Physician at Work: Knowing when not to operate

For colorectal surgeon Walter E. Longo, MD, the biggest challenge of his job isn’t standing on his feet for hours in the operating room. “For people with benign disease like hemorrhoids or diverticulitis, or other situations where surgery may be problematic, the real art of surgery is to know when not to operate,” he said. Longo estimates that for every five patients he sees in surgical consultation, one or two don’t need surgery.

When patients have such serious conditions as colorectal cancer, Crohn’s disease, and ulcerative colitis, Longo may perform coloanal anastomosis, strictureplasty, or the J-pouch procedure. He is able to achieve a greater than 90 percent success rate with the latter procedure, which involves removing all of the colon and rectum and making an internal reservoir from small intestine that is situated where the rectum would normally be, eliminating the need for a colostomy or ileostomy. He also operates on patients with low rectal cancer so that they don’t need a colostomy and on women who have suffered obstetric trauma to repair the sphincter. And he performs screening colonoscopies.

Longo has honed his skills through more than 5,000 colorectal procedures he has performed on patients ranging in age from 18 to 100. He often collaborates with colleagues in gastroenterology, medical oncology, and radiation oncology to manage his patients’ treatment. His interactions with patients benefit from Longo’s own family history—his father suffered from rectal cancer and survived 31 years. Longo sometimes faces situations that are equally challenging. He recognizes that, for a patient with a limited life expectancy, extensive surgery may not be the best course of action, and may only prolong hospitalization.

His biggest joy, he says, is supervising surgical residents. It is also a huge responsibility. “I teach them how to be accountable, take ownership of their patients, and, above all, be professional,” he said, adding that working with young doctors has its rewards. “They always challenge you professionally,” he said. “Being around young people keeps you current and up to date, and it keeps you excited.”

- Originally published in the September 2009 issue of Yale Practice.