The surgeon likes to give hourly updates when he is operating, so about 3:00 I was starting to get a bit excited for the phone call report. It didn't come. Hard to decide if that's a good thing or a bad thing. About 3:15 the door opened. In walked the surgeon (sometimes surgeons leave to tell really bad news, sometimes surgery is just short). He was already finished.
J's appendix had perforated (had a hole in it) and it was removed.
A little background. The appendix hangs off the end of the cecum, which is the first part of the colon or large intestine. The cecum is like a cul-de-sac and the appendix is a very skinny extension (it's abnormal when it is more than 6 mm thick). Imagine one of those long balloons that they make little dogs or other shapes out of and that little bit of balloon at the end that they never fully expand, that part at the end is like the appendix. Appendicitis usually occurs when something blocks the opening of the appendix. Since the colon is full of bacteria, there are bacteria that grow wildly in the blocked appendix. It starts to get inflamed, and bigger, and bigger, until it's so big that it pops (perforates). All that bacteria can then begin to grow in the abdominal cavity where there is no escape to the outside world and the body tries to fight it off and wall it off and you start to get abscesses.
The symptoms with appendicitis usually begin as vague belly pain that stays around the belly-button, but nobody can point with a finger to show exactly where it hurts (which happens as the appendix first gets inflamed). As the inflammation gets worse, adjacent structures (mainly fat, and some parts of the abdominal wall or other parts of bowel) get inflamed and you start to get pain that you can point specifically to. Usually this is in the right lower quadrant (but I can tell you I've seen appendixes that are deep in the pelvis and up by the gallbladder and in the middle of the belly and none of these people would have pain in the right lower quadrant because they are going to make different body parts get inflamed and their pain will be in other parts). Along the way they may have fevers. They usually do not want to eat, and this will usually go with the pain surrounding the belly button. Somebody whose immune system isn't working right may present differently. J had none of these symptoms, which he may not since he doesn't have a normal immune system this week. However, I don't think this is what happened with him.
His surgeon wonders if the the chemotherapy had weakened the appendix and as he was neutropenic (had no white blood cells) the same process that causes typhlitis (the serious complication we were hoping they wouldn't find where the cecum or first part of the colon, becomes very inflamed), happened in the appendix. The appendix became inflamed without being blocked off and then it broke open and formed the abscess. However, I also don't think this is what happened.
My theory is as follows. He started off three weeks ago with the mass, which already had some areas that were liquid within it. When we did the follow-up MRI after the first part of chemotherapy, nearly the entire mass was fluid (which as I said in a previous post, was like a luxury retirement home for the bacteria). Some bacteria found it and started growing. The body made an effort to enclose it as an abscess. Along the edge of the abscess there is always a lot of inflammation, and that inflammation can spread to adjacent structures. It just so happens that the tip of the appendix was sitting on the edge of the abscess. I think it became secondarily inflamed, became weak, broke open, and started adding it's own contents into the abscess. It needed to be removed, but it was probably not what started the problems, it just wanted to join in the fun.
The reality is, figuring out how it happened is an academic exercise, and it doesn't really matter. The important thing is that the appendix has been removed. The only bit of news the surgeon thought was bad, was that they decided that since he is just barely recovering from having no white blood cells, and that since there was so much inflammation from the abscess, they would not close the incision in the belly. Instead there is an awesome device somebody smart invented called a wound vac. It's basically a tight bandage that has a vacuum attached to it. It puts a gentle negative pressure (causing suction) where the wound is. Any bad stuff from the abscess will start to pulled out (like a vacuum). It is possible to leave these in place and let the body slowly form a big scar at the incision. For J, they plan to take him back to the operating room in a couple days and they will clean out his belly again and close the incision. He should have plenty of white blood cells by that time to help with normal healing.
If you are left wondering how to respond to his surgery, just know that I think this is about the best news to receive. We have a cause of the perforation, and surgery without an answer would have led us to keep J from eating or drinking anything at all for a week. It was a very simple, straight-forward fix. We found it as the blood was recovering from the effects of chemotherapy, so his body will help clean this mess up. He did not have to have part of his colon removed. He did not need an ostomy (where the bowel is brought to the skin surface). I think tonight is a night I am going to feel grateful (and hopefully I can sleep and J's pain can be well controlled).
To be complete, we talked about J in a tumor conference and this is probably the best explanation for what happened. The tip of the appendix became trapped in the tumor. Since the tumor was dying rapidly, there would have been inflammation, which would have weakened it. There may have been added insult during the time he was neutropenic. At some point it burst, probably what started the infection to begin with. It just took a few days to make that abscess grow large enough to grab our attention. My theory would have placed the perforation sometime after the infection started. There I feel better, even if my thought was probably less correct.
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