Monday, August 06, 2007
Sometimes it's hard to see in front of your face.
When I started in practice here, I took over for an older surgeon who was retiring, and inherited most of his long-term patients. One was a woman with a pretty amazing surgical history, beginning with a rare tumor in her pelvis, slow-growing but difficult to eradicate. She'd had several increasingly difficult operations, and with her last recurrence she was told she'd need a hemipelvectomy to have any sort of chance of control. Facing such a thing was too much for her -- in her twenties at the time -- and she refused. Somewhere along the line, she'd had a transverse colostomy, the most unpleasant of all to manage: the output is semi-liquid, bags don't fit well. A mess, often. When it had been done, it was because of impending colon obstruction from tumor. Suboptimal for a permanent stoma, the transverse location had been chosen in order to avoid operating close to the pelvis. When I first met the lady, it was twenty years later.
Now in her late forties, an advertising exec from out of town, she'd been coming for yearly checkups ever since. Who knows? Maybe it was the last-ditch irradiation or the not-much-chance chemo. Perhaps her immune system finally figured out how to recognize the tumor and gobbled it up. Whatever the reason, year after year her exams turned up nothing, and she felt fine. She lived an active life, putting up with the occasional leak, the sometimes smells, and kept on keepin' on.
It didn't dawn on me until after seeing her a couple of times, doing a physical exam, a pelvic, getting a couple of blood tests, as had been done regularly by my predecessor ad nearly infinitum. Had anyone ever raised the idea of closing her colostomy? Was there a reason why she still had it, all these years later? No, she said. She just assumed that's the way it was, and no one had ever suggested anything different. Well, I offered, let's think about it. How 'bout we check things out?
A barium exam of her distal colon showed it to be anatomically normal. On a CT scan there were post-surgical changes but nothing to raise flags of concern. The only thing was, I'd never heard of closing a transverse colostomy so many years later, and I wondered if somehow or other the long-defunctionalized bowel had lost its ability to do what it does; namely, to absorb liquid to produce formed stool. Not to mention keeping continent. The high-tech "squeeze my finger" test confirmed a functioning -- if pretty tight -- sphincter.
Calling around, I talked to a couple of my old profs. No one had any experience to bring to bear, but none thought there'd be a problem. Worse coming to worst: it could always be re-colostomized. She was more than willing to give it a try.
Closing a colostomy is one of those operations that can be fairly easy, or a frustrating nightmare. Not usually, however, a transverse colostomy. The area hasn't been much disturbed, both ends are right there (in this case, differing from the linked diagram above, it was a loop colostomy: potentially messier to live with, but a slick little operation to close up and drop back inside. Which is what I did. And, having reminded myself often enough that I started telling me to shut up, I remembered, while she was asleep, to dilate her anus manually.)
Long story medium-long: she did great. I'd told her to expect she might have diarrhea with or without control issues for a while, pending her colon getting up to speed, as it were. She didn't. Delighted is an understatement. Imagine getting rid of that thing after twenty years! I saw her once or twice more and we both started wondering why: she came from a ways away for the visits, and had a doctor at home. Never saw her again, but for a few more years she sent me Christmas cards. Hardly a surgical tour-de-force, nor a journal-worthy case; not a diagnosis for the ages or an ovation-inducing operative save. But I felt good about it. A slap on the forehead moment. A look at what hadn't been seen, making a nice lady's life a little better. Sometimes it doesn't take much.