Colorectal Surgery

Contact phone number: 2255 4762
Fax number: 2872 8425

STAFF

Professor Wai Lun LAW Clinical Professor of Surgery Chief, Division of Colorectal Surgery MBBS(HK), MS(HK), FRCS(Ed), FCSHK, FHKAM(Surg), FACS Email : lawwl@hkucc.hku.hk	Professor Wai Lun LAW
Dr. Judy Wai Chu HO Consultant Honorary Clinical Associate Professor MBBS (HK), FRCS (Ed), FCSHK, FHKAM (Surg), FRCS (Eng), FACS Email : judyho@hkucc.hku.hk	Dr. Judy Wai Chu HO
Dr. Hok Kwok CHOI Associate Consultant Honorary Clinical Assistant Professor MBBS, FRCSEd(Gen), FCSHK, FHKAM(Surg) Email : hkchoi@hkucc.hku.hk	Dr. Hok Kwok CHOI
Dr. Jensen Tung Chung POON Associate Consultant Honorary Clinical Assistant Professor MBBS, FRCSEd(Gen), FCSHK, FHKAM(Surg) Email : jtc@netvigator.com	Dr. Jensen Tung Chung POON
Dr. Joe King Man FAN Associate Consultant MBBS, FRCSEd(Gen), FCSHK, FHKAM(Surg) Email : drjoefan@netvigator.com	Dr. Joe King Man FAN
Dr. Oswens Sui Hung LO Specialist Resident MBBS, FRCSEd(Gen), FCSHK, FHKAM(Surg) Email : oswenslo@yahoo.com	Dr. Oswens Sui Hung LO

ACTIVITIES AND SERVICES

The Division of Colorectal Surgery is responsible for the management of patients with benign and malignant diseases of the colon, rectum, anus, small intestine and appendix. With the expertise in general surgery and advanced laparoscopic skills, the Division also takes care of patients with abdominal wall hernias, both on the elective and emergency settings.

With its 42 hospital beds in QMH, and 20 beds in TWH, the Division manages over 3000 hospital admissions each year. Four sessions of Outpatient Colorectal Clinic are held weekly in QMH, which amounts to over 10,000 outpatient visits to the Division annually (Table). One session of Outpatient Clinic in Queen Mary Hospital is also currently held for the referral of new patients with abdominal wall hernias.

STRENGTHS AND DEVELOPMENTS

Colorectal Cancer

Colorectal cancer is the second most common cancer and the second leading cause of cancer death in Hong Kong. Each year, the Division manages more than 250 new cases of primary colorectal cancers.

A multidisciplinary approach with the emphasis on minimally invasive surgery is adopted by the Division in the management of colorectal cancer. Being a tertiary referral centre, the Division manages a high percentage of patients with rectal cancer. The specialists of the Division are capable of different approaches in the management of rectal cancer, with the objectives of sphincter preservation and a low recurrence rate. Total mesorectal resection for mid- and low-rectal cancer has been adopted as the standard surgical technique in the treatment of mid and distal rectal cancer since October 1993. Currently, laparoscopic total mesorectal excision is regularly performed with equivalent oncologic outcome in patients with rectal cancer. The sphincter-saving rate is maintained at 90% for all mid and distal rectal cancers. The local recurrence rate for patients with low anterior resection has been maintained at around 7%.

Transanal Endoscopic Operation (TEO) has recently been introduced for the management of early rectal cancer by local excision with greater precision. The initial results are encouraging.

Transanal Endoscopic Operation

Endoscopic View of Dissection

Clinics and Operating Sessions run by the Division

Being a tertiary referral centre, the Division also manages patients with advanced or recurrent colorectal cancers. A multi-disciplinary approach with interaction with radiologists and clinical oncologists is adopted to design treatment plan for individual patients. Preoperative chemoradiotherapy as well as postoperative chemotherapy and radiotherapy are employed as adjuvant therapy in addition to surgery if necessary. Ultra-major resections such as abdominosacral resection, peritonectomy and exenterative surgery are performed regularly - with a low mortality and morbidity.

A protocol for expedited postoperative recovery after elective colorectal resection has been developed recently and will be promulgated shortly. The aim of this protocol is to standardize the treatments for postoperative patients so that a more efficient and systematic patient care can be provided and hopefully the length of hospital stay can be shortened. This, together with the minimally invasive approach, has improved the postoperative outcome and shortened the hospital stay.

Patients also receive postoperative follow-up care and surveillance from the Division. The establishment of the Hereditary Colorectal Cancer Registry has also helped to screen and provide counseling to high-risk individuals.

Inflammatory Bowel Disease

The incidence of inflammatory bowel disease (IBD) is much lower in Hong Kong compared with Western countries. Consequently, most local doctors are not so familiar with the management of IBD. The Division works closely with gastroenterologists in the management of these patients. Each year, approximately ten patients with ulcerative colitis or Crohn's disease undergo surgical resection. Restorative proctocolectomy is the treatment of choice for patients with chronic ulcerative colitis and this operation can now be performed either by open surgery or by a laparoscopic approach. With the advanced skills in minimally invasive surgery, laparoscopic approach is increasingly used to treat these patients.

Anorectal Surgery

Anorectal diseases are common among patients presenting to our Clinic and out-patient procedures for haemorrhoids are commonly performed. The Division also collaborates with TWH in the establishment of direct referral one-stop rectal bleeding clinic, which aims at rapid and efficient management of patients with anorectal complaints.

We are also the first in Hong Kong to perform stapled haemorrhoidectomy. The procedure is regularly performed and has been found to result in less wound pain and early recovery. Since 2000, stapled haemorrhoidectomy has been regularly performed in TWH as ambulatory surgery. We also actively investigate other modalities of treatment for haemorrhoidal diseases. Equipments for Doppler guided haemorrhoidal artery ligation are also currently available.

Stapled haemorrhoidopexy

Doppler guided haemorrhoidal artery ligation

Complicated anorectal diseases such as complicated fistulas, rectal prolapse and faecal incontinence are objectively investigated and treated with the availability of anorectal physiology and transanal ultrasound. New and more effective treatments are constantly utilized in the management of these diseases.

Laparoscopic Surgery

The development of laparoscopic colorectal surgery has been rapid. With increasing experience, the Division can perform most, if not all, colorectal operations laparoscopically nowadays. Advanced surgical procedures such as abdominoperineal resection, low anterior resection with total mesorectal excision, and restorative proctocolectomy are now regularly performed. Our results show quicker patient recovery and greater patient satisfaction. Laparoscopic surgery is also performed in patients with complicated benign colorectal conditions such as complicated colonic diverticular disease and inflammatory bowel disease.

With the availability of advanced laparoscopic skills of most members of the Division, the development in minimally invasion colorectal surgery is the main direction of the Division. Besides the regular performance of complicated colorectal procedures, we are now exploring the techniques of incisionless surgery and natural orifice surgery.

Laparoscopic intracorporeal anastomosis

Laparoscopic low anterior resection without an abdominal incision

Moreover, we also started to perform robotic-assisted colorectal surgery with the Di Vinci Robotic Surgical System.

Di Vinci Robotic Surgical System

Surgeon at the console

Endoscopy and Stenting

The Division performs over 1,500 colonoscopies and 2,000 sigmoidoscopies each year. In addition to the diagnostic procedures, therapeutic procedures such as colonoscopic polypectomies and insertion of metallic stents are regularly performed. Since 1997, about 130 self-expanding metallic stent insertions have been performed in patients with malignant colorectal obstruction. The need of stoma creation was spared in most of these patients.

Advanced endoscopic techniques are continuously acquired by members of the Division. Some members have received training in techniques such as endoscopic mucosal resection (EMR) and endoscopic submucoal dissection (ESD).

Conventional Colonoscopy

Narrow Band Imaging Colonoscopy

Post-Endoscopic Mucosal Resection (EMR) of colonic polyp

Anorectal Physiology

• Colonic transit study
• Transrectal ultrasound
• Anal manometry
• Pudenal nerve conduction test
• Electromyography
• Defecography

With the introduction of anorectal physiology investigation, functional bowel disorders such as constipation and faecal incontinence can be more accurately evaluated. Transrectal ultrasound helps in the accurate staging of patients with rectal tumour. This then allows the most appropriate treatment to be offered.

Intestinal Obstruction

Adhesive obstruction is the most common aetiology of benign small bowel obstruction. Through active research, a new treatment protocol for adhesive obstruction has been developed by the Division. With the use of Gastrografin in our protocol, the need for operative treatment was markedly reduced in adhesive obstruction.

Obstructing colorectal cancers are the most common cause of colonic obstruction. One-table lavage and one-stage operation for left-sided obstruction were first performed in the late 1980s, and over the past decade, more than 300 patients have been treated with this procedure. Preoperative decompression of acute obstruction by self-expanding metallic stent is performed regularly in poor-risk patients to improve their surgical outcome. We are among the first few groups in the world to perform and report laparoscopic colon resection following decompression by self expanding metallic stent. This surgical option remains as our armament in the management of obstructing colon cancer.

Hernia surgery

Hernia surgery has evolved rapidly in recently years and is field of continuous development and research. The Division, together with the staff of TWH, manages patients with abdominal wall hernias. A clinic catering for new cases of abdominal wall hernias was set up in 2007 in Queen Mary Hospital. Emphasis is put on the laparoscopic repair and continuous research in the types of prosthetic mesh and the technique of extraperitoneal repair of groin hernia is underway. Moreover, incisional hernias are now mostly repaired with the laparoscopic approach to reduce the surgical trauma.

With the advanced laparoscopic skills, we are currently performing emergency hernia repair in selected patients with incarceration.

Needleoscopic Total Extra-Peritoneal (TEP) Hernioplasty with 3mm instruments

Cosmetic outcome after operation

Emergency Laparoscopic Repair for Incarcerated Hernia

Use of Intra-Peritoneal On-Lay Mesh (IPOM) for Incisional Hernia Repair

HEREDITARY GASTROINTESTINAL CANCER REGISTRY

In 1995, the Division established the territory's first Hereditary Colorectal Cancer Registry. This is the first such registry in Hong Kong and China. The aim of the Registry is to achieve secondary colorectal cancer prevention in high-risk families through early detection, timely treatment, education and ongoing research.

Up to the end of 2005, we have enrolled 608 families (1,325 individuals), including 53 FAP families, 106 HNPCC families, 440 colorectal cancer families that satisfied criteria C, and 9 families with other rare polyposis syndromes. In addition, the Registry receives referrals from Hospital Authority-run hospitals and private doctors. In 2005, 480 screening/surveillance procedures were performed for recruited patients. Screening of asymptomatic family members detected 7 individuals with FAP; 16 individuals with colorectal polyps treated with polypectomy; one individual with colorectal cancer; and one individual with endometrial cancer. There were 56 families that attended counseling sessions organised by the Registry.

By the end of 2005, we have successfully detected APC gene mutation in 41 FAP families, and HNPCC gene mutation in 71 HNPCC families. Genetic testing confirmed 240 individuals as carriers of the mutated gene. Regular surveillance programmes were organised for those affected.

Two self-help groups: one for FAP families and one for HNPCC families, have been established with the aim of providing support for each other.

RESEARCH

The Division actively engages in both clinical and laboratory-based research. Current research interest includes:

• Colorectal Cancer
  • Total mesorectal excision for rectal cancer
  • Adjuvant therapy for colorectal cancer
  • Laparoscopic surgery for colorectal cancer
  • Bowel function after rectal cancer surgery
  • Hereditary colorectal cancer
  • Relationship between anastomatic leakage and cancer recurrence
  • Laparoscopic versus open surgery for metastatic colorectal cancer
• Screening for high risk families
• Cancer genetics
• Intestinal obstruction
• Prospective audit on surgical outcome
• Colonoscopy
• Colorectal polyps
• Natural Orifice Transluminal Endoscopic Surgery
• Robotic surgery
• Hernia surgery

Animal Laboratory, Faculty of Medicine Building, Sassoon Road

COLLABORATIONS

Besides surgical treatment for colorectal cancer, the Division also takes an active part in adjuvant therapy. In cooperation with the Department of Clinical Oncology, preoperative chemoradiation for advanced rectal cancer and postoperative chemotherapy for colon and rectal cancers is now available for our patients.

COMMUNITY AND MEDIA RELATIONSHIP

The Division maintains a good relationship with the media by providing health education and medical advances in the subspecialty of colorectal surgery. The Division also contributes by participating in the patient education programmes of organisations such as the FAP Families and Stoma Association.