I walk down to the waiting room and call out his name. After introducing myself we walk down to the consulting room together. Bob is in his fifties, owns his own successful company and knows his own mind. I open his notes, there’s a brief letter from his GP about piles causing rectal bleeding which have been treated with piles creams for the last 6 months, these haven’t helped his symptoms. He would like some more definitive treatment for his symptoms. I imagine him putting the morning aside to get his piles sorted, I can almost see the entry in his diary.
Bob tells me about his symptoms. “It’s been going on for ages now. I get bleeding pretty much everytime I go to the toilet. It’s fresh blood mainly when I wipe. The GP gave me some piles cream to use – but it hasn’t really done anything.” “So what about your bowels, have they changed?” I ask. “Yeah maybe a bit l go to the toilet maybe 3 times a day no. Sometimes I go a sit on the toilet and nothing happens. I have had couple of times when I have thought I needed to pass wind and just blood came out”. My cancer antennae start twitching, Bob is describing tenesmus – a feeling of wanting to defaecate when nothing happens and also “wet wind”, both these are symptoms associated with rectal cancer. I ask a few more questions about his past medical history, Bob is pretty fit and his only health problems have been knee injuries from football. I ask Bob to undress and get onto the couch so I can examine him. The abdominal examination is normal and I ask Bob to turn over on his left side so I can do a rectal examination. “Don’t fancy your job much!” he quips. I put on a pair of blue rubber gloves and apply some lubricating jelly to my finger. “Just a little finger inside the bottom now” I warn. I feel it immediately, a hard, craggy malicious mass in the rectum – its a rectal cancer. I take some biopsies with a pair of forceps and ask Bob to get dressed.
I leave Bob behind the screens and go and sit back at the desk. I imagine the next few weeks for Bob; scans, a colonoscopy, maybe some radiotherapy and a big operation. Bob reappears, “So what’s the verdict then, Doc?” he smiles. I want to pause time, I know he has cancer and he doesn’t. I want to preserve and stretch this exquisite moment. Of course I cannot do that. “Well Bob, I have found the problem. When I examined you I can feel a lump in the rectum. I am afraid that it’s not piles. The lump I can see is almost certainly a cancer of the rectum.” Bob’s face dissolves, smile gone now, confusion and anguish in its place. He swears, several times. “So err its not piles then?” he says, clutching at straws. “No” I say quietly. We sit there together in silence for what seems like ages, but was probably a minute or less. I feel a huge urge to break the silence and speak, but I know Bob needs time to process the bombshell I have just dropped. I manage to control the urge and sit in silence opposite Bob meeting his gaze. Eventually it is Bob who breaks the silence, “So what happens know?” he asks quietly. We make arrangements for some scans and a colonoscopy. Bob is distracted and I know any more information in, the unexpected bad news has overloaded his mind and shut down his capacity for rational thought. I arrange to see Bob after his scans and ask him to bring his wife with him next time.
The doors fling open and they wheel her in on a trolley. Eyes taped shut, tube down her throat, flimsy hospital gown barely hiding her modesty. We slide her carefully onto the operating table and position her for the operation.I know her, not well; enough to say hi and smile though. She’s young; shiny hair, slim limbs and smooth skin. Her belly is enormously distended in a grotesque parody of pregnancy; except there is no baby in there. Instead there is a tumour inside which has completely blocked the colon; gas and liquid shit backed up behind the tumour unable to escape. She came into hospital yesterday with constipation, feeling embarrassed and sheepish, hoping that an enema would sort her out. Instead she had a CT scan which showed us the tumour. Her caecum is distended and at the point where if we do not operate soon then it will perforate, sending litres of liquid bacteria-containing shit into her peritoneal cavity.If that happens then the outlook is much worse. Fortunately there are no signs of spread outside the bowel, if all goes well we can cure her, I think to myself. I paint her belly with a red coloured antiseptic liquid, taking care to apply it evenly and making sure that there are no missed bits. At the head end the anaesthetist is adjusting some dials to get her settled for the operation. We carefully cover her nakedness with sterile green drapes, leaving a rectangular piece of abdomen exposed. We do our final checks and the scrub nurse passes me a scalpel in a sterile bowel. I pause for a moment, I need to detach myself from her as a person to do the next bit. Usually this comes naturally to me and I do not even think about it. Today is different, it’s hard. I look at the smooth unblemished skin which I must cut. It seems a violation, sacrilege, like painting graffiti on an ancient monument; yet cut I must. I summon up some detachment, somewhere deep in the surgical centre of my brain some neurones fire and the detachment comes, not before its time. I notice my assistant and the scrub nurse looking quizzically at me, I’ve no idea how long I have been in this reverie. I pick the knife in my right hand and a large white swab in my left. Now I can do it. I make a long sweeping cut down the centre of her abdomen. Bead of blood well up from the skin edges, we swiftly mop them up with swabs and I swap the blade for a hand held diathermy. The machine buzzes, lights flash briefly and the bleeding is stopped.I cut through the fat layer and reach the shiny white fibres of the linea alba. There are fewer blood vessels here and swiftly we enter the abdomen. As I cut through the peritoneum, vast coils of slipper, distended small bowel spill out on to the drapes. The colon follows, paper thin and tensely blown up with gas. I insert a needle into the colon, attach into to a suction machine and suck out as much gas as possible. Now I can see what is going on. I feel the liver, its nice and smooth – no signs of cancer there thankfully. I feel down into the pelvis, there is an abrupt change in the diameter of the colon and at that point I feel a small hard, walnut-sized cancer- just as the scan predicted. My assistant pulls in the retractor and I use a swab to retract the distended colon towards me. I can now see the white line of Toldt, the surgeons’ equivalent of a cut-here line. I swiftly mobilise the colon and tie the blood vessels feeding it. We wash the bowel out, litres of liquid shit emerges from the other end of the tube. Once it runs out clear we cut out the cancer and then staple the ends back together. I close the wound taking care that the skin incision is a neat as possible. A clean white dressing covers the wound and then we are done. Carefully I peel the drapes off and the person underneath emerges once more. We carefully rearrange her gown to preserve her modesty and gently move her back onto her bed.
Next day I see her on the ward. She look little pale against the yellow print on her hospital gown. She’s feeling a little sore and bit sick. I tell her it all went well, no unpleasant surprises – a tiny smile flickers across her face.
April is Bowel Cancer Awareness Month
Every year about 2,500 people under 50 are diagnosed with bowel cancer in the UK