Emergent reoperations in bariatric surgery

Emergent reoperations in bariatric surgery – experience in the first 100 cases in a private hospital in Oman.

Rajkumar Janavikula Sankaran, Dharmendra Kollapalayam Raman, Anant Shankar, Bader Aflah Salim Al Hadhrami

Department of General and Laparoscopic Surgery, Al Hayat International Hospital, Muscat, Sultanate of Oman

Abstract :

Laparoscopic bariatric surgery though growing rapidly in the past two decades has a high degree of immediate postoperative complications. We present three emergent complications in our series of first 100 cases in a private hospital in Oman which were tackled appropriately by our team of professionals. These complications were one staple line hemorrhage in laparoscopic sleeve gastrectomy, twist of gastric pouch in mini gastric bypass and leakage of gastrojejunal anastomosis in Roux‑en‑Y gastric bypass. In all the three cases, thorough postoperative vigil has been stressed upon as an important factor in postoperative bariatric surgical care. In the gastric bypass case, despite the absence of definite findings in the radiological investigations, patient was taken to the operating room on high degree of clinical suspicion as a part of diagnostic algorithm.


Laparoscopic bariatric surgery, albeit growing by leaps and bounds across the world, is not to be taken lightly, because of higher rate of complications compared to nonbariatric surgery. This is because many of the patients have comorbid illnesses such as diabetes, hypertension,coronary artery disease, dyslipidemia, and because of excessively obese abdominal wall, adequate leverage of instrumentation is often difficult to obtain, making otherwise simple hemostasis, a difficult affair. Positioning of a bariatric surgical patient is another challenge for the entire operating team, and often times complications are related to prolonged operating time, in a given position, i.e., causing nerve injury. In our 36 months of experience in operative laparoscopic bariatric surgery in Oman, we report three emergent reoperations, for various indications (1. Staple line hemorrhage [laparoscopic sleeve gastrectomy (LSG)],

2. Twisted anastomosis [mini gastric bypass (MGB)], and 3. Leaked anastomosis [Roux‑en‑Y gastric bypass (RGB)]).


Of all 100 patients in our center, are all operated by the senior author. The surgeries are:
1. Laparoscopic sleeve gastrectomy: 70
2. Laparoscopic MGB: 14
3. Laparoscopic RGB: 16.
In this group, we have had one major emergent reoperative complication in each of the groups. We would like to discuss these complications and how we had handled them.

Case no. 1: Staple line hemorrhage
A 38‑year‑old gentleman had undergone an uncomplicated LSG. He had two distal green (60 mm × 4.8 mm) staple cartridges fired and the remaining were blue ones (60 mm × 3.5 mm). There was a little bit of staple line bleed at the level of 2nd firing, but it seemed settled.The operation went off uneventfully. About 8 h of postoperatively, patient developed tachycardia, sweating, and hypotension. There was a sharp decline in urine output. O/E, patient was anxious, pale, and sweating. Pulse rate: 102 beats/min, blood pressure (BP): 90/60 mmHg, Hb‑7 gm%. Ultrasound was not contributory and we proceeded with the contrast‑enhanced computerized tomography (CECT) scan of abdomen which showed large amount of blood pooled in the perigastric region, Morrison’s pouch, and perisplenic area.

After rushing in 2 L of crystalloid fluid, we brought the BP up and we took the patient back to operating room (OR). Re‑laparoscopy revealed a small and steady spurter from the 2nd staple line firing. There was a definite spurter and the spurter was oversewn with continuous 2‑0 polypropylene.Perfect hemostasis was obtained. The patient underwent an uneventful postoperative period. About a year of postsurgery, he was down by 85% of his excess body weight and otherwise he was asymptomatic.

Case no. 2: Twist of gastric pouch
A 46‑year‑old gentleman of body mass index (BMI) 48 with Type II diabetes mellitus and hypertension underwent MGB. The standard 200 cm afferent limb was brought in and anastomosed to lesser curve based gastric sleeve. No Brolin suture to hitch up the anastomosis was inserted.Postoperatively, patient developed persistent vomiting on day 1, which did not settle with standard antiemesis regime.An urgent contrast study with the gastrografin revealed no passage of the dye beyond the stomach pouch. We opted for re‑laparoscopy and examined the MGB. It was found that afferent loop from the right side had come over to the left side with complete twist and shutting off the anastomosis. This was devolved and there was some doubt about the viability of the gastrojejunal anastomosis, so it was refashioned thus; the afferent and efferent loops were taken down from the stomach and the afferent loop was joined to the efferent loop 50 cm from the gastrojejunal,thus converting this into a Roux‑en‑Y loop. Postoperatively, patient was very well with no further  complications.

Case no. 3: Anastomotic leak
A 30‑year‑old man with a BMI of 52 with severe gastroesophageal reflux disease and hypertension aggressive with; possibly, an earlier re‑laparoscopy in the third case might have cut short a few days of ventilation and would have hastened his recovery.

Except in extreme circumstances, there is no reason why a patient who has just had laparoscopic bariatric surgery cannot have another laparoscopy, especially if it might turn out to be a life‑saving one. Yet another learning point is CECT, when available, trumps all other investigations in the search for a leak. Although ultrasound is a helpful modality, especially if CECT scan is not available, in a set up where underwent laparoscopic RGB. Although in the immediate postoperative period, he passed flatus and motion and went home on 3rd postoperative day, he was back again within 48 h with fever, vomiting, abdominal pain, and breathlessness. He was admitted and investigated. Complete blood count showed leukocytosis with a shift to left. Ultrasound abdomen did not obviously show any fluid collection. CECT of abdomen was too inconclusive. Since he was tachycardic and hypotensive, peritonitis was suspected purely on clinical grounds. He was aggressively resuscitated and taken back to OR. Re‑laparoscopy showed the following findings:

1. An intact gastrojejunal anastomosis which showed no sign of leak with the methylene blue test. However, there was evidence of postoperative leak with purulent fluid in the perigastric area

2. A jejunal loop distal to the gastrojejunal anastomosis had entered the mesenteric defect, causing an obstruction – perforation syndrome (the increased intraluminal pressure of the proximal jejunum had caused a gastrojejunal leak that sealed spontaneously).

The loop of bowel was pulled out from the mesenteric defect and the defect was closed with 2‑0 vicryl. Thorough peritoneal lavage was done and the gastrojejunal anestomosis although with the sealed leak was resutured and reinforced with 2‑0 vicryl. Postoperatively, patient was hypotensive, acidotic, and oliguric. He had features of fully fledged septic shock. He was aggressively treated with broad spectrum antibiotics and was put on ventilator and underwent temporary renal filtration therapy. He made a steady recovery over the next 10 days and discharged after 2 weeks of re‑laparoscopy. On follow‑up after 1 year, he had lost 45 kg and got rid of all comorbid conditions and had no further problems.


The fact that all three patients were well managed and that we had no mortality in all 100 cases vindicates the advantages of paranoid postoperative vigilance in these patients. An increasing pulse rate was the common factor in all three cases. It has been repeatedly shown in literature as a harbinger of disaster in the postoperative bariatric patients.In the first case, it was due to hypovolemia and hypotension and in the second case, it was due to gastrointestinal obstruction and in the third case, the culprit was sepsis. We would like to reiterate the truth that tachycardia in the postoperative bariatric patient is to be taken very seriously. The second learning point for us and others is that in the postoperative period, it is better to look and see rather than wait and see. Indeed we believe that being even more CECT is readily available, it is still the gold standard for postoperative leak. However, still CECT misses 30% of leaks, and here aggressive re‑laparoscopy holds the key as seen in our third case where re‑laparoscopy was done on high degree of clinical suspicion. In the first case, CECT findings were contributory though it is noteworthy that ultrasound had shown the same findings.

Figure 1: Hemoperitoneum in laparoscopic sleeve gastrectomy

Figure 2: Staple line bleed in laparoscopic sleeve gastrectomy

Figure 3: Staple line bleed – suturing in progress

Figure 4: Twist of anastomosis in mini gastric bypass

Figure 5: Twist of anastomosis in mini gastric bypass  Figure 6: Inconclusive contrast-enhanced computerized tomography in leaked Roux-en-Y gastric bypass patient

Figure 7: Leaked Roux-en-Y gastric bypass patient

In an age, when patients’ perceptions are constantly bombarded even by a single complication in the bariatric arena, we are happy to report the first 100 laparoscopic bariatric surgeries done in our center with zero mortality and three emergent postoperative morbidities that were promptly tackled by re‑laparoscopy.
In terms of prevention of complications, one must conclude with the following points:

1. In the first case, perhaps if a pericardial buttress has been used along with the stapler, this bleed might not have occurred. However, increased cost engendered will rarely be justified and this is not a standard practice in most of the centers worldwide.Glaysher et al. conclude that current evidence suggests that staple‑line reinforcement reduces the incidence of leakage and postoperative complications than nonreinforcement but does not significantly reduce bleeding complications.[1‑4]

2. Perhaps the Brolin stitch taken to afferent and efferent loops might have helped to fix the loops to the stomach and might have prevented the twist that caused the acute gastrojejunal volvulus in a patient with MGB. We have subsequently made it a policy to take this stitch in all patients who undergo MGB. Noun et al. concludes in his series of 1000 cases that MGB is an effective, relatively low‑risk, and low‑failure bariatric procedure. In addition, it can be easily revised, converted, or reversed.[5,6]

3. Gastrointestinal leak after gastric bypass surgery is an infrequent complication which can happen at some
point in every bariatric surgeon’s experience. Early detection and treatment of a gastrointestinal leak after
gastric bypass could be pivotal in reducing morbidity and mortality. CECT might be useful to detect postoperative leaks in some patients, but important limitations exist in its accuracy, in part because of issues inherent to the bariatric patient population that could make CECT imaging impractical or impossible. Surgical reexploration is an acceptable and important strategy to diagnose and treat patients who are highly suspected of having a postoperative leak after gastric bypass. Surgical reexploration that reveals no explanation for a postoperative patient’s adverse clinical findings or deterioration after gastric bypass should be considered an appropriate and indicated intervention and not a complication and should indeed be included in the diagnostic algorithm.[7‑9]

4. More effective closure of mesenteric defects (we now close mesenteric as well as Petersen’s defects) might
have prevented the loops from herniating within, creating the higher pressure in the gastrojejunal anastomosis (obstruction – perforation syndrome). However, Cho et al. reports in his series of 1400 cases of RGB that antecolic antegastric laparoscopic RGB without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.[10‑12]

We would like to pass on these few learning points to the medical and surgical fraternity. To conclude, an intensive and careful postoperative vigil always pays rich dividends in terms of successful patient outcome, a generalization that is even more relevant for the postoperative bariatric surgical patient.

Walking Down The Memory Lane

I begin with a little narrative, as I walk down a 25-year-old memory lane , with the story of a patient who stands foremost in the columns of my memory, indelibly, not just for the complexity of his case, not just because he died, but for the amazing bond he developed with me. As one walks into the main hallway of my home, one finds the first ten feet of the wall spotted with the necessary photographs of the children at their wedding, my wife and I at our 25th wedding anniversary, et cetera.
There is one patient’s photograph in this collection. It shows a young man of about 20, standing proudly next to me. It was Saren’s customary annual birthday visit to me. But I am reaching out beyond the pale of the story just now. Perhaps I mention that because I’m starting the story on the day of his birthday,4 years after he left us.I’ve known hundreds, nay, thousands, of patients to relate emotionally and intensely , to me in the past 25 years of my practice. However, no one has thrown himself completely at me as Saren did. Visiting his home when he passed away, I was struck by the number of photographs of me , either alone or with him, splattered on the walls, as his laptop screen saver or as his telephone screen, et cetera. Even though this butterfly flitted into and out of the earth in a very short time, he would tug on my heart strings from the great beyond.

How did all of this start? And more importantly where did it begin? My mind races back to the year 2006, and to the image of a little boy, then twelve something, flanked by his parents, standing in front of me with a huge cut on his abdomen. (We call this a laparotomy scar ). The cut was fresh and he had a fairly large number of sutures because he had just had the surgery of having his belly slit open from top to bottom. The doctors at the renowned cancer institute in Adyar, had to cut open in order to remove a large tumour that was growing in close relationship to a huge vein, the I VC or the Inferior Vena Cava. As the tumour looked like a cancerous growth completely engulfing that area, with an increased risk of death on the table, they abandoned the procedure, explaining to the shellshocked patient’s parents that the risks of the surgery was higher than the benefits.

Those were the days before the illogical, savage onslaught on the doctors that is happening now in India, in which we are accused of one thing or the other, and constantly. Indian doctors were supposed to be blatantly commercial in their outlook meaning, not caring of their patients; taking payments from pharmaceuticals for prescribing their products; and sometimes even using patients as ‘lab rats’...This to me, is the most sickening change of mindset that has occurred over the last decade or two and is the harbinger of a terrible state of affairs!  If the  populace becomes distrustful of the very forces that have sworn to defend them from disease , then how will that society find peace? 

But more of that later……
Saren had a very rare tumour that usually arises within the adrenal gland, a phaeochromocytoma,. I’m so sorry , some of these Greek and Latin terms will look Greek and Latin, but there is very few of such terms in this book -Pronounced as Fee-yo-chromo-sy-toma, which is notorious for spilling its poison into the blood and will spiral the BP up , cause palpitations (racy beating of the heart) sweating , headache, etc. Fortunately in his case, it was a non functioning tumour , which means it did not have the poisons loaded up in it. But it had two other major problems – it was malignant or cancerous and it was stuck to the major vessel near it, that precluded dissection and removal. The sad fact is that surgeons have to extend ourselves outwith our comfort zone, when we deal with tumours like this. We need to deal with death on the table and massive bleeding, coagulation or clotting abnormalities, failure of kidneys and other and most importantly the ire and wrath of a thoroughly misguided society. On the other hand it is much easier for us to open and sew it closed again, blaming God above for the unfortunate turn of events and not do much else except for usually ineffective, futile ( read useless) chemotherapy. With the sharp blade of the Sword of Damocles shining closer and closer to our exposed necks, it is no surprise that several patients with potentially curable diseases are being more and more shown the door, with surgeons increasingly opting out of major procedures , since they fall into the potential danger zone of being labelled reckless or ‘ experimental’ !! This had happened to Saren too.

At that point of time when he was brought to me, I explained the potential risks to his parents who had been perfectly well informed about the same. His parents being teachers, they had understood the implications. Now barely less than 2 weeks after his first operation, they wanted a chance to redeem their son.

In the movie , Schindler’s list, a Jewish woman in the ghetto, when being shown a temporary hiding place, says, ” Don’t you know that even an hour of life , is still life itself? “This rings true for patients with major illnesses. And so it was with Saren. I once more reiterated the risks of death on the table with massive bleeding but the parents and the boy himself, young as he was, were emphatic that they would like a shot at reducing the tumour size at least, what we call debulking in surgical parlance, to buy a  little more time.

After a quick consult with the concerned members of the surgical and parasurgical team, namely, the anaesthetist, cardiologist, endocrinologist and the vascular surgeon, etc, and after reserving several units of blood, I decided to go ahead and operate. The decision to proceed with a major surgery of this magnitude comes with a lot of baggage. By a curious process of self preservation, the entire family shifts the onus of life on you. That is to say the decision is usually a conjoint one but the responsibility rests on a single man that is the leader of the surgical team. Not only that, the term that I hear all the time, and one that I have been hearing for the last two decades is “We have left it in your hands and you are equal to God”. Unfortunately we don’t have the power of God. Most people say that to unload the responsibility from their shoulders to ours. At the point of time when the surgeon takes the scalpel in his hand for such a case, he is Brahma, to create new life, Vishnu, to protect the life from the ravages of cancer and Shiva, to annihilate and carve out the bundle of cells which form the cancer. There is a dark side to this kind of power. Many surgeons unwittingly every now and then succumb to what Hippocrates warned against, Apotheosis, or the condition where they consider themselves equal to God Himself. Probably the only positive outcome of the increasing legal pressures is that doctors have shied away from God like acts like pulling the plug on very ill patients. I remember a surgeon in the United Kingdom ,who was operating on a Aneurysm of the Aorta ruptured, where the large blood vessel coming from the heart , expands in size, causing a dangerous leakage of the blood. Thirty years ago the death rate in such patients beyond a certain age was more than 80% in most centres. Halfway through , realising that our efforts would certainly be futile, the surgeon in question, calmly undid the metal clamp on the Aorta which was holding the blood within the system, and let the entire volume of the blood to spill out in minutes and terminate the event. Fortunately such dramatic acts are not seen nowadays. !!

Back to Saren!
Even as we started the procedure, we had the entire team of specialists  prepped and ready. Although this was from eleven years ago it is still etched in my memory. Remembering surgical procedures is a multi sensory experience. When I close my eyes and revisit these moments , the eerie silence in the theatre, broken only by the rhythmic beep-beep of the monitor , reminding us of the beating heart, the constant conversational chatter on the side of the anaesthetist ( only about the fluctuating vital parameters of the patient, and not about the share market fluctuations, as often portrayed by cartoonists), and the occasional interruptions by the theatre nurses to remind us about the number of pads kept in the abdomen etc, all  play out before me like a movie.

With a lot of difficulty we re-entered Saren’s abdomen and dissected our way through the bowel that was stuck at the cut of the previous surgery. Generally speaking, re-operative surgeries are far more difficult than the primary one. The main reason for this is the clumping of the bowel loops and the fat inside the abdomen to the inner aspect of the cut. This is known as ‘adhesions’. Most people who have open surgeries have pain arising from adhesions and they often require re operations.
These adhesions can make the surgery very hazardous and sometimes even more so than the target of the surgery itself! Anyway we proceeded by releasing all the clumped bowels and it took us a full two hours to even approach the tumour. In those two hours, I carefully dissected out with the scissors and released every little bit of the fat and intestine stuck to the wall of the abdomen, ensuring that all the loops of bowel were all out of harm’s way , ensuring that we could proceed with the planned operation. Very often relatives of patients assume that an operation is finished when we have barely started! The contrary is true as well! After thousands of laparoscopic gall bladders, I’m often in the position of finishing the surgery in ten minutes and waiting for a suitably longer time before declaring the successful outcome of the procedure. It’s a fine tight rope that we surgeons walk, for skill is often so easily misconstrued as recklessness ! Picasso on the other hand could finish a sketch in two minutes and then easily explain to the bewildered patron, that he was coughing out a large sum of money not for the two minute it took him to sketch the masterpiece but for the twenty years of practice that brought him to that level of skill and experience!
It is saddening that in India a doctor has to be constantly defensive about skill in finishing the surgery very swiftly.

On approaching Saren’s tumour , I found that it was in close juxtaposition to the Aorta and the Inferior Vena Cava, both being the largest blood vessels in the abdominal part of the body. I could understand why the previous set of surgeons backed off. Being uncharitable about another surgeon is a very flawed mutation that has somehow crept into the DNA of the current medical system. Similar to the Indian crabs that pull each other down even in open buckets, Indian doctors apply a curious ‘one upmanship’ on their colleagues in order to pump themselves up in the eyes of the patients. It is sad that the patients themselves are aware of this game , playing it to the hilt!
As we handled Saren’s tumour, we had to make sure that it wasn’t spilling its toxic chemicals into his blood stream that would cause a dangerous rise of his blood pressure and precipitate a stroke on the table. Although the chemical analysis of his blood and urine showed the tumour to be a non secreting or non functional one, one could never tell. You see , there are no absolutes in medicine. It will probably always remain an imperfect science. The blood vessels supplying a part of his large intestine, were densely stuck to the front part of the tumour and I had to sacrifice these blood vessels and consequently that portion of his bowel. And so to cut out that part was my first major step of the operation. After this was done , I had access to the tumour. As it was straddling the great vessels, a stray movement would be sure to cause massive bleeding. With the cardiovascular surgeon standing by in the team, I gingerly dissected the tumour , removing perhaps 98% of the enemy within. The two great vessels that lie side by side are the Aorta and IVC , as I mentioned before. The aorta, carrying arterial blood (being pumped from the heart) , has a much tougher wall and lends itself to dissection.

It is possible to very carefully dissect out a tumour is which is stuck around the aorta, through the entire circumference. On the other hand, the Inferior Vena Cava,the large channel carrying blood to the heart, has a thin wall (as all veins do). It is almost impossible to completely rip off an adherent tumour from the wall of the Cava. Also, the area of the tumour encasing this large vein was exactly the place where the great veins from the kidney were going into the cava. Therefore, to cut out the entire channel and put in a prosthetic graft on the Cava , and to reconnect the veins from the kidney was not just difficult. It was impossible!!!!!
Indeed when I finished the operation, a tiny noggin of tissue, barely a few grams in weight was left stuck to the IVC. In the interests of safety, and acknowledging that considerable debulking of more than 95% was accomplished, I completed the procedure, sewing up the abdominal wall together and took him back to the Intensive Care Unit!

It was in the next ten days of his stay in the hospital, that my equation with Saren hit a new high. Even on the first post operative day when I looked in on him, he was bright as a button and the absolute epicentre of human activity in the post operative one. He was chattering away to all the nurses, duty doctors and other staff asking them all details about me. When I explained to him that we had removed 95% of the tumour he grinned and said, “With your good heart I know I will be 100% okay”.
Was it denial, I wonder, or a blind complete faith that rode roughshod above all considerations of logic and science? I will never know, for Saren has passed on, to sweeter and greater realms, since then. But when I meet him when my time comes, I will certainly ask him. It is sad that we often miss out opportunities to know about the greatest and most profound truths of life by not asking or not waiting for an answer. It is said that Pontius Pilate after passing the sentence on Jesus Christ, asked him
” What is truth?” . Sadly, without waiting for a reply from the lips of the only man on the planet who could have told him what truth was, he turned away and washed his hands. Perhaps not asking questions is as much a flaw as asking a question and not waiting for a reply.

Saren’s recovery from the first operation was remarkable. He bounced back to normal and we were able to discharge him within 10 days after the operation. I still remember his father and mother waiting outside my consulting room and making a request, not as patients are wont to do , to reduce the bill, but for a few more minutes of my time as their son wanted a few photographs with me by his side. On the day of his discharge, a beaming Saren posed for several photographs with me and over the next several years there developed a repetitive pattern of Saren writing to me, phoning me, and taking photographs on all important days like his birthday.

As the months went by after his surgery post operative scans showed no evidence of the tiny button of tissue. Anyway, not for the first few years. Saren was also followed up by a number of top surgical endocrinologists. (Technically though this was inside the abdomen, the tumour was releasing hormones and so it also came under the purview of the endocrinologists). The topmost surgical endocrinologist Professor Vittal and his illustrious son Dr Sai Krishna , followed him up on a few occasions assured both me and Saren’s parents that nothing no need to be done. Over the next six years Saren grew into a strapping young man. His voice changed and his muscles bulged and he had a whole new confidence about him. What didn’t change at all was his total faith and love for me. He clearly told his parents that he was going to study medicine and settle down permanently as my assistant. A patient who was sitting next to him in my waiting room once told me that Saren was proudly telling all others around him , that he would one day walk down the same corridors as my assistant. He followed every major surgical procedure that I did, every press meet that I had and everything that was good or bad that was written about me in that space. Every time there was a negative comment on me it was Saren who took up his sword and shield, and flew in as the white knight in shining armour, defending me to the hilt. It is sad that so few of us would actually take the effort to defend something that we truly believe in. It is much easier to die for a cause, then to live for one.

Not a birthday of mine went by when Saren did not appear with a cake. Please understand that he lived nearly 300 miles away in the village outside ceiling. Just to see me for a few minutes, he would have to travel several hours and wait for an hour or two in order to get “special time “at the end of the clinic. This did not seem to deter the determined young man. I could feel his affection and love in many ways.

For example, every now and then when I was troubled by some events in my life , if I ever met him without my customary beam, I would get a spate of calls for the next few days from his parents and friends, that he was not eating well and was very distressed and because “I was upset”. I would then ring him and reassure him that was just a passing cloud and I was really alright. I was very touched that this boy was moved by my emotion and humbled simply by his faith. The years 2007–2008 were rough years with the recession hitting the market. We at the hospital, were struggling financially and I personally was working round-the-clock with every ounce of my energy, to meet our financial commitments, the so called EMI. In India , if you borrow in thousands of crores like the Mallyas of the world, you don’t have to pay back. But if you borrowed smaller amounts, much smaller amounts you would get threatening letters from the bank reminding you to pay up or else…… It was at this point that young Saren, having heard the market buzz of our troubles , went to his parents and requested them to give him his share of the property. When asked why he replied that he wanted to sell his share of the land and give that money to me, to ease my stress. Of course, his parents, rightly, talked him out of this and of course, we would never have consented to accept it. But the fact remains that, simply by the beauty of his intention, he had transcended.

I read somewhere that however noble our intentions are , men judge us only by the outcome. On the other hand, whatever the outcome God judges us only by our intentions. Saren’s thoughts and intentions were so lofty that for me nothing else mattered. If you look at the world, you might want to help with a large sum of money, but you are able to give only a portion of that. The society around us credits is only for that portion. Not for our hearts behind it. Thank God then, for He judges us for what we want to do rather than what we end up doing.

Around this time Saren finished his 12 th and wanted to study medicine. At that point of time one would have to systematically remove an arm and a leg in order to get a seat in a private medical college. For some unknown and completely inexplicable reason these are called capitation fees. I think, based on the anatomical effect they have on the parents of the student, they should really be called “decapitation ” fees!!!! This, I swear. If I had not been in the financial doldrums at that time I would’ve tried my best to procure a medical seat for Saren, locally. As things turned out neither his parents nor I could afford it and his marks –let’s say, his marks weren’t as good as his intentions. We went for a bail out option in the situation, and chose to have him educated as a doctor, but in the Philippines. I remember how he came and met me, the day before he left promising that he was doing all that he did to be with me. I could see somewhere along the line the tables had turned. Instead of my consoling him that he would be well he was telling me that things would get better soon and he would be there to support me and work alongside with me. This change happened softly and surely. Indeed he was actually bemoaning the fact, that the next generation medical students in the family could not stand and fight by my side at that time.
Intentions!!! Here we go again. I have repeatedly in my life, decided on the worth of a person’s character because of perceived intentions. You may well ask, as my wife often has, as to how accurate the perceived intentions are as compared to the actual intentions. I really don’t know the answer to that as to many other questions. Ben Okri, the Nobel Prize winning African author says the world is full of questions that only the dead can answer. One just bats on, nevertheless, against “as boats against a ceaseless tide”, a Karmic flourish  by Scott Fitzgerald, the concluding lines of the Great Gatsby.

A bright and beaming Saren , stood outside my clinic door, with his admission letter to a medical school, in Manila. With the capitation fee mounting , a number of aspiring medical students  look at overseas medical graduation, especially in three major centres, in the Philippines, China and the Russian states. These kids have to go through a year of learning the local language, and then apply themselves for 4-5 years in the rigour of the medical curriculum. When they finish they come back to India, and languish for two or three years, moonlighting in private hospitals, earning miserable sums , while they prepare for a rather difficult , qualifying examination. They needed this in order to get back into the mainstream of medical studies in India. Even a bright student taking this route would need to spend an extra 2 to 3 years to complete their qualification. But at least they could get a medical degree without the ‘decapitation’.

This, was the route chosen by Saren, and he settled very quickly into the medical course in Philippines. In some ways the gathering force of a candle light, which swells before it ebbs and dies, can sometimes take a protracted period. Another truth I have learnt over the years. In the case of Saren, the full force of his personality blazed in an extended swan song in the last few years before he left us. Suddenly he was in the thick of things amidst a group of Indian born medical students as his friends, competing in sports and studies, outings and social networking et cetera. Where I thought he would be isolated and mournful I found him to be more active than ever on Facebook, et cetera. Every post of mine would get a positive comment and a like by him within minutes. He was always onto everything I said and posted on the Internet. In the globally connected age of the Web, distances don’t quite matter. One often hears of the mother daughter duo spending more time together, FaceTiming twice a day after the latter’s wedding , than they ever did muchmore under the same roof!!! Connectivity has given rise to interconnectedness. And so it was with Saren, and just as his comments would flash on to my phone- Facebook screen , I knew that he was constantly keeping me in his thoughts.

Every sad movie has a half hour of happy times, used by glued couples to link hands, exchange smiles and stare at the screen, while the cynical  head for snacks and the aged  to the toilet. In Saren’s case, certainly in my perception, the happy hour was his time in the Philippines. The fact that he was working towards becoming a doctor was the single thought that fuelled him on, and the company of several youngsters sailing together seemed to have a very positive effect on his energy state. During this period I was in regular contact with his brother Arun and his parents who would now and then approach me for small favours to be done in the government (his mother was a school teacher in government service.). To the extent possible I slipped in my tuppence, and these visits were punctuated and embellished by their latest accounts of what Saren was up to. Interestingly, the entire family including his older brother Arun, seemed to consider him the centre of their lives. His brother, whilst doing his engineering course, was particularly proud that his brother was engaged in medical study abroad. In the states of Tamilnadu , ( and other states of India) the child who is studying to become a doctor is the blue-eyed boy of the family and the boy, on becoming a man, is expected to be the saviour of the entire family as well as a considerable portion of the society. Despite the relentless assault by the wayward media, the essential nobility of the profession and the fundamental fact – it’s the doctors who struggle to save lives- and the romance of the profession , still draws hundreds of thousands of youngsters towards medical studies.

Full 7 1/2 years after his first operation, disaster struck, and heavily. Back from the Philippines on holiday, Saren had complained of fatigue and weight loss and his parents had taken him for a CT scan. Pause. In the western countries, no one can walk in to get a CT scan and there is an orderly process by which the primary physician refers the patient to a specialist. If and when the specialist feels that the patient needs further imaging, then, and only then, will he send the patient to a specialised centre to do a CT or MRI. On the other hand the peculiar situation in India enables the patients or their relatives to get a scan done first and then approach the physician. Having said that in Saren’s case the main danger lurked in that little bit of residual tissue, and they were quite justified in getting the scan done. However this swallow doesn’t make a summer of a thousand scans being done peremptorily by the patients themselves.

There comes a moment, every now and then , in every surgeon’s life. A moment in which a lurking suspicion, a vague entity of dread that only moved back and forth within the dark recesses of the brain, surfaces suddenly, becoming a reality to face, becoming a demon to fight. Being blessed with – or cursed should I say – a memory that customarily grasps details I remember with great precision the multi sensory inputs of that dreadful moment. Peering into the CT films, slapped onto an X-ray lobby, through the muted white light of the illumination through the film, I could see the grim reality staring in my face. This reality had taken substance in the form of an olive shaped, irregular shadow hugging the Inferior Vena Cava, the large venous channel I had mentioned before. This was not the cute hug of a baby koala bear or a Kangaroo’s little one in its pouch.  It was the menacing hug of an alien that would soon disappear into the host only to emerge , having devoured the tissues and vitality of its victim.

There were a number of options available at this point of time. One of them obviously was to go back inside and operate aggressively. Another option was to see if the tumour was functional, that is to see if it was secreting chemicals, in which case one could poison the tumour by feeding it its vital substrate laced with a radioactive substance that would stay inside the tumour and destroy it over the following weeks. The third option was to blindly radiate the tumour area from outside, and  the fourth was to give chemotherapy.

It’s not only patients who run for second opinion, in this era of mistrust of the primary consult. Very often specialist doctors seek another expert opinion in order to throw light on a complex problem. It is sad that one mega corporate hospital even ran a publicity campaign on “second opinions”, suggesting subliminally to the public at large, that the first opinions obtained elsewhere were unreliable, and to seek expert help from the specialists under its banner. I believe that second opinion is very important and to be called for, in complex situations when more than one option exists. Not just because a corporate hospital says so.

Once more, a highly acclaimed expert in endocrinology, a father son duo, who are very dear to me, had a look at Saren’s CT scan and examined him. Their suggestion was to attempt to radiate the tumour from within, that is, to poison the tumour with radioactive material to destroy it. Accordingly, Saren fixed up to meet an oncologist in Bangalore which is very close to Salem, his hometown. A series of radioactive sessions was carried out over the next few months and formed the mainstay of his treatment. Needless to say Saren could not continue his medical studies in the Philippines. Many of his friends called me regularly for updates on his health. Outwardly he appeared quite confident and optimistic about his progress but he had his ruminative moments , and his parents later told me that he told them to constantly be in touch with me even if something “bad” happened to him.

A few months after starting the internal radiation he had another functional scan to study the tumour, and it showed a significant reduction in the functioning of the tumour tissue. This was a shot in the arm for all of us. Dear reader, I want you to spend a little time here so I can appraise you of the sad facts of life.’ Patients often think that a CT scan showing no evidence of disease is often the same as a scan showing evidence of no disease. These are the commonest misapprehensions that we labour under, which behavioural scientists call “cognitive biases”. Essentially when a CT scan says there is no evidence of tumour it tells me that within the limits of its resolution it is unable to pick up any signs of the tumour. However the human mind interprets it to mean that there is no tumour. There is a huge difference between the two phrases, ‘ no evidence of tumour “and “evidence of no tumour”. The MRI, CT scan and PETscans can tell us there is no evidence of tumour but only God can tell us that there is evidence of no tumour, and by misinterpreting one for the other people are left with so much confusion and misery. Very often we have patients coming back with films saying.” how could there be cancer now when only three months back the scans said there was no tumour?” What we struggle to make clear, without sounding too pessimistic ,is that at that point of time there was no tumour tissue visible. This is like the 99% paradox. Even if a chemotherapy drug can kill 99% of the tumour cells ,something that we would normally think is nearly the same as total cell kill, it is not so at all. In other words if a tumour comprises 10 million cells giving it 99% of cell kill would still leave us with a 1% of a million which is 1000 cancer cells alive and kicking. When one looks at the tumour dynamics and the fast rate at which the cells multiply, it is not surprising that the cancer comes back with a bang in no time at all. Anyway, there was some celebration at our army camp, that the scans showed decreased function of the tumour.

Second opinions have their advantages and disadvantages. Sometimes a demon seed of a negative thought is planted in the brain of the listener in the form of an opinion, whether it is right or wrong. Some of the doctors in Bangalore, seen by  the family for an oncology consult, opined that the cancer should be cut and removed. Suddenly the family was up in arms, convinced that at this point of time the tumour should be removed.

Truth often consists of multiple layers of information. It is very easy to be lost in one of the strata, without considering the structure of the other strata. On paper, a recurrent non functioning tumour is a weak and tottering alien army , that can easily be vanquished. Unfortunately the reality is not always so. Tumours often elicit a very dense fibrotic response from the surrounding tissue. This is known as desmoplastic response. The negative effect of this is that it encases the tumour and its immediate environs into a fibrous mess from which it is difficult to separate the tumour out. In other words, what begins as a clean operation will soon start resembling a dog’s dinner. Especially when an organ has been radiated either internally or externally the fibrous response begins very early. Moreover the intimate relationship of this tumour mass with the vena cava meant that the wall of the vessel could give way and cause exsanguination due to a massive bleed at any point of time.

Not knowing about any of these, and egged on by a couple of over enthusiastic surgeons, the family was very keen on giving it a bash again. They were envisioning a situation wherein we had the opportunity to annihilate the evil invader once and for all. For three months, there was a see sawing of various opinions and decision-making, when I finally gave in. But I explained to the family that I would take on the case with no guarantees whatsoever and if I had the slightest hesitation on the operating table I would not proceed with the surgery. On a sunny morning, saren was readmitted for early exploration surgery. Once more I had a team of multiple specialists with me, to tackle any possible emergency. Again, I went in very gingerly and after an hour or two we managed to reach the site of the tumour. When we did, a horrid surprise awaited. To our consternation we found that the tumour area was completely fibrosed and the vena cava was totally encased by the tumour. Little blood vessels were running all around and the area was a virtual minefield. What could we do?

I must confess that I have a tendency to bite the bullet and march into dense tiger country. I therefore suggested that we go ahead, removing the tumour and tackling the IVC. The majority of the surgeons with me, including the surgical endocrinologist who was following him up, opined against it. Let me stop and say something else here. I’m often confronted by members of the public who say , “doc is there no set way of doing this operation.? ” The truth is that although there is a preset way for about 60-80% of the operations, there is a fairly large area where there are no rules. And rules, recommendations and guidelines emerge from the experience of a large number of cases which are reported in the scientific journals, and based on which reports and statistical data can be taken out, which would help surgeons to know which particular choice would ensure the best outcome for the patient . However in upto 20 to 30% of the cases we tackle,  such data is not available One is only aware of three or four routes. Depending upon the temerity (or the lack of it) of the surgeon and the facilities and the backup available, one has to take a call. Other factors then come into play , like if the patient has had previous surgery or his tolerance to a possible major operation. In Saren’s case all bets were off. There was simply no way of knowing what was the right thing to do. Medicine ( all inclusive term for surgery ) is often educated guesswork?

Back to the tense operating theatre, where we had a hot debate about the right course of action for poor Saren, lying enshrouded by sheets and tubes. The most convincing argument was from the surgical endocrinologist, that the tumour was a slow-growing one and the major debulking that I had done several years earlier had helped him go on for that many years. It was more likely therefore, given the natural history of this particular tumour, it would be another seven or eight years before it grew to the stage it would actually take his life. Any cancer operation giving 15 years of life is considered to be successful by the toughest of standards. Although there was a slim chance that a second operation would give him another 15 years of life, there was a significant risk of losing him on the table to massive per operative bleeding on the table or losing him to kidney failure because the veins of the kidney were also involved. After a lot of discussion back and forth. I conceded that acccepting a few more years of life was better than losing him on the table. At the end of the day Ground Zero reality is the decision that is taken. On the table. At the moment. By the surgeons. And we decided to abort for the exploration.

No welcoming laurels, No olive studded wreaths, awaited me when I met Saren’s parents outside the Operating Theatre. I remembered how they had been overwhelmingly thankful and had fallen at my feet after the previous surgery. It is common practice for some of the patient’s family to fall at the surgeons feet after the successful completion of a procedure, especially with a possibility of a bad outcome.

Saren’s parents were quite disappointed when I told them of our decision not to proceed with the operation. When I patiently sat them down and explained the dangers that were in front of us, his father replies “Sir, I think you did not proceed because you have become too attached to him like he was your son. You did not want to take any chances. The first time around you were much more aggressive with the tumour because you did not know him well enough”.

This angle is often quoted when surgeons choose to operate upon their own family members. The question arises as to whether the surgeon would be aggressive enough with the disease process, sometimes sparing bad tissue in the worry of damaging the healthy tissue of his loved ones. Personally I feel that one needs to operate upon every patient, known and unknown, as one would operate upon one’s own, and indeed I have operated upon several of my closest family members. I grant, however that it’s a very personal choice.

Saren recovered rapidly from the second operation but I could see that his parents felt that more could have been done. There were repeated queries from them if there were other centres where the surgery could be done. I replied that I would ask around in the community of other surgical endocrinologists if there were any other routes that we could take. However I did not hear from them for an unusually long gap after that.

Over the next few months, I continued to hear only snatches of what was going on from various friends of the family. I heard that they had met a surgical endocrinologist at CMC Vellore, whom I knew to be of the highest calibre. I must confess 2013 was a dark year for me for various reasons. Completely enmeshed in my own web of problems, I had temporarily taken my eye off  Saren’s issue until I got his call one morning. He mentioned to me that he was really sorry and was almost weeping. I told him that did not matter where he got well as long as he was getting better. He said , ” Uncle I should have told you earlier but I got admitted in CMC today and I’m getting operated tomorrow. My parents did not want to tell you for fear of hurting you but I could not go through with it without speaking to you and getting your blessings Uncle”. I responded immediately asking him to relax and get well soon and reassured him. I also pointed out to him that probably his father and mother were right and I probably had trodden softly on the disease and perhaps a dispassionate third person might be a little more aggressive. After finishing the surgery,”Can I come over to Chennai right away, to see you uncle?” he asked. He also thanked me for some small favour I had done for his mother in relation to the school she was teaching in. I wound up the conversation after few minutes, promising him that I would keep in touch with his parents and keep myself informed of his progress. It was a pleasant conversation, one quite indistinguishable from the numerous conversations we had shared over the past few years. There was nothing unusual about this time. Except  that it would be the last time I would speak to him.

The human brain, they say, likes a good story. Even on retrospect, the cerebral cortex, where our memories are contained, is said to add on a few dabs of paint to moments in its memory bank that are later significant because they were at the head of a significant turning point. But – no dabs of paint on this canvas! What I shared with this boy didn’t need one dramatic telephone conversation to gild, nor will I condescend to be more maudlin, to be readable. The next day was a blur of activity until one of my managers came running up with “Sir, I’m so sorry to tell you this, but Saren expired on the table today”. A few minutes later I received a call from his brother who sketched out the details that the tumour was totally stuck to the IVC and a further exploration caused such a torrential loss of blood that poor Saren never recovered. This was the exact nightmare that some of the surgeons with me in theatre had visualised.

The more time I spend in the practice of surgery,the more I realise that there are no right or wrong surgeries, only right or wrong moments. The decision taken at Vellore to proceed was simply made at the wrong one. Someone important once said, “it is the easiest thing in the world to criticise someone else”. These days I find that a different opinion or a different angle is voiced immediately on social media. The same miasma of ‘being different is being wrong’, has crept into even fields of such complexity like surgery. Hindsight, they say, is 20-20 as far as vision is concerned. It’s all okay to comment about something after it was done. I would never blame the surgeon who attempted to complete resection because I was of the same view. I phoned up his parents a little later and his mother said “Sir, my only request is for you to see him once before we bury him, as he had given clear instructions for you to do the same “.

Newtonian – Cartesian logic and thinking , trash the sentimental in favour of the strictly logical and rational. Too many scientific folk have proudly claimed freedom from sentiment or emotion, merely holding it within a closed inner circle. For scientific folks as these, the killings in Syria, Turkey, Lebanon or Bosnia are merely statistical facts, cold figures on printed paper. 
I simply can’t imagine any of these professors picking up a white flag with a Red Cross and being airdropped into Sudan or the Congo or Rwanda or wherever…
There are some of us who would like to believe that the world is one place,a melting pot in which human beings can choose to be connected with each other and are willing to extend their arms along the lines and help each other whenever and wherever

Indeed I have not gone running to see a patient who lost at any point of my life but when Saren’s mother told me this I promised her that I would see him off , along with her, in the next few hours. After along back breaking drive of 5 to 6 hours (I wondered to myself how on earth they travelled up and down so many times). I reached Saren’s home. His parents came running out to meet us and his mother kept wailing that although they had invited us so many times to the home I could do that only after his demise. I walked in to see Saren on the floor, a shrunken wizened figure, made larger by the swathing white sheets. I could definitely see an expression of peace on his face which I had not seen for many many years. I looked around the walls of the hall, and to my surprise saw several photographs of Saren and I in some of  them. His mother showed several more scattered all over his room, laptop and his mobile phone.

Not only had he actually told his mother to call me home to send him off, he had even chosen a cool shady spot in the garden, kept moist by a water body nearly, as his final spot of rest, if things went wrong. He had given clear instructions about the disposal of his things, and there was an obvious state of preparedness in his approach to what turned out to be the last few days of his life. I said my goodbyes to Saren and left , feeling an acute hollowness- of things that have been. Too often in the surgical field when two roads of promise lie ahead and we choose the one that ends in disaster, The question that often pops in our head is whether we should have taken the other path. It is all very easy to say that in hindsight but that’s the human brain for you – always jumping at the negatives. Anthropologists attribute this to the deep ingrained measure of survival, as the negative memory of the growl of the sabre-tooth tiger would draw more attention and be more important to survival, than, say, the bleat of an antelope that might make for a tasty meal. To give negative stimuli more importance has been the very cornerstone of survival of primitive man, and so has been selectively hardwired into the DNA and it has been more difficult to prise it out from the genteel veneer of the civilised man over the centuries. I knew all this. Even then, I was asking myself if I should have tried to block the procedure. It is unwarranted, unwise, and sometimes even dangerous to impose our opinion on another equally skilled team. But that’s another Okrian question for the departed. 

As I come to the close of my story, I stand buffeted by  winds from two directions:  One carrying the sweet fragrance of   Saren’s affection for me, and the other, the wind of guilt, asking me, if I could have prevented the disaster which cost him his life.

What still stands out are the words that his mum spoke to me. She said  “Although we were his biological parents, he considered you a parent in every other aspect and told us that he would live and die for you”.

A mother saying this! At the last rites of her son! How much more love can one get?
Miss you da.
Sleep well.

HR Letter

LIMA (A unit of Lifeline hospitals) is leading with its specialty in Keyhole surgeries and also provides other healthcare services.

We provide a vibrant working environment where your innovative ideas and skills are more appreciated. We provide you a strong platform to learn and execute new things and offer a gradual growth in your career.  You’ll find a best Working Environment and Work culture that value Team Work and Potential Skills.

Applications are invited from determined people with good spirit to take the hospital to the next phase of growth.

If you want to be a part of our family, please write to us,

The HR Department

Lifeline Institute of Minimal Access

No. 47/3, New Avadi Road

Kilpauk, Chennai – 600 010

Ph: +9144 4245 2500, +9144 4294 9494

Extn: 518

Email: sdr@llh.bz