Friday, 13 October 2017

Laparoscopic Surgery: Why it is a boon?

                            Laparoscopic surgery is not a new word for most of us. People in general are quite aware of this mode of surgical treatment, that it is better than formal open surgery in terms of recovery. And it is not uncommon for patients to demand laparoscopic surgery for various surgical treatment they need. It is really good that people are aware of their options and are asking for it. 

                             Today  I feel like talking  about aspects of this modality of surgical treatment that people are not much aware about. Laparoscopy means Lapro that is your tummy and scopy means a telescopic camera, thus any surgery of abdomen that is done by a minimal invasive method using a telescope is called Laparoscopic surgery. Similar modality used for any surgery of your chest is called Thoracoscopic surgery. Thus a surgery is performed by making very small incision (cuts) in your tummy and inserting instruments and a telescopic camera through it and performing surgery. Whatever is done in your tummy  is seen on the monitor in the operation theater and thus a big cut in your tummy is avoided.   
                           The general perception is that the faster recovery is due to the small cut on the skin. My patients commonly ask me " Sir how many stitches I will get?" , and I always say it does not matter. What people don't know is that, the wall of your tummy is itself an organ. Just like your leg and hands, and it is not just skin but multiple layer of muscles, fat and skin. It has many important function also, like they are the key muscles in your basic body function like breathing, coughing, passing stool and urine. They are also very important for different body movements like bending, lying and getting up. Any decrease is the health of the wall of your tummy affects you in multiple ways. And laparoscopic surgery does not just reduce the length of scar on the skin but also on the whole wall of your tummy. Hence it helps to maintain the natural strength of your tummy, causes faster recovery, less breathing problems after surgery and decreases the chances of hernia through the operation site.     

                            It is a technically demanding skill, and also needs very specialized equipment. Fortunately with time there has been significant advances in the instruments and skills of surgeons. So the technique which was previously used for some basic surgeries like gallbladder and appendicectomy is now widely used for even very complex surgeries like cancer, weight loss and other major surgeries of your tummy and chest. For a lot of medical conditions, surgery was previously avoided due to the complications and poor recovery with open surgery and patents used to suffer, with no option of an effective treatment with low complication rate. But with laparoscopy, the recovery being faster and complications less, many of these diseases are very effectively treated with laparoscopic surgery with acceptable rate of complications. The patients are being able to walk within hours of surgery, can take liquids and diet very early depending on the type of surgery and are being discharged very early due to laparoscopy.         

                           Thus I would like to again reaffirm that " There is much more to Laparoscopic surgery than mere small scar and your tummy wall is not just skin but an active organ of your body".

Disclaimer: The same article has been published by me on

Sunday, 1 October 2017

Making genuine information available to the patients: Need of today's time

                      A lot of doctors get irked by the patients who come to their clinic with a self made diagnosis by reading a lot of things on Google. Sounds fair to some extent, because they come with the wrong facts firmly embedded in their head. This makes it difficult to treat them, as they are not convinced easily by the genuine advice that is given by doctors. The doctors have to spend more time to convince them and prevent them from making wrong decisions, which may harm them rather than being of any help.

                  What we doctors fail to understand is, the problem is not Google or the patients who search Google for their problems, and even if it is the fact is this is going persist. The problem is the false and confusing or wrong information that is there and the way to counter it is to provide the people in general with more and more genuine and authentic information. So that it helps them in making proper choices for their problems, especially when they are being advised different treatment options by different set of doctors. If we see from their perspective, they feel totally confused and clueless what to do when different qualified and expert doctors give a different opinion about their treatment.

                   To believe that someone is not capable of understanding the problems they are facing, and not capable of taking an informed decision is big mistake. So we as doctors should strive to get as much information about different problems as possible, in a language that is easily understood by a non medical person. This will not only help them take better decision, this will improve the compliance of patient to the advice of doctor as they will understand the reason behind the advice.
But with this the responsibility of the patient also increases, as they are now the active partner in their own treatment. They need to learn the art of understanding what is genuine and what is fake.

                       A lot of patient’s complaint that some doctors misguided them to a wrong treatment. From my experience I can say, all such patients had opinion of multiple doctors and among these doctors were also those gave them proper guidance. But they chose to follow the one who gave the wrong advice, either deliberately or out of their poor knowledge. Not going into the discussion who is to blame, it is very clear that only the patients are at an immediate loss. But it the responsibility of both the public and the doctors both to make sure that people in need of guidance should get a correct one. We are in a new age and literacy is no more just the ability to read and write. Literacy in today’s time is ability to read between the lines, and the ability to send a true message in a stronger way such that it is louder the wrong ones. The onus is on all of us, and surely we will achieve that mark.

Disclaimer; The same article had been published by me on practo health feed with the below link!/content/29965

Tuesday, 12 September 2017

Dilemma of a patient with Heartburn: How long to suffer? When to seek a permanent solution?

Acid reflux causing ulcers and damage to the foodpipe
I will briefly talk about a patient with severe
heartburn, suffering for the past 7 years. I saw him a year back with his latest endoscopy report showing Grade A esophagitis that is a mild form of damage to the foodpipe due to acid coming back into the foodpipe from the stomach. But his was despite high dose of acid suppressing medications he was having since past few years.

24 hr pH with Impedance study
He was unable to stop them due to severe heartburn giving him sleepless nights and a affecting his daily work. Significantly affecting his
quality of life. I suggested him to undergo a 24 hr pH with Impedance study and undergo surgery for a permanent solution. The pH with impedance study showed severe reflux and also suggested that all his symptoms are due to reflux (good symptom reflux correlation by high Symptom association probability or SAP). All this point to surgery as a permanent solution. Surgery is laparoscopic with very quick recovery.

But like all humans he being scared of surgery, differed it. Took opinion of multiple doctors physicians, gastrophysicians, surgeons and G I surgeons. All having their own opinion further confusing him. After a year that showed further worsening of his symptoms he is finally planned for surgery in a couple of days.

While I am sure of giving him a permanent solution to his problems with a Laparoscopic Fundoplication surgery, the question is when a patient should say enough is enough? Many doctors not used to see the outcomes of these surgeries may not be confidant in suggesting surgery for your problems. Again in our society sleepless nights and a poor quality of life is considered acceptable. But in doing so we just deffer the inevitable to a later date rather than able to prevent it completely. In  doing so we just push the patient to have a few more years with a poor quality of life.

To know more about acid reflux and its surgery watch our patient information video by clicking this link
Disclaimer: The same article has been published by me on practo health feed with the link!/content/29646

Sunday, 3 September 2017

Obesity: Why is surgery necessary? Why just surgery is not enough?

                                                                                                                                                                                            Obesity is a complex disease. Complex to understand, occurs due to a complex interplay of multiple causes, it causes a complex set of end organ damage and complex in its treatment. I would like to remind you that I am talking about obesity and not overweight. To make it clear overweight is the situation where your weight is above the ideal range but not too high. More objectively overweight individuals have BMI from 23 to 27.5. BMI > 27.5 is obesity for all individuals of Asian origin. Surgery is not mandatory for all obese individuals, but weight loss is very much necessary for all of them.                                                                                                                            
           Surgery is necessary because only Bariatric surgery has till date shown a significant and sustained weight loss required to get improvement in obesity related diseases. Obese individuals need to shed a large number of kilos to get significant benefit. Diet and exercise has failed to achieve these goals even in dedicated and committed individuals. The problem increases if you have knee or spine problems or you have heart or lung condition further limiting your exercise capacity. A few individuals who somehow manage to lose weight are unable to maintain it, gaining back all those kilos in few months. These individuals do not get the health benefits of weight loss.      
            Surgery is the ideal option for those whose BMI is more than 37.5 even if they do not have any other medical problems. Surgery is also the treatment of choice for individuals having BMI>32.5 and Obesity related comorbidity. Obesity related comorbidites, that is disease caused by Obesity include Diabetes, Hypertension, Cardiac problems, Acid reflux disease, NASH (Non alcoholic Steatohepatitis or Fatty Liver), Sleep apnoea and Asthma, Knee and spine problems, Infertility etc. I know the list is long, but this is a fact. Surgery is also very helpful for lower BMI obese individuals (BMI 27.5 to 32.5) with diabetes, especially if the diabetes is not well controlled with medical treatment.   

          Bariatric surgery helps you to achieve what you are unable to achieve with diet and weight loss, a significant and sustained weight loss. It thus brings you back to normalcy where you would again be able to control your food and activity and lead a healthy life.  What people fails to understand is that just like any individual can put up weight if they don’t care about their diet  and lifestyle, all those who have lost weight by bariatric surgery can also regain weight. Hence changing your lifestyle including your diet and activity level is mandatory irrespective of what treatment you undergo. There is no alternative for that. Unfortunately the idea of improving your healthy by doing nothing is so strongly promoted by a lot of quacks in the name of a lot of products. And sadly this idea is bought by a lot of people.  However harsh it may seem, it is a fact that if you don't want to do anything about your weight and health nobody and nothing is going to help you. Bariatric surgery is a great tool that has transformed a lot of lives but it is no magic.      

Sunday, 20 August 2017

Bloating, Fullness after meals, Constipation and Heartburn: When to take it seriously

               The above mentioned problems are quite common in their occurrence and many a times can be seen in clusters. This is because some of the underlying causes are the same. The good thing about it is that most of the times they are functional, meaning there is no serious underlying organic disease. This also means that they are due to deviation in the normal function of any of the digestive organs. The root cause of most of these functional problems is our lifestyle. The Lifestyle includes our eating habits, substance abuse i:e smoking or alcohol, our work habits, our sleep pattern, our physical activity and our mental health i:e our stress levels. So people with these problems need to go deeper to find out whats wrong in their lifestyle and correct it.             

                                    The worrying thing with these symptoms is that it could be due to disease of the digestive organs, sometimes grave problems like cancer also, and it is not possible to rule this out without thorough investigations. To add to these problems, many of the different disease of many of different digestive organs present with these similar complaints. Hence many a times to rule out that nothing is wrong or to find out what is wrong, multiple tests are needed. Let me give you an example, bloating and heartburn can be due to no so serious problem like deviation in your digestive process and can get better with change in lifestyle and some simple medications. But occasionally, very rarely it can be due to acid reflux disease, achalasia cardia, peptic ulcer disease, gallbladder stone disease, or worse cancer of either stomach, esophagus, gallbladder or pancreas. It also can be due to chronic pancreatitis.         

                            So what should be done? Should we panic with the occurrence any of the above symptoms and get all the investigations done? No the answer is no. First we should look into the root causes i;e lifestyle changes and seek the opinion of a doctor, who will most probably give simple medications and things should be fine. But it the problems persists after these measures then you need a thorough investigation. The problem is we don't seek medical attention even if the symptoms are there for years altogether. There is our general tendency to not get alarmed by the problems that are there for quiet some time, we learn to live with it, and that is really dangerous. Also there are some red flag symptoms that should make your doctor suggest investigation at an early stage before starting medications.                                    

                      These red flag symptoms are   blood in stool, blood in vomit, anemia, jaundice, weight loss, difficulty in swallowing  or if any of your close family member had any abdominal organ cancer at an early age.                                 
                         If any of these red flag symptoms are there then as a precautionary measure further investigations should be done. You need to understand that there are different investigation for different disease of different organs, so multiple tests may be needed. Which tests should be done is upto your doctor to decide depending on the whole presentation. Many a times a doctor needs to advise more investigation depending on the reports of the previous investigations. Many a times this is taken as a lack of doctors knowledge or understanding about your problem but most of the times it is not so. Always some primary or simple investigations like blood test and ultrasound are advised first and further investigations are advised based on the findings in these tests. This is done in good faith to avoid unnecessary tests or to get the best possible information by selecting the most appropriate test from the many available investigations. Many a times its a test of your patience and your faith in your doctor.                                                                                                                                                                                                          We also need to understand the fact that a large portion of these test would be normal and only a few patients from all those who are subjected to investigations will have disease. This is so because to diagnose the disease in early stage we need to keep a low threshold for getting the investigations done. We also need to be humble to understand that we including all the doctors and today's technology and medical science are not above nature, so even with all that we do we may still miss a disease which would be detected at a later stage where outcomes many not be very promising.   

Disclaimer: The same article has been published by myself on the Practo health feed page. The link to that page is!/content/29376

Tuesday, 7 February 2017

Diabetes: Does Surgery have any role in treatment of Diabetes? What is Metabolic Surgery?

Diabetes currently affects more than 150 million people worldwide and that number is expected to quickly increase. Over 90% of people with the disease have the Type 2 form, which is associated with obesity and overweight, lack of physical activity, family history and older age. Unlike Type 1 diabetes in which the pancreas fails to produce sufficient insulin, the pancreas in patients with Type 2 diabetes produces enough insulin, but for unknown reasons, the body is unable to use the insulin. Diabetes can lead to blindness, heart and blood vessel disease, strokes, kidney failure, amputations, and nerve damage. Current therapies, which include diet, exercise, oral antidiabetic drugs and insulin, do not always cure the disease.

The goal of treatment is to improve the symptoms of diabetes through normalizing blood glucose levels. The ongoing goals are to prevent long-term complications like eye and kidney disease, damage of nerves and blood vessels. Strict control of blood glucose reduces risk of death, stroke, heart failure, and other complications. Glycosylated hemoglobin (HbA1C) is a test that determines risk for long-term complications. It measures how much glucose has been sticking to red blood cells and other cells. The first-line treatment for type 2 diabetes is weight lost, diet and exercise. Appropriate meal planning includes choosing healthy foods and eating the right amount of food. Exercise is important for effective treatment of diabetes. Regular exercising helps burning excess calories, managing weight thus improves control of the glucose amount in the blood. 2 When diet and exercise are not sufficient to maintain normal blood glucose levels, medications may be needed. They work through triggering the pancreas to make more insulin, helping insulin work better, decreasing the absorption of carbohydrates from the gut or decreasing glucose production in the liver. Poor blood glucose control despite lifestyle changes and taking medications means insulin should be injected.

Despite continuing advances in diabetes pharmacotherapy, fewer than half of adults with type 2 diabetes mellitus (T2D) attain therapeutic goals designed to reduce long-term risks of complications, especially for glycemic control, and lifestyle interventions are disappointing in the long term. Metabolic surgery, on the other hand, has been shown to improve glucose homeostasis more effectively than any known pharmaceutical or behavioral approach.
For the patients having diabetes for les than 5 years there is a high lifelihood of  achieving normal blood sugar levels wihout any medications. If the person is obese and not yet requiring Insulin his chances of compelte stopage of medication and still acheiving normal sugar levels are very high. If they are having very poorly controlled diabetes , are on high dose of insulin and are having diabetes for a very long time, surgery helps in acheiving normal sugar levels with decresed requirements of Insulin and medications. Such patients may still need medications but they can achieve good glycemic control leading to prevention of diabetes related complications
While Metabolic surgery( Surgery for Diabetes) certainly has some risk, the long-term risk of continued diabetes (which is often inadequately treated with medication) typically outweighs the risk of a surgical procedure for most patients. Each patient’s individual risks for surgery, though, should be evaluated in the context of the duration and severity of their diabetes as well as their other obesity-related health problems.

A key finding of many studies is that the shorter the history of diabetes, the greater the likelihood of complete remission. Glucose toxicity, particularly in poorly controlled diabetes, accelerates B-cell failure. B-cells are located in the pancreas and produce and secrete insulin. Weight loss can improve B-cell responsiveness to glucose. If the bariatric surgical procedure is performed before irreversible B-cell failure has occurred, durable weight loss will be accompanied by a high likelihood of long-term remission.