Colorectal Surgery

What are types of colorectal surgery?

Colorectal surgeries are of various types depending on part of colon or rectum removed.

Types of colorectal surgeries are –

  1. Hemicolectomy – removal of half of colon – right or left
  2. Segemental resection of colon – removal of part of colon
  3. Subtotal colectomy – removal of whole colon leaving small part behind
  4. Total colectomy – removal of whole colon
  5. Proctocolectomy- removal of whole colon and rectum
  6. Anterior resection – removal of part of rectum
  7. APR – Removal of rectum and anus.
  8. Rectopexy for rectal prolapse

 All these are types of surgeries done for various indications –

  1. Cancer of colon
  2. Cancer of rectum
  3. Colitis
  4. Benign tumor of colon or rectum.
  5. Colonic perforation
  6. Diverticulitis
  7. Rectal prolapse

What is Colorectal surgery recovery time?

Laparoscopic colorectal surgery  is gold standard in today’s time. Open colorectal surgery is thing of past these days. Just like laparoscopy is gold standard for gall bladder removal, laparoscopy is gold standard for colorectal surgery. since introduction of laparoscopy in colorectal surgery recovery time has decreased considerably and patients are usually discharged from hospital within 3-5 days as compared to 7-10 days after open surgery. Patient is able to eat and move around early as compared to open surgery.  Shorter hospital stay also decreases cost of colorectal surgery. 

Risks involved in colorectal surgery?

Various risks involved with colorectal surgery are

  1. Bleeding after surgery – very rare
  2. Leak from anastomosis ( joints of intestine)
  3. Infection
  4. Injury to ureter ( urine pipe)
  5. Urinary bladder disturbance due to nerve injury ( especially after rectal surgery)

Jaundice ( Peelia) – Symptoms Causes Treatment

Jaundice-Myths-And-Facts

Jaundice (peelia)- It’s yellowness of eyes and skin due to disturbance in metabolism of bilirubin.

Liver produces bile and then put it into intestine through a tract called biliary tract.

Any disturbance from making of bile and obstruction to its outflow will cause jaundice.

If one has this idea then one can really negate the myths prevalent in society about jaundice.

Myths and facts

  1. Jaundice will subside on its own.  Majority of jaundice do subside on its own as majority are due to infection but it’s for doctor to decide by testing as which type will subside on its own and which type require further treatment.
  2. We should not eat turmeric in jaundice.  It’s untrue. Turmeric does not do any harm to liver and does not increase jaundice.
  3. We should not eat certain foodstuffs in jaundice. – Untrue . One can eat all types of foodstuffs during jaundice. One should have good healthy diet during an episode of jaundice.
  4. Jaundice can be cured some spiritual leader by some herbal medicine. Majority of jaundice are self limiting so will cure even if you don’t take any medicine. So these types of jaundice get cured by any means and credit goes to spiritual leader.
  5. Jaundice can be transmitted from one person to another. Some type viral infection can be transmitted by sexual contact or sharing needle with infected person as seen with AIDS while another can spread by consuming food contaminated by infected person so infected person should maintain good hygiene to prevent further spread to its family members and friends.
  6. How can one prevent jaundice ?
    • Maintain good hygiene and have well cooked food.
    • Drink clean water.
    • Do not have unsafe sex.
    • Do not share syringes or needle.

What is treatment for jaundice?

Treatment of jaundice depends upon type of jaundice. For treatment purposes jaundice is divided into

  1. Medical jaundice- this type is primarily treated with medicines
  2. Surgical jaundice- It requires surgical intervention for its cure.

Medical jaundice arises usually due damage to cells of liver while surgical jaundice is caused by obstruction to flow of bile from liver to intestine. Liver function tests, Ultrasound abdomen, MRCP helps in classifying the jaundice. Your general physician/gastroenterologist/gastrosurgeon can help in diagnosing the type of jaundice based on these tests.

Causes of medical jaundice –

  1. Hepatitis – infectious or toxic
  2. Drug toxicity
  3. Damage to liver by abnormal deposition
  4. Defect in bilirubin metabolism
  5. Alcohol hepatitis
  6. Autoimmune hepatitis

Causes of surgical jaundice

  1. Stone in bile duct
  2. Gall bladder stone
  3. Tumor of gall bladder or bile duct
  4. Tumor of liver
  5. Liver cysts
  6. Liver abscesses

Except for stone in bile duct that is treated with ERCP, all other causes of surgical jaundice require surgical treatment. These cases are best treated by surgeon with knowledge and expertise in liver and biliary tract surgery.

Upper GI Surgery

Upper GI Surgery is a subspeciality of GI Surgery. An upper GI surgeon is a doctor
who specializes in the surgical treatment of diseases of the upper gastrointestinal
tract. This includes the esophagus, stomach, and duodenum. Upper GI surgeons
also perform surgery to treat conditions of the liver, pancreas, and gallbladder.
Upper GI surgeons are trained in gastrointestinal surgery, but they also complete a
superspeciality training in upper GI surgery. This allows them to learn the latest
techniques and procedures for treating diseases of the upper gastrointestinal tract.
Upper GI surgeons play an important role in the diagnosis and treatment of diseases
of the upper gastrointestinal tract. They can provide a variety of services, including:

  • Diagnosis: Upper GI surgeons can perform a variety of tests to diagnose
    diseases of the upper gastrointestinal tract. These tests may include upper
    endoscopy, esophagogastroduodenoscopy (EGD), and barium swallow.
  • Treatment: Upper GI surgeons can perform a variety of surgical procedures to
    treat diseases of the upper gastrointestinal tract. These procedures may
    include fundoplication, gastrectomy, esophagectomy,
    cardiomyotomy, gastrojejunostomy, etc.
  • Follow-up care: Upper GI surgeons can provide follow-up care to patients who
    have had surgery or other treatment for diseases of the upper gastrointestinal
    tract. This care may include monitoring for recurrence of disease, providing
    support for patients and their families, and referring patients to other
    specialists as needed.

If you have any concerns about your upper gastrointestinal tract, it is important to
see an upper GI surgeon. Upper GI surgeons can provide you with the care you
need to stay healthy.

Here are some common conditions that upper GI surgeons treat:

  • Gastroesophageal reflux disease (GERD): GERD is a condition in which
    stomach acid backs up into the esophagus, causing heartburn and other
    symptoms.
  • Peptic ulcer disease: Peptic ulcer disease is a condition in which an ulcer
    forms in the lining of the stomach or duodenum.
  • Esophageal cancer: Esophageal cancer is a cancer that starts in the esophagus.
  • Gastric cancer: Gastric cancer is a cancer that starts in the stomach.
  • Achalasia cardia
  • Benign and malignant tumors of the esophagus and stomach.
  • Esophagus and gastric obstructions.

If you have any of these conditions, it is important to see an upper GI surgeon.
Upper GI surgeons can provide you with the care you need to stay healthy.

Esophagus Cancer

1. What are causes of esophagus cancer?

Risk factors for esophagus carcinoma are

  • Alcohol consumption
  • Smoking
  • Gastroesophageal reflux disease
  • Obesity
  • Barrett esophagus

2. What are types of esophagus cancer?

There are predominantly two types of esophagus cancers based on microscopic examination of tumor sample

  • Squamous cell carcinoma
  • Adenocarcinoma

Few other types of carcinoma can affect esophagus but are uncommon -e.g, smallcell carcinoma, neuroendocrine tumor, sarcomas etc.

3. What are symptoms of esophagus cancer?

Usual presenting symptoms are

  • Difficulty in swallowing
  • Stickiness of food while swallowing
  • Retrosternal discomfort
  • Pain chest
  • Chronic cough especially while swallowing
  • Weight loss
  • Hoarseness of voice

4. How can esophagus cancer be detected?

First line of investigation for diagnosis are

  • Barium swallow
  • Upper GI endoscopy and biopsy

These two tests not only provide us diagnosis but also tells us about location of tumor that will further decide future course of action for treatment. Biopsy provides us with tissue diagnosis regarding type of cancer as mentioned above.

5. What are tests to be done before starting any form of therapy?

After diagnosis staging investigation are required to grossly stage the disease and planfurther treatment

  • CT scan of chest and upper abdomen
  • Endoscopic ultrasound (EUS)
  • Whole body PET Scan
  • Bronchoscopy depending upon location of tumor

6. What is treatment of esophagus cancer?

Surgery has been mainstay of treatment for carcinoma esophagus. But long term survival was poor. With recent advent of few chemotherapeutic agents along with radiation the rapyhas really improved overall survival and outcomes. Even in patients with locally advanced disease chemoradiation has resulted in down staging of tumor and increased resection rate as well as survival rates. So now according to protocol patient usually under goes chemoradiation first followed by surgery.

7. What if the type of surgery done for esophageal cancer?

Esophagus cancer is treated by minimally invasive methods now. Thoraco- laparoscopi cresection of esophagus with reconstruction by stomach tube is method of choice for cancer of esophagus. Robotic surgery is further advancement in surgical armamentarium that increases safety of surgery and improves outcome. With minimally invasive methods side effects of surgery has been reduced to minimum and patient’s recovery is enhanced.

8. What are side effects of treatment of esophagus cancer?

The patient can have side effects due to radiation, chemotherapy or surgery. Side effects due tochemoradiation are

  • Nausea /vomiting
  • Difficulty in swallowing
  • Chest pain
  • Loss of appetite
  • Decreased cell counts
  • Mouth ulcers

Complications after surgery can be

  • Hoarseness of voice due to nerve injury- its usually temporary and recovers with time
  • Swallowing problems due to uncoordinated effects of swallowing reflex
  • Injury to trachea, blood vessels, thoracic duct (incidence has reduced considerablyafter using minimally invasive methods)
  • Lung complications (reduced significantly with laparoscopic approach)

Dr. Manmohan Singh Bedi

Specializing in surgery of Liver, Pancreas, gall bladder, biliary tree, esophagus, gastrointestinal, bariatric, and laparoscopic surgery.

He specializes in dealing with both cancerous and non-cancerous diseases of the digestive system. He has been associated with many institutes of national and international fame. He has three fellowships to his credit. He was also awarded (delete) the best young investigator award at the international conference of Pancreas for his research work in Pancreatic surgery in 2011.

 Hepato Biliary Surgery

What is hepato biliary system?

Hepatobiliary system involves combination of liver and its ductal system(hepatic ducts, bile duct and gall bladder) draining bile (juice secreted by liver) from liver to intestine.

What are diseases that can affect hepatobiliary system that require surgery?

Hepato biliary disease treatment is best achieved by multimodality approach with involvement of Medical gastroenterologist, Interventional radiologist and Hepatobiliary surgeon. Diseases that require surgery are

  1. Liver cancer
  2. Cysts of liver
  3. Cancer from other organs that have spread to liver
  4. Stones in liver and bile duct ( can be treated with endoscopy also)
  5. Neuroendocrine tumor in liver.
  6. Liver abscess
  7. Tumors of bile duct ( cholangiocarcinoma)
  8. Gall bladder cancer
  9. Shunt surgery for bleeding varices;
  10. Bile duct stricture and fistula

How hepatobiliary surgeon can score over general and oncosurgeons in treating these diseases?

Hepato biliary system is very complex system that involves not only dealing with liver but also its complex blood supply and bile ductal system. As surgery is main modality of treatment so every effort is made to convert the unresectable tumors to resectable stage with help of radiology and other interventions. This is possible only if case is initially assessed by hepatobiliary surgeon who can plan resection in such a way that tumor is also removed completely and adequate amount of liver is also left that is compatible with survival.

How much liver can be removed safely?

In patients with normal liver around 75% of liver can be removed safely and person can lead normal life. However in case of diseased liver e.g cirrhosis , jaundice etc ,more amount of liver needs to be left behind for person to lead normal life.

Is it safe to operate on patients with jaundice or with liver disease?

Before operating upon patient with jaundice every effort is made to lower jaundice by various means e.g stenting, putting catheter in liver to drain bile duct. After bilirubin decreases to near normal levels then surgery is planned.

Why liver or biliary surgery complex?

Liver is a solid organ in which complex network of small bile ducts and blood vessels are hidden. Also bile duct and blood vessels are very closely associated outside liver. So tumors of liver and bile duct very commonly involve these blood vessels thus making surgery complex. Moreover as they are hidden inside liver, surgery is planned by preoperative imaging and intraoperative marking that is possible for surgeon regularly involved in doing hepatobiliary surgery. These planes have to be followed otherwise lot of bleeding can happen that is dangerous for patient.

Who should consult hepatobiliary surgeon?

Any patient suffering from any of diseases mentioned above should always consult hepatobiliary surgeon before starting upon any form of treatment. As assessment by hepatobiliary surgeon increases chance of cure by resecting even advanced tumors.

Do hepatobiliary surgeon treat gall baldder diseases also?

Yes. Gall bladder is an important component of hepatobiliary system is most commonly diseased organ due increased prevalence of stone disease. Hepatobiliary surgeon treats gall bladder diseases more effectively as he is ready for all surprises that can be encountered with gall bladder diseases that are not detected before surgery e.g complicated gall bladder disease, ruptured gall bladder detected during surgery, gall bladder cancer detected during surgery etc. Hepatobiliary surgeon would be able to deal with all this during surgery.

Does hepatobiliary surgeon treat CBD Stones also?

Majority of stones in bile duct are managed by endoscopy done by medical gastroenterologist but in some cases stones are very large in size and are very high in numbers then surgery can be better choice of treatment in form of removal of stones or providing bypass to prevent recurrent stone formation.

Stomach Cancer

1. What are causes of stomach cancer?

Causes of stomach cancers are

  • Alcohol consumption
  • Smoking
  • Diet high in salt and processed meat and low in vegetables
  • Any previous stomach surgery
  • Conditions decreasing acid secretion in stomach
  • H.Pylori infection
  • Hereditary conditions like multiple polyps throughout GIT

2. What are the symptoms of stomach cancer?

  • Early satiety
  • Anemia
  • Recurrent Vomiting or blood in vomiting
  • Loss of appetite
  • Abdominal distension
  • Passing black-colored stools
  • Unexplained weight loss

3. Does cancer of stomach run in families?

Yes cancer of stomach can run in families especially in patient having multiple polyps
throughout gastrointestinal tract e.g, FAP, Lynch syndrome etc. first degree relatives of
these patient should undergo prophylactic screening endoscopy at young age.

4. How is stomach cancer diagnosed?

Stomach cancer is usually diagnosed by Imaging or endoscopy and biopsy. To establish
diagnosis endoscopy and biopsy is done. For staging purpose following investigations are
advised –

  • CECT Scan of abdomen
  • PET Scan of whole body
  • Endoscopic ultrasound

5. What is treatment of stomach cancer?

Treatment of stomach cancer depends upon stage of cancer and presentation of patient. In
case of patient who is unable to eat, surgery would be mainstay of treatment. While in patients with locally advanced disease chemoradiation followed by surgery is the treatment of choice. Surgery remain mainstay of treatment for stomach cancer.

6. What type of surgery is best for patient?

With advancement in technology and staplers stomach cancer is managed these days with
laparoscopy. Laparoscopy has been used widely for total or partial removal of stomach and
has been found to provide equal results with improved quality of life and early recovery in
these patients.
Robotic surgery is further advancement in surgical armamentarium that increases accuracy
of dissection thus improving results.

Diet in Patients With Gall Stones

Gall stones occur when bile, which is normally fluid, forms stones in your gallbladder. This is the organ that sits beneath the liver. Most commonly, gallstones contain lumps of fatty (cholesterol-like) material that has solidified and hardened. Sometimes bile pigments or calcium deposits form gallstones. Sometimes just a few small stones are formed; sometimes a great many. Occasionally, just one large stone is formed.

About one in three women and one in six men form gallstones at some stage in their lives. Gallstones become more common with increasing age. The risk of gallstones forming increases with:

  1. Pregnancy
  2. Obesity
  3. Diabetes
  4. Smoking
  5. Rapid weight loss
  6. Having a close relative with gallstones
  7. Taking certain medicines such as the contraceptive pill
  8. Eating a generally unhealthy diet, particularly a diet which is high in fat

You can reduce your risk of developing gallstones by:

Eating vegetable protein – for example, beans and pulses.

  1. Increasing fibre intake
  2. Eating nuts
  3. Increasing dietary calcium
  4. Increasing vitamin C intake
  5. Drinking coffee
  6. Drinking a moderate amount of alcohol.

The role of the gallbladder in digestion

The gallbladder plays a part in the digestion of food. It collects and stores bile, then releases the bile into the small intestine when food enters the small intestine from the stomach. This helps with the digestion of food because the gallbladder contains bile salts (and other substances) which break down fat. The bile duct which connects the gallbladder to the small intestine can become blocked by gallstones. This may cause symptoms such as pain, bloating, a feeling of sickness (nausea), and being sick (vomiting). The stone may cause a blockage and make it difficult for the bile to be released from the bile duct.

Dietary changes to help with symptoms of gallstones

There is no specific diet for treating symptoms of, or to prevent, gallstones. Most people with gallstones will have surgery to remove the gallbladder in an operation called a cholecystectomy. However, eating a low-fat diet is likely to reduce symptoms while you are waiting for the operation, as the gallbladder will not be stimulated to release bile into the small intestine. If you find that any particular foods trigger the onset of the pain then try to avoid eating those foods until you have had your gallbladder removed. Once you have had the operation there is no need to follow any particular diet, although of course it is always a good idea to eat as healthily as possible. If you are overweight, attaining a healthy weight will be beneficial. However, it is important to do this gradually, as rapid weight loss has been associated with the development of gallstones. A safe weight loss of 1-2 lbs (0.5 to 1 kg) per week is recommended

A healthy balanced diet consists of:

Plenty of fruit and vegetables. Aim to have at least five portions each day

  1. Plenty of starchy carbohydrates. Examples include bread, rice, cereals, pasta, potatoes, chapattis, and plantain. Choose wholegrain varieties where possible
  2. Some milk and dairy products (2-3 portions per day). Choose low-fat dairy products
  3. Some meat, fish, eggs, and alternatives such as beans and pulses
  4. Limited amounts of foods high in fats and sugars
  5. Limit saturated fat that is found in animal products, such as butter, ghee, cheese, meat, cakes, biscuits, and pastries. Replace these with unsaturated fats found in non-animal products, such as sunflower, rapeseed and olive oil, avocados, nuts, and seeds. But remember that unsaturated fats can also trigger gallstone pain
  6. Make sure your diet is high in fiber. This can be found in beans, pulses, fruit and vegetables, oats, and wholegrain products, such as bread, pasta, and rice
  7. Drink plenty of fluid – at least two liters daily, such as water or herbal teas

Try not to eat too much fat at one mealtime. It might be helpful to have smaller, more frequent meals. Some people find that specific foods are the triggers for symptoms. Keep a food and symptom diary to identify trigger foods. Avoid these foods for a two-week trial period and note any improvements in symptoms.