Understanding Surgery: A One-on-One with Dr. Ritu Khare

What are some recent groundbreaking laparoscopic surgical techniques for cancer patients?

It is an exciting phase. The first barrier has been breached. Patients’ understand how keyhole or laparoscopic surgery can benefit them. For cancers, the results of laparoscopic surgery are comparable or even better than open surgery. Patient acceptance and tolerance is better and post-operative recovery is faster. The survival of cancer patients’ has further improved with advances in adjuvant therapies. Minimally invasive surgery is by far the most important advance in the surgical field and is applicable In all sub-specialties. From a simple condition like repair of abdominal hernia or removal of the gallbladder to the most complex biliary and pancreatic surgeries; these can all be done by small holes in the abdominal wall. But it takes years of training and skills to get the correct combination.

What makes surgeries of the breast interesting to you?

“Women are women at the core. The breast is one part of the body which signifies feminism. Even after years, there is a strong element of inhibition in women to be able to openly express discomfort, pain, or something abnormal. This inherent issue leads to a delay in diagnosis of breast cancer, which if detected early is imminently curable. Being a female in this surgical field, it has been a privilege to have been able to break this barrier. It is overwhelming to see a large number of women seeking an opinion and eventually getting diagnosed. The presence of a female surgeon is required at the grassroots level. Breast cancer is increasing at an alarming rate and despite so much hype, we still have millions who need awareness and attention. It is an honor to be at a pedestal where one can directly offer valuable service, perform surgeries, and help save someone every single day.”

What are your favorite and challenging aspects about your job as a female surgeon?

“Being a surgeon gives you ‘power’ and the humility to accompany with it. You can only try your best to save or cure the patient. Many a times you succeed and there are times you don’t. The challenges are that you need to abide by the principles and ethics. Do not advise an un-indicated surgery. Always consider as if the patient was your ‘kin’ and try to do your best. Always remember ‘The patient trusts you and has put his faith in you.’ The other challenge is to deal with prejudice. A patient comes to you because you are a female surgeon; you diagnose a breast or a colon cancer and then the same patient gets operated by a male colleague, assuming him to be more capable. If a doctor is capable to diagnose, she is capable to treat as well. We need to keep our craft, training, and skill set updated. There is no scope of complacency. There is no scope for error. The patient also has to understand and respect the years of hard work before discriminating on the basis of gender.”

Dr. Ritu Khare,
Consultant Surgeon, Laparoscopic, Bariatric, and Breast Surgeon

A surgeon par excellence, Dr. Ritu Khare is a Consultant Surgeon practicing in the UAE for the last 15 years. She specializes in advanced laparoscopic surgery, gastrointestinal surgery, bariatric surgery, and breast diseases. Here she highlights some exciting aspects about her field.

All You Want to Know About Diabetes and Liver Disease

Diabetes and Liver Disease

A 62-year-old gentleman presented to our liver center with complaints of swelling of the legs since 6 months. He also complained of generalized weakness, fatigue, and loss of appetite. He was a diabetic since the past 20 years and had been overweight in the last 5 years. He did not consume alcohol. The patient used to visit his diabetes doctor regularly and had been told to have fatty liver on an ultrasound scan 2 years ago. A liver function test had been normal. Detailed investigations and scans of the liver done in our center showed that the patient had developed liver cirrhosis and had features of liver failure. Only a liver transplant could now give him long term survival. Visit us to know more about similar medications.

The prevalence of diabetes all over the world has increased considerably in the last 20 years. 19% of the adult population in UAE has diabetes. The most important factor contributing to this rising numbers is weight gain. Most people in middle east are getting overweight and this is related to food habits, sedentary lifestyle and lack of exercise. Even young people in the late 20s and early 30s are becoming obese. The primary reason for excess calorie intake is easy access to energy dense food i.e. food items with excess calories in a small portion such as fast foods, oily foods and sweets. A simple indicator to define overweight or obesity is the body mass index (BMI). This is a ratio of a person’s weight in relation to his height. You can calculate your BMI with an online calculator (http://www.calculator.net/bmi-calculator.html). BMI is used to categorize a person as underweight (BMI<18.5), normal weight (BMI 18.5-25), overweight (BMI 25-30), or obese (BMI >30). In the UAE, according to one survey, more than 43% people are overweight and 32% are obese (BMI>30). Another specific pattern of obesity seen in Middle East and Asia is abdominal obesity i.e. accumulation of fat in and around the belly. A waist >35 inches in women and >40 inches in men is classified as abdominal obesity. A person may have a normal BMI but presence of abdominal obesity itself increases the risk of diabetes. Analysis of long term demographic data has shown that the lifetime risk of developing diabetes at age 45 for a person with normal BMI is 12%, while in individuals with a BMI >30, this risk increases to 45%. Diabetics with high BMI are at much higher risk of developing diabetic complications viz. heart disease, stroke, kidney failure, liver disease, nervous system and eye problems. Most patients with diabetes are well aware that they can develop heart, kidney and eye diseases. Most doctors who treat diabetics also monitor for these associated diseases. However, most patients and a lot of doctors are not aware that the liver can also get affected in diabetes and can lead to serious complications including liver failure in some patients.

Diabetes essentially causes accumulation of fat in the liver. Since excess alcohol consumption also causes fatty liver, the diabetic fatty liver is known as non-alcoholic fatty liver disease (NAFLD). More than 50% of patients with diabetes have NAFLD.  Diabetics who are obese and have other associated problems such as high blood pressure, increased triglycerides have a higher risk of NAFLD. The link between fatty liver and diabetes is well documented in many studies conducted in different parts of the world. About one-third of all diabetics may actually have a more severe form of fatty liver known as non-alcoholic steatohepatitis or NASH. In these patients, the fat in the liver starts causing inflammation in the liver and this may eventually lead to advanced liver disease known as cirrhosis over a period of 15-20 years. Once a patient has NASH and advanced liver disease, the risk for developing liver cancer also increases. Diabetes and obesity are also independently associated with increased risk of liver cancer.

Most diabetics are not aware that they may have fatty liver. Even if they are aware, they may not realize the significance of the disease. In general NAFLD and NASH is typically undiagnosed, because of a lack of awareness among doctors and the hidden nature of the disease. Most individuals do not have specific symptoms and are often reassured by their doctors of the benign nature of the disease. Fatty liver is very hard to detect, often eluding blood tests and physical examination. Even the liver function tests can be normal. An ultrasound scan can detect fatty liver but does not tell much about ongoing liver damage. It is extremely important to know whether a patient with fatty liver has simple fatty liver or NASH. This is not possible with an ultrasound scan and routine liver tests. The most reliable way to diagnose NASH is a liver biopsy, which is an invasive procedure, and cannot be recommended in all patients with fatty liver. There are special blood tests (Fibrotest) and Liver scans (Fibroscan) that can help diagnose NASH and assess severity of the disease.

What can you do if you are diabetic & have fatty liver?

There are a number of steps you can take to protect your liver and prevent fatty liver disease from occurring.

• Good management of your blood sugar levels, with the help of medications and insulin (if required)
• Losing excess weight, and maintaining it through a healthy diet and regular exercise
• Considering weight loss surgery if BMI is above 35 and you are unable to lose weight by diet and exercise
• Keeping blood pressurewithin recommended limits
• Keeping your LDL or “bad” cholesterol and triglycerides levels low
• Cutting your alcohol intake
• Avoid any type of herbal supplements that have potential to cause liver injury
• Talk to your doctor about specific medications that can help both diabetes and fatty liver

The key to reversing the course of fatty liver disease in diabetes is good control of blood glucose levels and weight loss. Reducing carbohydrate intake reduces fat in the liver very quickly. A loss of 10 percent of body weight is good enough to start reducing liver fat and liver inflammation.

Dr. Kaiser Raja (author) is a consultant in Liver Diseases and Transplantation associated with the Integrated Liver Care Program of the Aster DM Healthcare Group. He is available for consultation in Aster CMI Hospital, Bangalore, Aster Hospital, Mankhool, Dubai and Aster Medical Centre, Hamdan Street, Abu Dhabi

How is Fatty Liver related to Excess Fructose in Diet Intake?

Fatty liver is an extremely common condition that affects 20-30% of all adults. Fatty liver is usually diagnosed on an ultrasound scan of the liver. The liver tests in the blood may or may not be abnormal. Individuals of any age can be affected including young children and adolescents. Most individuals do not have specific symptoms and majority of individuals are often reassured by their doctors of the benign nature of the disease. A certain type of fatty liver is related to excess consumption, but the more common one, which is known as non-alcoholic fatty liver disease or NAFLD affects people who do not drink or drink very little alcohol. Such individuals may have only fatty liver or more commonly suffer from diabetes, high blood pressure, and high cholesterol and triglycerides.

The increasing prevalence of fatty liver is generally linked to overnutrition and sedentary lifestyle. It may be intuitive to believe that a high fat diet can lead to fatty liver; however recent research has highlighted the role of excess carbohydrates in our diet as the cause of fatty liver. Carbohydrates are generally the sweet substances in our diet such as table sugar, fruits, juices, carbonated drinks, candies and related food items. Among the sugars, it is one particular type called fructose that has been found to be most damaging to the liver. Fructose is a simple sugar present in fruits and honey. Table sugar (sucrose) also contain fructose. High fructose corn syrup (HFCS) is a sweetener used in many canned foods. Fructose intake has increased remarkably in the last century and currently it constitutes about 15% of total calorie intake of a typical western diet with higher intakes amongst younger individuals and adolescents.

Non-alcoholic fatty liver disease or NAFLD is strongly related to a condition called metabolic syndrome in which affected individuals are overweight and have diabetes or pre-diabetes, high blood pressure, and elevated triglyceride levels in the blood. An affected individual may actually not be quite overweight; instead he or she may just have a large belly or have what is known as abdominal obesity. This form of obesity is extremely common in Asians and Middle Eastern people.

Scientific studies both in animals and humans have shown that a fructose in diet irrespective of other sugars and fats independently is associated with increased fat accumulation in the liver. It has been shown that it takes about 8-24 weeks on a high fructose diet to develop fatty liver. High fructose intake is also associated with development of high blood pressure and elevation of triglycerides in blood, both of which are components of metabolic syndrome. It has even been shown in studies that despite taking a low calorie diet, an individual can still develop fatty liver if the fructose content of diet is high. Another interesting fact is that diabetics who have high blood glucose levels convert the excess glucose to fructose in their liver and this fructose then damages the liver. There are good observational studies that individuals with high intake of sugar sweetened beverage drinks  have a higher prevalence of fatty liver. This is alarming because NAFLD is now the most common chronic liver disease in adolescents and this may be related to increased use of sweetened beverages in this age group.

The question that comes up is whether fruits also bad for liver since fruit sugar is actually fructose. Whole fruits are less likely to induce metabolic syndrome because of the lower fructose content per fruit (compared to a soft drink) and because they also contain constituents (flavonols, epicatechin, vitamin C, and other antioxidants) that may combat the effects of fructose.

It has been shown further that a diet rich in fats along with fructose is even more damaging to the liver. Similarly excess glucose intake is also converted in the body to fructose. A high salt diet has also been shown to exacerbate fructose induced liver damage.

Fatty liver is of two types. The first type is simple fatty liver, also known as NAFL (non-alcoholic fatty liver). NAFL does not usually progress to more advanced forms of liver disease. The second type of fatty liver is known as NASH (non-alcoholic steatohepatitis). NASH is the progressive form of fatty liver and leads to liver fibrosis and eventually to end stage liver disease or cirrhosis. Excess dietary fructose has been associated with NASH. Diabetes is also associated with NASH.

In summary, there has been a marked rise in sugar and high fructose corn syrup (HFCS) intake that has paralleled the rise of fatty liver disease. Experimentally, the fructose component of sugar and HFCS appears to have a major role in inducing fatty liver by both stimulating fat accumulation and inducing liver damage (inflammation). Clinically the intake of sugar sweetened beverages is strongly linked with NAFLD. Reducing sugar or HFCS intake may have major benefits for patients with fatty liver and specially those suffering from the advanced form of fatty liver known as NASH. While whole fruits can be consumed in good proportions, use of sweetened fruit juices, carbonated sweet beverages and food containing HFCS should be curtailed as much as possible. Special emphasis should be given to the fast food diet of children that is rich in fats and sweetened beverages.

Dr. Kaiser Raja (author) is a Senior Consultant in Liver Diseases and Transplantation associated with the Integrated Liver Care Program of the Aster DM Healthcare Group. He is available for consultation in Aster CMI Hospital, Bangalore, Aster Hospital, Mankhool, Dubai and Aster Medical Centre, Hamdan Street, Abu Dhabi.

Laparoscopic Whipple’s Pancreaticoduodenectomy – My take on it !

Family of Shantha a sixty year old lady was devastated when she was diagnosed to have a pancreatic head tumor. Fortunately, on CT scans she had an early tumor with no evidence of spread elsewhere. Although medically found fit, the complex nature of operation – ‘Whipple Procedure’, possible complications and possibility of prolonged stay provided little comfort. She was referred to me and after careful scrutiny of her reports I suggested a laparoscopic (key hole surgery) Whipple procedure. The course of stay in hospital, undergoing laparoscopic Whipple Procedure came as a pleasant surprise for the patient and family who were feared at the outset about the formidable nature of the operation. She recovered well and was discharged from the hospital on the sixth postoperative day.

The goals of lesser pain, shorter hospital stay and early return to productivity have inspired the believers in minimal access surgery to extend the horizons of laparoscopic surgery. The line between extending the benefits of laparoscopic surgery and questionable advantages with this approach is difficult to draw in complex procedures because of the lack of extensive peer reviewed literature as in the case of ‘laparoscopic Whipple Pancreaticoduodenectomy (LPD).

In a recent surgical meeting a senior surgeon commented that ‘the true benefit for patients with minimal access surgery is when the morbidity with the incision (surgical cut) is obviously more than that of the excision’. The corollary would be that there is less benefit in procedures where the morbidity of excision is more than that of the incision as with LPD.

Till a decade before my work in laparoscopy was limited to removal of a gall bladder, appendix, fundoplication or occasionally a spleen. However, with increasing experience and a desire to extend the benefits of key hole surgery to patients undergoing other gastrointestinal procedures I spent several hours training on the endo-trainer, spent several hours with experts in the country and abroad, on several occasions had the good fortune to join in for operations with them. By the year 2008, most of my foregut (food pipe, stomach) and colorectal work was laparoscopic. The collective experience from having done distal gastric resections, common duct explorations, distal pancreatic resections, choledochal cyst excisions and hepaticojejunostomies and proximal jejunal resections gave me the confidence to proceed to performing my first LPD in 2010.

I have been very selective about patients chosen for LPD selecting mainly with periampullary tumors or cystic neoplasms of pancreas. Patients with serious comorbidities, carcinoma head, previous upper abdominal surgery were excluded. Also in the initial two years patients with an aberrant or replaced right hepatic artery were excluded. To put things in perspective out of forty odd Whipple procedures in the last three years fourteen were done laparoscopically. In the first five the resection and part of reconstruction (hepaticojejunostomy) were completed laparoscopically, the specimen retrieval was done through a 8 cm midepigastric incision. Pancreaticojejunostomy and gastrojejunostomy were completed through this minilaparotomy. In the remaining the entire procedure was completed laparoscopically and specimen was retrieved through a small Pfannenstiel incision. Overall, twenty five percent of patients had morbidity. Although, I need to look at my data critically comparing short term and long term outcomes with the open and the laparoscopic approach, with LPD, I did see most patients recovering faster, having lesser pain, having fewer wound complications and starting adjuvant treatment earlier. In the subgroup of patients with LPD experiencing major morbidity such as bleeding or a Grade B or Grade C pancreatic fistula this benefit was clearly absent. Considering major morbidity was seen in 25% of patients, it would be safe to say that seven out of ten patients undergoing a LPD would have better short term outcomes than the open approach.

LPD is technically feasible for a surgeon with advanced laparoscopic skills with team work from assistant surgeons, anesthetists, scrub nurses and technicians. Also, the procedure requires high definition laparoscopic camera, HD monitors, vessel sealing devices and endostaplers. I am sure with increasing experience, improving technology more centres would adopt LPD as standard of practice in the near future.

Dr G Srikanth, MCh is a Senior GI, HPB & Advanced Laparoscopic Surgeon from Bangalore, Managing Director of Sahasra Hospitals and Visiting Surgeon at Gleneagles Global Hospital, Bangalore. He is certified Consultant Surgeon by Dubai Health Authority (DHA), Offering services at Medeor Hospital 24/7 and Aster Hospital, Dubai.