Surgical Gastroenterology and HPB Surgery Procedure

Robotic Whipples (Pancreas) Surgery

Robotic Whipple's surgery, or robotic pancreaticoduodenectomy, is a groundbreaking advancement in the surgical treatment of pancreatic diseases. This complex procedure, traditionally performed through open surgery, has been revolutionized by robotic systems, offering numerous benefits such as enhanced precision, reduced recovery time, and improved patient outcomes. The robotic platform provides an added advantage of clearing the local cancer spread completely and performing fine connections between the pancreas and the intestines- these advantages will eventually translate to lesser complications and more survival. 

Diseases needing Whipple's Surgery

• Pancreatic Cancer: The most common reason for Whipple's surgery, especially for tumors located in the head of the pancreas.
• Pancreatic Cysts and Tumors: Including intraductal papillary mucinous neoplasms (IPMNs) and neuroendocrine tumors.
• Chronic Pancreatitis: Severe inflammation causing persistent pain and complications.
• Ampullary Cancer: Cancer at the junction where the bile duct and pancreatic duct meet and empty into the duodenum.
• Bile Duct Cancer: Cholangiocarcinoma affecting the bile ducts.
• Duodenal Cancer: Cancer in the first part of the small intestine.

Symptoms Indicating Whipple's Surgery

• Persistent abdominal pain, particularly in the upper abdomen
• Jaundice (yellowing of the skin and eyes)
• Unexplained weight loss
• Nausea and vomiting
• Loss of appetite
• Fatigue
• Digestive problems

Treatment: Robotic Whipple's Surgery

• Resection: Removal of the head of the pancreas, the duodenum, a portion of the bile duct, the gallbladder, and sometimes part of the stomach. Along with these structures, lymph nodes will have to be cleared. Lymph nodes are tiny nodules around the tumour and may harbour cancer cells. If these are not cleared, the patient will stand a higher chance of recurrence of cancer. The robotic platform enables good removal of these nodes and hence better survival. 
• Reconstruction: Reconnecting the remaining pancreas, bile duct, and stomach to the small intestine to maintain digestive function. The pancreatic duct is only around 3mm wide and the bile duct is around 10mm wide. To connect these structures successfully with the intestine without leakage is a huge challenge. The robotic platform with its 10x zoom and precise instrumentation allows more successful connections. 

Benefits of Robotic Whipple's Surgery:

• Minimally Invasive: Smaller incisions lead to less pain, reduced scarring, and quicker recovery.
• Enhanced Precision: Superior 3D visualization and refined instrument control enable meticulous dissection and suturing.
• Reduced Blood Loss: Improved surgical precision minimizes the risk of excessive bleeding.
• Shorter Hospital Stay: Patients often experience faster recovery and shorter hospital stays compared to traditional open surgery.
• Improved Outcomes: Lower complication rates and better overall surgical success due to enhanced accuracy and minimally invasive techniques.

Diagnosis Leading to Surgery

• Medical History and Physical Examination: Initial assessment of symptoms and risk factors.
• Imaging Studies: Techniques like ultrasound, CT scans, MRI, and endoscopic ultrasound (EUS) provide detailed images of the pancreas and surrounding structures.
• Biopsy: A sample of pancreatic tissue may be taken to determine the nature of a lesion or tumor.
• Blood Tests: Tumor markers, liver function tests, and other blood tests help in diagnosing pancreatic conditions.

Conclusion

Robotic Liver Surgery

Robotic liver surgery represents a significant advancement in the field of hepatic surgery, offering numerous benefits over traditional methods. This cutting-edge technique utilizes robotic systems to enhance the precision, dexterity, and control of surgeons, leading to improved patient outcomes and reduced recovery times. Presently, there is plenty of medical evidence that shows definite advantages of minimally invasive approaches (Robotic and laparoscopic) to liver surgery. This advantage is not just in the small scars but also lesser complications and lesser liver removal especially in liver cancers with a damaged liver. Thus, the surgery will be more successful.

When is Liver Surgery needed

• Liver Cancer: Both primary (originating in the liver) and metastatic (spread from other organs) liver cancers may require surgical intervention.
• Benign Liver Tumors: Non-cancerous tumors like hemangiomas, adenomas, or focal nodular hyperplasia.
• Liver Cysts: Large or symptomatic cysts that impair liver function or cause discomfort.
• Traumatic Injury: Severe liver damage due to accidents or injuries.

Symptoms Indicating Liver Surgery

• Persistent abdominal pain, particularly in the upper right quadrant
• Unexplained weight loss
• Jaundice (yellowing of the skin and eyes)
• Ascites (accumulation of fluid in the abdomen)
• Fatigue and weakness
• Loss of appetite and nausea

Treatment: Robotic Liver Surgery

• Precision and Accuracy: Enhanced 3D visualization and superior control of surgical instruments allow for meticulous dissection and suturing.
• Minimally Invasive: Smaller incisions result in less pain, minimal scarring, and quicker recovery.
• Reduced Blood Loss: Improved dexterity and precision reduce the risk of excessive bleeding.
• Shorter Hospital Stay: Patients often experience faster recovery times and shorter hospital stays compared to traditional open surgery.
• Improved Outcomes: Higher success rates and lower complication rates due to enhanced surgical precision.

Diagnosis Leading to Surgery

• Medical History and Physical Examination: Initial assessment of symptoms and risk factors.
• Imaging Studies: Techniques like ultrasound, CT scans, MRI, and PET scans provide detailed images of the liver.
• Biopsy: A sample of liver tissue may be taken to determine the nature of a lesion or tumor.
• Blood Tests: Liver function tests, tumor markers, and other blood tests help in diagnosing liver conditions.

Conclusion

Reflections on the First 100 Robotic Surgeries: Advancing Surgical Precision with the da Vinci Robot

As a team specializing in complex liver, hepatobiliary pancreatic, upper GI, colorectal, hernia, and abdominal wall reconstruction surgeries, we have had the privilege of conducting the initial 100 surgeries utilizing the state-of-the-art da Vinci Surgical System. This cutting-edge technology has revolutionized our approach to minimally invasive surgery, offering unparalleled precision and control in even the most intricate procedures.

The transition to robotic-assisted surgery has been nothing short of transformative. The intuitive interface and ergonomic design, enhanced visualization provided by the high-definition 3D camera system allows for a level of detail and clarity that was previously unattainable with traditional laparoscopic methods.

In complex liver surgeries, the da Vinci system's articulating instruments have enabled us to navigate the delicate anatomy with remarkable dexterity, reducing the risk of complications and minimizing trauma to surrounding tissues. The ability to manipulate the instruments with six degrees of freedom replicates the natural movements of the human hand, enhancing our ability to perform precise dissections and suturing in the confined spaces of the abdomen.

Similarly, in hepatobiliary pancreatic surgeries, where precision is paramount, the da Vinci system has proven to be an invaluable tool. Its advanced imaging capabilities like Firefly allow for enhanced visualization of critical structures, such as the bile ducts and blood vessels, facilitating safer and more efficient procedures. By minimizing blood loss and tissue damage, robotic-assisted surgery has led to shorter hospital stays and faster recovery times for our patients.

In colorectal surgery – for both benign and malignant disease, the enhanced visualization and improved access to the pelvic anatomy enables us to perform superior oncological resection, and sphincter-preserving surgeries with greater accuracy. The Firefly–ICG visualization of the vascularity of the bowel to be anastomosed significantly helps in reducing the risk of postoperative complications.

In Upper GI surgeries, where intricate dissection has to be done at the hiatus, in close proximity with all vital structures, yet again the improved dexterity – enabled by the robot, has led to safer surgeries and faster recoveries.

Even in hernia and abdominal wall reconstruction surgeries, where precision and a sturdy fascial closure is crucial for optimal mesh placement and tissue repair, the da Vinci system has proven to be a game-changer. Its articulating instruments allow for precise dissection and closure of hernia defects, leading to reduced recurrence rates, significantly lesser pain, and improved patient satisfaction.

As we reflect on the first 100 surgeries with the da Vinci Surgical System, we are filled with excitement for the future of robotic-assisted surgery. With continued advancements in technology and ongoing refinement of surgical techniques, we are confident that we are only scratching the surface of its potential. By combining the art of surgery with cutting-edge innovation, we can
continue to push the boundaries of what is possible and deliver the highest quality care to our patients.

How Robotic Surgery is Transforming GI Cancer Treatment

GI cancer stands for gastrointestinal cancer, which refers to a group of cancers that affect the digestive system. This includes cancers of the oesophagus, stomach, small intestine, colon, rectum, liver, gallbladder, and pancreas.

The most common types of GI cancers are colorectal cancer, stomach cancer, and liver cancer. The symptoms and treatment options for GI cancer depend on the type of cancer and its stage. It is important to seek medical attention if you experience any persistent symptoms such as abdominal pain, changes in bowel habits, unexplained weight loss, or blood in the stool.

Gastrointestinal cancers are often difficult to treat and require complex surgical procedures to remove them. However, advancements in technology have led to the development of robotic surgery, which has revolutionized the field of GI cancer surgery. You can consult with a gastro surgeon to know the available treatment options for your condition including, Robotic Surgery in Bangalore.

What is Robotic Surgery?

• Esophagectomy for oesophagal cancer
• Hiatal hernia repair and fundoplication
• Cardiomyotomy (Heller’s procedure for Achalasia cardia)
• Sleeve gastrectomy, mini gastric bypass
• Distal gastrectomy, subtotal gastrectomy, and total gastrectomy for cancers and benign diseases

• Liver resection: both minor and major
• Pancreatectomy - Removal of a portion of the pancreas for tumours
• Splenectomy
• Radical cholecystectomy for gallbladder cancer
• Other complex HPB surgical procedures like biliary strictures

• Procedures for colorectal cancers - Right hemicolectomy; Left hemicolectomy; Low anterior resection; Abdominoperineal resection
• Procedures for rectal prolapse – Rectopexy
• Procedures for ulcerative colitis – total proctocolectomy with pouch anastomosis

• Complex Abdominal wall hernias- incisional, ventral, recurrent hernias
• Complicated Inguinal, and femoral hernias

What are the benefits of Robotic GI Surgery?

• Smaller incisions
• High Precision
• Less pain and scarring
• Faster recovery time
• Good accuracy

Who is the right candidate for Robotic GI Surgery?

• Patients who are generally healthy and have a lower risk of complications from surgery are often good candidates for robotic GI surgery. Patients who are younger and have a body mass index (BMI) within a healthy range may also be good candidates.
• Patients who have previously undergone abdominal surgery may also be good candidates for robotic GI surgery, as the minimally invasive nature of the procedure can help reduce the risk of complications related to scar tissue and other complications from prior surgery.
• Patients with certain medical conditions, such as severe heart or lung disease, may be at higher risk for complications during surgery and may not be good candidates for the procedure. 
• Patients who are very overweight or obese may also be less suitable candidates, as the robotic instruments may not be able to reach the surgical site as easily.

How to Treat Fatty Liver

Fatty liver, also known as hepatic steatosis, is a condition where excess fat accumulates in the liver. Normally, the liver contains some amount of fat, but when the amount of fat exceeds 5% to 10% of the liver's weight, it is considered a fatty liver. Fatty liver can be caused by various factors such as obesity, high blood sugar, high cholesterol, excessive alcohol consumption, and certain medications.

If left untreated, fatty liver can lead to liver damage, cirrhosis, and even liver failure. Therefore, it is important to consult with a liver specialist for diagnosis and treat fatty liver as early as possible to prevent complications. In this article, we will discuss the causes and treatment options for fatty liver.

Causes of Fatty Liver

• Obesity: Being overweight or obese is one of the most common causes of fatty liver. Excess fat in the body can accumulate in the liver, leading to fatty liver.
• High blood sugar and cholesterol: People with type 2 diabetes or insulin resistance are more likely to develop fatty liver. Also, high levels of cholesterol in the blood can cause fat to build up in the liver.
• Pregnancy: Some women develop fatty liver during pregnancy, particularly in the third trimester.
• Inherited disorders: Certain genetic disorders such as familial hypercholesterolemia can cause fatty liver.
• Rapid weight loss: Losing weight too quickly can cause fat to build up in the liver, leading to fatty liver.
• Excessive alcohol consumption: Drinking too much alcohol over a long period of time can cause fat to build up in the liver, leading to alcoholic fatty liver disease.

Treatment for Fatty Liver

• Lifestyle Changes: The first and most important step in treating fatty liver is to make lifestyle changes. Losing weight, exercising regularly, and eating a healthy and balanced diet can help reduce the amount of fat in the liver. Reducing calorie intake and avoiding sugary and fatty foods can help prevent further fat accumulation in the liver.
• Medications: Several medications can be used to treat fatty liver. However, these should only be taken under the guidance of a healthcare professional. Medications such as metformin, pioglitazone, and vitamin E have been shown to improve liver function and reduce inflammation in people with fatty liver. Obeticholic acid is another newer drug which can be used in certain subsets of fatty liver. 
• Control blood sugar and cholesterol levels: Controlling blood sugar levels and cholesterol levels is crucial in the treatment of fatty liver. High levels of blood sugar and cholesterol can cause further damage to the liver and increase the risk of liver disease. Medications such as statins can help lower cholesterol levels, while medications such as insulin can help control blood sugar levels.
• Avoid alcohol: If you have fatty liver, it is essential to avoid alcohol or limit your intake significantly. Alcohol consumption can cause further damage to the liver and increase the risk of liver disease. If you are struggling with alcohol addiction, seek professional help.
• Manage underlying conditions: Fatty liver can be caused by underlying conditions such as obesity, type 2 diabetes, and metabolic syndrome. Managing these underlying conditions is crucial in the treatment of fatty liver. Speak with your healthcare professional about the best approach to managing these conditions.
• Liver transplantation: In severe cases of fatty liver where the liver is damaged beyond repair, a liver transplant may be necessary. A liver transplant involves replacing the damaged liver with a healthy liver from a donor. This is usually reserved for cases where all other treatment options have failed. Sakra World Hospital has the best liver transplant surgeon in Bangalore to treat a failing liver.  

POEM Procedure (Per-Oral Endoscopic Myotomy)

Treatment for swallowing disorders caused by muscular issues, including esophageal spasms, involves a surgery called “peroral endoscopic myotomy” (POEM). POEM procedures use an endoscope which is a narrow flexible tube with a camera and it is inserted through the mouth (peroral) to cut muscles in the esophagus (a myotomy). Cutting the muscles allows food to pass easily to the stomach and prevents them from becoming tight and getting in the way of swallowing.

This procedure is performed using endoscopic techniques, so there is no need for an external incision. This is a minimally invasive option to Heller myotomy, a procedure that penetrates the esophagus through tiny incisions. Compared to conventional surgical treatments, endoscopic operations usually result in less discomfort and quicker recovery.

How POEM is performed?

• The endoscopist places the flexible endoscope through the mouth into the esophagus while an individual is under general anesthesia. 
• The innermost layer of the esophagus is cut in a minor way (the mucosa). The remaining portion of the esophagus's submucosa layer is then tunneled down with the endoscope. 
• The endoscopist cuts the lower esophageal sphincter's muscle fibers in the lower esophagus. 
• The treatment is finished by removing the endoscope and closing the first mucosal incision.

Who requires the POEM Procedure?

• POEM is primarily employed to treat achalasia, a disorder in which the sphincter between the esophagus and the stomach becomes tight. Due to the inability of this muscle to rest and other esophageal muscles to assist in pushing food down, esophageal achalasia patients are not able to enable food to pass into the stomach. This may lead to weight loss, vitamin deficits, choking, coughing, hoarseness, and food stuck in the esophagus.
• Patients for POEM procedures include people who suffer from symptoms of achalasia and have a poor quality of life. The surgery relieves achalasia by severing the muscles in the upper stomach, the sphincter, and the bottom part of the esophagus. This provides a larger passageway for food into the stomach.
• Other disorders that induce esophageal spasms that do not respond to medication, including diffuse esophageal spasms and nutcracker or jackhammer, esophageal diseases, can also be managed with POEM.
• Both children and adults can have POEM procedures; age is typically not a significant determinant. The procedure may be unsafe if there are underlying conditions including heart and lung problems. 

What are the complications of POEM?

• Infection
• Gastroesophageal reflux disease 
• Bleeding because of injury to the esophagus
• Inflammation of esophagus
• Collapsed lung

• Chest discomfort
• Stomach problems
• Shortness of breath
• Bleeding in your stool
• Black bowel movement 
• Fever and cold
• Vomiting

What does an individual do before POEM?

• Three days before the surgery, your doctor will advise you to stick to a liquid diet, and 24 hours before treatment, you need to take only clear liquids. 
• A medication like an antibiotic will be given by the doctor to take prior to the POEM operation. 

What exactly happens after POEM?

• An individual will stay the night in the hospital under supervision following the POEM operation. 
• The following day, an esophagram, and an X-ray of the esophagus will be obtained. The patient will be required to follow a liquid diet for about a week before going on to soft foods and eventually, a regular diet. 
• After the procedure, one will be prescribed an acid-reducing medication to take for a month. 

Liver Transplantation Simplified

Liver transplantation is recommended for people with end-stage liver disease or acute liver failure. End-stage liver disease is a condition in which the liver has become so severely damaged that it can no longer function properly. Acute liver failure, on the other hand, is a rapid deterioration of liver function that can occur over a short period of time.

Liver transplantation is a surgical procedure in which a diseased liver is replaced with a healthy liver from a donor. It is a life-saving surgery for people with end-stage liver disease or acute liver failure. If you experience any symptoms like jaundice, abdominal pain, and chronic fatigue, consult with a liver transplant surgeon in Bangalore to receive a proper diagnosis.

Why is Liver Transplantation Performed?

• Chronic liver diseases, like cirrhosis, hepatitis B, and hepatitis C
• Inherited metabolic disorders, such as Wilson's disease and alpha-1 antitrypsin deficiency
• Autoimmune liver diseases, such as autoimmune hepatitis and primary biliary cholangitis
• Liver cancer or liver tumors
• Acute liver failure, which can be caused by drug toxicity, viral hepatitis

Types of Liver Transplants

Liver Transplant Procedure

Recovery and Follow-Up

Inguinal Herniotomy

What is an Inguinal Hernia?

A hernia may be a protrusion of some of the contents of the abdomen into the groin area. It is a common problem in children, particularly seen in boys. This occurs because there is an area of weakness or passage-way which originally allowed the testis to descend from the tummy cavity into the scrotum. If this passage stays open, a loop of bowel can pass from the abdominal cavity into the groin and sometimes even right down to the scrotum. This is found painful for the kid and may damage both the testis and the bowel if it gets obstructed. In girls, a hernia may contain one of the ovaries and this may also get damaged whilst inside the hernia. A hernia should therefore always be repaired once it's been diagnosed irrespective of age, especially in children who are below 12 months of age as the risk of the obstruction is highest.

Sakra World Hospital has the best laparoscopic hernia surgeon in Bangalore, experienced in treating any kind of hernia. For inguinal hernia surgery in Bangalore consult the best hernia treatment hospital near you.

Inguinal Herniotomy

The aim of this procedure is to close the communication from the tummy cavity into the groin area. Unlike the operation in adults, here repair of weak muscle tissue or use of artificial mesh material is not required. The operation is performed as a daycare under general anesthesia. Generally, the operation lasts for 40 minutes.

Preparing for the Procedure

A child will get to fast generally for about 6 hours before the beginning of the procedure. Breastfeeding is allowed 4 hours before surgery. The child will be admitted to the Daycare ward before the surgery for Anesthesia and Surgical Briefing. It is often helpful to bring your child’s favourite toy on this day.
Feel free to reach any best hernia hospital in Bangalore and ask any questions you have regarding hernia surgery.

Anesthesia

You and your child will meet the anesthetist in the morning before the procedure. After the briefing session and examining your child, they're going to take one of the parents along with the kid to the operating room, they will get to accompany the child until they are asleep. The anesthetist puts your child to sleep via a mask (with children 5 years and over there's the choice of either a mask or a needle).
Once the child is asleep, the anesthetist will insert a ‘drip’ to permit fluids to tend directly into a vein. Usually, this is often located within the hand or arm.

Procedure

Cleaning the groin area with an antiseptic solution. A local anesthetic block is injected into the area so that the location of the operation is numb after the operation. This block usually lasts for about 4-6 hours. A cut is made within the groin on the side of the hernia. Once the communication between the abdomen cavity and the groin has been found, in boys it must be very carefully peeled off as it has two important tubes: the vessel to the testis and the sperm tube. The communication can then be tied up.
In girls, the ovary may have to be pushed back to the abdomen cavity before this step is performed. Then the wound is closed with dissolving stitches which are buried under the skin. A clear, water-resistant dressing is done to cover up the wound.

Recovery Post Procedure

After the completion of the operation, your child will be taken to the recovery room or area. Once awake, you'll be called into the recovery ward. Initially, children appear mildly distressed and a little confused due to the residual effects of the anesthetic, hunger, and discomforts. Generally, they're going to settle quite quickly, especially if offered a drink or feed. The recovery and ward staff also are ready to give pain relief medication once your child is awake and this is often sometimes required. The nursing staff will check the wound and make sure there is no bleeding before you go home. Usually, this may be about 2 hours after the surgery.

As a result of the local anesthetic nerve block, your child may complain of a numb sensation within the groin and in some cases some weakness within the leg on the side of the surgery. This is temporary and will generally settle within a day or 2 days after the operation.

Return to Normalcy

Your child may return to daycare or school when comfortable, usually within 4-6 days. They should not participate in sports or swim for 3 weeks after the surgery and should strictly avoid riding straddle toys (bikes, walkers) for two full weeks after surgery. While travelling in the car they use car seats/Bassinet.

Looking for the best hospital for hernia repair in Bangalore, then consult Sakra World Hospitals where your child will get the best treatment and care.

Living Safely Through Covid-19 Pandemic With Hepatitis

With Covid-19 outbreak, we are living through a tough time like no other. The deadly virus has not just infected our body but also our mind and has disrupted the normal course of life. Nothing is the same as before, including hospital visits or reaching out to the doctor to treat conditions other than the Coronavirus. It has been observed that the SARS-CoV-2 virus does affect liver inflammation and liver enzymes and can also result in liver dysfunction. This makes it essential for individuals with liver cirrhosis or Hepatitis B and C to take special precautions like enhanced monitoring of liver enzymes as one goes through the pandemic times. As we observe World Hepatitis Day on July 28, we must emphasize the safety protocols that one must follow in case they are suffering from Hepatitis or chronic liver issues. 

The link between Covid-19 and liver: Why Hepatitis patients must be more careful?

While no official claims have been made that having Hepatitis B and C may put one at a greater risk of contracting Covid-19 as of now, it is certain that the virus can increase liver disease progression and decompensation of the organ. Clinical expertise and available information suggest that those with chronic conditions like Hepatitis may be at a higher risk for severe illness from Covid-19 virus, specifically if Hepatitis is not adequately controlled. 

Staying safe during COVID -19 crisis with Hepatitis

It is important that an individual with Hepatitis effectively practices social distancing like anyone else but with more restrictions. Self-isolate with or without an official order. Maintaining hand hygiene, i.e washing hands with soap and water or sanitiser, sanitising frequently touched surfaces along with the supplies from outdoor must be used after proper wash/care.

If one is on medications for chronic hepatitis during this time,  they must ensure that they have adequate stock for an extended period of time. The stocking up is important during uncertain times of lockdown as skipping a day's medicine can flare up the virus and increase liver damage risk.   

It is suggested to opt for a virtual meeting with the doctor if need be and use the telemedicine facility offered by most hospitals at this time to make sure the condition is under constant check. Hepatitis related tests like ultrasounds or blood tests could be kept on hold under the supervision of the doctor, if and only if, the delay does not affect one's condition. In case of visiting the hospital for any test, make sure one takes adequate protective measures to avoid contracting Covid-19 and makes a prior appointment with the doctor before visiting him or her.

Tips to keep your liver healthy during a pandemic 

As we live through the pandemic, it is essential for those suffering from Hepatitis to be cautious about keeping up the health of their liver. 

• Keep an eye on the nutrition labels and make informed food decisions that are particularly favourable for liver health. 

• If possible, get fresh fruits and vegetables and freeze them for the upcoming weeks. 

• Do not give up on physical activities, both indoor and outdoor. Do indoor exercises and go out for a pinch of fresh air in a private garden or rooftop. Maintain social distancing for outdoor activities and get creative for indoor workouts. 

• Please beware of Over the counter/Unauthorized Herbs for any conditions during the pandemic as most of these are toxic to the liver.

• Prefer home cooked foods as acute Hepatitis A and E are foodborne.

Covid-19 and treatment for Hepatitis B or C

Those living with Hepatitis B or C should not stop or change their treatment unless they are advised by their doctors to do so. They must be prepared to pile up their medicines for a month, for now, to make sure they do not skip a dosage. 

Although access to doctors may vary, continuous monitoring of health should not suffer. Make use of telemedicine consultancy as much as possible and in case the liver check-up has already got delayed, it is wise to schedule one on priority and go for it with adequate supervision by the treating doctor.

How COVID-19 affects the Gastrointestinal System?

Ever since the outbreak of Coronavirus reported from China back in December 2019, it has spread to the rest of the world and became a global pandemic. Till date, the virus has infected over 56,523 people in India and resulted in 1,895 deaths. 

Any virus has the potential to destroy healthy cells and multiply themselves. The new virus SARS-CoV-2 (COVID-19) mainly attacks the lining of the airways in the cells thus affecting the respiratory tract, with a spectrum of symptoms, from mild infections as fever and cough to pneumonia and acute respiratory distress syndrome in the most severe cases. However, what is unnerving about the infection is that its effects are not limited to the respiratory system only. Other organs such as the gastrointestinal (GI) tract and liver seem to be targeted by the virus as well. According to a report, the disease severity can cause haematological changes and even worsen the condition of patients with digestive system diseases.

How does the virus affect the Gastrointestinal system?

Angiotensin-converting enzyme II (ACE2) acts as the potential target site transmitting SARS-CoV-2 to humans. ACE2 was found not only highly expressed in the lung alveolar type 2 cells but also found in the oesophagus (food pipe), absorptive enterocytes from the ileum (small intestine) and colon large intestine). It is also found in the liver and biliary system.

According to a study from Wuhan, 16 per cent of patients presented with gastrointestinal symptoms reported:

1. Loss of appetite is the most common symptom.  Nausea and vomiting, Diarrhoea, abdominal pain are the other GI symptoms. 

2. Faecal samples remained positive for SARS-CoV-2RNA for nearly 28 days from the first symptom whereas respiratory samples were positive up to 17 days from the first symptom. It means a patient can continue to shed the Virus RNA in stools in spite of getting cured of respiratory ailments. So, the role of the feco-oral route of acquiring the infection cannot be neglected and one needs to follow hygienic practices after using toilets.

3. Liver dysfunction is seen in patients with severe COVID-19 disease. An abnormality in liver function blood test is generally found in COVID-19 symptomatic patients. One of the components in liver function tests called ALT is elevated in them.  ALT elevation was found in 16 to 53% of patients.  However, one need not panic as no cases of acute liver failure have been reported so far.

The above observations highlight the gastrointestinal and liver involvement in COVID-19 patients; however, the final outcome or recovery depends primarily on the management of lung issues. Development of GI symptoms does not indicate the severity of COVID-19 disease.   

Use of immunosuppressant medication in the treatment of COVID-19

One of the other concerns in COVID-19 pandemic is related to immunosuppressant medication which a patient may be taking for some other gastrointestinal and liver diseases like IBD (Crohn’s disease, Ulcerative colitis), Autoimmune hepatitis, etc. If somebody is on steroids, the dose needs to be decreased to the minimal dose possible. Patients who are already taking immunosuppressants like Budesonide, Azathioprine, Methotrexate and Biological therapies are advisable to continue using the same dose as long as the primary disease is under control. However, if the patient is suffering from COVID-19, then only all the immunosuppressant medications mentioned above need to be stopped and alternative medications need to be considered.  

Endoscopy during COVID-19 pandemic

It is important to adopt certain measures related to endoscopy in COVID-19 pandemic so that patients are not unnecessarily exposed to the risk of acquiring the infection. This also ensures the protection of the endoscopist and other health care workers not to get the infection from patients. We at SAKRA World Hospital have set up stringent safety protocols and are equipped with state-of-art endoscopy facilities with negative suction endoscopy theatres to combat infections. 

Screening colonoscopy, endoscopy for dyspepsia and intestinal metaplasia can be postponed for 8 weeks or more and reassess the pandemic and guide the patient appropriately for endoscopic procedures. However, in case of gastrointestinal bleeding, cholangitis, food impaction, perforation, stenting for gastrointestinal obstruction are some of the conditions which can be considered for emergency endoscopic interventions with full PPE for all healthcare workers.

During this pandemic people are reluctant to visit a hospital, hence SAKRA Hospital also provides video consultation to recognize the problems during a routine check-up. Once the problem is identified, a physical examination and appropriate investigation like labs/USG scan/CT scan or endoscopy should be considered so that the risk of transmission can be minimised.

Understanding Bariatric surgery

The increased economic growth has brought prosperity no doubt but has also resulted in a higher incidence of diseases such as diabetes, hypertension, and of course obesity. With the higher consumption of highly refined and ‘junk’ foods, these diseases have reached epidemic proportions. Refined foods are high in carbohydrates and fats, but poor in protein, vitamins and minerals essential for optimal functioning of the body. The ‘junk’ foods are rich in sugar, fat and salt, which make it very palatable and so are consumed in large quantities.

Insulin is a hormone that is secreted by an organ called the pancreas in response to carbohydrate intake. It helps the body in proper utilization of carbohydrates which is its primary fuel; but when they are consumed in excess quantities, this hormone converts them to fats, which then accumulates in the body. Fat is a latent energy source of the body, they are the reserve fuel when the body runs out of carbohydrates. This happens in a state of starvation. With our regular civil supplies and ready access to food, starvation, of course, never happens. So, we end up accumulating the fats over the years. With the cumulative increase in fat, obesity occurs.

With the onset of obesity, the sensitivity of the body to insulin decreases and diabetes manifests. Other problems that occur include hyperlipidemia (increased cholesterol and fats in the blood), hypertension (increased blood pressure), obstructive sleep apnea (excess fat in the neck resulting in snoring and obstructed breathing), decreased bone density. Conditions such as PCOS and hypogonadism may be aggravated by obesity.

Obesity is graded by what is called body mass index (BMI), which is a ratio of weight to the height of a person. As the weight increases the BMI increases as the height remains constant in a fully grown human. Based on BMI, obesity is graded as follows

It has been seen that the incidence of diabetes, hypertension etc, increases with the increase in the class of obesity. These diseases contribute significantly to reducing the life-span of a person as well as decreasing the quality of life. However, the good news is that by decreasing the BMI, this risk can be reversed.

BMI can be decreased by reducing the daily intake of calories. The cumulative net caloric deficit coupled with regular exercise reduces the weight. But our fast-paced life ridden with stress and easy accessibility to refined food has all but negated this option; moreover, the decreased bone density, breathing difficulty, joint pains restrict exercise. Even if one achieves weight loss, the moment they are off the diet, weight gain rebounds. These practical problems led scientists to investigate and find a solution, thus was born the field of bariatric surgery.

What is bariatric surgery?

The word bariatric derives from a combination of two Latin words – Baros meaning weight or heavy and iatros meaning doctor. This is an umbrella term for various operations done for morbid obesity which results in significant weight loss. These procedures date as far back as 1954, when Dr Kremen of University of Minnesota Hospital, US., performed the first jejuno-ileal bypass. Since then many a procedure have been devised for achieving weight loss. These procedures are the result of years of research in animal models and a thorough understanding of digestive physiology.

Bariatric procedures can be divided into

1.    Those that restrict the consumption of food

2.    Those that decrease the absorption of nutrients

3.    A combination of these two

The various procedures include Adjustable gastric banding, Sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB) and its variant Mini gastric bypass (MGB), Jejunoileal bypass and Biliopancreatic diversion-duodenal switch (BPD-DS).

Adjustable gastric banding

In this procedure, a band is placed over the top of the stomach near its junction with the esophagus (food pipe), which is adjustable to decrease the passage of food into the stomach and induce early satiety. The caliber of the band can be adjusted by filling it up with saline. With this procedure, a weight loss of 50% - 60% can be achieved in about 2 years.

Sleeve gastrectomy

This procedure involves the removal of 75% - 80% of the stomach, which reduces the size of the stomach. This results in early satiety and faster emptying of the stomach. Removal of the larger part of the stomach also lowers secretion of a hormone called Ghrelin which reduces hunger and decreases insulin secretion. This procedure achieves a 65% weight loss within six months.

Roux-en-Y Gastric bypass (Mini-gastric bypass)

This is both a restrictive and malabsorptive procedure. The stomach is reduced to a small pouch and part of the small intestine is joined with this pouch. This change in the configuration of the digestive organs results in changes in various gut-derived hormones which increase satiety decreases appetite and increases insulin sensitivity. The weight loss achieved here is 75% in the first six months.

Who requires bariatric surgery?

Class III obesity, Class II with complications such as diabetes, hypertension, OSA, and Class I with uncontrolled diabetes. Research has shown that in the Asian population, bariatric surgery may benefit even overweight patients of BMI 27.5 and above.

Pre-operative, operative and post-operative period – what to expect

The person who qualifies for bariatric surgery must have tried dietary restriction prior to the procedure. Before the operation is scheduled, a thorough interview by the physician, various blood investigations, x-rays of the chest, ultrasound of the abdomen and in some cases bone mineral density are done. This serves to optimize the condition prior to the procedure; also it helps the physician to choose the appropriate procedure.

The operations are performed laparoscopically (key-hole) where the intraabdominal organs are accessed with the help of only small holes on the abdomen. The procedures usually last from 2-4 hours. It is done in general anaesthesia where one remains completely unconscious in the entirety of the procedure.

In the postoperative period, ICU monitoring may be required to optimize recovery. Intake through the mouth is started the next day after an x-ray test. Once the oral intake is established, the patient is discharged in about 2-4 days.

Lifestyle modifications

Bariatric surgery initiates weight loss, but a good diet and regular exercise perpetuate it. Postoperatively, a diet plan is prescribed for about three months which takes a person through a graded increase in volume and consistency of foods. Physical rehabilitation with graded exercises improves form and function. These practices when inculcated results in reversal of diabetes, hypertension, OSA, osteoporosis, PCOS and hypogonadism.

Dr. Manoj Kumar R
Associate Consultant - Gi & General Surgery
MS (General Surgery), M.Ch (Surgical Gastroenterology) MRCS (Edinburgh)

Acute Pancreatitis- 8 important things you should know

1. What is Acute Pancreatitis?

Acute pancreatitis is an inflammatory disease of the pancreas, in response to an irritant, which leads to a spectrum of symptoms. It usually affects young individuals in the prime of their lives. 

2. What are the causes of Acute Pancreatitis?

The two common causes of pancreatitis are alcohol consumption and gallbladder stones migrating into the bile duct. The other possible causes are hypertriglycidemia, autoimmune pancreatitis, developmental anomalies of the pancreas (pancreas divisum), ingestion of certain drugs and trauma to the pancreas. In 15-20% of all patients, no cause is identified, which is labeled as Idiopathic pancreatitis. 

3. What you can do to prevent pancreatitis?

A healthy lifestyle, avoiding smoking and limiting alcohol intake are the most important ways to preventing pancreatitis. One must take a balanced diet, with good intake of antioxidants and undertake a regular health check to detect any other risk factors for developing pancreatitis.

4. What to do if there is pain?

The diagnosis for pancreatitis should be made by a physician. Meet a doctor and present exact details of the pain, its onset and course. Give a complete medical and personal history. Follow the doctor’s advice regarding treatment especially with regard to hospital admission and investigations.

5. What is the usual course of the disease?

Mild pancreatitis is self-limiting and pain abates in 2-3 days. During this period, medication and diet should be maintained, as prescribed by the doctors. In case of high severity, the disease becomes unpredictable and has a long drawn course. Patients with severe disease require prolonged hospitalization and ICU care. The course of the disease is dictated by the complications and the resolution of the same. 

6. What to expect in terms of treatment and outcomes?

In mild pancreatitis, most patients will improve with medical treatment and will have no further problems. If an underlying cause, such as alcohol or gallstones, is identified, then abstinence from alcohol and surgery for removal of gallbladder, respectively, should be advised.

In severe disease, any of the complications which ensue may require some procedure, such as endoscopic intervention, ultrasound or CT guided intervention and/or surgery. The timing and method of intervention, is a critical in decision making, which is undertaken by a multidisciplinary team. Patients and family should be prepared for a long haul with fluctuating course of illness including the need for one or multiple procedures. Patients may even be required to be put on ventilator and dialysis. With improving ICU care, multidisciplinary team approach and availability of sophisticated methods of intervention, 70-80% of patients survive this terrible disease.  Despite the best efforts, 20-30% patients succumb.

7. What is the key to achieving a successful outcome?

Early diagnosis and critical supportive care is the key to a successful outcome. Patients suffering high severity of the disease, should be identified, carefully monitored for development of any complications, and appropriate intervention should be performed at the right time. An expert multidisciplinary team, experienced in managing pancreatitis, is vital to critical decisions being taken.

8. What are the long term ill-effects of severe pancreatitis?

Patients recovering from severe pancreatitis will require a prolonged period of rehabilitation and nutritional support. They may develop diabetes on follow-up, making it important to get regular blood sugar checks and monitoring. These patients may also develop malnutrition due to the decreased secretion of pancreatic juices. Patients should be placed on pancreatic enzyme replacement therapy, under medical supervision. About 10% of patients will develop chronic pancreatitis on a follow up of 2-3 years.

There's more to PANCREAS, than meets the eye!

Pancreas is the organ which resides between our stomach and spine. From the moment we are born our pancreas is like a machine on autopilot, silently working, doing its job meal after meal, day after day!

The pancreas is a specialist in two functions:

1. Exocrine- Which  releases enzymes to digest our meals (carbohydrates, fats, proteins and acids)

2. Endocrine - It releases hormones, insulin and glucagon, that help regulate our blood sugar level.

Pancreas is an important organ of the body, it is one of its kind and lasts a lifetime, extracting nutrients, processing over 100,000 meals in a lifetime without ever breaking down. But whenever it does, it becomes imperative to diagnose and treat the root cause.

Pancreas find it easy to digest a Meal but not when it needs healing! Every step, between making a diagnosis and achieving the desired prognosis, is a milestone in treating a pancreatic condition. A process that goes beyond surgery and intervention. Where surgery itself is a lot more than – making the cut and repairing the damage done by a disease. Meticulous planning and preparations towards patient counseling, stabilising general health, improving nutritional status, preparing the patient for surgery and immaculate post-op care is what goes into, not just treating but healing a patient in its truest sense. All this backed with an interdisciplinary approach is what makes it possible to handle even the most complex cases.

When would you need to see a doctor?

 Loss of appetite and indigestion

• Severe gnawing pain that wraps the upper part of the abdomen

• Foul-smelling fatty stool

• Chronic conditions – may manifest as malnutrition and sudden weight loss

• Recent onset diabetes in elderly patients

• Cancers specifically manifest as painless jaundice with no initial symptoms though, but later exhibiting yellowish discoloration of eyes and skin and itching all over the body.

Common Pancreatic Conditions

Some of the commonly seen pancreatic conditions are:

• Diabetes Type 1 & Type 2

• Acute Pancreatitis

• Chronic Pancreatitis

• Hereditary pancreatitis

• Cystic Fibrosis

• Cystic tumors of the pancreas

• Neuroendocrine tumors of the pancreas

• Pancreatic Cancers

How peculiar can a pancreatic condition get?

Cases can be as minor as an episode of mild acute pancreatitis and as severe as an insidiously developing tumor of the pancreas. There can be a routine case of detecting diabetes from the symptoms or it can be a case where the symptoms of diabetes are silently camouflaging a life-threatening tumor.

What would decide the fate of such a pancreatic condition:

• Factor-1- The right diagnosis made by the right doctor at the right time followed by proper planning and execution of the appropriate line of treatment.

• Factor-2- multidisciplinary approach wherein specialists from different departments come together as a team to validate the Factor-1.

The prognosis of a pancreatic condition depends a lot on the age of the patient, stage of diagnosis, underlying diabetic condition, general health , along with the medical and surgical approach with which it is being managed. Patients beyond 50 years, of age, exhibiting non-specific symptoms, and recent onset diabetes need to be critically evaluated, as they might harbor small tumors of the pancreas. At Sakra Institute of Digestive & HPB sciences, a team of specialists from the departments of Surgical & Medical Gastroenterology, Medical Oncology and Diagnostic & Interventional Radiology work together in order to provide a more comprehensive treatment to the patients. It is a blessing to have all these specialties under one roof, especially when dealing some of the most complex cases.

Pancreas Care Program

Doctors at Sakra understand this portentous Power of Pancreas, and the ability of this silent organ to blatantly affect the quality of life of a patient- Diabetic or not. This is the reason why our doctor have very carefully designed the Pancreas Care Program, to deal with this organ that has only come to light when used synonymously with Diabetes up till now. But now is the time when we start looking at this organ beyond its ability to attack our body with the weapon of Insulin alone. Considering that, keeping a holistic approach towards Pancreas and its disorders, the Pancreas Care Program at Sakra operates with the following objective:

• To develop a center with a comprehensive approach to treatment by a multidisciplinary team of specialists who will assess the risk, current disease status, and appropriate therapeutic interventions.

• To provide state-of-the-art treatment and research for pancreatic diseases.

• To offer all modalities of treatment such as advanced endoscopic and interventional treatments, surgical treatment depending upon the disease status.

• To develop a supportive counselling, awareness and educational program for the patient and the family members of the patients with pancreatic disease.

• To maximize outcomes for patients with pancreatic disease.