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MARK HOUSTON: Hello again everybody, and welcome to another edition of Doc Talk with Monument Health. My name is Mark Houston. And this episode's going to be a little like the one I did a couple of months ago when I had, uh, the anesthesiologist doctor, Michael Hewitt, and to do a podcast with me. Um, he was in the operating room for a surgery that I had back on February twentieth, which was to remove part of my colon due to diverticulitis, and finally roped the doctor that did it into the studio for this podcast. Uh, I remember, doctor, the first time I kind of asked you about it, you, you, you didn't seem like you wanted to come in here and do this.
DR. STEVEN DONAHUE: Uh, not necessarily. I mean, not necessarily. It's just, you know.
MARK HOUSTON: Yeah, it's fine time. And you're in here.
DR. STEVEN DONAHUE: Yep.
MARK HOUSTON: Doctor Steven Donahue is a colorectal surgeon here in Rapid City, uh, at Monument Health. So I get to sit down and ask not only about the condition that I experienced when surgery actually becomes necessary, and the da Vinci robotic system that was used on it, what it does and what it means for patients facing similar decisions. So first off, doctor, thank you for coming in here and doing this.
DR. STEVEN DONAHUE: I know. Happy to be here.
MARK HOUSTON: You, um, you do a lot of these from what I understand.
DR. STEVEN DONAHUE: So I mean it's, it's, it's busy. Yeah.
MARK HOUSTON: To get you roped into doing some of this... it takes a minute.
DR. STEVEN DONAHUE: Yeah, yeah.
MARK HOUSTON: Um, give me a little bit of your background first, doctor. Where, where did... how did this whole journey for you begin? Did you know this is kind of what you wanted to do?
DR. STEVEN DONAHUE: No, not even in the slightest. Um, which maybe I shouldn't admit, but no, I, I had always been interested in healthcare, uh, I wanted to tinker with the idea of going into physical therapy, occupational therapy, something along those lines. And then I met my lovely wife, and her dad was a physician, and he just said, hey, you should take the MCAT. And so I did, and that's how I got into med school. Um, and then my wife's brothers are all surgeons, and I saw their lifestyle. Thought about it, and now, I mean, I love it. I fell in love with it in med school. So that's, that's where I started.
MARK HOUSTON: That's a big difference from physical, I mean, therapy to, to being a surgeon.
DR. STEVEN DONAHUE: I mean, that's... I mean, that was, this was like first, second year in college. I had no idea. Right? I had no idea what I wanted to do.
MARK HOUSTON: Yeah, yeah. But, do you have any of this in your family? Is there any background in my family?
DR. STEVEN DONAHUE: No, nobody.
MARK HOUSTON: Yeah. You get to be the first doctor.
DR. STEVEN DONAHUE: My mom's a teacher. Yeah. Trust me, it's great being the only doctor in the family.
MARK HOUSTON: Hey, what about this?
DR. STEVEN DONAHUE: Yeah, I'm a mom. I'm a colon and rectal surgeon. I don't know what to tell you. I don't know what that spot means. I'm sorry.
MARK HOUSTON: Um, well, let's, um, let's talk a little bit about, for someone who's never heard the term, um, how would you, um, explain diverticulitis in just, like, simple terms.
DR. STEVEN DONAHUE: Yeah. Diverticulitis and diverticulosis are the same process. The diverticulosis is a simple presence of having these little pockets. I usually call them pockets when I'm talking to patients. Um, pockets are outpouchings, weaknesses in the colon wall. They all kind of mean the same thing. What it is, essentially, is a ballooning of the colon wall that causes a weakness in that area. And then once you have them... people find them on colonoscopies all the time. People's colons are kind of littered with these little pockets and outpouchings. And then, for whatever reason, though, they can get plugged or blocked, swollen, inflamed. And then the pocket itself is kind of blocked off from the rest of the colon. And that's when you start to run into issues, where maybe you get a little perforation right there. A little bacteria kind of seeps out through a micro hole, and then you get diverticulitis, which is inflammation.
MARK HOUSTON: So why, why are we getting these so much? Yeah, it seems like your colon has, you know, a pretty specific job, right? And it seems like it's a pretty easy job, honestly.
DR. STEVEN DONAHUE: The colon's main job is to absorb water. The small intestine absorbs almost all of the nutrients. And so the colon doesn't even do a whole ton of nutrient absorption. It's just to essentially gather the water after the small intestine has done its job. And so, yeah, you're right, it's not the brightest organ in the world. Uh, but, but, but, uh, in terms of why we're getting diverticulitis, a lot of it's, it's theories, um, a lot of it's theories. Some component of genetics, some component of diet, obesity, Midwestern diet, low fiber. Fiber is really healthy for the colon, and we don't get a ton. You know, the recommendation is twenty five, thirty five grams a day of fiber, and if you look in the food packets of what you're eating, you'll get two, three grams of fiber per serving of whatever it is. Um, and so low fiber diet has a lot to play into it, but some of it's genetics, some of it's diet, some of it's obesity. Um, some of it's bad luck.
MARK HOUSTON: Yeah.
DR. STEVEN DONAHUE: And then once you have the diverticulosis, the outpouchings, then again, it's a theory of what causes diverticulitis to happen. You know, there was an old adage of, you eat a nut, a seed, a popcorn kernel, they get stuck in the little diverticulosis, the outpouchings, and then that causes diverticulitis. Maybe that's still happening, but it's kind of been debunked, actually. Um, and so we don't one hundred percent know why it's all happening. There are a lot of theories.
MARK HOUSTON: But I didn't have a strawberry for twenty years after I was diagnosed with it, because that was one of the very first things, back in two thousand.
DR. STEVEN DONAHUE: We still tell people that, because we don't know, we don't know what to say. And it's easy to say, okay, don't eat nuts, don't eat, uh, fruits with, with, uh, like strawberries with the little seeds in there. Because in theory they can, and I don't know if it's true or false. But, okay.
MARK HOUSTON: Um, well, what are... um, you know, you mentioned the Midwestern diet a couple of times. It seems like out here we would have higher fiber diets just because of the vegetables alone. But I suppose it's, you know, a high meat diet, it's not meat and potatoes.
DR. STEVEN DONAHUE: And then, um, there's a lot of, uh, there's different types of fibers, to actually, soluble fiber, insoluble fiber. You have to get a combination of both. Um, certain ones will affect the colon in different ways. Um, anyone that comes to my office that has constipation or other issues, I just recommend they take a fiber supplement, just because nobody gets enough. And I do the same thing to myself, too. Um, you just take a fiber supplement, Metamucil, and then you cover your bases for the entire day. You don't have to worry about it.
MARK HOUSTON: So what are, what are warning signs then that tell someone that this, that this isn't just a stomachache? Yeah, I mean, from my own experience, I can tell people the pain is unbelievable when you have a flare-up, right? But what are warning signs for people, that maybe, like, well, wait a minute, maybe that isn't just a...
DR. STEVEN DONAHUE: And that's how it goes for a lot of people, too. Diverticulitis is a spectrum. And so it can be anywhere from, like you're saying, I have a little twinge of pain on my left side and who knows what it is. It's a gut good egg. Did he eat something bad? Am I constipated? It could be a very mild diverticulitis flare, but then it can range anywhere from that all the way to... you know, I have a free bone perforation, there's stool in the abdomen, you're going in, you're septic and sick, and you need emergency surgery. Colostomy bag. So people usually lie somewhere in between there and a real diverticulitis flare, but a more severe one is not very subtle. It's, it's severe pain. This is, this is not just a routine stomach ache. Fevers, chills, sometimes blood in the stool, or sometimes you can't poop, when the colon gets swollen and inflamed and the wall is thick, then it can block the stool coming through, and you can get really severe constipation right around the time of a flare. Or sometimes it's even the opposite, the colonic spasm, and then you get severe diarrhea. And so, severe pain, diarrhea, um, left-sided pain, usually in the presence of diverticulitis.
MARK HOUSTON: Where else can it happen? Where else could it happen?
DR. STEVEN DONAHUE: Anywhere in the colon. It can happen anywhere in the colon. The sigmoid colon, which is where you had yours...
MARK HOUSTON: Yeah.
DR. STEVEN DONAHUE: ...is the most common location, because it's got the highest pressure. Um, uh, well, that's not necessarily true, the cecum does, but, um, for whatever reason, it's almost always in the sigmoid colon where people get diverticulitis. But you can have it anywhere, anywhere in the entire colon, really.
MARK HOUSTON: Okay. How far... One thing that surprised me, um, after my surgery was done, and I asked you, well, how much did you take out? I was expecting you to use your thumb and pointer finger.
DR. STEVEN DONAHUE: Yes, but you use both palms of your hands.
MARK HOUSTON: Yes. And how much is taken out of there?
DR. STEVEN DONAHUE: I always... that's people always ask about that. Uh, we use about twelve inches or so.
MARK HOUSTON: How much colon do you have?
DR. STEVEN DONAHUE: Uh, you've got a couple of feet at least of colon. So, starting, you know, in most people it loops a little bit here and there. And so you've got a couple of feet, and I usually take out less than a quarter of the colon to do diverticulitis surgery.
MARK HOUSTON: Yeah, it is amazing, because you said it's kind of accordion-like in there, correct?
DR. STEVEN DONAHUE: Yeah, so you can kind of stretch that out a bit, a little bit.
MARK HOUSTON: Okay.
DR. STEVEN DONAHUE: You can stretch. It takes a couple of turns. And then, um, it's always hard when you're making a decision: how far do I go? You know, even if it looks actively inflamed in one area, well, how far do I go on either side? I always go down to the rectum. Um, that's standard, to just go down to the rectum, so that end is easy. But how far proximal do you go? Um, because a lot of people will have diverticulosis through the whole colon, and we don't remove the entire thing. And so you have to make a decision on how far up you go. And so usually I end up going about that twelve inches or so, okay, until it starts to look pretty healthy towards the descending colon.
MARK HOUSTON: Well, by the time a patient gets referred to you, then, um, what are you looking for to determine if surgery is the right path?
DR. STEVEN DONAHUE: Yeah. Not everybody with diverticulitis needs surgery, and it's just a discussion now. It used to be, we used to say, okay, you get one episode, you're fine. You get two episodes, maybe three episodes, yeah, it's time to consider doing surgery. But it's not like that anymore, because everyone has different goals and what they want. Some people are really averse to having surgery, they don't want to undergo the risks. Um, and so it's a discussion to be had. If you get a diverticulitis flare once every five years... this is just in theory... and then you go in, you get antibiotics, and maybe you spend a day or two in the hospital, and you're okay with that, then that's fine. I mean, the chance of people progressing to a full-blown perforation after they've had a mild flare is pretty low. Um, but it can happen.
MARK HOUSTON: Okay. That's the risk.
DR. STEVEN DONAHUE: And so then the other side of things is, well, do you travel a lot? Do you go overseas, can you handle having a diverticulitis flare if you're a truck driver, or things like that? They're all things to consider. But, um, and those are for more mild flares. Someone that comes in who's had a perforation, and an abscess, a drain placement, a fistula, obstruction... those are all pretty hard signs where, yeah, we should probably just do surgery, get it out.
MARK HOUSTON: Well, and that's in my case. I was first diagnosed in two thousand and three. And I probably, uh, for the first maybe five years, there was a flare-up once a year, maybe progressively started to get worse, where I was at least having one or two a year, probably. Right. Uh, got to a point where antibiotics generally took care of it, um, or just rest, just like a liquid diet for a few days kind of took care of it. And then, back in December, um, for the first time in this whole twenty year run of having it, I ended up in the hospital for eleven total days, five at one time and then six in another. Well, that's counting the surgery that I had as well, I guess. Um, and, and the concern for you, I believe, in my case, was because you had mentioned the fistula, where it had actually gone, I believe, from the colon and into the bladder.
DR. STEVEN DONAHUE: Correct. So, I mean, that's, that's obviously... if that's happening, you need to talk about surgery.
MARK HOUSTON: Yeah.
DR. STEVEN DONAHUE: So that's a colovesical fistula, is the name of what you had. And it's not... it's not as common, but it certainly happens, we certainly see it. Um, and because of this repeated cycle of ongoing inflammation, abscess, irritation, the colon sits right on the bladder in the abdomen. And so it will start to irritate the bladder and erode through the wall of the bladder. And then, once you get what's called a fistula, which, like you said, is a connection between the two, um, that usually doesn't go away until you have surgery. And you run into issues with frequent UTIs and bladder pain, bladder spasms, and people can even pass stones, um, stool through their urine, which can be painful, too.
MARK HOUSTON: And the first time my family doctor said that, I knew then: yep, I'm having surgery. Yeah, you're like, 'yeah, let's not get to that point, that sounds terrible.' Um, and, uh... what I want to talk about, uh, mostly for this conversation, to a lot of people, I think... um, everything you just explained is very good to know, when, when you experience pain like that.
DR. STEVEN DONAHUE: Absolutely. Get it checked out, don't let it go too far, certainly, because, you know... and you'll know, trust me, if you have a flare-up, it's unmistakable.
MARK HOUSTON: Yes. Um, but to get it fixed, and to get that surgery... and we've done a couple of podcasts on the da Vinci robotic system that you used for this surgery, which just... I mean, I was half excited to get into the room just to see it, and then to know that this thing was going to happen. Um, so for people who picture robotic surgery and, you know, they imagine stuff... you know, as a kid, I remember thinking, God, someday we're going to have this kind of thing. And we kind of do. It's kind of sci-fi, almost, with this machine in the room. It almost looks like a sci-fi machine. It's got four big, long arms with joints that move.
DR. STEVEN DONAHUE: Um, and, uh, you're not anywhere near it when you're operating, which is bizarre. So this thing just looks like it's moving on its own. Um, but it's opened a lot of windows, and, not necessarily... I mean, we can do all of these surgeries without the robot, it just makes it easier. Um, and there's been, at least in surgeons my age, a movement moving from laparoscopic surgery, which was the old minimally invasive operation, into robotic surgery. Some of the benefits of doing that: the biggest one is the arms on the robot articulate, meaning they have a wrist. And so I can use a wrist to turn around corners, um, get deeper into the pelvis, bend up, look sideways, things like that, which is really hard laparoscopically. Um, and then another benefit is control. Uh, so it always takes two people to operate, an assistant and a surgeon. And in laparoscopy, you're dependent very heavily on the assistant. Um, and, uh, they have to be operating two hands while you're operating two hands, and you have to be essentially one brain operating together, in order to get everything to move in the proper way so that you can see or do what you need to do. Um, and robotically, you can do it all yourself. So you get to control all four arms, including the camera, and you can manipulate them with your two hands. So you get to operate, you know, twice as much, essentially.
MARK HOUSTON: Well, and when I went into the room, I remember looking at the robot and seeing it, asking a few questions before, you know, Hewitt, who's very efficient, gets you out. Um, I looked over and was surprised at how far away you actually sat from the machine. And the patient... there is that... is that... I mean, it's not weird to you now, but do you ever think, God dang, I'm pretty far away, when you say it like that?
DR. STEVEN DONAHUE: It is weird. I mean, we were talking about this earlier... when you walk in the room, the robot's tucked away in the corner behind some drapes, and then we wheel that up to the bed. You're sitting on the operating room table after you're asleep, we get everything all set up, myself and an assistant. Uh, we get the robotic trocars in place, and we dock the thing, and then I scrub out and leave. It's almost like you're essentially going into another room over there. Not really, but you're in the corner, facing a wall, away from the patient, behind the anesthesia machine. Um, and that's where you operate from. Uh, it's quite bizarre.
MARK HOUSTON: Yeah, to think about it.
DR. STEVEN DONAHUE: And, um, you know, it's all Bluetooth, but when you get into the surgeon console and you put your eyes in the machine, there's microphones in both of your ears, you've got two eyeballs, and you're looking through the camera. Um, and it's, uh, it's pretty cool.
MARK HOUSTON: Yeah, well, it is, it's about as sci-fi as you can get right now. Um, you know, until we're at a point where you're doing it from home.
DR. STEVEN DONAHUE: Yeah. Right, just remote in at that point, right?
MARK HOUSTON: Yes, yes. Um, I think one of the biggest advantages to having robotic surgery, at least from my standpoint... again, I can talk about it because I had it... there were five incisions total. The robot has four.
DR. STEVEN DONAHUE: Correct.
MARK HOUSTON: So, for the robot, one is for my assistant to operate through, and then the bigger one is an extraction site, right?
DR. STEVEN DONAHUE: That's it. Yep.
MARK HOUSTON: Um, the most amazing thing about it, frankly, is the healing process afterwards. Um, I was amazed at how quickly all of that healed up, just within weeks. You're like, well, I mean, if you didn't see it, you wouldn't even know that robot was inside of you.
DR. STEVEN DONAHUE: Yeah, it is amazing. And people usually recover quite quickly. And that's one of the big benefits, too, of this... you get out of the hospital a little bit faster, you get on a diet a little bit faster. Um, recovery is a little bit easier, because you don't have this big, huge incision, all the way from your pubis up to your sternum, essentially.
MARK HOUSTON: Is that how big it used to be?
DR. STEVEN DONAHUE: It used to be. I mean, for some surgeries it would be quite that big, because if you're doing surgery on the colon and you have to mobilize the top half of the colon to bring it down to the rectum, then you're doing surgery on both ends of the abdomen.
MARK HOUSTON: Yeah. So it was a big incision before.
DR. STEVEN DONAHUE: Um, and so recovery is a lot easier, a lot easier. That, and scar tissue is a lot less, too. You know, God forbid you ever need surgery again, the scar tissue is going to be significantly less than if you had an open operation. It is. And if you looked right now... if you didn't know what you were looking for, you wouldn't see the robot scar specifically. The extraction scar, obviously, is bigger.
MARK HOUSTON: Sure. That's probably, you know, that will probably always be there. But still, even that seems tiny compared to the way things used to be.
DR. STEVEN DONAHUE: And we usually try to tuck that one a little bit low, uh, a little bit lower, too. But, yeah, yeah, a lot smaller than it used to be.
MARK HOUSTON: Right. Um, if someone in the community right now listening to this podcast, um, you know, is nervous about needing this kind of surgery, what would you want them to know before they even walked in to meet you?
DR. STEVEN DONAHUE: Um, yeah. I mean, people... the questions people are always asking, everyone's always asking the same questions, and they're good questions. Um, you know: what is my bowel function going to be like after I have this surgery? Am I going to be incontinent? Am I going to, you know, have ten stools a day? That's pretty much the biggest one, I think, a lot of people want to know about. And the answer, for this specific operation, is you shouldn't notice a ton of change. You shouldn't notice a ton of change. I tell people, if you have a stool once a day, maybe once every other day, well, you might have two stools a day, or one a day. You know, it might move up slightly in frequency, but it shouldn't be a huge change. And that's what a lot of people worry about, specifically incontinence. And this should not affect incontinence at all. Um, you know, there's a lot of risks to surgery, but, again, it is overall very safe. We do a lot of these. And so most people do quite well.
MARK HOUSTON: Well, and one thing we didn't really talk about, which, um, was my number one main concern going into this. I wasn't worried so much about the surgery, I wasn't worried about the outcome generally, because you, you know, you were pretty confident in how you felt it was going to go. That colostomy... the bag. Everyone hates the bag. Yeah. So what determines whether or not you get that? I mean, I didn't have to have one, right?
DR. STEVEN DONAHUE: Um, and the whole goal of doing elective diverticulitis surgery is to avoid a bag. Mhm. And I tend to scare people when they come to my office and tell them, it's always a risk. If you get colon surgery with me, I'm going to tell you there's a risk of getting a bag, right? It's just, I can't justifiably do surgery without saying, well, there's some chance you get a bag. But the whole goal, and the whole thing we're trying to avoid here, is having to do that, because I know everybody hates it.
MARK HOUSTON: Yeah.
DR. STEVEN DONAHUE: And, um, you know, we want to make people happy, and it requires a second surgery to fix. So, yes, you're right. The determination comes from the extent of inflammation, the extent of diverticulitis, the extent of dissection we have to do. And the simple presence of having a fistula, like you did, doesn't mean you necessarily have to get a bag. Some people might think that if you do diverticulitis surgery and you have a fistula, you're getting a bag, but it's not necessarily that. After you've taken everything down, it all depends on how the two ends of colon look. So you take out the segment, you divide it, and now you're stuck with two divided ends of colon, and you have to look at them and say, um, are they inflamed? Are they healthy? Do you smoke? Some other factors that would, um, predispose you to developing what's called a leak, which is a hole in the anastomosis that we make, um, where you're leaking bacteria and stool out of that new connection. And that's a big problem, right?
MARK HOUSTON: That's a huge problem.
DR. STEVEN DONAHUE: Um, and we want to avoid that at all costs, because that requires multiple surgeries to fix. Probably a colostomy bag, may or may not even be permanent at that point, too. So we want to avoid that. Um, and so that's when we talk about doing temporary ileostomy bags, and that protects and diverts the stool away for about eight weeks. So, um, not everybody needs one, but it is something I always talk to people about. And that's the determination... what's the extent of inflammation, essentially.
MARK HOUSTON: Um, what's something about colorectal health in general that you wish more people understood, or even felt comfortable talking about? Because I know a lot of people still can't help but giggle when they talk about stuff like this, right?
DR. STEVEN DONAHUE: Everybody, everybody that comes into the office is always... they're like, oh, I'm sorry, this is so awkward, I wish we didn't have to talk about this. And I'm like, well, I saw twenty-five people today, and I had the same discussion twenty-five times. Um, you know, you just have to make it normal. Talking about poop, and talking about stool bags, and talking about hemorrhoids and fissures, and all of these things that are very, very, very common, of course. And nobody talks about them, right? So that's how I phrase it, too. When people come into clinic and I can tell they're a little nervous about it, it's like, hey, chances are you've got a friend that had this too, or at least know somebody that had a problem like this and they just didn't talk about it at your dinner party, right? So it is very common. People get very nervous talking about those things, and you just have to make it normal, or make it funny, crack jokes, whatever.
MARK HOUSTON: Well, and I would assume you'd think that if more conversations were had, and it was much, much more common, people might take it more seriously at that point, too, and be like, oh, well, I should go get it checked out, I should see a doctor about this, and not just try to fight through the pain all the time, or hide from it. Or, so many people, like you said, are nervous about, well, if I go into a surgeon, I'm going to get a colostomy bag, right?
DR. STEVEN DONAHUE: Every... you know, people think that, and they come in, and that's like the first thing out of their mouth, before we say anything. They're like, am I going to get a colostomy bag? Um, and even if it does get to a point where we have to do that, it's almost always temporary. Almost every colostomy can be reversed. That's not true for everybody, but almost always.
MARK HOUSTON: Well, and just imagine, like myself, how surprised you are when you wake up and you don't have one.
DR. STEVEN DONAHUE: And it's a great day, especially when I scare you in the pre-op bay, like, you might come and wake up with a bag, and then it's like... it's like the worst gift bag ever. Sometimes I say it on purpose. Then you wake up and you're like, wow, I didn't get it. Ah, that's great.
MARK HOUSTON: Uh, well, doctor, I really appreciate you coming in and talking more about this, because I do know, uh, you know, probably more people than I would think... that, you know, have this condition and don't know where to turn, or don't know what questions to ask. And just speaking from somebody that went through the whole procedure start to finish, and having it for two decades... um, you know, like you said, having more than one flare-up a couple times a year, I think you absolutely have to have that conversation with your doctor, about... maybe it's worth at least having a conversation.
DR. STEVEN DONAHUE: Yeah. You don't have to decide you want surgery, but at that point you should have the conversation. I'll tell you the risks of surgery, I'll tell you the risks of not having surgery. And then it's just... it's your decision, right?
MARK HOUSTON: And not everybody goes for it, like you said, but at least then, you know, at least then you know, and it can be in the back of your head: if I get another flare, well, maybe I'll go back and talk to that guy who told me I might have a bag. And, honestly, it's not... it's not as bad as I thought it was going to be. I think, because of the advances in surgery, the robots, the way that you guys at Monument handle it from start to finish... I mean, it couldn't have been better, from getting checked in with that first nurse, um, you know, to leaving on that third day. Mhm. It just, it was handled so well. So to your team and everybody else, you know, I mean, I, I can't be happier, honestly.
DR. STEVEN DONAHUE: Yeah, absolutely, man.
MARK HOUSTON: Uh, doctor Steven Donahue, colorectal surgeon at Monument Health here in Rapid City. Thanks for taking the time. I know you said you probably have a procedure yet this afternoon.
DR. STEVEN DONAHUE: That's true.
MARK HOUSTON: You're going to be doing okay, back at it?
DR. STEVEN DONAHUE: Yeah.
MARK HOUSTON: All right. Thank you, doctor, I appreciate it.