How to Lower Uric Acid and Heal Gout - What to Eat, Home Remedies and Su...

Laparoscopic Cholecystectomy for Gangrenous and Perforated Gallbladder w...

Laparoscopic Cholecystectomy has been a gold standard for removal of a diseased gallbladder. Conversion to Open Cholecystectomy is indicated for gross gallbladder pathology that makes laparoscopic approach significantly hazardous. Gangrenous gallbladder, Perforated gall bladder and Empyema gallbladder are three such extreme pathologies that usually warrant a conversion. This video shows how successful laparoscopic cholecystectomy may still be successful in such hazardous conditions.

DuodenalPolyp

A small Duodenal Polyp is being removed with a Thermal Forceps at Endoscopy.

Laparoscopic Cholecystectomy - Aberrant Structures

Laparoscopic cholecystectomy is a common surgical procedure. Theoritically, there can be up to 25% of structures variations to the biliary tree. Surgeons will always have to keep in mind this brute anatomical fact in order to avoid biliary tree injury

Why Patients With Haemorrhoids Bleed in Their Stools

The above picture shows a view of the lower rectum at colonoscopy. It is obvious the prominent dilated veins in the wall of the rectum. These veins are bigger than usual and appears greenish-blue in colour. Dilated vascular systems always carry more blood flow than otherwise.

Patients with haemorrhoids that present with rectal bleeding always have these dilated veins in the lower rectal walls. These dilated blood vessels may rupture especially during bowel motion due to sudden increase in pressure within the blood vessels. Bleeding tend to be self-limiting due to minute rupture and the vessels will get clotted by itself quite easily.

Why these dilated blood vessels occur in the first place in patients that suffer common haemorrhoids is not well understood. It may be related to the stagnation of blood flow due to persistent intraabdominal pressure preventing normal blood flow out off the rectal wall area. These may explain the frequent occurence of common haemorrhoids in patients that always constipate and in pregnant ladies.

One unique medical condition that give rise to the dilated veins above is the varicose veins of the recto-anal region due to the new blood vessels connections between the systemic blood vessels of the anal region with the portal blood vessels of the lower rectum. This condition usually occur in patients with chronic liver disease and cirrhosis. Varicose veins in the recto-anal region is less common than the varicose veins(varices) in the oesophago-gastric region which presents with vomiting of blood.

The Pandemic Endoscopist

During this Coronavirus Pandemic, we the Gastrointestinal Endoscopist were advised to strictly select our patients indicated for endoscopy. For mild symptoms we will treat the patients symptoms first with a clinically presumed diagnosis without confirming by endoscopy. Only patients who do not respond to the initial medications or patients with severe symptoms suggesting the possibility of serious diagnosis like Ulcer or Cancer, only then immediate endoscopy is indicated.

Some patients will have to be done without knowing their Coronavirus status. For these patients, we will gear up with our protective shield and garments as shown in the above pictures.

All the endoscoped patients will be tested for coronavirus status at some stage of their hospitalisation. So far I have been lucky. None of my endoscoped patients turn out to be positive for coronavirus infection.

Common Skin Tumour

Many patients have been living with their skin tumours without any problem.

Benign skin rumours are common and they are usually small and pose no problem whatsoever to patients livelihood.

There are varieties of skin tumours. The above skin tumour has a shape of a Polyp. A polyp is a tumour which is made up of a stalk the attaches to the skin and the body that makes up the bulk of the tumour. The polypoidal skin tumour is frequently called Skin Tag.

Benign skin tumour grows very slowly if at all. If it does not cause any problem to patients, it does not need any particular treatment. If it causes a problem, even the unsightliness, the treatment is Surgical Removal. For a small skin tumour, it can be removed by various ablative methods like Thermocautery(heat)or Cryotherapy((ice).

A big skin tumour like in this picture requires a formal surgical operation. The above polyp has been causing pain and bleeding to patient with his pant on while walking. The polyp is located in his thigh.

The removed polyp is sent for histological examination which revealed a final diagnosis of Squamous Papilloma.

Post Thyroidectomy Complication

Surgery is one of the modern advances in Medicine. There are so many diseases which could not be cured before but with the advent of Surgery now become a routine success.

However, the Achilles heal of Surgery is the Surgical Complications. Although most surgical operations done by a well trained surgeon will go smoothly without any complication. Complications loom in every single operation nonetheless.

I have done so many Thyroidectomy ie. operation to remove thyroid glands during my surgical career. There are usually three possible complications that may occur after thyroid operations;

- hoarseness due to nerve injury

- cramps due to damage to the parathyroid glands

- bleeding

The above picture shows a patient after undergoing a thyroid operation suffering from a complication of minor bleeding post surgery. The central neck swelling is due to bleeding under the skin.This is confirmed by an ultrasound examination. Since the bleeding is small and the blood was quite solid clot, there is no specific treatment needed here. With time, the blood clot will be resorbed by the surrounding tissues.The Surgical scar is seen to be fully healed.

When Advanced Technology Do not Salvage The Day......

This Corona virus pandemic has exposed the many weaknesses of health systems of many countries. In fact,all countries for that matter, from the richest and most powerful such as USA to the poorest countries of Africa.
Common virus infections is a daily occurence in most people. Name me one person who never caught some kind of virus infections in his or her life?
But this Corona virus is a novel species of the known genus of Corona virus. In fact,during my student days in the late 70s-early 80s, I have learned about the model structure of viruses including the Corona virus. How this new corona virus become pathogenetic to humans is still an ongoing studies by scientists. But the real fatal clinical effects of this virus is very well known to clinicians by now.
The main stay of treatment of any virus infections is merely supportive, meaning; there is no specific treatment against the virus per se, but the treatments merely support the normal body functions to ride through the duration of illness.
These include;
-rehydration of the body by giving intravenous fluids
-paracetamol to reduce temperature
-painkillers for any pain
-even the controversial anti-malarial Hydrochloroquinine was used as an anti-oxidant to mitigate the abnormal production of the oxygen free radicals produced by the body in reaction to the virus
-the most resource and capital intensive support system is non other than the Ventilator machine in ICU to sustain body oxygenation

The sudden geometric rise in demands for Ventilators and ICU care during this pandemic has caught all health services systems by surprise. Even the richest countries which pride advanced technology in medical services were inundated by this sudden demand. I just turned 60 recently and on my birthday, my son reminded me that if I had caught coronavirus in Italy and required a ventilator to sustain my oxygen, I would have been dead since the cutoff age to triage for ventilator use was 60 years old.

This is the irony, ventilator is relatively low tech as compared to many high tech cancer-treating machines and also the many robotic systems. Even the ventilator-producing manufacturers could not increase the ventilator production in short space of time. The existing medical instruments manufacturing processes are not versatile enough to design and produce the standard medical devices on demand. This is due to sheer priority of resource allocation rather than lack of technical capability.
One big lesson of this pandemic crisis is the way we invest in our technology. There should be enough flexibility in medical device manufacturing through appropriate resource investment instead of merely spending on highly advanced technology which are useless in time of crisis.

Which doctor should I see?

I am quite frequently asked by patients and parents which particular specialists they should see for their health issues.

This confusion is understandable with so many medical specialists out there available to render their services to patients.

Medical specialisation is just like any other professional and knowledge specialisations.

With the advent of new technologies and discoveries of many new scientific knowledges, the old scientific disciplines become loaded with information and the consequent extensive services related to them.

One of the reasons of specialisation and sub-specialisation is the pragmatic need to distribute work load and manpower to ensure that knowledge distributions and services rendered are effectively and efficiently maintained to meet the demand of modern standards.

Medical specialisation follows the same need. Most modern hospitals will have basic medical specialists to cover most of the health needs of  a community.

These are basic specialists and specialisations in any modern community hospital;

General Surgeon - General Surgery

Orthopaedic Surgeon - Bone and Muscles Diseases

Ophthalmologist - Eye Diseases

ENT Surgeon - Ear, Nose and Throat diseases

Physician - (Adult) Medicine 

Paediatrician - (Children) Medicine

Obstetrician and Gynaecologist - Obstetrics and Gynaecology 

Anaesthetist - Anaesthetic/Anaesthesia

However, in a bigger tertiary centres and teaching hospitals, the above basic specialisations will be further subdivided into many more sub specialisations, eg;

General Surgery will be further subdivided into;

Hepatobiliary Surgery

Upper Gastrointestinal Surgery

Colorectal Surgery

Breast and Endocrine Surgery

Vascular Surgery

One can see that the process of specialisation/subspecialisations do follow a certain kind of boundaries based on organ systems. This is not a strict rule. Sometimes, due to human resource allocation and logistics,  these specialisations do cross those boundaries.

For some familiar with surgical disciplines, you will notice that Plastic Surgery and Neurosurgery are not classified here. These 2 disciplines have carved out of General Surgery and exist on their own as independant Surgical specialisations but mainly within tertiary referral centres rather than community hospitals.

Patients confusion about the above specialisations can be easily cleared by a good discussion with their primary care doctors who will usually write a referral letter to the appropriate specialists. Then in turn, the specialists may refer to the appropriate sub-specialists if the patients health issues mandate so.