There are many reasons of having jaundice. On many occasions, jaundice is due to medical diseases like hepatitis requiring medicines only.  Sometimes however, stones, strictures (narrowing of bile duct) or tumors, blocking the channels carrying bile, can cause them.

Many bile duct stones can be removed by Endoscopy without the need for any hospital stay or surgery. However, some patients will need surgery- conventional or Laparoscopic.  The latter method obviously is more comfortable for the patients.

Tumors in the Gall Bladder, Bile duct, Pancreas and Liver can cause jaundice. Normally, people would be unhappy to hear that they have jaundice due to tumor in their abdomen. But one should appreciate that jaundice could be an early warning signal that can be helpful in diagnosing a tumor early. Then it would be beneficial if the patient reported to the Gastrosurgeon early since this could mean a possible cure for the patient.

Sadly, many patients do not pay attention to this symptom and waste their time with inadequate investigations and unscientific treatment. When they ultimately land up with the surgeon, the tumor is too advanced for treatment. It is important that patients detect and report their jaundiceearly so that these tumors can be picked up in the initial stage for treatment. Cure of these tumors are possible only if detected early.

Another important thing to remember is that endoscopy can also relieve jaundice due to tumors by the use of a stent.  But it is wise to remember that it is only a temporary method to relieve jaundice and surgery is the only definitive treatment.

There has been a lot of progress in the treatment of these tumors. Surgery for  the tumors in the pancreas by a procedure called Whipples operation- earlier thought to be a formidable operation-  has become increasingly safer due to improved technique and technology. Liver tumors can now be removed safely with the improved understanding of liver anatomy and availability of better tools to cut liver. Even blood requirement has become rare for these procedures. However, these surgeries should be conducted in centers performing these surgeries routinely for better outcome.

To conclude, patients should be aware that jaundiceneeds to be evaluated early to identify which are amenable to medicines and which will be best served by endoscopy or surgery.  It is especially important to pick up jaundice caused by tumors because their early surgery is the only way to cure them.

The Occam’s Razor suggests that entities should not be multiplied endlessly. Although it is true in many situations, in some fields where evolution and progress is ongoing, this is not true. One such field is in Bariatric surgery where yet another procedure is making great promise. It goes by the name of Mini Gastric Bypass (MGB).

Dr R Rutledge, an American surgeon devised the procedure in 1997 and the author had the honour and privilege to learn the procedure directly from him.

Literature suggests that when compared to the other bariatric procedures, MGB is a simpler, shorter and a very effective technique in weight loss surgery. In fact it takes less than an hour to do this surgery. Most patients are home the next day.

The other significant short-term advantage is the time to get back to a solid diet after surgery. In other bariatric procedures, it is common for the patients to get back to solid food after a period of 3 to 6 weeks. However a patient after MGB can get back to a solid diet as early as 2 days! No more listening to the patients post surgery “Doctor, when can I eat? I am tired of drinking”.

The MGB works differently from other procedures in the sense that it causes more malabsorption than standard procedures like sleeve gastrectomy and conventional gastric bypass. So a patient who eats more will still lose weight or maintain the weight loss achieved even years after bariatric surgery- a phenomenon not seen consistently in other procedures. This has been documented in some studies where MGB was found to be more effective in sustained weight loss even at long term where the durability of other procedures have been questioned.

There is one more novel advantage of MGB. In all the bariatric procedures thus far, the surgery would be the same irrespective of the weight loss and metabolic effect desired. In MGB, however the procedure can be tailored to produce a measured response. In this manner, the surgery can work as a pill with the dosage in our control. Practically this is achieved by altering the length of the bowel bypassed in MGB. Shorter bypass achieves a lesser weight loss and metabolic control. The longer bypass obviously achieves more.

The other great thing about MGB (it doesn’t seem to end!) is that it is both easily reversible and revisable. Let me explain. If for some reason (and that would have to be something great, considering the benefits) a patient wanted to undo the procedure, it would take less than an hour in the operation theater to do so.  Lets take another situation. If after some time after bariatric surgery, the patient does not have the desired result of weight loss- it may have been too much or too less of weight loss- then the surgery can be revised by performing another simple procedure.

Though there is a lot of evidence in the benefits of bariatric surgery on obese diabetics, there is actually little data and good evidence on the benefits of bariatric surgery on non-obese diabetics. Some studies are showing promising results of MGB even in non-obese diabetics.

With excellent long-term weight loss and these wonderful benefits, it is not surprising to know why this surgery is fast becoming more popular with the obese and diabetic patients.

You can see how we do the procedure at the YouTube

What is the conventional treatment of Diabetes?

Diabetes is conventionally treated by a low sugar diet, physical activity and medicines that lower sugar levels in the blood. In advanced stages, insulin is also needed.

What are the complications of Diabetes?

There can be long-term complications in the Eye, Kidneys, Nerves, Heart, Brain and Limbs – practically every part of the body- in diabetes. This is because of chronic cell starvation – sugar staying in the blood and not entering the cells. This may result in eye surgery for cataract, stenting for heart disease, strokes, dialysis for kidney disease, infections, loss of limb, etc. And all this can still happen despite medical treatment of diabetes.

What is Surgery to “cure” Diabetes?

Recent research has shown that the small intestines play a major part in diabetes. When food comes in contact with certain part of the gut such as the duodenum, it releases certain hormones that are responsible for inactivity of insulin. Based on such knowledge, operations have been devised to reroute the food in the gut by altering its path. This results in the “cure” of diabetes. It is also called bariatric or metabolic surgery.

Who are the candidates for surgery to “cure” diabetes?

Diabetic patients who have are obese, have diabetes for less than 5 years and are not on insulin, have the best chance of resolution of diabetes from the surgery.

How is the surgery done? What is the cost of the surgery and is it cost-effective?

It is a laparoscopic surgery requiring a 2-day hospital stay. The cost of the surgery varies from 2-5 lakhs INR depending on the procedure, technology and the class of accommodation. If one calculates the expenditure of medications, tests and the risks of complications, one may find this price cost-effective.

How effective is the surgery to resolve diabetes?

So effective is the diabetes surgery that it has been hailed as the most important discovery of the decade. Many patients are exchanging their life of medications with a single shot surgery. The disease that was till recently considered incurable is now being considered “potentially curable”.

Watch the video on Diabetic Surgery on YouTube.

What is Chronic Pancreatitis?

Chronic pancreatitis is a diseaseof the pancreas in which the pancreas gets progressively destroyed. It is seen in patients who consume alcohol or harbor stones. Sometimes, it runs in families and sometimes there is no reason to be found.

How do they present?

They present with recurrent pain in upper abdomen usually after meals, indigestion and sometimes diabetes.They may multiple hospital admissions for their pain.

What is the Treatment of Chronic Pancreatitis?

The treatment of chronic pancreatitis is done by medical, endoscopic and surgical methods.  The main idea is to relieve pain, improve pancreatic function, and manage complications.

What are the Medical approaches to Chronic Pancreatitis?

They comprise of

1. Analgesics for pain relief
2. Pancreatic enzyme supplementation to aid in digestion and giving pancreatic “rest”.
3. Avoiding Alcohol
4. Nerve blocks under CT scan guidance- by injecting drugs that block pain-carrying nerves of the pancreas. Multiple sessions may be needed in this starategy.
5. Endoscopy- Sometimes, the pancreatic duct can get narrowed that require dilatation with plastic pipes put during endoscopy (Stenting)
6. Lithotripsy- Sometimes the pancreatic duct gets blocked by stones that need to be broken down by shock waves. This is called lithotripsy and is available in few centers. Both endoscopic stent and lithotripsy helps in restoring the flow of digestive juices.

When is Surgery done for Chronic Pancreatitis?

Surgery is usually reserved for people with chronic pancreatitis who have pain that does not respond to other treatments mentioned above.

It is reserved for patients whose CT/ MRI scan reports show dilated pancreatic ducts or a tumor/ cyst formation.

A surgical procedure called pancreaticojejunostomy relieves blockage and pressure in the pancreatic ducts. It alleviates pain in about 80 percent of people.  The objective of the surgery is to relieve blockage by stones and narrowing and hence help in diminishing the pressure on the pancreatic cells. This, in turn, helps in restoring the flow of digestive juices and preventing cell damage.  Sometimes, when a tumor like formation is seen in the head of the pancreas, its removal is also carried out- this is called “Coring”.

In the future, cell damage that produce diabetes may also benefit from “islet transplantation”.

How safe and effective is the Surgery for Chronic Pancreatitis?

This surgery is very safe with complication rates of less than 2%. The majority of the patients, when selected well have significant and sustained pain relief. In patients fulfilling the criterion, surgery should always be a strong option.

What is Heartburn?

Heartburn is the feeling of burning sensation in the upper abdomen or the central chest. This happens when the stomach acid enters the esophagus (foodpipe in the chest). This can happen when the muscle at the junction of esophagus and the stomach gets weaker and hence is unable to prevent the reverse flow of food and acid from the stomach to the esophagus.

Occasional heartburn isn’t dangerous, but chronic heartburn or gastroesophageal reflux disease (GERD) can sometimes lead to serious problems.

What causes Heartburn?

Two excesses often contribute to this problem: too much food in the stomach (overeating) or too much pressure on the stomach (frequently from obesity, pregnancy, or constipation).

Certain foods such as tomatoes, citrus fruits, garlic, onions, chocolate, coffee and peppermint can also cause it. Meals high in fats and oils (animal or vegetable) often lead to heartburn, as do certain medications.

Stress and lack of sleep can increase acid production and can cause heartburn.

Addictions such as smoking and alcohol are major contributors.

The correctable medical problem that can be responsible is Hiatus Hernia.

What is a Hiatus hernia?

In a hiatus hernia, a part of the stomach that should normally be in the abdomen protrudes through the diaphragm into the chest (See picture). This hernia allows food and acid abnormally to travel upwards and may produce symptoms.

What are the symptoms in Hiatus hernia?

These individuals experience heartburn when acid produced in stomach enters the chest. They also experience the distressful symptom of regurgitation (feeling of food coming up in the throat) when food travels into the chest due to this wide defect. Some hiatus hernias can lead to dysphagia (difficulty in swallowing) too.

What causes a Hiatal Hernia?

Most of the time, the cause is not known. A person may be born with a larger hiatal opening. Increased pressure in the abdomen such as from pregnancy, coughing, or straining during bowel movements may also play a role. Being overweight and obese is a definite risk factor for hiatus hernia.

How is a Hiatal Hernia Diagnosed?

A hiatal hernia can be diagnosed with a specialized X-ray (using a barium swallow or with endoscopy.

What is the first-line treatment of Hiatus Hernia and GERD (heartburns)?

Most heartburns with or without hiatus hernia can be controlled by dietary changes and medicines. Surgery is required if these measures fail.

When Is Hiatal Hernia Surgery Necessary?

Hiatus hernia surgery is needed if symptoms of GERD and regurgitation cannot be controlled effectively by medicines. Also, if the hiatal hernia (in the paraesophageal variety) is in danger of becoming constricted or strangulated (so that the blood supply is cut off), surgery may be needed to reduce the hernia, meaning put it back where it belongs.

Hiatal hernia surgery can nowadays be performed as a laparoscopic procedure. The advantages of laparoscopic surgery include smaller incisions, less pain, a one day hospital stay and a more rapid recovery.

Nobody wants to listen to bad news. That is why, we do not want to accept any deadly diagnosis such as cancer (a term which should be replaced by ”tumor” so as not to scare people). We also want to believe anybody who gives us a hope of treatment by easy methods even if they are unscientific and irrational.

These are very common occurences  in practice. The main reason behind this is fear. The fear of disease and death makes us irrational. The term “cancer” plays havoc in our minds. It spells doom. Nobody is ready to accept that it can happen to anyone. It is an unfortunate incident in anyone’s life. But isn’t the tsunami unfortunate too? Don’t we accept it? Turning away from the problem (any problem in life for that matter) does not make the problem disappear. It allows it to grow.

Let us take acquire some knowledge about these abdominal cancers. They can arise from the stomach, liver, bile duct, gall bladder, pancreas and colon. Amongst these cancers, the colon cancers are the slowest to grow and offer the best opportunity for cure.

Whatever be the origin of the cancer, all abdominal tumors are best treated by surgery. If the CT scan shows the tumor has not spread to other areas, the correct treatment is to remove the tumor appropriately with surgery. If the tumor cannot be taken out by surgery, the outcome is poor. The surgery when done appropriately by trained surgeons gives us the best chance for cure and long survival. Recent development permits us to use laparoscopy in some cancers such as the colon thereby imparting more comfort to the patient without compromising on the tumor clearance.  The advent of modern technology has considerably reduced the complication rates. For instance, after excising the diseased segment of foodpipe, the joining of two ends can be done with staplers that reduce the incidence of wound infection. In case of the liver cancer surgery, the use of Modern gadgets can reduce blood loss considerably. This translates into less blood transfusion, less complications and prolonged survival. In cancers of the pancreas, the complication rate that was once high, has been reduced by improvised techniques of pancreatic anastomosis. Gallbladder cancers when detected by accidental pathological diagnosis after a cholecystectomy, have a good outcome when operated early and correctly.

The research in cancer in the last decade has resulted in better cancer medicines (chemotherapy) and radiotherapy techniques. We can now use them in some situations before surgery to make a large tumor smaller and amenable to surgical removal. Chemotherapy and radiotherapy can also be used after surgery in some cases to improve survival.

However, if we were to talk about one single step that makes a difference in the treatment of abdominal cancers, it is the appropriately performed surgery. So getting an effective and early surgery is crucial.

A good counseling by your doctor is of immense importance. Ask your doctor regarding the disease, its prognosis, and treatment options. Learn more about the tumor to have a realistic expectation. Knowledge and awareness of tumor treatment should bring a change in the way society looks at cancers, or should we say ” tumors”. Accepting and facing it scientifically and staying away from the unscientific remedies are the first steps in the right direction. A good surgery is the best possible method to cure wherever possible.