The Flying Goitre

I first met Mr Syed Maktum in 2004. A good looking tall man of 42 with great poise, he came bearing a letter from his doctor about a thyroid swelling. He wore a worried look on his face.

Further tests revealed a 4.4cm solitary nodule in the right lobe of his thyroid gland. A needle biopsy of the nodule was reported to be benign (harmless).

Nevertheless, in view of the size, I recommended removal of the right lobe of the thyroid gland with the nodule.

He replied that he would think it over. He had a busy job as a senior airline steward and spent more time out of the country than in.

No show…

He reappeared in my clinic 2 years later in 2006 bearing another letter from a different doctor. The neck swelling had increased significantly in size and had started to push his trachea (windpipe) to the other side. By this time, there were many nodules, suggestive of multinodular goiter, a benign condition.

Multinodular goiters can get very big.

My personal record was a 900g monster, a subject of a future story. The need for surgery was clear.

However, thyroid surgery is not without risks. The main risk is to the recurrent laryngeal nerve, a nerve that lies very close to the thyroid gland.

Anyone taking on thyroid surgery would have to approach the area of the nerve with extreme caution, with extra careful and gentle dissection. Injury to the nerve would result in a weak or hoarse voice for the patient.

I carefully explained all this to him and after a good deal of persuasion, he agreed to go ahead and arrangements were made.

He never showed up.

“…my job depends on my voice…”

Fast forward to 2009.

He turns up again with another letter from yet another doctor.

By now, the thyroid gland had grown huge.

The previous nodule had grown from 4.4cm to a whopping 8.5cm. He had neck discomfort and his voice had gone hoarse by itself! Concerns had been raised at work about his neck swelling and his voice.

He was having difficulty doing up his collar. He was worried about his goiter, worried about his voice before surgery, and after surgery. He needed to make clear inflight announcements. His job and livelihood depended on it.

I had an ENT colleague look at him.

He diagnosed an infection of the vocal cords and thankfully his voice improved after a course of antibiotics. But it could have been due to the thyroid gland pressing on the nerve!

This time he did not need so much convincing. He revealed that his sister Puan A had been operated by me way back in 1998 for a thyroid swelling too. The operation had gone well, without complication and she was egging him to get on with it and have the operation done. He was very worried about the risk to his recurrent laryngeal nerve and the impact that would have on his job.

I did my best to reassure him, silently making a note to set aside plenty of time for his operation so I could approach the nerve with extra meticulous care. We looked at his flight schedules and made plans.

The operation proceeded without a hitch, staying well clear of the nerve. The left lobe looked normal so I left it well alone.

The lab report on the lump showed it to be benign. But best of all, his voice was completely normal afterwards and he was so relieved!

Another thyroid swelling!

In October this year, another sister of his, Puan K comes to my clinic (this time in Gleneagles Penang), also with a large thyroid swelling!

She had noticed it since last December but had put off coming to see me. This time, it was Syed Maktum who was egging her to come for a consult.

Her operation went smoothly. As she had hardly any normal thyroid tissue, I had to remove the entire gland. This carried an additional risk of a low blood calcium level after operation but happily, not only was her calcium completely normal afterwards but so was her voice.

Syed Maktum still flies and still has a hectic work schedule.

A model jumbo jet sits on my desk silently reminding me of Syed Maktum jetting his way around the world.

Syed Maktum & me, when he came to visit his sister at Gleneagles Penang
Syed Maktum & me, when he came to visit his sister at Gleneagles Penang
Postscript

My name is Syed Maktum. I had a thyroid operation on my neck done by Dr Khoo Saye Thiam. The operation was very successful and I am very happy because the growth in my neck was very big.

I am very impressed Dr Khoo did the operation very well and there no scar seen in my neck. My 2 sisters also had their thyroid operations done by Dr Khoo very successfully. Thank you for everything and all the best to Dr Khoo!

Syed Maktum, November 2013

Colon Cancer: Symptoms & Treatment

What Is Colorectal Cancer?

Colorectal cancer is cancer of the large bowel. In Malaysia, it is one of the top 3 most common cancers for men and women.

Like all cancers, it is dangerous because it can spread to involve other organs in other parts of the body. Once the cancer has spread, it may not be possible to remove it completely with surgery.

 

Colorectal cancer causing obstruction
Colorectal cancer causing obstruction
Symptoms of Colorectal Cancer

Colorectal (large bowel) cancer may be silent and display no symptoms. However, most patients would have had some symptoms at one time or other.

Here are some symptoms to check for:

  • Passing blood in the stools
  • Recent change in bowel habit – constipation or diarrhea
  • Difficulty passing motions
  • Passing slime or mucus in the stools
  • Unexplained abdominal pain
  • Abdominal mass

If you have any of these symptoms, or if you have a strong family history of bowel cancer you should have your bowel checked with a colonoscopy.

What If I Don’t Have Pain?

If you don’t experience pain that does not mean you are OK.

Although cancers can cause pain, very often we see cancers without any pain at all. In fact, painless rectal bleeding is often a sign of colorectal cancer.

Am I At Risk For Colorectal Cancer?
  • Age – more common in middle aged & elderly
  • Gender – more common in males
  • Diet – more common if diet is rich in red meats or in low fibre diets
  • Genetic – family history of colorectal cancer
  • Polyps – Polyps are now regarded as having the potential to become cancerous (see my explanation on polyps)
  • Inflammatory bowel disease – ulcerative colitis & Crohn’s disease (uncommon in Malaysia)
How Should I Change My Diet?

I get this question all the time. My advice is, take less red meat and consume more fruits and vegetables.

However, diets are weak risk factors for colorectal cancer. In other words, changing your diet may not necessarily prevent you from getting colorectal cancer.

Can I Take Preventive Medicine?

You can.

Some studies suggests that Aspirin and Celecoxib can reduce the risk of getting colorectal cancer but this is only recommended for those who are at high risk.

Colorectal Cancer Treatment

Colorectal cancer treatment depends on several things including what stage the cancer has reached as well as whether other organs are involved.

Surgery is one of the main ways of treating colorectal cancer and if it can be removed safely, it should be removed. Surgery is often combined with radiotherapy and chemotherapy.

This is not a one-size-fits all treatment plan. The treatment plan can be complicated and varies from patient to patient, especially if other organs are involved. On the whole, as doctors, we do tailor the treatment according to your needs as a patient.

If you suspect something amiss or have been diagnosed with colorectal cancer and need someone to advise or discuss your options either for medication, management plan or surgery, I may be able to help.

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A Thank You is Simply Inadequate

Yes, I did not forget to thank Mr. Khoo Saye Thiam who effectively removed the cancerous colon bothering me. Yes, I repeated that each time I bumped into him subsequent to my operation. Mr. Khoo is a surgeon who listens and understands his patients well. He has done all he could to put away the first huge problematical part of my medical journey to provide me with the necessary foundation and confidence to engage with my other medical challenges.

Dr. P. S. Yeoh
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All You Ever Wanted To Know About Piles

What Are Piles?

Piles or haemorrhoids are swellings around the anus caused by enlarged or engorged veins.
Piles 01

Piles Symptoms

Piles may present as a lump at the anus or the lump may come out only when passing motion. Piles may also cause bleeding, typically dripping into the toilet bowl after opening the bowels. If the piles prolapse out and the blood inside clots, the piles become very painful. Patients may have difficulty sitting down. Not all of the above symptoms are caused by piles. I have personally seen many cases where the cause of the lump or bleeding is something else. Common examples include:

  • anal fissures
  • anal polyps
  • mucosal prolapse
  • perianal fistula
  • cancer
What Causes Piles?

Piles are most commonly caused by constipation. When your stools are hard, you have to strain hard during bowel movement. This increases the pressure inside your abdomen and also in the veins. Over time, your veins become swollen and engorged. Sometimes, when the veins get very large, they may prolapse or slip out through the anus. Chronic laxative abuse can also cause excessive straining. Pregnancy causes piles too. As your baby presses on your pelvic veins, this partially obstructs the flow of blood back to your heart and results in rising pressure in your pelvic veins, including the veins around the anus. Piles can also be caused by liver disease like cirrhosis, tumours in the pelvis and abnormal vessels around the anus.

Types of Piles

There are two types of piles: external and internal piles. External piles appear as a bluish lump at the anus. If a clot forms inside, it can become sensitive & painful. Internal piles are usually not visible. They often cause bleeding especially when opening bowels. If they get very large, they can prolapse or slip out as a lump at the anus. When this happens, the piles can become very painful. Often there is a combination of internal and external piles.

Treatment for Piles

If you have been told you have piles, do not delay in seeing a doctor. If you come to me for a check-up, I will conduct a detailed examination to make sure it is really piles and not something else. You’d also be advised in terms of treatment. You can then decide exactly how far you want to go and which treatment to opt for.

4 Common Ways To Treat Piles

If your piles are small and do not cause much trouble, they can be left alone. Small piles which bleed can be helped with medication. This includes medication to deal with constipation if you suffer from constipation. In terms of larger piles, they can be “banded” which means placing a small tight rubber band at the base of the pile. This stops blood flow into the pile so that the pile can shrink down. Later, the rubber band will fall off on its own. Another way to treat piles is by injection. This method has become less and less popular because it causes bleeding and discomfort. If you have very large or multiple piles, I suggest you remove them using surgery.

Using Surgery To Treat Piles

Many people are now opting for stapled haemorrhoidectomy (PPH haemorrhoidectomy) as a treatment method. In this treatment, we use a circular stapler to excise and staple the piles. As the operation is carried out on the inside, you won’t see any visible scars. There is considerably less pain using this method and healing is also faster compared to conventional surgery. However, not everyone can be treated this way. If your piles are not suitable for this method, you can still have them removed using conventional surgery, that is, removing the piles and then suturing the wound. You then have to wash twice daily with salt baths until the wounds heal, which takes about 3 to 4 weeks. Alternatives to stapling include ultrasound guided suture ligation of the piles as well as laser haemorrhoidectomy. Each method has its strengths and weaknesses.

Hernias: A Pain in the Groin

What Exactly Is A Hernia?

Your abdominal cavity is surrounded by muscles which keep all the internal organs from falling out. In the back, the muscles of the spine are thick and strong but on the front the muscles are thinner. At the upper part of your abdomen, the diaphragm separates your abdomen from your chest.

You’d experience a hernia if there is a weakness or rupture of part of this muscular wall. Basically, a hole forms in the muscular wall of your abdomen.

Some of the contents of your abdomen may protrude through this hole. It can be some fat but it can also include your bowel.

Abdominal wall muscles
Abdominal wall muscles
Your Lump Is A Hole!

From the outside, you may see a lump but that lump is in fact a hole!

In the early stages, the lump may come and go. When you lie down, the contents return to your main abdominal cavity so the lump “disappears” only to return when you stand up or cough.

At a later stage, your lump may become stuck and remain visible even when you are lying down.

Hernias are more common in men and occur in the groin (called an “inguinal hernia”). An inguinal hernia starts as a lump in the groin but if large, it can fill the whole scrotum. It can also occur in a previous abdominal wound due to poor healing (incisional hernia). Other areas for hernias to appear include the umbilicus (umbilical hernia), lower groin (femoral hernia) or diaphragm (diaphragmatic hernia).

Inguinal (groin) hernia
Inguinal (groin) hernia
Are Hernias Dangerous?

Generally, no although they can cause discomfort and pain. If your bowel protrudes and gets trapped in the hernia, it may become obstructed. Your bowel will then swell and may go gangrenous if the blood supply is cut off. If that happens, it becomes a surgical emergency and needs an immediate operation to avoid rupture or perforation of the bowel.

Can Hernias Be Prevented?
Bowel protruding through a hernia in the abdominal muscles
Bowel protruding through a hernia in the abdominal muscles

Hernias are caused by excessive muscular straining which is associated with heavy lifting or persistent coughing.

Footballers often get a hernia. If you are overweight with weak abdominal muscles. you may be at risk of getting a hernia. If you have had previous abdominal surgery and the wound has not healed well, you may also get a hernia. Possible causes include previous wound infection, obesity and thin weak abdominal muscles (such as in the elderly).

  • Lose weight!
  • Avoid heavy lifting or strenuous activity
  • Keep your bowels regular, avoid constipation and straining too hard
  • Stop smoking! All smokers cough!
Treatment for Hernias

If you have a hernia, you need surgery to repair your hernia.

In the past, if you had a defect in your muscle, the surgeon would repair this defect with sutures or stitching. But this can lead to re-occurrence of your hernia if the sutures or stitches tear out of the muscle, especially if your muscles are weak to begin with.

You have a better option today.

As surgeons, we now use a special plastic mesh to cover up the hole and the mesh stays permanently.

Mesh repairs have a much higher success rate compared with the older method of using sutures. Scar tissue grows into the mesh (made from polypropylene, a sturdy and strong type of plastic) adhering the mesh firmly to your surrounding muscle. A skilful surgeon will have no problems inserting the mesh into the right place.

What’s even better is that the mesh can be inserted using laparoscopic surgery or keyhole surgery. We simply roll up the mesh and stick it in! This method results in faster healing, smaller scars and less pain.

If you come for a hernia surgery, I suggest you consider using laparoscopic surgery for your hernia repair.

Will My Hernia Come Back Again?

It is possible but not common for hernias to recur if a proper mesh repair has been done.

My own personal results was 1 case of recurrence out of a series of over 300 repairs – that is 99.7% success and only 0.3% recurrence.

Of course, if you get an inguinal hernia, you could still get a hernia on the other side if you continue to do heavy lifting or straining!

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.

Gallstones And Gangrenous Gallbladder

From time to time I will share some of my more difficult cases so that you understand what happens during surgery.

The case below involved a Chinese man in his 60s who suffered from gallstones and an inflamed gallbladder.

Mr C, a 61 year old Chinese man came to see me with right upper abdominal pain and high fever. When I did an ultrasound scan of the abdomen, I noted that the scan showed large gallstones and an inflamed gall bladder.

gallbladder-inflamed
An inflamed gallbladder

After a careful preoperative assessment, I advised him that he needed a laparoscopic cholecystectomy.

During the operation, the gallbladder was badly inflamed and had started to become gangrenous. What made it more challenging was that the gallbladder was stuck to the surrounding tissues making surgery difficult.

The gallbladder wall oozed pus and we found a fairly large gallstone jammed into the neck of the gall bladder!

While it was rather challenging, we finally managed to carefully dissect and remove the gallbladder laparoscopically without conversion to an open procedure. This is always good news for the patient as laparascopic surgery possesses many more benefits compared to open surgery.

I am happy to report the laparoscopic surgery did Mr C a world of good. He recovered well from his operation without any complications.

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.