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

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.

All You Ever Wanted to Know about Gallstones

What Is The Gallbladder?

Your gall bladder is an organ that sits under your liver on the upper right part of your abdomen. It stores and concentrates bile from the liver. While the gallbladder contains bile, it does not actually make bile – that is done by the liver.

Bile is necessary for the absorption of fat in our diet – rather like soap, it allows fat to mix with water making it easier to absorb from the small bowel.

Whenever we eat a meal rich in fat, our gallbladders contract, squirting out a small amount of bile into the small bowel to aid digestion.

Diagram of the gall bladder and organs around the gall bladder
Location of gallbladder (liver partly cut away)
How Then Do Gallstones Form?

Gallstones form when the bile has become too concentrated.

It is like thick soya sauce which has been kept in the fridge for too long – it solidifies and forms crystals.

Initially, the gallstones are small, like sand, but over time they can grow quite big. The largest stone I have removed via surgery was about 5cm long.

How Do I Know If I Have Gallstones?

Here are some common symptoms if you have gallstones. Symptoms can also vary, depending on where the stone is.

  • Jaundice (where your skin and eyes turn yellow)
  • Nausea & vomiting
  • Upper abdominal discomfort when you eat fatty food (fat intolerance)
  • Flatulance (wind, belching)
  • Upper abdominal pain (centre and right upper abdomen)
  • Fever

On a positive point, although gallstones are common, not all cause trouble.

Typically you will have pain because the gallstone gets stuck at the narrow part or neck of the gallbladder. Whenever you eat a fatty or rich meal, the gall bladder contracts but the opening is blocked. It’s like pushing against a closed door.

When this happens, you feel pain. This pain is usually felt in the upper part of the abdomen in the centre or to the right under the ribcage.

If your gallstone gets well and truly stuck at the neck of the gallbladder, the gallbladder becomes inflamed, red and swollen.  It may become infected so you may have a high fever along with the pain. You may feel a tender mass in your upper abdomen. This is known as cholecystitis.

If you don’t get it treated, your gallbladder can become gangrenous and even perforate. Sometimes, if the gallstone is large and erodes its way into your small bowel, the gallstone can block the small bowel. This is known as “gallstone ileus”.

If your gallstones are small, they may pass into the common bile duct. There, they may obstruct the common bile duct and block the flow of bile from the liver into the small bowel. This causes jaundice where your skin and eyes turn yellow and your stools may become pale and float.  Jaundice is always potentially serious and if you have jaundice, you should see a doctor immediately.

If the obstructed bile becomes infected, you will develop a high fever with the jaundice. This could lead to septicaemia (infection in the bloodstream) which is a serious and dangerous condition.

If the stone gets stuck at the lower end of the common bile duct close to the pancreatic duct, the surrounding inflammation could block the pancreatic duct as well leading to a condition called acute pancreatitis. Acute pancreatitis is a serious disease that can result in multi organ failure and death.

Will Large Gallstones Cause More Problems Than Small Gallstones?

Size is NOT the cause of the severity of pain from having gallstones. Large stones tend to cause inflammation and block the gall bladder. Small stones slip out but are more likely to get stuck at the common bile duct causing jaundice.

Pain caused by gallstones can be severe – some patients report that it is the worst pain they have ever had.

I Suspect I Might Have Gallstones. What Do I Do?

If you think you may have gallstones, contact me and I can arrange for you to take some tests such as an ultrasound scan of the abdomen and some blood tests. You may also have your abdomen scanned.

I Have Gallstones. What Should I Do Now?

If your gallstones are causing symptoms, I recommend that you remove them, together with the gallbladder. This can be done with keyhole surgery and it is specifically called laparoscopic cholecystectomy.

91% of all my patients’ gallbladder operations are done this way.

You’ll be assessed (with additional tests or procedures) before we progress to surgery. If your gallstones have already caused acute pancreatitis, we may want to let the inflammation in the pancreas settle down before surgery.

Why Can’t We Remove Just The Gallstones?
Why Must We Remove The Gallbladder Too?

The stones are inanimate and sit in the gallbladder or bile ducts. They do not become painful by themselves (because they have no nerve supply) but they cause the gallbladder to become painful. Removing just the stones therefore may not get rid of the problem. Besides, the gallbladder is the stone factory – picking out the stones and leaving the factory behind is inviting further trouble in future when more stones form!

Sometimes there are hundreds of tiny gallstones like sand. It is impossible to pick these up one by one. If stones spill out and fall between the loops of your small bowel, it becomes difficult to find and remove all the stones.

Based on these reasons, if you have gallstones, the recommended (as well as recognised and accepted) treatment is to remove the entire gallbladder with the stones inside using a method we call laparoscopic cholecystectomy.

Will I Still Be Able To Live Healthily Without A Gallbladder?

After we remove the gallbladder, you will still be able to eat and digest food normally, including fatty food (though of course too much fat is also not good for the heart amongst other things!). You do not need to restrict your diet or activity.

The gallbladder does not produce bile – that is produced by the liver. It merely stores and concentrates the bile. Like the appendix, it is present in your body but it is not 100% needed.

Some patients may notice their stools become softer after their gallbladder operation. In general, if done properly, you will have very few problems after gallbladder removal.

Can We Dissolve Gallstones With Medication?

This won’t work on all types of gallstones. Medication works best if you have cholesterol stones. Even so, medication does take a longer time to work and it is hardly ever used now to treat gallstones.

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.