To say the least, it was a ' sage' experience! My first attendance at the Society of American Garstrointestinal and Endoscopic Surgeons' International meet at Baltimore, 3rd-6th April, 2019. I had sent in an abstract on ' Cholelithiasis in Sickle cell disease’, this particular complication and it’s therapeutic surgical challenges being a part of my day to day surgical practice, as sickle cell is a major health issue in Vidarbha in Central India. My abstract was accepted as an eposter and was part of the ongoing display at the conference. As an icing on the cake, I was selected recipient of the prestigious Margret Ottsdottir travelling fellowship award,which is awarded by the SAGES Foundation to an international woman delegate for her professional work as assessed from her CV. Margret Ottsdottir was an exemplary general surgeon who hailed from Iceland and did extensive work in laparoscopic foregut surgery, including achalasia and oesophageal malignancy. She died prematurely in 2009 and her colleagues have instituted the award in her memory. I am extremely proud to have been selected for this honour in memory of a great surgeon. The award winners' luncheon on the first day of the conference was an amazing personal experience for me, getting recognized amongst the ' Who's Who’ of American Garstrointestinal Surgeons. The award was presented to me by Prof John Hunter and Dr Desmond Birkett. I also had the privilege of giving an acceptance speech! The event brought me up and close with dynamic young surgeons and researchers, innovators and pioneers from all over the world. The various sessions in the program were wonderfully chalked out and I attended hepatobiliary pancreatic ( HPB) , bariatric, hernia and abdominal wall reconstruction and colorectal cancer sessions over the 4 days. The volume of work, the excellent surgical ( laparoscopic and robotic) techniques, , the trouble shooting sessions, the discipline in maintaining and presenting records and studies, the surgical videos and papers presented by the Bold and the Beautiful, all made for a comprehensive and eye-opening experience! The session on ' mishaps and disasters' in HPB, on the first day, candidly addressed issues on management of a surgeon's worst nightmares. The International Hernia Collaboration symposium on large ventral hernias and AWR, was a great learning experience. The various sessions on bariatric revisions, solid organ videos, laparoscopic and robotic techniques in GI and HPB surgery were awe-inspiring. The content of the eposters was excellent. The highlight of the conference was the morning session on day 3, the Presidential address by Jeff Marks on ' Defining Passion'. His passion for ' everything in surgery' to ' everything in life', was punctuated by a run on the treadmill with a strong message that running on a treadmill can get you nowhere, was hard hitting! One must hit the road to get work done! Dr Marks's introduction of his mentor, Dr Jeffrey Ponsky and the latter's exemplary presentation on the development and application of Endoscopic Intramural Surgery over the past 40 years, was tremendously inspiring! I also had some good interaction with some scientist technology innovators. I also tried my hands at the robotic simulator and used some amazing upcoming surgical devices in the trade exhibition hall. We visited the most reputed Johns Hopkins Medical Center in Baltimore, where Dr Amita Gupta gave us an insightful tour of the historic institution and medical school. Having read about the founding members of this great hospital in the annals of surgical history, I was particularly interested in visiting it. The overwhelming and vibrant participation of so many women MIS and robotic surgeons was truly heartwarming. Thank you SAGES, for the knowledge, the inspiration, the honour and the experience !
As we advance into every new year, we look back at what we gained or lost in the past year and what we need to resolve for betterment in the year ahead. While gains are good in all other aspects, abnormal or excess weight gain is not. Body weight in excess of the ideal prescribed for our height and age, causes serious adverse effects on our metabolism. It causes abnormalities in insulin secretion thus affecting glucose metabolism, leading to type 2 diabetes. Obesity is associated with hypertension, lipid profile abnormalities, cardiac disease, obstructive sleep apnoea ( Pickwickian syndrome), increased predisposition to cancers, arthritis, back pain, etc. Homo Sapiens evolved by subsisting on natural foodstuffs grown from the Earth and by consuming meat of animals. Gradual refinement in lifestyle, eating habits, use of preservative chemicals in food, consuming less fibre and more carbohydrates, lack of exercise, has led to a global obesity pandemic, along with all its associated complications. Management of diabetes is complex and mostly lifelong. In the era of raging debates between advocates of various types of diets such as keto, vegan, paleo, frequency of meals, intermittent fasting versus frequent small meals, it is difficult to achieve a fine balance between weight management and blood sugar control. A person is said to be morbidly obese when his/her Body Mass Index BMI= weight in kg/ (height in m)2 exceeds 35. Blood sugar management is extremely difficult in morbidly obese patients. Bariatric surgery ( also known as Obesity surgery/ Metabolic surgery) provides an effective solution to such patients. Different bariatric procedures are tailor made depending upon various patient criteria, such as BMI, diabetes mellitus, age, diet, occupation, comorbidities. All the procedures are performed using minimally invasive ( laparoscopic) techniques. The commonest procedures are sleeve gastrectomy, Roux-en- Y gastric bypass with or without band, mini gastric bypass, duodenal switch. They may be restrictive or malabsorptive or a combination of both. They bring about physiological changes in the gastric and intestinal hormones that regulate appetite and glucose and fat absorption, for eg. Ghrelin, intestinal polypeptide, pancreatic polypeptide, PYY. Newer procedures such as endoscopic gastric plication, artificial bezoars are undergoing trials. Bariatric surgical procedures bring about weight reduction, better control of blood sugar and insulin levels and thereby cause resolution of other obesity related metabolic issues. They also improve mobility, stamina, fitness, confidence. Public health authorities have now identified obesity as a disease and the government is now implementing various programs to curb it. Let us all pledge to stay lean stay fit!
Hernia is scientifically defined as the abnormal protrusion of a viscus from one cavity into another through an opening in the walls of its containing cavity. Hernia presents as a swelling that can be felt on the abdominal wall, the common sites being the groin, through the belly button or through an old surgical scar or through a gap in weakened abdominal muscles. Accordingly they are known as inguinal, paraumbilical, incisional or ventral hernias respectively. The swelling may reduce on manual pressure (reducible) or irreducible. Hernia is made up of a sac of thin membrane derived from the peritoneum lining the abdominal cavity. The sac may contain omentum (the fatty tissue that covers the intestine) and/or small intestine. Groin hernias are more common in men than in women. They occur due to laxity of supporting muscles and ligaments along natural defects in muscles. Incisional hernias occur through weakened surgical scars and may be very large. They are more commonly associated with obesity, wound infections and poor abdominal muscle tone and increase in size due to raised intra abdominal pressure such as long standing cough or chronic constipation. Complications: The most dreaded complication of a hernia is intestinal obstruction, wherein a segment of the contained small intestine may suddenly become irreducible, swollen and lose its blood supply, thereby resulting in gangrene of the intestine. Hence, it is necessary to surgically treat hernias before they get complicated. Treatment: The only treatment of a hernia is surgical repair. the surgical procedure comprises opening the hernial sac and reducing its contents, clearing all adhesions between the contents and repair of the primary defect. The defect is most commonly repaired with the use of a net-like implant, which is known as a “mesh”. The mesh helps in reinforcing the supporting structures in order to prevent recurrence. This procedure is now done laparoscopically. This helps in reducing the hospital stay, reducing postoperative pain and ensuring early return to work. the mesh is a highly sophisticated implant which is hypoallergenic, tissue friendly and easily assimilated into body tissues. It is fixed into place with the use of a specialized fixation device. With the use of advanced technology and minimally invasive techniques such as laparoscopic IPOM, TAR, component separation methods, even large and multiple hernias can now be managed very efficiently. Internal hernias: Diaphragmatic hernia, hiatus hernia are internal hernias, where abdominal organs get pushed into the chest cavity and cause symptoms. The treatment of these is also done laparoscopically and will be discussed in a separate blog.
I first heard the term ' general surgeon' during my school days. Unable to understand what 'special' a general surgeon does, in those days of being medically ignorant, I kind of gave it a thought and brushed it away! A few years later, I entered medical college and as a student posted in general surgery, was left wide-eyed with the magnitude of work a general surgeon does! From performing complex gastrointestinal surgeries, onco-surgeries, thyroid and parathyroid surgeries, to running around the campus arranging blood for patients, doing dressings, taking rounds and finishing off the day or rather night performing emergency and trauma surgeries, all in a normal day's work! The OT is a beehive of activity, with patients being shifted on and off tables, surgeons, nurses, anesthesiologists, support staff, all work in sync with each other. The palpable excitement, the silent jubilation, the sheer variety of cases, totally hypnotized me into dreaming of becoming a surgeon! I found love in 'Bailey and Love', every page thrilled me and I succeeded in entering the realm of a budding surgeon as a post graduate resident. The joy of working with one’s hands and making someone perfect again, the satisfaction after performing a challenging operation confidently, the feel of warm tissues between our fingers, the soft feel of the abdomen as the patient recovers, all blur into Oblivion, the dirty dressings, lack of sleep, cramped hostel rooms and the chiding by the Registrar! The reward is Pure Bliss! Then laparoscopy came and made life both complex and simple at the same time! Complex because of the learning curve, getting versed with hand-eye-brain coordination, and the dependence on technology, a new feat for not-so-techno-savvy doctors! Simple, because it was so simple, for patients! Even today, when we do advanced extensive laparoscopic surgeries, the patient thinks it’s a ' chotasa durbin operation'! Good for them! What impressed me about general surgery was the wonderful scope and variety of organ systems that we treat! Everything except the heart, brain and bones comes under the purview of a general surgeon. We are empowered by our training, experience and qualification, to operate across a wide range of sub specialities. Our dexterity at handling all types of tissues, from muscle to intestine and thyroid to pancreas has made us ' Generals' of all systems. This whole idea of being able to do everything and anything to precision, thoroughly matched my personality trait of wanting to do everything! Our generation of general surgeons are blessed to be born into the world of conventional open surgery, trained ourselves in minimal access surgery and are now learning robotic surgery and using artificial intelligence! Hence we are in the best position to understand any body tissue, having begun with our not bare, but gloved hands! Sadly today, youngsters who specialize in more focused areas, look down upon general surgeons. We get experiences where young new super specialist practitioners come up and say, ' do call me if you need help'. One feels like saying, “Baby, you were in your crib when we had donned our cap”! In a conference I attended recently, it was saddening to hear one general surgeon say to another, “Don’t think like a general surgeon who does nothing”! It’s actually the other way round! A general surgeon does everything! It’s time we celebrate our work and respect ourselves! Every surgeon is primarily a general surgeon, because one cannot bypass MS before going into more focused areas. We are in fact masters of our trade, taught to us by the famous Sushruta, Kocher, Carrel, Halsted and the like. We are, in fact, the ' Surgeon Generals'!
Breast cancer is the second most common malignancy in women all over the world, second only to cancer cervix. It's rising incidence in India must set alarm bells ringing in our collective minds if we have to achieve good survival rates. At present, the 5-year disease-free survival rates in stage 2 are a dismal 60% as compared to those of about 85% in the western countries. The main reason for the unfavourable statistics arises from the following factors: a) lack of 'breast awareness' b) absence of national screening programs c) misunderstanding about treatment modalities d) social and psychological make-up e) defaulting from treatment and regular follow up Although we do not have a structured National Screening program for Breast cancer, we do have all the modalities that constitute these programs in the western countries, namely, clinical examination, mammography and fine needle aspiration cytology, easily available in most centres. The most important factor in achieving cure, is early detection of disease and it is precisely for this reason that one has to be 'breast aware'. Breast self-examination must be performed by every woman above 40 years of age. In the presence of suspicious findings, your doctor will be ready to give you correct advice. Mammography is a simple and sensitive radiographic examination that helps distinguishing non-cancerous from cancerous lumps. Needle aspiration biopsy is another excellent tool used in diagnosis. The treatment of breast cancer is multimodal and individualized depending upon many complex factors. it includes surgery along with other scientific treatment methods as per various criteria. As of now, there is no vaccine available to prevent breast cancer. until such a time that the disease can be totally prevented, the society as a whole can help by encouraging their fellow women to get themselves regularly screened for breast cancer so as to achieve very high cure rates. October is commemorated the world over as, Breast Cancer Awareness Month and so let us all pledge to become 'BREAST AWARE'!
The obesity pandemic has long achieved epidemic proportions amongst Indian women. Although more of a lifestyle disease, race, heredity, associated medical problems such as hypothyroidism, polycystic ovaries, various psychosocial factors influence the incidence of obesity. 5% of the Indian population is morbidly obese, having BMI above 35 kg/m2. About 50% of these are women. The prevalence of obesity is more in North and West of India, largely due to diets rich in carbohydrates and fat. Although we are all aware that a healthy diet and adequate exercise are the necessary prerequisites for optimum weight, we tend to bend good advice as per our convenience. Obesity is associated with a gamut of metabolic diseases, the most common and ominous of which, is type 2 diabetes mellitus, the combination of the two, now being termed, ' diabesity'. Hypertension, cardiac disorders, respiratory insufficiency, obstructive sleep apnoea syndrome, joint pains, are all secondary to obesity. A disciplined lifestyle prevents obesity. Management of obesity includes multiple approaches. Diet: a balanced diet containing carbohydrates, proteins and fats in proper proportions is a concept that we have understood since long. A structured, customized diet is one which is required for weight/ fat loss. Restriction of dietary carbohydrates results in fat loss, by inhibiting insulin spikes in the blood, this is the phenomenon which speeds up conversion of dietary carbohydrate into deposited fat. Recent research has revealed that healthy fats should not be entirely eliminated from the diet. Minimizing intake of simple carbohydrates such as sugar, results in better utilization of nutrients and fat loss. Thus, one must avoid eating refined and processed food that is high in carbohydrates. Exercise: Regular exercise under expert guidance aids in mobilization of stored fat. A combination of aerobic as well as anaerobic exercises is desirable to achieve optimum results. Estimation of fat percentage helps in attaining desired goals. Exercise boosts metabolism and also brings a sense of well being. Adequate care must be taken to avoid gym related injuries and requisite protein intake must be maintained in order to aid muscle repair. Surgical Management of morbid obesity: A severely obese person is unable to exercise efficiently due to various logistical reasons. For such morbidly obese patients, bariatric surgery provides the solution. Patients with body mass index above 35 kg/m2 and those with BMI above 30 kg/m2 with associated co morbid conditions, Bariatric surgery is an extremely effective method of management. Bariatric surgical procedures may be restrictive or malabsorptive, or a combination of both. It is a life changing surgery in that it not only improves the health and well being of the person, but also brings about a magical welcome change in overall personality. Bariatric surgery is thus a boon for our times.
A lot is being said about medical students not getting good grades (read marks).I haven’t quite attended the silver jubilee reunion of my batch yet,nor do I have silver-streaked batchmates, but back in our time, the 1st MBBS student was quite a prototype! Late in the 80’s (yes, that’s when i stepped into the imposing structure of LTMMC,Sion hospital), a 1st year budding medico used to be an aproned, stinky, commonly bespectacled coy boy/girl wonder with a dazed look in the eye! The stench came essentially from the said apron which absorbed the odours of the anat hall and the Physio and biochem labs all-in-one. Those were the only places where it used to see the light of the day,being wrap-rolled and thrust amidst books in the dull college-bag of the time. About once a week, the odour used to make its way to the mothers’ nostrils and would then receive a well-deserved laundry, only to be assigned to the same fate as the week wore on. The spectacles were the baggage one accumulated on way from the English medium school to the hall of fame, aka the std XII merit list of PCB! The daze came from a variety of sources. For one, the wonder boy/girl had metamorphosed from a bookworm to a half-butterfly, still confused about how much to spread its wings, lest the seniors spot it as a vulnerable target for a rag! Secondly, the said wonder, the apple of the parents’ eye, suddenly finds himself/herself in a whole classroom full of such apples. So, down comes the collar again! Then again, the 1st part exam results get publicly displayed on the individual department notice board and the wonder (who has never seen a red mark in his life), begins to ponder over the sudden debacle. So, all in all, LTM or Lo Ti Ma, as it was called, was full of such bright beginners who were forced to put on a brave face! Then the Professors in the lecture halls and the Lecturers in the tutorials began to sermonise on the brief history of Anatomy and Physiology and the list of books with foreign names was endless, adding to the poor child’s confusion about what to buy and what not to buy out of their middle class pockets. So the conflict between Gray and Last and Cunningham had to be resolved by a cunning lasting decision with due strain on the grey cells! The girls and boys loved to show off their 5kg books that somehow got assimilated into their brains. The millennium changed and so did medical students! We went round to the other side of the table and expected to see a hapless novice with a similar countenance across it. But lo and behold! This was no hapless teenager! This is a smart, hair gelled, slick, confident individual who can look a Professor in the eye! He/she carries a chic cell phone and may be a tablet PC. He is not burdened by 5 kg books anymore, his biceps have rather grown in the gym, actually! He carries cash, but not for books though. He hasn’t heard of a guy called Guyton because he has a pocket sized version of a physiology encyclopaedia in his starched apron! Why go for a Gray when even a Chaurasia has abridged itself! Reading and understanding is out of fashion, man! Ready-to-eat-and-reproduce guides are the name of the game. Has medicine become pocket sized? Point to ponder, isn’t it? Dr Guyton and Professor Gray would turn in their graves! I think it’s time we learnt the back-to-basics game, for basic is what is going to take us places. It’s not marks on the notice board, but sound knowledge of physiology that’s going to be translated into proper prescriptions for patients or understanding of anatomy that is going to make skilled surgeons of tomorrow. So, medical teachers and students, give it a thought and see your grades and dreams soar!