flwyd: (spam lite)
It's my body's half birthday and my new swallowing mechanism is five weeks old. Sounds like a good time to check in. If you're just tuning in, I had surgery in February to address achalasia.

As previously reported, I took the week of surgery off from work. This was a really good move: even though I was feeling a lot better than I'd expected (and my work basically involves reading words on a computer screen, typing, and occasionally talking to people), the dedication to resting and relaxing really helped my mind reset, my energy rebound, and focus on readjusting to food.

I spent the second week working from home, which was also a smart move. I was still on a liquids-and-purées diet which was made much easier by having a refrigerator and a fancy blender fifteen feet from my desk. My dad brought over a big ring of red Jello (a food with strong Stone family associations), Lucky's Market recently started carrying nice cashew yogurts, and I had several bunches of bananas with staged ripeness. I noticed that I pretty quickly transitioned back into "Wait, there's one more thing I should do" mode while working, but since I'd handed off a lot of responsibilities, the number of just-one-more-things was fairly low.

A week and a half after surgery I drove back down to the hospital for another x-ray barium swallow to see how thing were going down. After about two swallows of barium liquid the lab tech got a worried look on his face and called a doctor in to look at the images and compare them to what they saw the previous month. After conferring and calling my surgeon's office, they announced that the study was done and I could leave. Not particularly reassuring…

I had a "review the barium study" appointment scheduled with the surgeon two hours later, so I hit up the army surplus store between the hospital and his office. While trying on a pair of nice "tactical trousers" the hospital called and asked me to return (also not very reassuring…). My surgeon showed me the imagery sequence and pointed to a pattern of liquid spreading that looked like it could be a leak. He was suspicious of this interpretation, though, because I didn't show any signs (like total misery) of having been eating with a perforated esophagus, stomach, or junction for ten days. He had me lie down for a regular x-ray and then conferred with the folks from the barium swallow. After a few minutes he came over and said "What I thought was a leak and what they thought as a leak were two different parts of the image." The additional x-ray and mutual second opinions ruled out leaks in both cases. Thank goodness for questioning data and interpretation.

The recommended diet progression is soft food for the third and fourth weeks. I returned to work since I knew I could depend on tuna salad, egg salad, and hummus in the daily lunch salad/sandwich bar and soggy Cheerios (working up to granola) for breakfast. These were my work-food staples for the second half of last year, so I was confident I'd be able to handle them. I was also very excited to reintroduce things like moist grains (rice, barley, oats, and friends), noodles, berries, and tofu. In week four I made three peanut butter, tofu, and chocolate pies for our office's π Day celebration. The puréed legume goo was a little challenging for my swallowing skills, but not problematic. I was also able to eat several folks' apple pie filling and even some flaky crust. I was able to survive some corned beef, potatoes, mustard, and lamb stew on St. Patrick's Day, though I had a regurgitation episode and concluded that was a little too ambitious.

By the recommended diet progression, I should be more or less back to a normal diet. I'm still eating slower than a normal person, but I can now finish most or all of a large lunch in an hour, which is 80% faster than I could handle a medium plate four months ago. I can get through about 75% of a meal at a restaurant before taking home a box. Spices, dry fish, and little bits that slip through without chewing are still challenging and have led to a few regurgitation episodes, but I'm able to respond to most issues by just pausing a meal and walking around. I've been fairly shy about meat that hasn't been soaked in soup, but I was able to handle ground beef today. I think I'll wait at least another week for meat that I have to cut, but I'll be trying sausage in a day or two.

I've had several intense reflux bouts, usually about half way through the night, though yesterday featured an extended before-bed adventure with mild heartburn. Combinations of Altoids, crystalized ginger, and water only sometimes help settle symptoms. When planning surgery I was aware that a significant fraction of folks experience ongoing heartburn and acid reflux. Having spent 2015 dealing with painful reflux and 2016 dealing with regurgitation and weight loss, I'd decided that I'd gladly trade the latter for the former. I need to get better at building up sleep reserves, though, 'cause I can lose an hour to three of sleep from heartburn without advanced warning.

This month I switched projects at work (still under the umbrella of Drive). We're in the "Figure out what the heck our users really need" phase which means our engineering pace is fairly relaxed and we spend a lot of time reading and theorizing, which has been helpful in continuing my "avoid stress" plan. Unfortunately, I've easily fallen back into the habit of going to bed at 1am, so I'm not making many deposits in the sleep bank, despite not needing to take a lot of withdrawals.

I've still got a "eat as many calories as you can" mindset, but I thankfully don't have to micro-optimize my decisions around it. I'm finally back to having alternating phases of hunger and meals rather than a continuous stream of slow eating and reduced metabolism. I've got way more energy than I did during the second half of last year and I don't feel like I'm in survival mode. I was able to quickly get my weight back to the low 120s but haven't been able to make progress beyond that. I guess my normal metabolism—which has basically been at late-teenager levels for twenty years—has returned. I've abandoned my "eat a pint of ice cream for dessert" weight gain plan, since it seemed to be more effective at triggering heartburn than fat storage. Maybe I should try increasing my beer intake :-)
flwyd: (Trevor over shoulder double face)
Surgery was a success, and recovery has been smoother than I had imagined.

On Monday, I had a laparoscopic Heller myotomy and fundoplication. It was performed at Swedish Medical Center in Englewood by Dr. Reginald Bell, Nurse Practitioner Kate Freeman, and an anesthetist whose name I very quickly forgot.

My almost eery sense of calm about the surgery continued on the day of the procedure. I think scheduling it for noon rather than 10am helped a lot. I was really relaxed and upbeat in pre-op and got to hang out with my wife and our friend Michelle–who happens to be a hospital chaplain–for at least an hour. We also had a great conversation with Deb, the nursing liaison. Michelle said this position was created for Deb, and I think it's a model which should be adopted widely: she acts as the point of contact for family members, providing patient status and helping the family navigate the hospital and recovery process. She overheard my wife calling my dad to ask him to pick up my prescription in Boulder before the pharmacy closed but after we got home (since he'd need my ID); Deb made a couple calls and got the prescription sent to the Walgreens across the street from the hospital so we didn't have to race the clock.

I would love to provide a fascinating narrative about the experience of having my torso inflated like a balloon and tools cutting my lower esophageal sphincter, relocating my stomach (I had a 3cm hiatal hernia), and wrapping it around my esophagus. (Un)fortunately, very quickly after I was wheeled into the super-bright operating room and I shifted onto the operating table, the anesthesiology drugs kicked in and my next memory is grogginess in post-op.

My "wake up, the anesthesia is wearing off" progress was counterbalanced by hydromorphone for pain relief, so I kept closing my eyes and trying to sleep in recovery. But the act of falling asleep would cause my breathing to get shallower and the pulseox would trigger a noisy desat alarm, pulling me out of sleep. This process went on for an hour or two–taking deep breaths was hard because I had new stitches in my diaphragm–until the drugs wore off enough that I was fully conscious and just in dull pain. I spent another hour or so working up to walking around the floor and drinking water, though a few sips of a protein shake proved too adventurous.

Concerned about the breathing danger posed by the opiates, I only took acetaminophen (Tylenol) for pain. I'd been expecting the pain to be both sharper and stronger; instead, it was more of a big ache. I also hadn't expected my shoulders to hurt significantly more than my abdomen (where the incisions were) or chest (where the esophageal operation took place). The shoulder pain was apparently partly from laparoscopic gas but mostly because of the diaphragm stitches. I had not previously realized the connection between shoulders and diaphragm, but I think it may explain some of my recurrent issues. I'll need to notice their relation in the future.

I had the presence of mind to pee right before the procedure. Through post-op and several hours at home I wasn't able to urinate, despite having gained 7 pounds of liquid that day. After my third bout of trying different positions on the toilet produced no results, I decided to try taking a shower, since I often reflexively open my bladder when immersed in water, even if I just peed. To my surprise, I didn't even have to turn on the water: stepping on the wet floor of the shower was enough to remind my nervous system how to let go.

The first night of sleep was a challenge. I find it difficult to fall asleep on my back, so I spend most sleep time on my side, which is a big challenge with painful shoulders. Five seconds after lying down, I could tell that my bed was not going to be conducive to sleep. I set up some thick pillows on the arm of a couch so my head could be significantly elevated and laid on my back with a pulseox on my finger. My wife curled up on the other couch and asked my oxygen levels when she'd hear me rustling around. She's so sweet.

Other than being tired, having sore shoulders, and a very raspy voice, I felt really good on Tuesday. I had wisely planned to take the rest of the week off work and set no goals for the week beyond resting, hydrating, and reading books. I spent the day sitting on the couch, reading about public discourse and drinking water and vegan protein shakes. The recommended diet progression is two weeks of liquids, two weeks of soft foods, and then careful reintroduction of more challenging items to swallow. This week I've progressed from coconut water and nutritional supplements through apple sauce, gelatin, fruit smoothies, yogurt, creamy soup (think split pea), and ice cream. I think I need to cut back on sugar content, not because it'll make me fat (that's what I'm hoping for), but because my mouth feels pretty overwhelmed. After ⅔ of a pint of vanilla coconut ice cream last night and a probiotic, my stomach was feeling pretty queasy and I woke up with some really intense heartburn and liquid stool at 5:30, so I think I'll back off on the pint-a-day-for-weight-gain plan I concocted last fall.

After leaving the hospital, the pain was never enough that I wanted to take an opiate. I took Tylenol for less than three days, and a COX-2 inhibitor took care of aches for the rest of the week. My body hurts less a week after surgery than it has many times after a week sitting at a desk. With luck, this spring will feature fewer pharmaceuticals than any season since the early autumn of 2014.

My accumulated vacation time is usually focused on travel and adventure, so since I started working professionally I haven't really spent a week just relaxing at home, except when I'm sick enough that my brain doesn't work well. Spending several days in a row casually eating, reading, thinking, and listening to music brings back a sense of what I really enjoyed in college. I should do this six-day-weekend thing more often :-) I also had a really relaxing craniosacral massage on Friday which put my perisympathetic nervous system in a state conducive to some really good sex, so hopefully my libido will recover in tandem with my GI system.

While my body feels really good (the major shoulder pain only lasted about three days and my abdomen is only mildly tender), I'm planning to work from home for the next week so I can have a high-powered blender and a fridge full of low-viscosity foods handy. (A career as a software engineer and an employer who believes in flexible working conditions have been crucial to my ability to handle this disease.) My intolerance to dairy products would've made this adventure difficult two decades ago, but I've been able to find cashew yogurt, garbanzo pesto, and soy sour cream, and coconut/tapioca cream cheese cream, adding to hummus and guacamole in my "condiments I can eat with a spoon" repertoire. Between soy, almond, hemp, macadamia, coconut, and oat, I've also got a tasty variety of liquid milk alternatives.

I occasionally walk past a bag of crunchy snacks and instinctively start to grab for a cracker or something. We loaded up on frozen fish yesterday and I'm excited about my office diet plan next week of soggy Cheerios, tuna fish, egg salad, and canned peaches. I'm not craving solid food so much as I am excited about it, as though I'll be embarking in a week on a long-planned trip to a regular vacation spot: at once familiar and novel.

Thanks to everyone who sent me well wishes and offered to help. Not bringing me food and inserting themselves into my healing process turned out to be the best assistance folks provided. My mother-in-law's delivery of soup turned out to be somewhat stressful (mostly for my wife) and not particularly helpful (since I'd already collected weeks worth of liquids).

Weighing In

Monday, February 20th, 2017 08:28 am
flwyd: (spam lite)
Close to two months ago, my weight was hovering just about 110 pounds.
With a calcium channel blocker, I was able to eat a normal day's worth of food and not regurgitate most of it, so I managed to gain about 10 pounds in a month.
Making further progress on my annual goal of gaining 30 has been challenging, and I've hovered around 120 for the past month.
I weighed in at 120.5 on Saturday morning.
After a weekend of clear liquid, I'm heading into surgery at 115.
I'm quite glad I was able to invest in that fat buffer.
Here's to hoping I'll be able to swallow a lot of soft calories in the next two weeks.

Liquid Clarity

Sunday, February 19th, 2017 10:28 pm
flwyd: (spencer hot springs feet)
I've been surprisingly calm about my achalasia surgery tomorrow.
After scheduling it, I haven't had any second thoughts, bouts of dread, or even niggling worries.
Most of our office is playing musical chairs at the end of this coming week, when I'm out. So my last act of heavy object lifting for a while was packing my desk on Friday. This should help me unplug from work while I'm at home recovering: there is no longer an ethernet cable connected to my computer, so I couldn't SSH in and hack on something if I wanted to. (Email, of course, is a much more sinister temptation.)

I spent most of this week fighting a cold, which helped put me in "Hang around the house not expending much energy" mode but didn't help in the "fatten up before surgery" department. The cold reduced my appetite and severely depressed my appetite for sugar. Not wanting sugar sounds like it would be a good thing, but I had to spend this weekend on a clear liquid diet, so I'd been planning to get most of my calories from sweets.

My mom got me a jar of unflavored gelatin for Christmas (before she knew I was having surgery). Gatorade powder, gelatin, and water turns out to be a pretty tasty way to get some calories, protein, and electrolytes. And if you halve the recommended gelatin to water ratio it's pretty easy to drink. I should try this combo at Burning Man.

I had my last meal, of sorts, at Sushi Zanmai on Friday night. I wasn't especially hungry (because of the cold), but ate a bunch because it was so tasty. Rice and fish are some of the first items in the solid portion of the recommended recovery diet progression, so maybe I'll be able to return before too long. I had a hamburger at lunch and probably won't be able to do so again until the end of March. Maybe it'll be my half-birthday treat.

Part of my plan for recovery time was to read The Conscience of a Conservative so I'll be better prepared to have conversations with Republican lawmakers and potential issue allies on the conservative side of the spectrum. My plan for Saturday was to visit used bookstores until I found a copy. After five bookstores and $120 I didn't have any Barry Goldwater, but I did end up with a copy of A People's History of the United States. I also overheard a Bookworm employee tell a customer that they were sold out of 1984. I didn't end up without materials to strengthen my transpartisan dialog skills, though: Don't Think of an Elephant!, I'm Right and You're an Idiot, and The Righteous Mind are now in my possession. I still intend to read TCoaC, but now my plan is to borrow a copy from the public library, which seems like an especially apt approach to that book.
flwyd: (rush counterparts album cover)
The last time you heard from my esophagus, dear readers, it was freshly diagnosed with achalasia, a condition wherein the lower esophageal sphincter doesn't relax to let food into the stomach and the esophagus doesn't effectively squeeze to push food down. The result was that food would often build up at the bottom of the esophagus until it reached a critical volume (either from intake or buildup of mucus) and my regurgitation reflex kicked in, ejecting the contents. While the regurgitation was unpleasant, the biggest health problem was weight loss and inability to recover: I'd spend over half the day slowly eating, unable to gain any weight from one week to the next.

I was prescribed a calcium channel blocker, which relaxes smooth muscles for a few hours. I've been taking it before meals for the past six weeks and holy cow is it wonderful. Like night and day is the contrast between my pre-diagnosis experience and my eating ability on the medication. I take a pill, wait 30 to 45 minutes, and have a meal. A full meal. That only takes an hour or two. Not six hours spent eating a modest plate of hummus, tuna, ham, and carrots. And on the drug I can eat things of pretty much any texture: I ate ground beef on a hamburger bun with lettuce and tomato recently, with only mild discomfort and occasional pauses. Three months ago, any of those foods individually would have been a risky venture.

I get a wry grin when I tell folks that my new year's resolution is to gain thirty pounds. I was able to put ten pounds back pretty quickly. I even gained three pounds in one day early on, which was a very worrisome trajectory, but it turned out it was just due to water retention: calcium channel blockers dilate your blood vessels and cells too, so my feet and ankles got kinda puffy. I've kind of stalled out around 120 lbs for the last few weeks, hitting as high as 123 and as low as 119. I feel way better though, since I'm able to get enough water every day.

Taking a pill before each meal isn't a perfect solution. I need to time it for about 45 minutes in advance, which can make a restaurant visit tricky (Will there be a waiting list? How long will the dish take to cook?). It can also wear off before I expect, leading to a couple hours of discomfort and regurgitation at the end of a meal. And I sometimes get caught in a situation where a light snack would be ideal, but the options are pretty constrained. This isn't the first time I've had Mi-Del ginger snaps play an important role in healing.


January was the month of doctor's visits: eight (four in Denver), plus twice-weekly physical therapy. (Compare to last January when I averaged a doctor's visit every other day.) My rheumatologist, gastroenterologist, and two foregut surgeons thought the achalasia and psoriatic arthritis were unrelated; Dr. Lutt guessed that the study correlating achalasia to uveitis was the other type of uveitis. Psoriatic arthritis leads to inflammation in the connective tissue and intestines, neither of which are related to the sphincter or esophagus, so scratch that theory. I've also been curious if Chagas disease might be causing my achalasia–I was in Central America 7 years ago, which is close to the typical incubation time. Both surgeons said a Chagas diagnosis wouldn't change anything from a surgical perspective, but it comes with some worrisome cardiovascular issues, so I'll see what the CDC says after they closely inspect my blood for parasite antibodies.

Achalasia can be treated with several procedures, all of which address the constricted esophageal sphincter and not the squeezing abilities of the esophagus itself. The conceptually simplest is a balloon dilation: feed an inflatable tool down the throat and carefully expand it inside the sphincter. This tears the sphincter muscle fibers a bit, so they don't constrict as much. This isn't permanent–the muscle will eventually heal–but it could last ten or fifteen years (or potentially just a year and a half). Another temporary option is Botox, though its duration is usually measured in months and it leaves scar tissue, so it's only recommended for the old and frail.

There are two surgical options, both myotomies which cut the sphincter so that it opens easier. The Heller myotomy is has been performed for over a century, is well studied, and has reliable results. It's performed laparoscopically, with instruments inserted through small incisions in the abdomen and operating on the esophagus from the outside, underneath the skin. This is generally complemented by a Dor fundoplication, which wraps the stomach around the esophagus. When the stomach contracts, it will close the sphincter, helping prevent acid reflux and heartburn. The POEM procedure is fairly new: developed in Japan in the late naughties and brought to the U.S. in 2010. POEM works from the inside, tunneling between the mucosal and muscle layers in the esophagus, and doesn't include a fundoplication. POEM has the advantage of a quicker recovery time: one week on soft food and back to work in less than that, whereas Heller is followed by two weeks of a liquid diet followed by two more weeks of soft food; it also comes with a week off work and a month of not lifting heavy objects.

The fewer cuts, quicker recovery, and earlier return to a normal diet make the POEM a very attractive option. In Denver, Dr. Emily Speer has experience performing the procedure, but won't have the equipment until the latter half of the year, and she'll then need to assemble and train a team of POETs to support the surgery. Dr. Reginald Bell is an old and experienced surgeon who's probably performed more myotomies than anyone in Colorado. He said he performed the POEM a few times but found that his hands felt more comfortable with Heller; since his patients didn't have significantly better outcomes with the POEM, he decided to stick with what he does well. When there are sharp instruments next to one's throat, it's important they be wielded by someone who can use them properly.

I've therefore got four reasonable choices. Do the tried-and-true Heller procedure soon with the very experienced surgeon. Wait a year and do the POEM with the freshly-trained POEM surgeon. Travel to Portland and do the POEM with the U.S. experts, then recover at a friend's house for a few days. Get a balloon dilation and hope it lasts several years, then get a myotomy when the sphincter starts overconstricting again. I was initially inclined towards the balloon-and-wait strategy since I was worried that my weight loss and weakness would make surgery recovery challenging. The tearing from dilation makes subsequent surgeries more challenging (POEM moreso than Heller) and my weight gain in January has made me think I'll be better able to recover from a surgery this year than in my late forties. Waiting a year would be attractive, but there's a big risk: calcium channel blockers tend to stop working after "a few" months, so I might fall back to the realm of eating-challenged for months before the procedure. The risk of being forced into a soft diet for several months in advance of a POEM doesn't seem like a good tradeoff for avoiding a month of liquids and soft foods after Heller. Finally, I called The Oregon Clinic, where the national POEM experts are and where I know enough Rangers that I could probably find a spare bedroom and good friends to aid recovery. They would want to schedule some tests in late April and then schedule a surgery after that, which would mean early summer at the soonest. Between the risk of the drugs becoming ineffective this spring and the challenges of a recovery in an unfamiliar environment, this didn't seem like a great plan.

Dr. Bell, after confirming that I'm an engineer, pointed at his frontal lobe and said "I think you know that people don't usually make this kind of decision up here," and then circled the base of his skull, saying "they make it somewhere back here." So after a month of reading, interviewing, mulling, and listening to my nurse practitioner wife's insights about healing and surgical recovery I decided that a Heller when I know I'm feeling good is better than a long wait, and a risk of backsliding, for a quick recovery down the road.

The next step toward long-term health is on February 20th. I'm a little nervous, but mostly I'm excited. Fingers crossed, sphincters open.
flwyd: (intense aztec drummer DNC 2008)
Despite a long-time hope that my jaw would remain whole, I accepted prudent dental advice and had all four wisdom teeth extracted last Friday. They were all pointing in unhelpful directions, endangering the future of my more useful chompers.

In preparation for this adventure, last weekend I spent $170 at Pacific Ocean Market, mostly on foods that sounded enticingly soft. Six flavors of refrigerated udon and ramen, frozen shrimp balls, miso, dried black fungus, and seaweed for soups, avocados, papaya, plantains, burro bananas, Thai bananas, and red bananas, and frozen jackfruit for smoothies. Small cups of coconut mango jelly for quick snacks and a pile of coconut yogurt and frozen berries from the health food store for times when umami might seem overwhelming.

My most important preparation for healing was planning to take it easy. I tend to deal with injury and illness by doubling down on will and focus. When I'm fighting a cold I often end up staying late at work, my brain determined to get through my inbox or finish all the design and code reviews on my plate. The voice saying "You'll feel better if you go home early" usually loses to the voice that says "If you focus on a single task, you can get it done." Plus, when I feel sick it's a lot easier to stay in a chair and stare at a screen than to get up and leave the building.

I'd been fighting some sort of minor body attack for a couple weeks, somehow managing to survive New York City, a week of cold and snow, and an annual exposure to milk products at Pie Nite with little more than an occasionally queasy stomach and a morning sore throat. I could tell that fighting a cold wouldn't help my face heal, so I focused my Thursday late stay at work on making sure I'd be set up to work from home for several days between painkiller-induced naps and soft meals.

Most importantly, I made sure I didn't have any goals to accomplish anything this weekend. It was dedicated to lying in a hammock, eating soup, and reading National Geographic magazines (with a focus on my current geographic and historic interest in the Black Sea and Caucasus regions), enjoying the intellectual fruits of my summer physical labor schlepping glossy printed material from house to house.

The first few hours after the surgery were pretty surreal. I was prepared for the grogginess of post-general anesthesia but hadn't considered the challenges of a nerve-deprived bottom lip. I could manage tiny spoonfuls of coconut mango jelly and managed to get most of a coconut yogurt in my mouth, though an embarrassing amount ended up on my beard. Hot food was off limits for day one; I was glad that my shopping foresight remembered a tub of fresh-ground peanut butter, a spoonable protein that can reach the roof of the mouth even with minimally cooperative lips and tongue.

Friday was, I believe, my first experience with narcotics. (I think my only prior adventure with prescription painkillers was IV morphine when I broke my arm in middle school.) I really don't see the attraction: reduced coordination followed by a sudden nap onset. It's like the downside of being drunk without the fun of a tasty beverage and boisterous carousing to kick it off. Fortunately, when I woke up on Saturday I was mostly pain-free with a dull sense of soreness in my jaws that I was happy to let relax while I read RSS feeds in bed.

Kelly observed that she doesn't really have to take care of my family so much as remind us to follow doctors' orders. In this case it was "Oh yeah, even if I don't need medication for pain, ibuprofen will reduce inflammation and help healing." I also took this weekend to absorb her energy of home relaxation and media consumption, letting the things sit still and the future details fuzzy.
September 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 2017

Most Popular Tags

Expand Cut Tags

No cut tags

Subscribe

RSS Atom
Page generated Sunday, September 24th, 2017 07:25 pm
Powered by Dreamwidth Studios