When Danny Cullers arrived by ambulance at the Sentara RMH Emergency Department on Nov. 29, 2015, he didn’t know what was wrong—he just knew he was very sick.
“At first I thought I was having a heart attack,” says Cullers, 64, of Mathias, W.Va.
But Cullers was also feeling pain in his abdomen. Sure enough, imaging revealed a tumor in his large intestine. The mass had burst through the colon wall, releasing toxins into his bloodstream, and the resulting infection was stressing his heart.
Thanks to emergency surgery performed by Robert Garwood, MD, Cullers is alive and well today, feeling better than he has in years.
Failing Health, Hidden Condition
“I knew I was having some problems, but I was never one to go to the doctor,” says Cullers.
His health had been failing for several years. He had lost his appetite, lost weight, suffered from stomach cramps, and was passing blood in his stool.
“I was tired and had no energy, but I just thought it was old age sneaking up on me,” he says. He became so weak and ill, in fact, that he retired from his manufacturing job at age 62.
Then, in November 2015, when deer season rolled around, Cullers felt too sick to go hunting. That’s when his cancerous tumor perforated his colon wall, resulting in the medical emergency that sent him to the hospital.
The colon, or large intestine, comprises the last four to five feet of a person’s bowels, Dr. Garwood explains. It absorbs water from waste material (feces) and returns it to the body, and also absorbs any remaining nutrients before the solid waste is eliminated from the body.
Dr. Garwood says Cullers had underlying heart issues—of which Cullers was unaware—that made it more complicated to diagnose the source of his problem. But when Dr. Garwood saw the X-rays showing the mass in Cullers’ colon, he knew he had to perform a colon resection to remove the mass and stop the source of infection, which ultimately resulted in a temporary colostomy as well.
“The initial issue, which was an emergency, was to get the infections—the peritonitis and sepsis—under control,” says Dr. Garwood. “The infection came from the hole in the colon and spread through Mr. Cullers’ blood stream through the abdominal cavity.”
Peritonitis, usually caused by bacteria or fungi, is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of the abdominal organs. Left untreated, peritonitis can rapidly spread into the blood and become sepsis, which occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body. This inflammation can trigger a domino effect of changes that can damage multiple organ systems, causing them to fail.
These infections posed the most immediate threat to Cullers’ life.
“Once we got him stabilized, I performed emergency surgery to remove the diseased portion of colon, which contained the cancer,” Dr. Garwood says.
Forty-eight hours after Cullers arrived at Sentara RMH, he underwent an emergent colon resection with colostomy. In a colostomy, the surgeon brings one end of the large intestine out through an opening, called a stoma, made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the abdomen.
“We don’t see a lot of perforated colons from cancers,” Dr. Garwood says. “A colostomy is usually required due to severe and complicated diverticulitis. So because of the tumor, I had to remove more of the colon than usual.”
Sentara RMH’s general surgeons perform about 200 colectomies (removal of a portion of the colon) per year, with about two dozen of them requiring colostomies as well.
“This operation isn’t as routine as it used to be, and it’s usually done only in emergency situations,” Dr. Garwood says. “Even with a perforation caused by diverticulitis, we try to hold off on performing a resection and colostomy if we can.”
Cullers’ surgery took about two hours. When he awoke afterward, his two daughters, along with two nurses, were in his room.
“I didn’t know where I was or what had happened,” he recalls. “I had a big bandage across my stomach and a bag on my side, and I was under contact isolation [a protocol under which physicians and nurses use extra precautions to prevent the spread of any bacteria to other patients]. The nurses answered my questions and tried to make me comfortable.”
Cullers spent the first week after surgery in the Critical Care Unit and then was moved to a regular patient room. He was in contact isolation for 14 days until all his tests came back negative, showing he had no more infection. He was in the hospital for a total of two and a half weeks.
Living With a Colostomy
The bag at his side, Cullers learned, was a colostomy bag. Before he left the hospital, his nurses instructed him on how to take care of it. Dr. Garwood told Cullers that at some point over the next six to 12 months, it might be possible for him to reverse the colostomy.
After five weeks of rehabilitative care to restore his strength, Cullers returned home. He was walking with a cane, but he felt good.
“It was a complete turnaround from a couple of months before that,” Cullers says. “I felt strong. I felt like I could go back to work again.”
Cullers gradually returned to his normal activities: fishing, hunting, gardening and mowing yards. On his 25-acre farm, there was always something to do.
“But the bag was a pain to deal with,” he notes. “And it was expensive. It had to be replaced every few days. And being active, it was cramping my lifestyle.”
Dr. Garwood says most patients are able to tolerate their colostomy fairly well and can resume everyday activities.
“People usually resume their normal lives,” he says. “There are even football players who play with colostomies.”
Every time he visited Dr. Garwood, Cullers asked about having a colostomy reversal surgery. Each time, Dr. Garwood told him they needed to be sure first that all the cancer was gone. Finally, Cullers’ physicians felt certain that all of the cancer had been confined to the surgically removed tumor, and that no further cancer treatments were necessary.
In June, Dr. Garwood decided that Cullers’ colon looked good enough to perform the reverse colostomy, and Cullers’ cardiologist agreed that his heart was healthy enough to undergo the surgery.
However, preparing to do surgery on a patient with multiple health problems typically takes considerable planning. Because Cullers had a blood clot in his heart at the time of his initial illness, he was placed on anticoagulant drugs, also known as blood thinners. He had to have his heart retested to confirm that he no longer had the clot, so he could be taken off his anticoagulant medications for surgery. Taking him off his blood-thinning medication with the clot still in his heart would have increased his risk of stroke.
“When we did the test, his body had dissolved the clot, and it was totally gone,” says Dr. Garwood. “Mr. Cullers’ case is a good example of the excellent care we provide at Sentara RMH to patients who have complicated health issues.”
Some patients, however, aren’t good candidates for the reversal procedure. In patients with metastatic cancer, for example, another colon obstruction could occur later. And in some patients, radiation treatment can create a higher risk for a leakage at the reconnection site. Reversing a colostomy in such cases could lead to more problems down the line.
“Of course, some patients don’t mind the colostomy,” Dr. Garwood says. “They can live with it fairly easily.”
Recent advances in equipment and other technology have made it easier for surgeons to reconnect the colon during colostomy reversal. Following Cullers’ reversal, which went smoothly, his bowel function came back quickly.
“Often after a reversal it can take a while for the system to get reoriented, but after just three days in the hospital, Mr. Cullers was eating and drinking normally,” says Dr. Garwood. “He recovered more quickly than is typical.”
Back to an Active Life
Cullers returned home after his second surgery on July 5, 2016.
“On July 6, I was mowing my lawn,” he laughs. “But I did have to take it easy.”
Since Cullers lives alone and cooks for himself, Sentara RMH nurses educated him on what to eat to help prevent colon problems in the future.
“No soft drinks, and I eat more fruits and vegetables and lots more ‘superfoods’ like beets and tomatoes,” he says. “I’m feeling good.”
Cullers can’t say enough good things about his care at Sentara RMH. He speaks highly of the nurses and physicians who treated him in the hospital, and especially of his surgeon, Dr. Garwood.
His experience has changed his attitude toward doctors. He now admits that if he had been going for regular checkups, the cancer likely would not have become so advanced and required the type of surgical intervention he had to undergo.
“Now if I get sick,” he says, “you can bet I’ll go to the doctor.”