removed and less storage space. That combination means that I will need to have a pretty good idea where the nearest bathroom is, and at least at first, there may/will be times when I may not make it. In the meantime, I will be investing investing in double strength undies and mission brown slacks.

How am I feeling about it all?

With all puns intended, I’m shitting myself. The surgery will take 3-4hours and I’ll be in hospital for over a week. I’ll have 4-6 weeks recovery time before returning to work, but it is more than likely that I’ll be back having chemo within a couple of weeks of going under the knife.

Visitors will be most welcome, but in small doses, and preferably only if you have boring stories because apparently it hurts to laugh.

It’s also while I’m in hospital and for at least a couple of weeks afterwards that Lyndell and I will need the most help, and in that regard I’m (read: we’re) so grateful for everything that you wonderful people have done for us so far. It is a huge thing for me to ask for help but in light of the fact that I’ll be a cripple with two asses but who can’t fart, I need to suck up my pride and ask for a little assistance.

So now we’re all up to date. I’ve finished my treatment and will now be focusing on giving the body a rest from the rigours of treatment, and getting strong and fit so that surgery is smooth and my recovery is smoother.

Until next time folks, be kind to your colon’s, and each other…

 

 

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A day in the life of – Chemoradiation (CRTx)

As I near the end of my chemoradiation, I thought that I would do a day in the life of, with a bit of info about the radiation aspect of it in particular, because it’s interesting as hell.

Most of my recent treatments have been in the morning, which is good on the one hand because you get it out of the way early and then have the day to yourself but on the other, it’s fucking brutal having to fill your bladder so early in the morning and hold it. It also means that I piss like a racehorse for the rest of the day. Adding insult to injury is that despite the best intentions of Zeus in attempting to spare my bladder, it still cops some of the radiation, which means that each piss is accompanied by a not-so gentle reminder I’m unwell, in the form of a hot poker to the bladder.

Chemo

As per a previous post, the chemo aspect of this side of treatment is pretty easy. I take three of these puppies in the morning and again at night, within half an hour of eating. Sounds simple right? It is, except for “chemo brain”, which is an actual thing I’ve found, which sometimes makes me cut it pretty fine in terms of sneaking into that 30 minute window.

Below is a pic of the tablets:

Xeloda

As discussed, this is a pretty fucking smart drug. It is almost completely inert until such time as my liver converts it to Fluorouracil or 5-FU, which then travels directly to the tumour itself, where it basically tricks the tumour into giving it a hug and then it kicks it in the balls and steals it’s lunch money. OK, so it doesn’t commit robbery, but it does interfere with the DNA/RNA of the cancer cells which prevent it from reproducing. If it can’t reproduce, then the tumour can’t grow. It also works by starving the cancer cells of nutrients they need to just continue being cancer cells. That also leads to cell death and as the DNA is fucked, they can’t replicate and so the tumour shrinks.

Where it really comes into it’s own though is the combined effect it has with radiation. Tumour cells don’t like being irradiated at the best of times, and they like it even less when they’re struggling for life. Kind of like almost drowning, and just when you get to the edge of the pool, some bastard kicks you in the face and holds your head under water until your name is changed to ‘Bob’.

Fortunately, of all the side effects that Xeloda can cause, the only unwelcome visitor I have had to endure is fatigue. The fact that I am coming to the end of the treatment and have escaped the more sinister symptoms is a huge relief, kind of like doing a a really big poo for the first time in months, which also happened recently, but thats another story.

Full to the Brim

An hour or so before treatment, I start to drink as if I’m in a bar and they’ve just called last drinks, or pretty much a Tuesday afternoon.

It takes between 30 and 45 minutes for water to reach the bladder according to various websites. I thought during the first round of CRTx that I had shortened it to around 15 minutes but eventually realised that wasn’t the case, and that it was rather a ‘trickle down’ effect.

Prior to starting treatment, I had a ‘planning CT’ scan. Unfortunately for me, I took their advice to have a ‘full bladder’ to the extreme and turned up resembling the Hoover Dam. I now have a new found respect for my wife, having to endure multiple ultrasounds when pregnant with our spawn. Unlike my wife however, I have become the master of the ‘strategic wee’ and am able to let out little bits at a time so that my bladder is still full enough for treatment, but not so full that the therapists have to wear wellingtons while cleaning up the flood that was my bladder.

Radiation

Anyways, they take that CT image, and fuse it with the staging MRI I had following the diagnosis to make a incredibly detailed, 3D image of my pelvis. Going throughout that image are a number of different coloured lines showing the directions of beams that Zeus will administer from, and different coloured ‘clouds’ which show the principle radiation zone, as well as the areas that they administer lower doses to, such as areas where my lymph nodes are, to make sure that nothing is left behind. The end result is that my pelvis will resemble Hiroshima at the end of treatment…barely inhabitable and forever stained with the blood of Miguel (I don’t know whether any of the victims of Hiroshima were named Miguel – I suspect not).

Treatment itself is a walk in the park, most days.

I try to avoid eye contact with the other patients in the waiting room except for Terry. He’s a good bloke who has rectal cancer as well. I gave him my paper once after I had finished with it and now I am his best friend. I think he has a ‘radiation shirt’ in much the same vein as I have my ‘chemo’ shirt because he’s always wearing the same thing.

Anyways, it’s somewhat surreal sitting in the waiting room of a radiation oncology clinic. But for two other people, each of whom I saw once and never again, I am by far the youngest person in the room, and by a long stretch as well. People are shocked when I tell them the type of cancer I have because, as you might have noticed, I’m not a 65 year old man.

Then, often as they are about to enter the final round of a game show I’ve been annoying the other patients by answering the questions aloud, before the question is even finished, my name is called and it’s show time.

I lie on a gantry, on my back, place my legs in a custom mould and pull my pants down so that the elastic of my underwear is just covering the top of my shaft. The therapists are kind enough to hold a towel over me so I can retain what little dignity I have left as they shunt me and twist me into the optimum position, and so that the three tattoos they gave me during the planning stage (one on each hip and one on the front of my pelvis, right above my shaft) are lined up with the lasers that bounce around the room.

The lights are off at this stage and it’s kind of like being at a rave, except that I’m not drunk and I need to wee. Once, one of the therapists touched my penis. I’m sure it was ‘deliberately accidental’ but since she is helping a brother out and helping to make me better, I didn’t make a big deal out of it. The lights come on and the therapists flee the bunker like rats from a sinking ship.

On a good day, they only take a couple of quick x-ray images of my insides before the radiation treatment begins. On a bad day, they do a full 360* ‘cone-beam CT scan’ which itself only takes less than a minute, but ends up adding between 3 and 5 minutes to the total time because the therapists then need to check everything.

It’s then a waiting game, and this is by far the worst part. You lie there, perfectly still, looking at the illuminated ‘Caution – Radiation imminent’ sign near the door and hope that it remains illuminated. If my bladder isn’t full enough or I haven’t dropped the kids off at the pool and my ass resembles a Tarago then the light goes off, the door opens and I know that I’m in for a long day.

On good days, and fortunately I’ve only had a handful of bad ones, you feel the gantry being moved remotely and it locks into place. Then the fun stuff starts.

Most of you reading the blog will have seen the video I posted of my mate Zeus and I spending some quality time together. In total, he does a full rotation, stopping 7 times to hit me with his rhythm stick. When the radiation is being administered, it sounds like a swarm of robotic bees. Interspersed with that mechanical drone is a grinding noise as the less in the collimator move, shaping the radiation beam so that it hits the tumour, and doesn’t completely napalm the rest of my pelvis.

Zeus is a linear accelerator, or LINAC for short. He is, quite simply, a fucking marvellous bit of gear. He’s huge, think the size of a truck, but also nimble as Jarryd Hayne as he revolves around me. Basically, he makes x-ray beams, in the form of photons, and high-velocity ones at that. The photons are accelerated from the body of the machine, into the arm which holds the head, before being directed through a series of buffers and into my ass.

Inside Zeus’ head is what called a ‘multi leaf collimator’, sounds fucking impressive, right? Below is a picture of what I’m talking about, because it makes it easier for you to grasp if you can see what I’m talking about:

Collimator.jpg

The ‘leaves’ are those metal stick looking things and they move. As you can see from the image above, that machine is probably irradiating an apple. In all seriousness, those leaves move while the radiation is being administered, to shape the beam to make sure it goes where it’s supposed to, and doesn’t go where it’s not.

Each pass Zeus makes lasts between 25 and 33 seconds. After he does that for the seventh time, the warning light goes off, the door opens, I pull my pants up, jump off the gantry, exchange pleasantries and sprint to the toilet, or, if I have done a strategic wee before hand and don’t feel like I’m about to do the reverse Moses, I ask mundane questions which allow me to provide the information contained herein.

Anyways guys, this was a longer post, and if you’ve made it to the end, you should be applauded.

Until next time, be kind to your colon, and each other…