FAQ

Open surgery is easier to perform on a slim person compared to obese person. However, laparoscopy and robotic surgery enables surgeons to perform major and complex procedures even in obese patients with greater ease.

Chronic pancreatitis is a common ailment treated at all G.I.surgical centres in the country. However, the prevalence of this disease is more common in south India especially Kerala and Tamilnadu, probably due to an entity called tropical chronic pancreatitis which occurs due to consumption of tapioca (cassava).

The remedies include

• Abstinence from Alcohol and smoking
• PERT medicines ( Pancreatic enzyme replacement therapy)
• Endoscopic options
• Surgical options

Though open Frey's procedure has remained the surgical procedure of choice for alleviating the pain in chronic pancreatitis, in recent times minimally invasive surgical options(laparoscopic Frey's procedure) have made sufficient progress to provide almost the same degree of pain relief with added advantages of minimally invasive surgery like lesser pain and fewer scars , quicker onset of bowel function and recovery, faster discharge from hospital and quicker ability to get back to usual routine.

Thanks for A2A.You will get to know what your choice is, by the time you complete your house surgeon postings. You will be posted in all the departments of the hospital in turns. In surgical postings, you will assist a lot of cases and also get to perform a few minor cases under supervision, during this period. By this time, you can assess your physical fitness, interest and flair for surgery. But more than your physical stamina, it's the mental strength that matters. During your pg period in surgery, you may have to stand for long hours assisting cases, run to blood bank at odd hours, sacrifice your meals and also let go off your sleep while on duties. All these sacrifices are worth their weight in gold, in shaping your career as a surgeon. Your passion in this field and work ethic matters most when you contemplate choosing a surgical speciality.

Thanks for A2A.Combiflam is a combination of Ibuprofen 400 mg with paracetamol 325mg. These medicines are predominantly taken for fever, headache and body pain. This drug falls into the category of NSAID ( Non Steroidal Anti Inflammatory drugs). Though they may be taken 6th or 8th hourly, taking them beyond this frequency is not advisable. These kind of drugs are mild irritants to stomach, cause gastritis and need to be taken with extreme caution or preferably avoided in those with pre-existing liver and kidney problems, as they are harmful to both.

In short, taking Combiflam upto thrice a day is acceptable, beyond this is preferably avoided. These kind of medications are to be taken only for a short duration (5-7 days),until the acute episode resolves. Prolonged over-the - counter (OTC) consumption of these drugs are best avoided.

Technically Yes. In stage II liver cancer, a single primary liver tumor (any size) has grown into the blood vessels, or there are several small tumors, all less than 2 inches (5 cm) in diameter. The cancer has not spread to nearby lymph nodes or distant sites (Example: T2, N0, M0) .

If there is no extra -hepatic (outside liver) spread of liver cancer, it is curable by a Liver transplant. Though surgical resection of tumour is also an option ( in the absence of portal hypertension ), liver transplant offers the best possible chance for survival.

Beautiful question. It is in these scenarios we need to balance science and humanity, knowledge and compassion, mind and heart. As doctors, we deal with this situation differently with the patient and their relatives. We are very frank with the patient's close relatives about the prognosis of the disease and give them a fairly clear picture about how it would progress and what they need to do.

However, while talking to the terminally ill cancer patient, we put forth the most optimistic, encouraging and compassionate talk of ours to motivate them fight this ordeal. We even quote anecdotal incidents of how few patients have fought such battles and marched on. In this era of information explosion, we are aware that most patients themselves know what stage they are in, still few comforting words from the treating clinician, a smile and an optimistic reply to allay their fears, is all they require at the end of the day.

Yes, colonoscopy is a safe procedure. You will be given a solution to cleanse your bowels, initially. After that, the procedure is preferably performed with mild sedation , so that you don't feel the pain or discomfort. It roughly takes about 20–30 minutes for a complete examination of colon.This is the most important screening tool for colorectal malignancies, hence it is recommended for adults after 50 years or earlier if there is a family history of colorectal cancer. It helps detect colonic polyps, tumors, inflammatory bowel disease and a host of colonic diseases. Complications like bleeding (after biopsy of a lesion) and perforation after colonoscopy are far and few. On few occasions, you may feel a sense of discomfort due to the gas used to insufflate the colon. On the whole, it is a very safe procedure.

The best treatment for acute pancreatitis is medical management, which includes hydration with I.V. fluids, pain control, nutritional support and evaluation of the cause of pancreatitis. Antibiotics are generally not indicated in mild acute pancreatitis. Patients with severe acute pancreatitis will require ICU admission because within hours to days, a number of complications (eg, shock, pulmonary failure, renal failure, gastrointestinal bleeding, or multiorgan system failure) may develop. The goals of medical management are to provide aggressive hydration, to decrease inflammation, to limit infection and to identify and treat complications as appropriate. Evaluation of the cause of acute pancreatitis- alcoholic, biliary or others determines the subsequent treatment plan.

Thanks for A2A.The actual cost of hernia surgery would vary from one hospital to another. We, at our institute routinely perform only laparoscopic surgery for inguinal hernia unless specific anaesthetic considerations contra-indicate general anaesthesia. Laparoscopic surgery for inguinal hernia would cost anywhere between 40 to 50 k rupees. Laparoscopic surgery for hernia has proven advantages with lesser pain, no scars, early discharge and immediate return to your usual routine.

No, it does not. Citrus containing fruits and juices ( orange, lemon, grapes) are preferably avoided during acute gastritis, as they tend to aggravate the pain

My answer is simple. Alcohol is best avoided and a jaundiced patient should consider it a taboo, considering that alcohol damages a compromised liver pretty easily. If you still want to go ahead and challenge your liver, you may do at your own peril!

Thanks for A2A. Uncomplicated direct inguinal hernias in old age patients, with multiple co-morbidities, may be observed and surgery deferred, if patient is asymptomatic. Otherwise, I believe, there's no need to delay surgery in a 45 year old fit patient. Laparoscopic inguinal hernia surgery is a relatively straightforward procedure and you can get back to your routine, the next day.

General Surgeon or a Urologist. If you have a family physician or general practitioner, first consult with him and then go for a specialist opinion. That's the best way to go about it.

No, gall bladder surgery has got no effect on liver size.

Thanks for A2A. You cannot remove gallbladder stone without surgery. Stones in the bile duct can be removed by endoscopy. Gall bladder stones, will require surgery. Laparoscopic cholecystectomy (gall bladder removal) is a relatively simple day care procedure and that is the best option too.

Medical advice on internet is a tricky issue. Unless answered to the point, by a qualified specialist, it would be too vague and nonspecific. In addition, general search on the internet for a medical issue would crop up too many unnecessary issues in this regard and create stress and anxiety for the patient. I advice patients to clarify whatever doubts they have with their family physician or a specialist instead of “googling” them.

Thanks for A2A. Surgical Gastroenterologist operates on diseases affecting the digestive tract, starting from oesophagus to anal canal. This speciality has branched into multiple subspecialities like:

• Upper GI surgery- Surgeries on Oesophagus, Stomach
• Colorectal Surgery and Proctology- Surgeries on colon, rectum, anal canal
• HPB surgeries- Surgeries on Liver, Pancreas and biliary system.
• Bariatric and Metabolic surgeries- Surgeries on stomach and small bowel for weight loss and diabetes control
• Liver transplantation.

Hence, a surgical gastroenterologist trained in India will pursue a Mch or DNB G.I.SURGERY degree where one will be trained in all these surgeries and can then consider specialising in one particular subspeciality. Considering that we are living in the era of minimally invasive surgery, training in laparoscopic or robotic surgery, helps one practice as a competent surgical gastroenterologist.

Bilirubin does not cause cancer directly. In cancers affecting the biliary system, bilirubin may be raised. Whenever there is a tumour in the bile duct, periampullary region (around entrance of bile duct into duodenum) or head of pancreas, the flow of bile into duodenum is obstructed and manifests as raised bilirubin on liver function test. Raised bilirubin may be associated with yellowing discolouration of eyes, passing high coloured urine, clay coloured stools, fever with chills and pruritus(itching) . This symptom complex of “Obstructive jaundice”needs immediate evaluation.

An interesting question. A good sleep, calm mind and a lion's heart are the essential pre-requisites that determine the surgeon's temperament during a major surgery. Though too much of introspection or preparation may not be required, the following points need to be taken care of, before you begin a major surgery:

1. A thorough pre-operative planning of the procedure is essential before complex surgeries. Surgeon needs to discuss the CT/, MRI in detail with the radiologist to clarify and confirm certain issues like exact location of the lesion, its proximity to major blood vessels, probable arterial or biliary anomalies, the future liver remnant ( in cases of liver resection).

2. Similarly, the anticipated duration of the procedure, the estimated blood loss or the probable need for transfusion has to be discussed with the anaesthetist.

3. The scrub nurse needs to be briefed about the plan of surgery, the list of instruments and type of suture materials required. (Though most experienced nurses would know this, it is better to cross-check before you begin the surgery to avoid temper flares!!)

4 The plan of the surgery, likely complications and the post-operative course has to be explained to the patient's family in detail and consent obtained.

All these would probably be the most important part of the "surgeon's preparation". Any other administrative issues, family and social commitments generally take a back seat once you enter the operation theatre.

“A calm and uncluttered mind ensures a smooth surgery."

Technically and theoretically, Yes. There is a risk of needle tract seedling when doing biopsy for a cancer.

In certain conditions like liver tumors, when imaging modalities are quite obvious, doing a pre-operative biopsy on clearly resectable lesions are to be avoided. Biopsy is done only if the diagnosis is doubtful or when other non-operative treatment modalities are contemplated. However, in certain situations doing a pre-operative biopsy is unavoidable. Hence, certain surgical principles need to be adhered to while doing biopsy on a cancerous tissue. For example,

1. In case of pancreatic head tumors, it is always preferable to do an EUS (endoscopic ultrasound) guided Fine needle aspiration cytology/ biopsy over a percutaneous ultrasound guided biopsy, as EUS biopsy is performed through the lumen of bowel (trans-luminal)and there is no spill of tumor cells outside the tumor region.

1. Willingness to listen to the patient's history and symptoms.
2. Ability to communicate perfectly.
3. Art of gaining confidence of the patient and their family.
4. Being frank and honest in their explanation about patient's condition and prognosis.
5. Not being too judgemental or dismissive towards treatment offered by their colleagues for the same condition.
6. Being extremely knowledgeable and having a keen desire to constantly update the latest technique in their speciality.
7. Being punctual, having a strong work ethic and paying attention to minute details in providing excellent patient care.
8. Taking responsibility for the entire team.
9. Ability to treat co-workers, juniors and staff nurses with respect
10. Most importantly being humble and having feet firmly on the ground.

The cause of acute liver failure needs to be ascertained at the earliest. He needs to be listed for a liver transplant and the workup needs to be done. The prognosis depends upon

• Degree of hepatic encephalopathy( hepatic coma)- poorer with higher degrees
• Age - <10 or > 40 years carries higher risk
• Extent of prolongation of PT (prothrombin time) - if coagulation parameters are grossly altered, prognosis is poorer.
• Cause of acute liver failure- better with acetaminophen toxicity and certain viruses like hepatitis A, poorer with conditions like wilson's disease.

There are criteria called King's college criteria to stratify the risk and prognosticate patients with acute liver failure. These criteria will help define the risk better and decide the urgent requirement for liver transplant.

Haemorrhoids treatment by rubber banding is done by Surgical Gastroenterologists/ General surgeons with experience in Proctology. There are limited indications for rubber banding for haemorrhoids, hence consult your specialist and let them offer the best type of treatment based on their clinical examination. That's the best way to go about it.

The simple reason being , allopathic medicine is based on evidence and is more scientific.

Every allopathic medicine has :

• Its own mechanism of action,
• Pharmacokinetics and pharmacodynamics,
• Dosage range- based on age and body weight
• Safety profile and probable drug interactions
• Side effects and contraindications.

Add to all this, the structured learning programme of allopathic medicine and the strong marketing strategy of pharma companies.

Hence alternate forms of medicine need to go a long way before they catch up with allopathy (which I doubt will ever happen!!).

I am afraid to say, both may not cure an alcoholic liver disease because there's no evidence to say it does , at present.

Thanks for A2A. All Gall bladder polyps ( GB polyps) do not require surgery. In fact, surgery for gall bladder polyps is required only in following conditions:

• GB polyp more than 1 cm.
• Symptomatic or rapidly enlarging GB polyp.
• Polyps with associated gall stones or Age > 50 years.
• GB polyp of any size, associated with a condition called primary sclerosing cholangitis, is an indication for surgery.

Asymptomatic GB polyps of size 6-9 mm can be followed up by an ultrasound scan (USG) after 6 months. If that USG is normal, the next scan can be done at 12 months. If the second scan is normal too, patient can just be asked to follow up.

Just remember that asymptomatically detected small GB polyp does not warrant surgery. It's a combination of risk factors (as mentioned above) that need to be assessed before contemplating laparoscopic cholecystectomy for GB polyp.

Thanks for A2A. All Gall bladder polyps ( GB polyps) do not require surgery. In fact, surgery for gall bladder polyps is required only in following conditions:

• GB polyp more than 1 cm.
• Symptomatic or rapidly enlarging GB polyp.
• Polyps with associated gall stones or Age > 50 years.
• GB polyp of any size, associated with a condition called primary sclerosing cholangitis, is an indication for surgery.

Asymptomatic GB polyps of size 6-9 mm can be followed up by an ultrasound scan (USG) after 6 months. If that USG is normal, the next scan can be done at 12 months. If the second scan is normal too, patient can just be asked to follow up.

Just remember that asymptomatically detected small GB polyp does not warrant surgery. It's a combination of risk factors (as mentioned above) that need to be assessed before contemplating laparoscopic cholecystectomy for GB polyp.

It cannot. Please don't fall prey to false promises and lose out on the window of opportunity to get your tumour operated. As such that window is quite small, considering that it is a biologically aggressive tumour.

We have proceeded this far in the management of cancer only because of research. Cancer is a battle that needs to be fought scientifically to reach the goal of cancer cure. All the success stories of cancer survivors that we come across, is only due to mammoth research done so far in surgical techniques, chemotherapy and radiotherapy. With ongoing research and future trials, the fight for cancer cure will get stronger with gene therapy, epigenetic drugs, immunotherapy and precision medicine with gene sequencing.

“So there's always light at the end of the tunnel.”

Be optimistic.

Though most physicians with good clinical acumen would agree that prescribing antibiotics indiscriminately would lead to antibiotic resistance, the practice is unfortunately quite prevalent among general practitioners. Strict antibiotic protocols and strong legislations are needed to curb this practice to prevent the emergence of drug resistant strains in the future.

I guess, the image of doctors in the society depends on the perception and outlook of Indian patients . Though most doctors are sincere, genuine and humane in their approach, unrealistic expectations from patients and inadvertent false promises given by few doctors lead to stray incidents of mob fury and attack on doctors (which unfortunately is on the rise!) in recent times. Here again, media needs to handle this sensitive issue with utmost concern and rationale.

“The pen is mightier than sword and in a few cases the surgeon's scalpel too.”

The essential pre-requisite for a successful doctor- patient relationship is the trust and confidence that the patient has on his clinician. It is the mutual responsibility of both, to ensure that this trust is not shaken anywhere through the course of treatment.

“A happy and satisfied patient will remember you for his lifetime.”

The cancer needs to be staged and the treatment plan is generally taken at a multi disciplinary tumour board meeting. If the tumour is large, locally advanced, infiltrating adjacent structures or if there is bulky nodal disease initial chemotherapy is considered. This is done to downstage the tumour and reduce the size, to make it amenable for resection. In all other scenarios, surgery is considered upfront. However, if the patient has metastatic disease( where cancer has already spread to distant sites), palliative chemotherapy is required.

Yes. Gall bladder (GB) cancer T2N0 needs to be treated by a surgical procedure called radical cholecystectomy. In this procedure, gall bladder, wedge of liver adjacent to gb fossa, all lymph nodes and fibro fatty tissue adjacent to gall bladder , nodes in the hepato- duodenal ligament, nodes along common hepatic artery upto celiac origin, needs to be removed completely. After complete surgical removal, the specimen is sent for a detailed histo- pathological analysis and further plans regarding adjuvant (post-op)chemotherapy is taken at MDT (multidisciplinary team meeting). With the completion of adjuvant chemotherapy, the person needs to be on a regular follow-up protocol as advised by the treating clinician. Though Gall bladder cancer is generally considered an aggressive malignancy, 5 year survival rates for completely treated stage 1 cancer is around 50% and stage 2 is around 28%, as per American cancer society data.

As per literature evidence, biliary colic (pain due to gall stones) develops in 1–4% of patients with gall stones annually. Acute cholecystitis develops in 20% of patients with biliary colic, if left untreated. The incidence of acute cholecystitis has been decreasing in recent times, owing to increased acceptance of laparoscopic cholecystectomy as treatment for symptomatic gall stone disease. Hence, in most cases, patients may not wait until they suffer an attack of acute cholecystitis.

A middle aged person should not take much time to recover from a relatively straightforward procedure like laparoscopic cholecystectomy. There are centres practising lap chole as a day care procedure, hence you don't expect to see much of weakness or fatigue with this procedure.

“ So get up and get back to work at the earliest”.

The true advantage of laparoscopy lies in lesser pain, quicker discharge and early resumption of normal activities.

Thanks for A2A. Surgery is the only curative treatment for inguinal hernia. If there's no pain or discomfort, you may postpone the surgery as per your convenience, but you would eventually require surgery, sooner or later. I have answered a similar question on the same topic. Sharing that answer here:

Srivatsan Gurumurthy's answer to In case of a right inguinal hernia, if the defect is small (19mm) & reducible for people at the age of 45, can we delay the surgery to several years, until the defect is not painful & doesn't bother activities of regular life?

Yes, all laparoscopic surgeries can be recorded. The decision to offer the patient, a copy of the surgical video is the discretion of the operating surgeon. Though this may not be required for routine surgeries, while performing difficult surgeries or when there are rare and interesting intra operative findings, I generally find it easier to explain to patient attenders about the procedure with intra operative pictures or short video clippings. This brings in a lot of transparency and helps us gain the confidence and trust of patient's family, especially while making them understand the complexity of the procedure, the risks involved and the probable post operative outcomes.

Any stage 4 cancer is considered to be metastatic, wherein cancer has already spread to sites distant from primary origin. Depending upon the site of tumor, the prognosis of stage 4 cancer may vary, however the intention of treating stage 4 cancer is palliation ( alleviation of symptoms and improvement of quality of life, palliative chemotherapy ) and not cure. However, no two stage 4 cancers are alike. For example stage 4 colonic cancer has a better prognosis compared to stage 4 gall bladder cancer where the outcome is dismal.

Regarding turmeric water, I have no evidence to say it is useful.

Yes, Most of these non-invasive studies like usg, ct or MRI can pick up stomach cancer as an abnormal thickening of the wall of stomach. However, an upper GI endoscopy is mandatory for the following reasons:

• The exact location of the lesion
• Biopsy of the lesion to confirm whether it is malignant and to know the subtype and grade of cancer.
• The proximal and distal extent of the tumour to plan the type of surgery

The above mentioned details, especially the histopathological proof of cancer, is only provided by an endoscopy by performing biopsy, hence imaging modalities can't substitute an endoscopy in the diagnosis of cancer stomach.

Pancreatitis is treated by Gastroenterologists -both medical and surgical, as this disease requires a multi disciplinary care.

To subspecialise this further, surgeons who operate on liver, pancreas and biliary system are called Hepato-Pancreatico-Biliary (HPB) surgeons.

I have answered a similar question on this topic. Providing the link for the same here: Srivatsan Gurumurthy's answer to How do surgeons prepare themselves before performing a surgery?

Current progress in immunology-based therapy targets the highly heterogeneous pancreatic tumor immunosuppressive microenvironment.

Novel therapies targeting the tumor microenvironment with an aim to decrease the resistance to chemotherapy, improve immune tolerance and increase the efficacy of the current treatment have shown some promising preliminary results in preclinical and clinical trials.

However, these are yet to be used in clinical practice and hence adjuvant chemotherapy with gemcitabine plus cisplatinum, would be ideal for your mother, now that she has been operated.

I guess that seldom happens in medical science, today. Most of the clinicians practice evidence based medicine. So a doctor, or a surgeon would never be party to a procedure just because his senior insisted on that.

There may be times when the senior could have a different view or opinion regarding the choice of treatment or plan of surgery, which is discussed before hand by the team and the final decision is taken in concurrence with the entire team, not as per the whims and fancies of a single person.

However, there could be rare instances of senior people taking autocratic decisions, it is unfortunate if a young surgeon lands up with such a person.

Surgery is the only definitive treatment for inguinal hernia. Having said that, an uncomplicated, small,direct inguinal hernia which is asymptomatic need not be operated upon, especially in a 82 year old person.

Laparoscopic inguinal hernia repair may be offered if the patient is symptomatic and if he clears the anaesthetic and cardiac fitness required to undergo the surgery.

Unlike other cancers, stage 4 colon cancer has a slightly better prognosis. Hence, multiple treatment options are available. For instance, in most of the intra abdominal malignancies, cancer spread to liver would mean only palliative chemotherapy and no surgery.

However, for Colon cancers Liver resection is a part of treatment strategy for stage 4 colon cancer depending on the number, extent and location of the metastasis in liver.

So, stage 4 colon cancer isn't a dismal condition, unlike most of the other malignancies. A lot of medical, surgical and chemotherapeutic options are available and the ideal approach is taken for the individual patient at a MDT ( MULTIDISCIPLINARY TEAM MEETING).

In this perspective, alternate medications or home remedies are best avoided as they are not backed by adequate scientific evidence.

Laparoscopic cholecystectomy( removal of gall bladder) usually takes around half an hour, for uncomplicated cases, in experienced hands. However surgery on acutely inflammed or gangrenous gall bladder may take more than an hour.

Thorough delineation of anatomy and demonstration of the “critical view of safety” are of paramount importance in performing a safe laparoscopic cholecystectomy.