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KARACHI: Prof. Mahmood Shaukat Prof. of
Paediatric Surgery who is also Registrar of KEMU delivered his invited
lecture on Role of Stem Cell therapy in paediatric surgery in the
session devoted to paediatric surgery during the SURGICON 2010 organized
by Society of Surgeons of Pakistan at Karachi from January 16th to
January 17th2010. He discussed in detail the advances in medicine based
on discoveries of principles of nature. Regeneration, he said, is the
ability to regrow lost or damaged body parts. It will ensure
availability of ready to use organs but there are certain economic and
social problems which need to be answered.
Picture on left shows Prof. Mumtaz Maher presenting a
memento to one of the guest speakers during the SURGICON 2010 while
right Prof. Saleem Khan and Prof. Shafiqur Rehman are seen demonstrating
laparoscopic surgery techniques during the workshop.
In the possible use of stem cell technology, we can collect our
resources and start doing it. We can turn on and off the genes. He also
referred to rejection of stem cell transplants. Cloning laws are upheld
in twenty three countries of the world. India is considered as one of
the leaders in this area. With the adult stem cells there is no problem
but embryos should be destroyed. More than twenty centers are working in
India doing a commendable job. In future drug research will be done n
stem cells because it will enable the researches to get financial
grants. Understanding of our genes will be the future treatment of
cancer and not therapy. Umbilical stem cord cells are another potential
regeneration therapy. Lot of work on stem cell research is being done in
India, Singapore and Malaysia in this region. A modestly equipped stem
cells lab, he said, will start functioning at KEMU by the end of March
2010 and by June or July 2010 we will be able to give some results, he
added.
Postgraduate training in Paediatric
Surgery
Prof.
Haroon K. Pasha from Nishtar Medical College Hospital talked about
Postgraduate training programme in paediatric surgery. Tracing the
history of paediatric surgery, he said it was Prof. Amanullah who
started it in JPMC in Karachi in 1961. Later on a paediatric surgery
unit was established at Nishtar Medical College Multan in 1969. In 1983
a similar unit was set up at Lahore and now there are about fifteen
paediatric surgery units functioning all over the country. It was the
general surgeons with special interest in paediatric surgery who
pioneered it. In 1986 CPSP started Fellowship programme in paediatric
surgery and so far it has produced about one hundred fifty Fellows.
Prof. Zafrullah Chaudhry President CPSP, Dr. Farooq
Sattar and Senator Abdul Haseeb Khan speaking at the SURGICON 2010
organized by Society of Surgeons of Pakistan, Karachi Chapter recently.
Giving details of the training programme Prof. Pasha said that the
trainees are required to spend two years in general surgery training
with six months rotation and after having attended basic workshops they
can sit in IMM exam. After qualifying this intermediate exam, they are
then supposed to continue three years training in paediatric surgery
without any rotation and no further workshops. Basic training is of a
general paediatric surgeon. Special workshops are organized for
paediatric surgeons and now in the developed world, there are many
sub-specialties within the paediatric surgery. These sub-specialties are
still in infancy and facilities are available at a few centers in
Pakistan. However no fellowship is offered in these sub-specialties. He
highlighted the importance of specialized sub-specialty training. There
is high mortality of surgical neonates. It is important that the
postgraduate trainees are rotated in paediatric intensive care units.
Laparoscopic surgery procedures are also being performed at a few
centers though lot of endoscopic and laparoscopic surgery is being done
in the field of paediatrics in the developed world. There is no center
offering facilities of fetal surgery. Overseas now robotic surgery is a
reality.
Prof. Pasha suggested that efforts should be made to promote and
maintain quality of education in paediatric surgery. Paediatric surgery
departments should be established in all the teaching hospitals. We
should encourage resea5ch in paediatrics and encourage
sub-specialization in paediatric surgery. He felt there was no need for
training of postgraduates in general surgery as we can teach them
principles of general surgery as well. He suggested direct induction of
postgraduates in paediatric surgery and intermediate module exam after
two years. This can be followed by three years training in high level
skills. Surgical Skills workshops should be mandatory besides rotation
in paediatric intensive care units. We also need to establish minimal
invasive surgery centers besides having foreign collaboration for
training in robotic surgery. It is unfortunate that the CPSP Faculty of
Paediatric Surgery, he said, has not met for the last two three years,
which could have taken up some of these issues, he remarked.
Laparoscopic Sleeve gasterectomy
Prof.
Mumtaz Maher made a presentation on laparoscopic sleeve gasterectomy.
Among the different treatment options he mentioned were life style
modification, use of drugs and surgery. For management of obesity,
surgery remains a choice and it has a role in taking care of obesity.
Surgery, he felt, was an accepted and effective approach to weight loss.
He then referred to benefits of bariatic surgery which started fifty
years ago. Speaking about contra indications to sleeve gasterectomy he
mentioned pregnancy and use of alcohol. The advantages it offers include
no anastomosis, no use of foreign metal and low risk of peptic ulcer.
There are staple time complications besides irreversibility and
haemorrhage. Liver sleeve injury has also been reported in some cases if
guidelines are not followed. Then there are the problems of DVT, leaks
are rare but the problem of GER must be kept in mind.
Continuing Prof. Mumtaz Maher said that it is a team work in which apart
from the surgeon, dietetician, psychologist and endocrinologist play an
important role. Preoperative preparation and anesthetic evaluation of
the patient is very important. Then there are a few pre requisites for
this operation. He made it clear that this is not a surgical procedure
for every one. One needs to have a right set up, right timing, proper
positioning of the operating table, good anesthetists and lot of
investment is required in instruments. For post operative care, ICU
monitoring is essential besides DVT prophylaxis. He then showed a video
of laparoscopic sleeve gasterectomy. He also pointed out that the
surgeon needs a team of assistants who can read his mind at different
steps of the procedure. Since June 2008, I have done thirty six
gasterectomies and most of these patients were females, he added. Two of
these patients were twenty years of age while five patients were between
20-30 years of age. Post operative results showed that 80% of them had a
fair weight loss in one year. Some of these patients also overcame their
problem of sleep apnea and medications for diabetes. He concluded his
presentation by stating that laparoscopic bariatic surgery is a
preferred approach in obesity.
Prof. Abul Fazal from Lahore described his personal experience with
bariatic surgery. He was of the view that lipo suction was a plastic
surgery procedure and not bariatic surgery. Surgeons can offer some help
to these obese patients. However, some of the problems that one faces in
these procedures are that it requires a multidisciplinary approach. Non
availability of nutritionists, equipment and heavy duty on operating
tables are some of the hurdles. The patients have to be kept on soup
diet for at least two weeks. Chest physiotherapy may be required. Most
of these patients, he said, should be and can only be managed in high
dependency units and not intensive care units. They should not smoke and
ensure regular exercise after follow up. Only then glycaemic control
becomes possible.
He further stated that we have so far managed sixteen patients. We
started with open surgery which was better but after some complications,
we shifted to sleeve gasterectomy. These patients had fewer
complications which included incisional hernia. His conclusions were
that bariatic surgery works. Doctors should refer these patients to
experts. Most of the general surgeons, he felt, can do it after some
training. Open surgery is as good but complications are high. If
laparoscopic surgery facilities are not available, patients should not
be declined surgery. Earlier Dr. Amir Khan from UK delivered a state of
the art lecture on obesity management.
During the discussion it was stated that open surgery is possible but
one has to avoid complications. It is better to offer both these
facilities to the patients for body contouring of different body parts.
At times there is excessive weight loss and ideal weight may not be
achieved. We should not be doing a procedure whereby the patient stops
losing weight. It was also stated that weight gain and weight loss is
linked to caloric intake. That is where the dietetician comes in if the
patient is having increased calories intake. Prof. Mumtaz Maher opined
that a dietetician is a must for an obesity clinic. After surgery the
patient is put on liquids for two weeks followed by semi solids and
solid food. But if the patient is addicted to food, he or she must stop
it otherwise they will go on eating and the weight will come back and
they get into depression. Once they lose weight, they get a happy
feeling. Comparative studies of diet and surgery have showed that Diet
alone does not work. The patients need to restrict their intake of food.
Total gasterectomy patients live and they do not gain weight. In
addition there is a 15-20% reduction in mortality in surgery compared
with non-surgery because of comorbid diseases. Surgery it was reiterated
was not a permanent solution as even in cancer we talk about five years
survival. In obesity surgery there is gastric bypass. People are working
on different options. The first principle is that we should not harm the
patient. Do stage one and then move forward. Referring to obesity,
infertility and PCO diseases it was pointed out that some of these
female patients do get pregnant once they lose weight. Dr. Baddar
Siddiqui opined that one must start with restrictive surgery first.
Prof. Mumtaz Maher suggested that world has gone for specialization. We
must develop specialization and not every body should start doing
bariatic surgery. We must develop a team and then move forward. Prof.
Abul Fazal said that wound infection and incisional hernia are the only
problem with open surgery. Dr. Amir Khan from UK said that the National
Health Service only pays the patients for open procedures but there is
no difference in results.
Another participant remarked that sleeve gasterectomy does not require
any nutritionist. Only experienced surgeon should start doing it. Deal
with the complications if they are encountered. Prof. Mumtaz Maher
opined that it is a specialized procedure and only specially trained
surgeons should be doing it for a team. One must remember that in your
absence, if there are complications, they have to be managed by someone
that is why one should always start it as a team work. It is an advanced
and specialized laparoscopic procedure and they should know how to
stitch it. The trainees should learn these procedures on endo trainers.
We must have dry and wet labs and then people should practice in animal
labs before operating upon patients. Dr. Amir Khan remarked that one
should not do experiments on human beings. The seniors should hold the
hands of juniors and train them properly |
