Surgery

A big step

As scheduled, tomorrow Noah will head back to McMaster for the operation meant to remove as much as possible of the large mass which has been growing on his spinal cord. This is the growth that had been causing all of his pain and discomfort late last fall and early last winter and it was this pain and discomfort that led us to take Noah to the hospital where he eventually would be diagnosed with neuroblastoma.

That time of diagnosis, though only three and a half months old, seems like a memory from a different life time and being on the eve of this operation it feels as if we are getting ready to take another big step on this journey. This is because, if all goes well and is successful during surgery, more of Noah's cancer will be removed in a short amount of time than at any other stage of his treatment. They will be going at it with the big guns. This is direct action.

And, approaching this direct action we feel both excited and nervous. It's going to be a big day.

Noah, Kim and I met with Noah's surgeon on Monday and she was able to give us a pretty good idea of what to expect. There has also been a consultation with the anesthesiologist to hear about plans for pain management and sedation. Noah received a blood transfusion on Monday to make sure his hemoglobin counts are high enough for tomorrow and he had a Covid swab done on Wednesday just to make sure there isn't that complication as well. He is ready to go.

And here is a brief rundown of my basic and non-medical understanding of what is going to be happening.

On an empty tummy, Noah is going to be checking it to the surgical ward early tomorrow morning. During pre-op, the team will work to get Noah ready by sedating, intubating and setting up an epidural.

One likely preparation that will take some extra care is the intentional collapsing of Noah's lung. Back when Noah was newly diagnosed, there were issues with Noah's oxygen absorption because of the pressure being placed on his lung by the mass. Back then, the mass was getting in the way of the lung. Now, the lung is getting in the surgeon's way of the mass and so to make a bit of extra room they will collapse the lung. This will help prevent damage to the lung and provide better access to the tumor.

The actual surgery will begin thoracoscopically. Through three different sites between Noah's ribs, scopes will be used to get to the tumor. This will be done through the side of Noah's chest. What happens next depends a bit on the tumor itself.

Sometimes, cancerous growths respond to chemotherapy in a way that weakens their adhesiveness. The tissue peels away from itself easily and the growths come apart readily. If this is the case, once the thoracoscopic work is mostly over, a larger incision will be made between Noah's ribs and the tumor will be pulled out.

Another way, though, that cancerous growths can respond to chemotherapy is to become more adhesive and more sticky. This makes a thoracospicic removal of the tumor much more difficult and increases the risk of bleeding greatly so if, after the thoracoscopy, this is determined to be the case, a more open surgery will take place. An incision will be made, the ribs will be spread and the surgeon will then work to remove as much of the tumor as possible through that incision.

The goal, in either case, is to complete the surgery as safely as possible.

The hope, of course, is to remove as much of the tumor as possible.

The risks are there but they are not all what we expected. As with any surgery, there is the risk of bleeding and the risk of infection. There is particular risk of bleeding around the bronchioles which is why they will likely collapse Noah's lung. There are also the regular risks associated with anesthesia and intubation.

What is not of particular risk, somewhat surprisingly, is spinal damage. This was our big concern, knowing the location of the tumor, but the operation will not be so invasive that it will put Noah's spine in any sort of immediate peril. There is still a slight risk of swelling but, once again, the risk is minimal.

We are especially grateful for the surgeon and team assembled. They are experienced, they are confident, and they are accomplished. And we could not ask for Noah to be in better hands.

Hopes

Of course, our biggest prayers and hopes for this operation are that Noah is able to come through safely and that he recovers quickly. It is nerve racking to think about everything the little guy will be undergoing tomorrow and I don't think Kim or I have slept soundly for the last few nights - nor will we until this thing is done and over with.

A bigger hope is for a smooth and productive tumor extrication. The more of this awful thing they can get out the better and we hope that it falls apart so that it can be scooped out easily and quickly.

And, finally, our last hope is that this is just one more step in a long journey towards healing for Noah. One piece of good news to come out of the pre-op discussions is that, based on the CT scan and MRI, the size of the mass in Noah's chest has been shrinking. It is now "only" the size of a tennis ball. As remarkable as it seems to me that the little guy was able to hide so much cancer in his thin frame, it is even more remarkable to hear and learn that his cancer has been responding well to the chemotherapy treatments. There is a lot of waiting, hoping and praying and not a lot of concrete feedback available on how well things are going during chemo and so this news is definitely as encouraging as we can hope for at this time in his treatment.

Gifts of grace

And though this news is certainly one gift of grace, there have been so many, many more over the nearly three weeks Noah has been home since his last stay at the hospital.

In that time Noah has become stronger and healthier and more energetic than at any time since his treatment and diagnosis and pre-diagnosis pain began.

The usual activities (strider bike riding, dancing, hockey playing, ball kicking, sister tackling) have resumed in earnest and still, beyond this, he continues to grow and learn. Among other things Noah can now:

• Bounce on the trampoline with his sisters, not just by taking turns but by playing real games like "Ring around the Rosie". He can get back on his feet after a bum drop and he celebrates mid-air hand clapping by shouting, "Yes!".

• Speak clearly enough to both tell you off and to tell you that he loves you.

• Understand that, though not as good as mommy, daddy is still good enough to put him to bed every once and a while and that when mommy and daddy leave him to fall asleep, they are still there to take care of him when he needs them.

• Run, hide or play a wicked joke.

• Build more and more elaborate and complicated and easily destroyed setups that take much more time to put together than the time that will be spent playing with them.

This blissful normality and progress of life culminated today when, because of dirty and non-adhesive dressings and imminent replacement, we pulled Noah's nasogastric tube out and were able to, for the first time in weeks, see his full and beautiful little face.

It's crescendo was when we were able to give him a very shallow but very fun filled bubble bath. Carefully protecting his Hickman catheter, Noah squealed and giggled a dream that we hope will be the reality for a not too distant future.

And so as Noah grows and learns and shares and loves, the beauty of the moments we live in our everyday lives begin to resonate with the importance that they are always sounding but which we are rarely attuned to hearing.

These moments are also gifts of grace that aren't heard without knowing the other noise.

And knowing that our lives and that Noah's life are in God's hands, we pray our hopes for tomorrow and our thanks for today and trust that, no matter what, that God's hands are good hands.