Help! Surgery Monday! What is this surgery?

[JMRWife]

Laproscopic sigmoid/Low anterior resection/Proctectomy

Good news: CAT scan does tumor has shrunk from the size of a fist to the size of a strawberry. But are they planning to remove my rectum? This was never discussed!

From the report:

FINDINGS:

CT abdomen: The examination of the lung bases demonstrates minimal parenchymal scarring within the lower lobes. The liver and spleen appear normal in size with no focal abnormality seen. Gallbladder is normal in size and position with a possible 6 mm gallbladder polyp. The pancreas and adrenal glands are unremarkable. Kidneys normal in size and position. There is a stable subcentimeter hypodensity within the left kidney. There is no hydronephrosis. There is atherosclerotic disease. There is minimal soft tissue stranding the previously described 2.2 x 1.4 cm soft tissue masslike nodule within the left para-aortic region has improved in the interval. There is no discrete mesenteric or retroperitoneal lymphadenopathy. There is a stable left lower quadrant colostomy. Colonic diverticuli with no CT evidence of diverticulitis.

CT Pelvis: There has been improvement of the previously described 6.4 x 3.8 cm circumferential colonic mass involving the proximal sigmoid colon. The current mass measures approximately 2.6 x 4.5 cm. There is no discrete adenopathy seen. There is no bowel obstruction. There is no ascites. There is no significant inflammatory changes. The uterus and adnexa appear unremarkable. The urinary bladder appears unremarkable.

IMPRESSION:
1. Improvement of the previously seen circumferential sigmoid colonic mass which currently measures 2.6 x 4.5 cm.

2.. Improvement of the previously described 2.2 cm soft tissue masslike nodule within the left para-aortic region.
Left lower quadrant colostomy.

4. Colonic diverticuli with no evidence of acute diverticulitis.

5. Possible 6 mm gallbladder polyp versus sludge.

6. Minimal soft tissue stranding within the mesentery which likely is related to a inflammatory process.

Please tell me what this surgery means!

[roadrunner]

There are a number of questions raised here, and others will have more informed responses than mine, but I will venture the following:

This is a major surgery, with potentially significant impact on post-surgical QOL. Not to say it’s bad, or not indicated here (you seem to have substantial residual tumor). But I don’t think anyone should go into this surgery as uninformed (no offense meant, just seems to be the case) as you seem to be. I think you need to consider postponing until you can get a better explanation of why they are doing this, what it entails, the risks involved, what recovery will look like, and what long term effects may result from it.

I see at least two other potentially relevant points: (1) there is an indication of atherosclerotic disease—have you been checked out by a cardiologist to ensure you’re ok for the surgery? And (2) what is their view of the “soft tissue mass-like nodule within the left para-aortic region”? Did it “improve” with chemotherapy? If so, do they think it’s malignant? If so, how do they plan to address it?

To answer your question: yes, a proctectomy means removal of the rectum. A question here is whether they will “reconnect” you in this procedure or later, in which case a an ileostomy may be required in the recovery phase.

[JMRWife]

I see my surgeon Thursday, so I will be able to ask a lot of questions.

I know they have to remove the tumor, but I'd keep my colostomy over having accidents at work. I LOVE my job and working is important to me.

The surgery was scheduled for this time in July, the last time I saw my surgeon. FwIW, I trusted him immediately. I think he made a sound decision to do neoadjuvant chemo. It's just that he never said anything about removing any of my rectum and I'm not spending my life searching frantically for restrooms. Me and Mrs. Wiggins (named after the the secretary on the Carol Burnett Show) will do just fine.

I'm having pre-surgery testing Thursday. I am assuming they will check my heart but will make sure to ask. Ditto for the soft-tissue stranding. The soft-tissue module was assumed to be an injury from when the surgeon removed a lymph node. They didn't use the word "suspicious" so we won't know what it is until he goes in.

One thing is for sure. I'd rather keep my bag than s**t myself at work

[JMRWife]

One more thing. In July, my surgeon said he planned to reconnect me. But I see no evidence of this in the description of the surgery. NEVER ONCE did he say rectum removal, only reconnection.

I don't see anything in the report that would explain such a radical departure from what he said in July, unless he's doing it to ensure clear margins.

[O Stoma Mia]

Two points:

1. I agree with roadrunner. You need to urgently clarify what this surgery is all about, especially since it seems to have substantial implications for quality of life (QOL). Maybe you will need to postpone it.
   .
2. Your signature is incomplete; it doesn't tell the whole story. Your screen name JMRWife suggests that you are the caregiver, but your signature suggests that you are the patient. Actually, you are both a caregiver and a patient, but this is not clear from your signature, which has changed from what it was in 2015.

   Same thing: colon cancer. Mine is in sigmoid colon. 6.7 x 5 cm when diagnosed in the ER--I'd been told it was diverticulitis. Had night sweats and fevers before diagnosis. Got a diverting colostomy. Not too bad.
   
   Surgeon decided on neoadjuvant FOLFOX because of the size. I've seen my CEA go from 107, before chemo, to 9 (nine!) after round 5. Haven't had sweats or fevers since round 1.
   
   Not much nausea or side effects; no pain at all. I've only had to take one Zofran. Clinical stage is IIa, but surgery in late August, after 8 rounds.
   
   My husband is NED for over 5 years. I'm hoping for the best.
   
   Hoping and praying for all of us here.
   
   Reference:
   Husband in 2015, me in 2021
   https://coloncancersupport.colonclub.com/viewtopic.php?f=1&t=65709&p=509567#p509567
   

   
   

[stu]

Hi ,

I remember when you posted with your own health issues !

I am just wondering if the surgeon had hoped to do a different procedure if a little more shrinkage had occurred!

However you are operable and seem very adjusted to your current stoma bag !

Good on you for enjoying your job so much . I big motivation in recovery !
Maybe having your knowledge from your husbands situation has propelled you forward in understanding and accepting what is best for you !
I hope the surgery goes well and you recover well !
Stu

[JMRWife]

Another question; does the surgery have 3 different names because it's 3 distinct procedures?

Laproscopic sigmoid (colectomy)?
LAR
Proctectomy

If so, that's a lotta surgery!

As I said I'm seeing my surgeon tomorrow but I cannot wait to find at least some ballpark answers to my questions. I know that you guys aren't doctors but I'm very anxious. This is not at all what is an all my surgeons notes on my portal. Consistently he said sigmoid colectomy.

[catstaff]

Proctectomy means removal of at least _part_ of the rectum, not necessarily all of it. You may have a rectosigmoid tumor so they need to take some of it for margins. (The original was very large and "shrinking" doesn't guarantee no surviving cells, only pathology can confirm that). If they were going to remove all the rectum that would generally be called an abdominal perineal resection (APR), not a LAR which is a low anterior resection. Laparoscopic refers to the technique (minimally invasive) as opposed to open.

Please do make sure all your questions are answered by your surgeon. Make him draw pictures if it's not clear.

If most of your rectum is left you should not have as much trouble with "LAR syndrome" as those who have less. But ask the surgeon about this.

[O Stoma Mia]

Another question; does the surgery have 3 different names because it's 3 distinct procedures?

Laproscopic sigmoid (colectomy)?
LAR
Proctectomy

If so, that's a lotta surgery!

As I said I'm seeing my surgeon tomorrow but I cannot wait to find at least some ballpark answers to my questions. I know that you guys aren't doctors but I'm very anxious. This is not at all what is an all my surgeons notes on my portal. Consistently he said sigmoid colectomy.

I understand your concern. I think the best way to approach this is to look at the defined Current Procedural Terminology (CPT) billing codes for various colorectal procedures. A list of some of the 2021 CPT codes is given in the document below :

https://asiapac.medtronic.com/content/dam/covidien/library/us/en/services-support/reimbursement/reimbursement-coding-guide-medicare-colorectal-surgery.pdf

What I would suggest is to look at this in two steps. First, what procedure(s) did they use on April 28 when they did the «diverting colostomy»? Then, once you have figured out which procedure(s) they probably used 5 months ago, you can hypothesize which procedure(s) they have left to do this time around.

Since I am not a doctor, I can only speculate on what the situation might be, but I will share my thoughts and you can go from there to speculate on what might be the actual situation.

• April 28th procedure(s). You say that they did a «diverting colostomy» to handle an obstruction in the proximal sigmoid colon at 30 cm from the anal verge but you didn’t say what kind of surgery was involved, either laparoscopic or open. So there are several scenarios possible for what they did on April 28.
  
  
  • A simple diverting colostomy done by laparoscopy, leaving the tumor in place, clamped off, and isolated. This would probably be coded as :
    
    443188 «Laparoscopy, surgical, colostomy or skin level cecostomy»
  • A simple diverting colostomy done by open surgery, leaving the tumor in place, clamped off, and isolated. This would probably be coded as :
    
    44320 «Colostomy or skin level cecostomy»
  Thus, after the April 28 operation you were left with a diverting colostomy for sure, but also a sigmoid colon with a tumor still in place, so the procedures to be done on October 4th would depend on what is still left to do according to the surgeon’s current, updated judgment.
  .
• October 4th procedure(s). There are a number of possible scenarios, depending on what was done on April 28 and what the surgeon thinks should be done at this time.
  
  In particular, the question is whether he is planning to do a surgery to remove only the segment of sigmoid colon containing the tumor and then re-connect the remaining part of the upper sigmoid colon to the upper part of the rectum while at the same time removing the diverting colostomy, or whether he is planning to do a more extensive surgery that involves removal of both the sigmoid colon and all or part of the rectum while leaving the diverting colostomy in place.
  
  In one scenario, the surgery would involve a sigmoid colectomy, an anastomosis procedure for re-connection, and a colostomy takedown procedure. After this set of procedures you would then be left without a colostomy but would be expected to have normal bowel function after a short period of recovery from surgery. What would be removed permanently would be the segment of sigmoid colon containing the tumor along with good surgical margins, and the diverting colostomy connection. (According to your September 10th post, this is the option that he preferred at that time.)
  
  In a second, more drastic, scenario, the surgery would leave the current diverting colostomy in place (i.e., no colostomy reversal), but remove everything from the sigmoid colon down through the rectum. There would be no re-connect and no anastomosis procedure, since the plan would be to leave the diverting colostomy in place from now on. This type of procedure is normally called an abdominal perineal resection (APR), not low anterior resection (LAR).
  
  These are not the only possible scenarios. There are other scenarios, depending on what the surgeon feels should be removed at this time.
  
  The CPT codes for these procedures would be the ones involving terms such as «partial colectomy», and possibly «proctectomy», «anastomosis», «mobilization (take down)», etc.

What I would suggest is for you to to go through the list of CPT procedures before Thursday and familiarize yourself with the basic terminology so that you can carry on an informed conversation with the surgeon.

Whenever a surgeon does an operation, he will eventually have to create a special surgery report for billing and insurance purposes with the report containing all of the CPT codes for the procedures that he ended up performing during the operation.

Some of the procedure codes that might be relevant for your October 4th surgery are :

44143 Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure)

44206 Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure)

44213 Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure)

45110 Proctectomy; complete, combined abdominoperineal, with colostomy

These are not the only ones possible. You need to look through the whole list of CPT codes and try to understand which of the available procedures might be used to cover the

Laproscopic sigmoid (colectomy)?
LAR
Proctectomy

procedures mentioned in your post.

[roadrunner]

O Stoma Mia’s post is in my opinion super helpful in giving you a framework for discussions. There is a lot of great information in there for you to consider. Given your time constraints, however, this situation may still—or it may not—seem overwhelming. I am a great believer in informed judgment in matters of this nature. If you are as well, you need to determine how much information you need to base a judgment on and how much *time* you need to process that information and get comfortable with the approach (or get a second opinion if you think that’s important). Since there’s such a disconnect (no pun intended : ) apparent in your questions and concerns, I suspect more time may be helpful. I am conscious, however, of the scheduling challenges of colorectal surgeons, so that may also be an obstacle.

For what it’s worth:

From what you’ve said, it *seems* to me that your surgeon is contemplating removal of at least some of your rectum and reconnecting the remaining colon to the remaining rectum. If that’s right—and that’s a big “if”—a fairly large and complex set of questions potentially remains. For example: How much rectum will remain? What type of re-connection (anastomosis) will be employed? Will there be diversion during recovery? If so, how? What are the likely consequences from this (long/short term)? (You may want to research the last one, as some surgeons are not great at focusing on post-surgical complications/side effects.) How does your current colostomy play into all this? If reconnection is not a priority, can you just keep the colostomy? Perhaps most important, is this the only reasonable approach, or is the surgeon making judgments in designing this approach (for example, could a less substantial procedure—for example, taking less or no rectum—be an option?)? Or, as others have suggested, does the location and nature of the tumor necessitate this approach?

[catstaff]

Beyond that, if you think you really want a permanent colostomy you'd probably be better off with an APR because if the rectum and anus are left you can still have discharge and such. I don't know what you have currently, if the plan is to reconnect they'd likely leave it or perhaps move it (my husband had a diverting colostomy that was just moved during his surgery because it was intended to be temporary). If it's a loop colostomy then material can also get through it resulting in more discharge etc. sometimes. However, an APR is an even bigger deal than a LAR in terms of recovery from the immediate surgery.

[catstaff]

I should have also mentioned that first, at least in the US the surgeon has a lot of discretion as to what he or she will do, second, they are unlikely to change the plan they have now, and third, an APR is an irreversible decision so you'd probably be best off to see how the LAR goes and what the surgeon says. But as others have said, you really need to be very, very clear on what the plan is so get your questions organized in advance.

[rickker20]

I would go with a LAR if possible. They will remove the rectum and part of the sigmoid colon but on later date they will connect you back.

[JMRWife]

I sent a frantic message last night to my surgeon via my portal. This guy actually left me a message today! He said, don't worry, "they" probably got it wrong when they scheduled it.

Weird, but I feel slightly calmer.

I see him tomorrow at 10 but am adamant that I will NOT be chained to a loo. Mrs. Wighins has been a pretty faithful friend to me. I'll update tomorrow. And thank you everyone for the thoughtful, informative responses! I appreciate your help.

[JMRWife]

After all your long and thoughtful replies...the surgery on my portal was a coding mistake.

Just a sigmoid colectomy. I have no idea how they got it so wrong, but grateful that my surgeon called me to ease my mind.

So relieved.