Cases of colorectal cancer have been rising in Asian countries like Singapore, Malaysia and Philippines who have adapted to a diet heavy in processed ‘fast foods’.
Medical professionals now advocate screening for colorectal cancer starting at the age of 40 or 45. Dr.Ooi Boon Swee, a colorectal surgeon at the Mount Elizabeth Hospital (Orchard) in Singapore has been urging people through talks with professional groups to go for screening which is a relatively easy procedure.
Dr. Ooi specializes in minimally invasive surgery (MIS) or laparoscopic surgery of the colon and rectum. Here are excerpts of the interview with Dr Ooi Boon Swee.
Q: What made you decide to specialize in colorectal surgery?
Colorectal cancer is one of the most common cancer in the world. That is the most important reason why I chose colorectal surgery.
When I joined the Department of Colorectal Surgery, the incidence of colorectal cancer was going up and the demand for specialists was really there.
Q: What happens when you perform colorectal surgery?
Basically, you remove a portion of the colon or rectum that was affected by cancer. For example, when we remove the colon on the right side and we have to cut off the part of the small intestine that connects to the large intestine and cut a part of the large intestine as well. After that, we connect the small intestine with the large intestine.
To join them, we either do hand stitching or use a new device called a stapler to join the ends together.
Q: You specialize in minimally invasive surgery, how is it different from traditional surgery?
Laparoscopic surgery or minimally invasive surgery, has many advantages over traditional or open surgery where the wound is very long. In traditional surgery, we would cut from the top part of the abdomen and move down to the lower abdomen.
In laparoscopic surgery, we make two to four small cuts, of 5 mm in diameter, and then we insert long instruments inside the body to resect the diseased part. The surgeon will need a camera that is inserted through a 10 mm hole in the umbilicus to help him locate the problem.
After the laparoscopic dissection, we make a small wound on the abdomen, about 4 cm long, depending on the size of the tumor, to extract the resected colon or rectum.
A smaller wound causes significantly less pain to the patient. The patient recovers faster and the intestine functions more quickly. And therefore we can allow the patient to drink and eat earlier. The wound heals faster as well.
Q: If you have a patient with colorectal cancer requiring surgery, would you recommend laparoscopic surgery?
We have to assess the patient first. Whenever possible, my first choice would be laparoscopic surgery. If we know that the tumour is small, and the cancer can be removed through a small wound, then we would do laparoscopic surgery.
When the tumor or the cancer is too big, then it is best not to do laparoscopic surgery. The aim of laparoscopic surgery is to minimize trauma and handling of the intestine. But if a large wound is needed to remove a large tumour, it is better to do open surgery.
The other situation is when the cancer has invaded other organs like the small intestine, uterus, bladder or major blood vessels. In this situation, we perform open surgery.
In laparoscopic surgery, case selection is very important.
Q: What are the benefits of robotic-assisted surgery?
Robotic-assisted surgery is a considered part of minimally invasive surgery (MIS) or laparoscopic surgery. In this type of surgery, the surgeon performs the procedure with the help of robotic arms that can reach down to the deep and narrow areas of the pelvis.
Q: When does one undergo surgery?
When the cancer has not metastasized to other parts of the body, the patient should go for surgery. If it has spread beyond the colon, then there is a consideration to have combined treatment like chemotherapy and radiotherapy.
We have to assess each and every patient by taking a complete clinical history, a good clinical examination and thorough imaging investigation such as CT scan to ascertain exactly what we are dealing with. We need to determine if the tumour is localized, or if it has spread to other organs. Ultimately we look at the final treatment outcome. If the patient is curable, then we go for cure by doing surgery. If the patient is not curable, then we try to prolong life or to give them a better quality of life.
Q: How does a patient prepare for colorectal surgery?
Before we operate on the colon, we need to cleanse the colon. The patient has to take medicine to cleanse the intestine so that there is no spillage of feces during surgery. We also need to prepare the patient for the general anaesthesia. We check the patient’s cardiac status, lung function and blood count to make sure that they are fit for surgery.
Q: How does recovery of laparoscopy patients compare with traditional surgery?
Recovery from laparoscopic surgery could be as fast as four days depending on the fitness of the patient. I have patients who go home on the third day or fourth day after their surgery.
At two weeks after surgery, majority of the patients have recovered well. That is very important in cancer surgery. Because after surgery, we have to wait for a biopsy report that will tell us whether this patient requires further treatment, like chemotherapy. So if a patient has recovered quickly from the surgery, he will be in a better shape to start chemotherapy.
In traditional surgery, the patient’s recovery is slower. To make matter worse, there may be complications such as wound infection that requires daily dressing.
Q: What has been your most challenging case of colorectal surgery?
My most challenging case would be when I had to remove the entire colon and rectum of a young patient through MIS or laparoscopic surgery. To enable the patient to move his bowel, the small intestine was joined to the anus. This procedure usually takes about four to five hours.
Q: How is the patient now?
I am happy to report that the patient had a good functional recovery. We don’t actually need the large intestine (colon and rectum), to be healthy. After all of it is removed, we can use the small intestine, bend it backwards into a J pouch and connect it to the top of the anus. After the surgery, the patient can still live a normal life.
I operated on the patient when she was 18 and, five years after the surgery, she got married and had children. She is now living a normal life.
Q: After surgery, what advice do you give to help speed up a patient’s recovery?
Diet is very important. The patient needs food that contains a lot of proteins as well as carbohydrates for energy. Initially, the fiber intake should be reduced because the intestine is newly-joined and we do not want it to be blocked. After two weeks, you can have fiber from vegetables and fruits. One important dietary advice is to cut down on red meat. We also advise patients to cut down on smoking and alcohol, to exercise more and get enough rest and sleep.
Q: Colonics is said to be one way to clean the colon. Would you like to comment on this?
There is no proof to substantiate that colonics provides an added benefit. A lot of people promote colonics as a detoxification for the body. However, our colon has a lot of good bacteria that should not be washed away. They actually maintain a good homeostasis to promote the function of the colon.
Good bacteria are important to control the population of bad bacteria because an imbalance of the good and bad bacteria can result in infection of the intestine.
Q: How did you train for MIS or robotics-assisted surgery?
My training started off with open surgery, like all surgeons. The older surgeons still say that open surgery is better because you can see the disease or the problem, you can put your hand to it, and feel it.
When the laparoscopic technique was introduced in the 90s, it immediately showed significant advantages in a majority of cases. So I picked it up and learned in Japan, Korea, Australia and the US through fellowships, attachments, trainings and workshops. I have seen cases suitable for both open and laparoscopic surgery. Laparoscopic surgery depends on good visualization. We must see the surgical fields well before we can cut. If we cannot see clearly, then we have to convert to open surgery.
The take home message is: patient’s safety first.
Q:Hemorrhoids is also a condition of the anus affecting many people. However people seem to be reluctant to seek help until the condition is already serious. What do you advise people who are suffering in silence?
Haemorrhoids is a very common disease of the anus. It is not a cancer but it can be very irritating. The common symptoms are bleeding, prolapse, itchiness and pain. My advice is to get it treated before it becomes worse.
Q: Are there new treatment methods for hemorrhoid patients that can alleviate their condition?
Currently, the proven surgical technique is stapled haemorrhoidectomy that gives significantly less pain after surgery and faster recovery.
Q: How can this condition be avoided?
Haemorrhoids can be avoided by maintaining a good toilet and bowel habit. Do not sit on the toilet bowl too long to read a magazine or newspaper or play games on your smart phones. This is because the downward pressure on your anus is greater if you sit on the toilet bowl for too long. This causes the blood vessels in your haemorrhoids to become engorged and friable. It is also important to avoid constipation, excessive straining at stool or having hard stool, by drinking more water and increasing your dietary fibres intake.
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