Dr. Jeff Mosko

Fay has been dealing with gastrointestinal (GI) issues for decades.

Looking back to the early 2000s, Fay, whom Unity Health Toronto agreed to identify only by her first name, says, “I was losing weight so quickly. I was running to the bathroom a lot. I was worried it was cancer.”

The mother of three and grandmother of four didn’t have cancer, but she was diagnosed with colitis and mastocytosis. Due to complications from those conditions, she had to undergo surgery in 2006 at a different hospital site to remove her colon and part of her rectum, leaving her with a temporary external colostomy bag.

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With the invasiveness of the surgery, Fay was required to stay in hospital for a month to recover. During that time, she experienced additional complications.

“I was highly, highly allergic to the adhesive on the bag,” she says. Fortunately, the external bag was only temporary, and two months after the initial procedure she underwent ileal pouch surgery, where part of her small intestine was turned into a pouch that functions as an internal replacement for the external bag.

Aside from having to go to the bathroom more frequently due to less GI space and requiring regular pouchoscopy examinations, the procedure allowed Fay to live a normal life.

Identifying pre-cancerous tissue

Until one day in 2021, during a routine pouchoscopy, Fay’s physician found a medium-sized polyp/pre-cancerous tissue. She was referred to gastroenterologist Dr. Jeff Mosko and the Therapeutic Endoscopy team at St. Michael’s Hospital to remove the problematic spot using endoscopic mucosal resection (EMR), a minimally invasive method for removing precancerous tissue from the GI tract.

The procedure was successful, but that unfortunately would not be the last time Mosko had to remove pre-cancerous tissue from Fay.

In late 2023, during another routine pouchoscopy, Mosko found that 75 per cent of Fay’s remaining rectal tissue was precancerous, and the only way to prevent her from developing cancer would be to remove the internal layer of her remaining rectal tissue entirely.

Despite some specialists involved in Fay’s care advocating for her whole rectum to be removed and replaced with a permanent colostomy bag, Mosko and the team at St. Michael’s pushed back.

“That would have altered Fay’s life forever,” says Mosko.

Fay says dealing with a permanent external colostomy bag again wouldn’t have been possible, due to the bad allergic reaction she had years prior, and was hopeful for another treatment option.

So, Mosko came up with the novel alternative.

The world-first procedure

Using endoscopic submucosal dissection, a newer and technically more challenging technique allowing for removal and cure of pre-cancerous growths, he proposed making four parallel, equidistant tunnels around the circumference of the rectum underneath the problematic internal rectal tissue. These tunnels would then be released one by one allowing for what’s called an en-bloc excision – meaning all of the at-risk rectal tissue would be removed in a single piece, while the remainder of the pouch would stay intact.

“Dr. Mosko gave me the option. He phoned me and said, ‘Look, this is your choice, there are risks with this surgery as it’s never been done before, but I want to avoid having the bag on the outside,’” she says.

“He explained everything and he gave me all the time I needed.”

With her trust in Mosko and the St. Michael’s team, Fay decided to move ahead, and the new procedure took place in February.  

The three-and-a-half-hour surgery went according to plan, though “extreme” scarring from prior inflammation and previous surgeries made the procedure challenging.

Luckily, Mosko “does remarkable stuff,” says Fay.

Unlike her previous gastrointestinal surgeries that required her to stay in hospital for many weeks of recovery, Fay didn’t have any cuts, stitches or pain, and she was able to go home in just two days due to the minimally-invasive nature of the procedure.

She says she did have to use the bathroom more frequently in the weeks following – but being able to avoid a colostomy bag and prevent cancer was a worthwhile and potentially life-saving trade-off.

“I’m just so grateful,” she says, adding Mosko provided her with excellent care. “He’s amazing. He’s so kind.”

Though Mosko says Fay’s words are “heartwarming” and remind him of “why he got into medicine in the first place,” he’s quick to shift the praise to the Therapeutic Endoscopy team as a whole.

“Our GI division has been a national and international leader in terms of minimally invasive, organ-sparing, endoscopic innovation for many years in spite of funding barriers,” he says.

“I feel very fortunate to work with colleagues who push each other to find new ways to help patients and at a hospital that prioritizes patient outcomes.”

By Kaitlin Jingco

Photos by Eduardo Lima

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