Cancer In The Colon

Madam T was a 78 year old Chinese lady who was referred to me with blood in her stools. She also had diabetes, high blood pressure and had previously suffered a stroke.

When I met her, I advised her to undergo a colonoscopy.  During this procedure I found she had small polyps in her rectum and left colon which I removed with the colonoscope.

However, this was not the last of her problems.

Cancer In The Colon

The colonoscopy also showed a cancer of the left colon as well as a huge polyp in the right colon which looked very suspicious. The right colon polyp was too large to remove safely with the colonoscope and could only be removed surgically.

colon cancer and polyp removal
Madam T’s Colon Cancer and Polyp

I decided to do a CT scan of the chest, abdomen and pelvis just to be sure the cancer had not spread elsewhere.

As polyps can become cancerous over time, I could not leave the polyp alone especially as she had already developed a cancer in the left colon.

To remove the cancer in the left colon as well as the polyp on the opposite side, undergoing open surgery would have meant a long incision from the upper to lower abdomen.

I recommended laparoscopic surgery as this would mean a much smaller scar, less pain and faster healing. Nevertheless, the operation still had some risks due to her age, diabetes, high blood pressure and previous stroke.

She was also on blood thinning medication (antiplatelet drugs) which would increase the risk of bleeding during surgery.

But the biggest obstacle was yet to come.

She Refused Surgery

Madam T was completely against surgery. She was understandably worried and frightened.

She firmly refused surgery although I told her that this could be an early cancer. Her best hope was to remove the cancer through surgery. Untreated, it would most certainly progress, possibly to obstruction or spread elsewhere beyond the reach of any medical help.

Sensing her fear, I decided to keep my silence as I completed her tests including a thorough cardiac assessment.

Finally, I drew her family aside and explained the situation clearly to them. Yes, there were risks including leaks, bleeding and another stroke.

No, I could not promise to deliver an operation without complications but I did promise I would leave no stone unturned and would try my very best to make it as safe as humanly possible. It helped that the daughter had seen me as a patient on an earlier occasion and I had already won her trust.

Madam T finally agreed to proceed after much cajoling from her family, signing the consent form dejectedly.

The laparoscopic surgery was a success. We managed to remove both the cancer and polyp using just a 6 cm long incision. During the operation, we noticed there was no visible spread of the cancer which was a relief!

Soon after, Madam T had a good recovery post-operation without any complications. She was relieved that her surgery went well and was glad she was persuaded to undergo it, despite her earlier misgivings.

She is presently on chemotherapy and there are presently no signs of recurrent cancer.

Pregnant Mother With Perforated Appendix

When Madam A, a 24 year old lady from Indonesia, came to see me, she suffered from pain in the lower abdomen.

She had been having fever, pain and diarrhoea for the past 2 weeks. She was also 10 weeks pregnant.

I decided to quickly proceed with an ultrasound scan of her abdomen to find out the cause. The scan showed her 10 week old pregnancy with a large 14 cm abscess in the pelvis due to a perforated appendix.

Clearly, surgery was necessary.

But here’s the thing –  if she underwent an open surgery, she would have required laparotomy (long midline incision) which would have left her with a large lower abdominal wound.

This would then be a potentially weak area in her abdominal wall. As her pregnancy advanced, there would be a risk of developing a hernia or rupture of the laparotomy wound. Furthermore, a large abdominal wound would also make it more and more uncomfortable later in pregnancy.

She was quite worried. As all expecting mothers go, she was clearly worried about the risk of surgery to her unborn child.
I recommended that we try a laparoscopic approach first and if that did not work out as well as it should, we might have to go with an open procedure or open surgery.

While an operation sounds easy, it isn’t always the case. Every operation is a challenge on its own.

And this was one of my most difficult laparoscopic appendicectomies.

The womb was much larger than normal and was sitting just next to the abscess. It had to be handled with extreme care, if at all.

We discovered a large abscess full of pus in the pelvis in front of the uterus. The appendix had ruptured and disintegrated. After a lengthy and careful dissection, we found and removed the remnants of the shattered appendix and drained the abscess cavity of pus.

Madam A made a slow but steady recovery after the surgery. She went home to Indonesia when she was well enough to travel.

She happily reported that her pregnancy proceeded without further complication and she gave birth to a healthy baby 6 months later.

The Mooncake

As I sat in my clinic staring at the newspaper, the phone suddenly rang. It was the Accident & Emergency Unit, and they had an accident case for me. The voice at the other end of the phone sounded urgent, saying it was a bad case, asking if I would accept it.

The day had just gone pear-shaped.

mooncake

 

Broken Glass Everywhere

I hurried over to find Mr Woon, a 26 year old man lying on a stretcher. He was pale and had a large blood soaked pack applied to his neck.

The ambulance person recounted the details – Mr Woon had been involved in a head-on collision with a van. He had been catapulted off his motorcycle and went through the windscreen of the van. That he was wearing a helmet probably saved his brain, but his neck had landed on the jagged glass of the shattered windscreen.

Gingerly, I peeled back the blood soaked pack to be confronted by an absolutely ghastly wound in the neck stretching from ear to ear.

There was some bleeding coming from the wound and he was partly breathing through the wound indicating injury to the windpipe (trachea).

Everywhere there was broken glass.

Hastily I replaced the pack. A quick glance at the monitor showed the blood pressure was holding well though Mr Woon had clearly lost a lot of blood on his way to hospital.

Quickly, I checked to make sure there were no other major injuries elsewhere. I then calmly told Mr Woon that he needed emergency surgery as soon as possible.

Mr Woon weakly nodded and extended a shaky hand to sign the consent.

I then spoke to Dr Wong, the On-Call Consultant Anaesthetist.

In a move of sheer brilliance, Dr Wong instructed me to send Mr Woon straight up to the operating theatre (OT) where he would resuscitate the patient rather than the usual process of admission to the ward first which would have wasted much time.

In OT, I encountered Dr Wong getting Mr Woon ready for general anaesthetic. The bleeding in the neck seemed to be under control with the pack in place. Next door, the nurses were busy readying the trolley and instruments. Blood had been ordered from the Lab but it would take some time as the blood had to be cross-matched first.

…Disaster!

As I watched Dr Wong go about his preparations, suddenly Mr Woon coughed violently.

In that instant, something in his neck gave way. A huge amount of blood suddenly erupted forth from his neck, gushing to the floor.

His blood pressure, which had been 120/70 up to that point suddenly plummeted to zero – unrecordable!

For a split second, we stood rooted to the spot, horrified by the disaster unfolding before our eyes.

“O-negative blood! Forget about the cross match. Get me some O-negative blood! NOW!” barked Dr Wong, hastily slapping a new pack over the neck.

(O negative blood is used in desperate situations where there is no time at all for cross match.) All this was bad enough but what really scared me was seeing the normally calm and composed Dr Wong go totally pale.

There wasn’t a moment to lose.

Clamps, Clamps, Clamps!

I sprang through the door into the operating theathre, my mind racing as I went through what I would need and what I was going to do.

“Clamps! Lots of clamps! Vascular clamps. No, not those big ones! Medium sized and small ones. Bring the whole tray! Ties! Vascular sutures! Vascular needle holder! Skin prep! LOTS of it!”

I hastily scrubbed and gowned up, mindful that next door, Dr Wong was going through his own battle to maintain BP and do a crash induction of anaesthesia.

Surgical protocol dictates that at the start of each case, the surgeon carefully prepares the skin with antiseptic solution before carefully draping sterile towels exposing just the operative field to maintain sterility.

No time for that!

I figured all the sterility in the world was useless if the patient died from massive bleeding. If there was wound infection, I can always treat it with antibiotics later.

“Give me that skin prep!” I began pouring the skin prep all over the wound as the nurses looked on, protesting.

“Skin prep – DONE!”

I began clipping and clamping the bleeding vessels. One of the scrub nurses tried to arrange some towels around the wound to give it some semblance of surgical decency.

As I secured the bleeding, I glanced up anxiously from time to time to observe the BP monitor as well as the colour returning to Dr Wong’s face.

The rest of the operation progressed at a more measured pace.

I had to repair the jugular vein and the trachea. Then there was all the debris to clear, not to mention a lot of glass fragments.

The next day, I recounted to Mr Woon in a shaky voice what had happened in OT and how close we had come to losing him. He nodded feebly, understanding and whispered “Thanks”.

By then the hospital had got to hear of my little adventure.

It’s a curious feeling, having looked Death in the face, then having ripped someone from his jaws.

The “Hero Moment”

Years ago I was one of several short-listed candidates for a Registrar post in the UK. One of the other candidates was a smarmy lad with a smug face that looked on others with a patronising smile.

He spent his time in the waiting room telling the other candidates of a stab injury to the chest he had treated as a Casualty officer. The knife had penetrated the heart.

With tremendous courage and presence of mind, he opened up the patient’s chest in Casualty, withdrew the knife, then placed his finger in the wound to control bleeding while he sutured the wound in the heart.

He saved that patient’s life and was the hero of the day. He was known to the interviewers. None of the rest of us had a snowflakes chance in hell of getting that job. I went home dejectedly that day, like a dog with tail between the legs wondering why they had bothered to short-list the rest of us.

But here, right here with Mr Woon, my “hero moment” had arrived, unexpectedly.

What was it like?

Well, it was like walking on air for about a week. Sweet.

By the time I emerged from that state, it was time to send Mr Woon home.

The Mooncake…

I saw Mr Woon many times after that. He needed several minor operations to remove bits of retained glass that had slowly worked its way to the surface over the years.

But he never complained, and we were both glad he was alive. I can honestly say I couldn’t have chosen a nicer person to save.

And I could not have done it without the fantastic nurses at Lam Wah Ee Hospital and Dr Wong.

That is how every year without fail, a box of mooncakes appears at my door at the time of the Mid Autumn Festival. The mooncake followed me, even when I moved to Gleneagles Penang Hospital.

Yes, I do get other larger, more elaborate boxes of mooncakes too.

But it is this box that is, in its own quiet way, the most special one of all.

 

POSTSCRIPT – by Mr Woon
Mr W, his wife and daughter.
Mr Woon, his wife and daughter.

The first time I saw Dr Khoo was the next day after the accident. With a soft spoken voice, he told me what had happened the night before. I believe luck is not the only reason why I’m still living today; the skill and talent of Dr Khoo and all the personnel in the OT had saved me. Thanks Dr Khoo, you have become an integral part of my life.

Thanks for attending my wedding ceremony in 2004.  My wife (then girlfriend) was riding together with me when the accident happened. She was, luckily, unhurt.

My daughter Zi Yi is 7 years old now. One day I’m going to tell her of the adventure I had.

casestudy-drkhoo
Dr Khoo (in blue, seated on the far left) at Mr Woon’s wedding dinner.