Dr. Liau Kui Hin, Senior Consultant, General Surgery, Mount Elizabeth Novena Hospital

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Give us a brief account of your work as a surgeon and your subspecialty in the other fields of interest?
As a surgeon, I see cases where the patient is either diagnosed with cancer or suspected to have cancer. So, for the first group, if the patients are diagnosed with cancer by a medical oncologist, refer to me. These cases are ones where there is room for surgery as cancer can be removed from the body through surgery. Generally, surgery offers them the best long term survival. The second group can be a bit more challenging as they are suspected to have cancer. The patients are not sure whether the tumor they have is a malignant one or just benign. The third group of patients includes people coming in for screening procedures. Thus, we do a cancer check, the extent of the check depends on the subjective risks of the patient. Whether they have a family history of cancer or predisposing risk factors, this might lead to its development.

I was trained as a general surgeon and for my higher training, I was sent to New York City. In my experience, I worked with varieties of cancer, from the liver, gallbladder, pancreas and digestive tracts. Also, I developed a special interest in a rare type called Neuroendocrine Cancer. It’s a form of rare tumor development which affects 3-5 people per 100,000. The two commonest Neuroendocrine Tumor (NET) comes from the pancreas (PNET) and small bowel (INET). We call them carcinogenic because they look like cancer but don’t quite behave like one; they’re very lazy. Hence, patients diagnosed with this can survive a long time on average with little to medium signs of symptoms.

What is the prevalence of GI cancer in Asia and what are the key risk factors contributing to this?
In Singapore, if you look at the top 5 cancers, 2 out of the 5 are Gastrointestinal (GI) Cancer. In Bangladesh, the top 5 cancers are prevalent in the male populace – 4 out of 5 and for females – 3 out of 5 cases are digestive cancers. Digestive cancers refer to the chain starting from the mouth and ending at the anus.

The risks are predominantly dietary with regards to food safety. More so, improper waste disposal from industrialization can contaminate agriculture lands. In the past, arable lands were located far from the industries. Whereas, now we see them co-existing side by side; sharing the same river flow and usable land. The result being the food is getting contaminated from the heavy metals used by factories which are in turn wrongly dumped in the nearby lakes. Eventually, these seep into the soil and the plants; thus, entering our food chain. Adding to this, urbanization has led to the consumption of more processed food rather than fresh, natural produce.

What factors play a role in the likely development of surgical infections? Please provide an account of your work with the International Surgical Infections Studies Group.
Most of the surgical infections are related to how we practice surgery. With the emergence of modern hospitals, proper facilities and proper techniques, the prevalence of surgical infections has fallen rapidly. Unfortunately, In Asia, as our countries are so diverse and heterogeneous, practices vary per country; even in the same country. This is mainly because certain facilities don’t always get the proper funding to develop standard operation theatres, tools, staff training, or an overall good and healthy practice. Surgical infections is one of the most preventable and avoidable infections. Taking measures to eliminate this won’t just save lives but also a lot of healthcare costs and resources for the facilities and country.

My interest in this is due to the fact that it causes a lot of unnecessary mortalities. I can save the patient from cancer and lose the patient to surgical infection. During my tenure as the Deputy Chief of the department, I managed to write a grant of about 100,000 Singapore Dollars from the Ministry of Health, Singapore. The project was to reduce and eventually eliminate the surgical site infections in the hospital. I started by looking at the best means of practicing, that can reduce this issue. After combing through the literature, I decided upon 3-5 from a possible 20. More so, I went around departments and gave lectures on my philosophy and how it can make a difference. After analyzing the data, surgeons who were convinced came on board the project. Initially, the project started out for 6 months but then we extended it to 3 years and running. The results of this project were published in the Surgical Infections Journal.

What are the symptoms of gallbladder cancer? Are gallbladder polyps and gallstone, associated with gallbladder cancer?
Gallstones are a very common issue generally. However, cases of gallstones co-existing with gallbladder cancer are only prevalent in very few isolated geographical locations in the world. We have seen that Indians who have lived alongside the Ganges River have a very high incidence of gallbladder cancer. Due to this general prevalence of cancer, they have a tendency to remove the entirety of the gallbladder at the first sign of even a basic gallstone formation. In Singapore, the incidence of gallbladder cancer is very low. The cases are seen to be high in parts of India, Japan, Chile and some parts of Russia. We suspect, after studying the epidemiology of gallbladder cancer, that it must be related to the environment. The gallbladder is actually a storage organ for our bowels. Any and all impurities that enter our body gets detoxified and gets excreted through the liver and kidneys and into the bowel. We suspect that the presence of the industrial toxins and chemicals in the river eventually makes its way into our food chain. Countries with the incidence of gallbladder cancer (10-15%), may have developed this situation as per the presence of certain chemicals in the gallstones which irritate the gallbladder and lead to gallbladder cancer. Thus, this can be a probable correlation between the environment and the development of gallbladder cancer. More so, gallstones that are not removed for a long time can also lead to the forming of cancer. In Singapore, we only remove the gallstones when the patient shows symptoms of pain from stone blockages. General treatment is to perform keyhole surgery. However, in cases of severe blockage and the coexistence of gallbladder cancer with the stones; it makes the procedure very challenging.

In Asia, as our countries are so diverse and heterogeneous, practices vary per country; even in the same country. This is mainly because certain facilities don’t always get the proper funding to develop standard operation theatres, tools, staff training, or an overall good and healthy practice. Surgical infections is one of the most preventable and avoidable infections. Taking measures to eliminate this won’t just save lives but also a lot healthcare costs and resources for the facilities and country.

Can pancreatic cancer be prevented? Is there a direct correlation between breast cancer and pancreatic cancer?
A segment of patients with pancreatic cancer come in with cases of chronic pancreatitis – it’s seen to be high in patients who have a history of alcohol abuse, or in-gestation of chemicals like magnesium; which leads to the thickening of the pancreatic arteries. Interestingly, some reports claim that people who consume cassava throughout their lives have developed this issue.
The second group of people is the ones who don’t have chronic pancreatitis but develop this form of sporadic pancreatic cancer. The third group of people is the ones who have inherited these particular cancerous genes. Right now, we are aware that certain genes predispose a person to develop cancer. One such gene is – BRCA 1 & BRCA 2; which also are the genes responsible for breast cancer. Testing positive for both the genes relate to an 80% probability of breast cancer in the patient; whereas, in the case of pancreatic cancer it’s only 10-20%. Hence, we can infer that the correlation of the subsequent development of pancreatic cancer if the patient suffers from breast cancer is generally low.

What are the fundamental roles of the Asian-Pacific Hepato-Pancreato Biliary Association?
I was the founder of this association. It’s essentially a form of knowledge and expertise in the fields of liver, gallbladder, and pancreas. Resulting in a consolidation between the professional and the expert group, forming an association where the people living in the Asian-Pacific can come together and share their philosophy on good practices, sharing their own practical experiences and the collective knowledge of the recent developments in the respective fields. At that time, Japan was leading in the world in terms of liver and hepatobiliary surgery and therefore were instrumental in setting up this association alongside us. More so, the association provides a platform for younger surgeons to tap on the funds of the fellowship and thus have the opportunity to travel to developed countries to further hone their skills.

What’s one piece of advice you always give to your patients?
For surgery, I always tell my patients to hope for the best and prepare for the worst. During the actual procedure, anything out of the ordinary can occur which can hamper the surgery. We only have statistics and thus we can only predict a group of patients but not an individual patient as their case is uniquely subjective to them only. During patient counseling, we gather our knowledge with respect to the larger group or population parameter. Hence, the quoted statistics are just averages. However, because I have the knowledge and know the probability of risk and success factors, we gather the necessary resources and move forward to the best of our understanding and abilities.

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