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Guts and Glory
Unravelling the mysteries of the complex GI and HPB disorders, in candid conversations with leading experts.
Guts and Glory
Endoscope Or Laparoscope ... Debates and Reflections
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Join Dr. Sadiq Sikora on Guts and Glory with Prof. G Choudhuri, New Delhi’s premier medical gastroenterologist. They dive into achalasia cardia, GERD, and IBD—where endoscopic innovations clash with laparoscopic precision. Expect candid debates, evidence reflections, and paths to teamwork. Essential listening for GI pros!
Hi, good morning. Welcome to this episode of Guts and Glory, wherein I have a renowned gastroenterologist, a compassionate, well-rounded, and my professional twin who has his heart in the right place. Let me invite Professor G. Chaudhry, who's the chairman of gastroenterology at the Fortis Memorial Research Institute at Gurgaon. He was formerly the head of SGPGIMS Medical Gastroenterol for several years, and that's where we shared a deep bond and which is continuing since then. And I'm really delighted to have you on this podcast, Dr. Chaosy. It's a pleasure to have you here.
SPEAKER_02Sadik, it's a unique pleasure. We are connecting after a long time, and this time over Zoom. It's good. We used to have more direct conversations over a cup of tea, trying to decide what to do with patients, but now I think technology has taken us in a different way.
SPEAKER_01I want to get back to that. You know, you remember uh since long in SGPGI when we started in the 90s, early 90s. You remember we had a serious thought that medical and surgical gastroenterology should be a single entity, simply because we deal with common problems and we probably have common solutions and a choice of options to be exercised. I don't know. Over a period of time, I feel that that the unified sphere has become very narrowed now. I remember we used to be participants in Indian Society of Gastonology as an uh equal shareholder. But uh I don't see that kind of uh you know interaction and uh uh working together uh kind of thing. What do you think? Did was that a good thing to do? Does it make sense? And does it what do you think about that strategy at this point of time?
SPEAKER_02So, Sadiq, everything I think is a matter of evolution with time. So uh if I might take you a little behind, um if you remember you are quite a few years younger than me. So earlier on gastroenterology meant that treating diarrhea with medicines. Okay, so there was really nothing else that one could do with one's hands, and I think obviously everything where a structural fix had to be done, it had to be done by surgeons. So I think those were good days, surgeons obviously were the pioneers in setting things right. So, you know, surgeons can cut, they can stitch, they can open up narrow things, they can resect and so on and so forth. But primarily it had been more on the mechanical fronts. Needless to say, those were the days when uh it was open surgery most of the way, and therefore uh it had its own problems, you know, like an open polysystectomy and so on. Yeah, there has been a lot of effort over the last say 40 years of how to make things a little less invasive uh to the for the benefit of the patient and for the benefit of the medical care. Uh to give an example from your own area, you see when laparoscopic cholysystectomy came and precisely the year was 1989, 90. You see, even before the trials came out showing that it was beneficial, most patients had actually offered to go in for a lap coli. Okay, so the problem that happened is that unlike this example that I gave you of laparoscopic chole cysteomy, that area has still remained with the surgeons, and rightly so. I will tell you another example from the good old days because you are from All India Institute. So, you know, diagnostic laparoscopy was started by the medical gastro department by Dr. D.K. Barga.
SPEAKER_00Yes.
SPEAKER_02And you know, we were residents and we used to go and watch him doing diagnostic laparoscopy, he would take a biopsy at best. Ultimately, you know, it didn't quite work out because more or less you realize that only diagnosis doesn't have much of a role. Once you go into the laparoscopic space, you have to also do some therapy, and therefore, most people who took it up thereafter have been surgeons.
SPEAKER_03Right.
SPEAKER_02On the medical side, what happened is we got endoscopy, we started not just looking but also doing. So, for example, treatment of portal hypertension, dilatation of strictures, and so on and so forth, which I think evolved. And to be fair, most of the endoscopists of the 70s and 80s were actually surgeons.
SPEAKER_00Yes.
SPEAKER_02So, you know, they were more familiar with anatomy, they were actually a little more bold if something happened, they would be able to intervene better. And then there came a plethora of evolution of techniques and studies and you know, so on and so forth skills. So then it became a little apparent that a surgeon who was very good and skilled in doing more complicated things should he be wasting his time doing diagnostic endoscopy or doing a sclerotherapy, which is actually doesn't require that much amount of skill, and the surgeon's skills can be probably better put to use in other places.
SPEAKER_01So, why I was asking uh GC, this thing is that you know one is concerned about the barbers phenomena. The point which I make is that if a person comes to a gastroenterologist, there are options which can be offered. There are surgical options which can also be offered. Because we have diseases and options uh in certain areas definitely. And then the question is that how to choose. It shouldn't be a barber's phenomena that if it comes to me, I operate, if it comes to you, do endoscopy. So are these uh in these areas, are these options competitive or should they be complementary? And therein I bring a point of interaction between the two specialities.
SPEAKER_02I fully agree with you. So, I mean, the other way of putting the same point is that if you have a hammer in your hand, everything looks like a nail. So it depends on who is holding the hammer.
SPEAKER_01Okay, exactly.
SPEAKER_02So now over a period of 35 35 to 40 years, you know that there are few areas where endoscopists have been able to do remarkably well, uh, tackle a lot of load, and at least 90% of the problems can be tackled at their end. I mean, for example, endoscopic therapy of portal hypertension.
SPEAKER_00Yeah, okay.
SPEAKER_02Um so there I think that the first aim should really be to let it be where expertise has developed, technology has developed. Therefore, you don't waste your time because if you remember the early studies on portal hypertension, that was also, by the way, by a surgeon, and uh he's the one who did devascularization surgery and uh shunts, you know. So, in a cirrhotic who's got child's B or C, you know that the results were pretty bad. I mean, you showed your best results only in some child's A patients. So I think that there has been a lot of improvement in terms of the scope and expansion and its availability to many types of patients, so that part has established itself. Whenever something new comes, there is always a challenge because you know you have to prove that you're first equal to what is already existing. So at that point in time, I would say surgery, and thereafter to show that actually doing it by you by endoscopic or other means is actually better than surgery, which may or may not always be the case to prove. Yeah, and then the handicap also comes, is because surgery has got a longer track record in terms of experience. So if you're talking about 15 years follow-up, obviously the surgeons would have a longer follow-up than, for example, the medical people.
SPEAKER_01So let's start one by one with that. So let me put first one which is no, which is uh I think uh a remarkable uh improvement and addition to the treatment, which is for echelasia cardia. Now, so we used to keep on doing the Heller's cardiomyotomy, and that has evolved with laparoscopy and then robotic and boom bullet precision, and then the poem which has come, which has made remarkable inroads in that. Now the question is where do we draw the line? When do we say this is better? Or how do we decide that which option to choose in a particular patient? Because gone are the days when uh post-laparoscopy we would keep the patient for seven days or five days or three days. Now they don't go home the next day anyway. So, uh, in your opinion, uh what do you think we should be offering what to which patients? Is there a role for discussion?
SPEAKER_02Absolutely, absolutely. In fact, to be honest, I sent quite a few of my patients to my surgical colleagues here, and Dr. Kriplan, you know he was from Ames. Uh so if I have a very difficult patient of echalasia, maybe with a sigmoid echalasia, very thinned-out esophagus, I think that you know most of the non-surgical therapies have their problems because it's a very thin esophagus, okay?
SPEAKER_00Right.
SPEAKER_02So just to put things in perspective for the audience, yeah. So we had four therapies. One was, of course, the botulin toxin.
SPEAKER_00Yes.
SPEAKER_02Now the botulin toxin doesn't work in that area. I do use botulin toxin once in a while, but I'll tell you a very separate story on that. It's only sometimes when you want to know if this fellow is likely to uh benefit from a different type of a procedure. So it's a trial almost, but it's risk-free. Then came the long era when we were using balloon dilatation, high pressure balloon dilatation. Uh, if you remember, you were in SGPGI that time, and we did quite a few, and we published our long-term results with balloon dilatation, and it was 67% successful.
SPEAKER_00Yeah.
SPEAKER_02Okay, so it wasn't 100%, let's be very upfront about it. And from my personal experience, I can tell you that there were two patients who I thought I had done a perfect procedure and post-procedure they somehow turned out to have a leak. Now, a perforated esophageus sometimes can be terrible.
SPEAKER_00Yes.
SPEAKER_02And both of them had to be operated upon. One of them uh I had to send to All India Institute, you know, and he of course came out, another one was in SGPJ. So now everybody knows that balloon dilatation, you can't do things under your close observation. It's under fluoroscopy, you're dilating it. So uh complications of perforation are known. And if it occurs, it's bad, difficult.
SPEAKER_00Yeah.
SPEAKER_02But having said that, it has its advantages that you come in, it's you don't require an admission, it's almost like an OPD procedure. Keep the person till evening, give him some water under observation and send him home. On the other hand, Heller's myotomy, laparoscopic Hellers, I think that overall the success rate has been very good. And you know, as a surgeon, you have also understood why some people have better outcomes than others. So there was the long debates as to how long has to be done.
SPEAKER_01The myotomy has to be correct.
SPEAKER_02Myotomy has to be done and all that. You know, if you are young and the anxiety is that will there be very good relief of uh dysphagia, then the tendency is to make the myotomy long. You remember those days we used to discuss how long it should be.
SPEAKER_01An extension onto the stomach and things like that, how much now if you look at it, poem actually does more or less the same thing.
SPEAKER_02Yes, that is, you know, you're doing a myotomy, but not from the outside, but from the inside.
SPEAKER_01Correct.
SPEAKER_02And again, what has happened is that since poem is in its early days, there is an understandable anxiety that the operator would want that the outcome should be very good in terms of dysphagia control.
SPEAKER_00True.
SPEAKER_02Now, what has happened is that when you have retrospective data or analysis, then you find that if you overdo the part of myotomy, it is complicated by reflux.
SPEAKER_00Reflux, yes.
SPEAKER_02So the official figures are 9 to 15 percent, but if you actually do a pH metry, you might find it goes up to 30 percent. Okay. Now, poem is in still, I would say, an early phase of evolution. So exactly how much to cut, whether it's the anterior fibers or the posterior fibers, how long should the myotomy be? I think that those are the same kind of things which the surgeons did about 40 years back, which we are doing now. So I don't think that there is an ideal situation, but if I have a difficult case, like I have a person with a sigmoid esophagus, very thinned-out esophagus, long-standing disease, I still think that surgery is a safer option. In fact, one of my patients, I remember the surgeon actually had to do a esophageomy because it was it was quite a bad one. Yeah. So there I think if a very adventurous endoscopist tries to do a balloon or tries to do a poem, it is fraught with danger. So I think there is a need for being able to think openly and discuss what is best for you.
SPEAKER_01And clearly, type 3 echalasia with uh this thing, poem is uh definitely superior because you can make a long myotomy. But on the other hand, you know, I feel we can do a good myotomy by surgery and uh anti-reflux procedure also. So, and the recovery period is more or less very quick in that. So that's why I feel that uh we probably need to offer the patients the pros and cons in a very open manner. Sometimes what happens is if it's non-surgical is very attractive to uh patients, and they don't realize that that is also minimal invasive, as is surgery, because there is anesthesia, there is intervention, and then there is a recovery period, isn't it?
SPEAKER_02I would fully agree with you. In fact, I'll tell you echillesia, probably it is an area which is evolving rapidly. In fact, as soon as the poem came, I was surprised that there were reports from all over the country where people said that they've done about 2,000 uh poems. I know, I know. I was wondering how did this happen? Where did this come from? Where did this come from? So everybody was on on that number-changing game, you know. And I didn't see so many echillasia coming to me that I did refer.
SPEAKER_01Yeah, yeah, yeah. I I understand.
SPEAKER_02But where surgery has actually done even better when it comes to the lower end of the esophagus, uh, you know, Sadiq, in those days when you and I used to work, a lot of patients had hytacornia and reflux. Yes, yes, and those days, you know, we were primarily resorting to an open uh you know surgery with the fundoplication, knees and findoplication. Nowadays, I think laparoscopic fundoplication has become so well established that from my side, you know, my threshold for referral has come down a lot.
SPEAKER_01But it's interesting that you brought this GERD in the discussion, the G R D. And I put to you that you know there are so many now endoscopic anti-reflux procedures, and they've been there for a long time, like the TIFF and Streta and things like that. Why they have not been so you know uh commonly employed in patients as in contrast to POEM, which is being offered to every patient. So, what is the difference and why there is this difference in uh endoscopic procedures for antireflux uh problems?
SPEAKER_02So, in the last I think about 25 years that I have been in gastroenterology practice, I think that endoscopic procedures for GERD uh they have come and gone. There have been at least five or eight of them. They all come with a huge promise. There is a workshop, and somebody who looks very flashy and confident does a procedure. But at the end of the day, you know it has to be easy to do, predictable, safe. Because you're again doing it for a consistent and also you're doing it for a problem which is more inconvenient rather than life-saving. Yes, see, unlike say, for example, a cancer or something like that. Okay, true. So there now I think that the yardstick of long-term assessment also has to be fairly strict, and most of them have come and failed and gone back. Uh, at the moment, I think that two or three of them are still in vogue. Uh, one of them endoscopically now they call as an anti-reflux mucosal ablation arma. I've seen it, I it's easy to do. Um, to be honest, I have not been too impressed with the short-term results because you know ultimately you burn an area and then you expect it to psychiatrize and therefore narrow the gap.
SPEAKER_01Psychiatrize in a manner you would want it to.
SPEAKER_02Want it to be. So, although it's fashionable, everybody wants to say that look, I am doing it, uh, I'm not too impressed. So, there is always going to be a placebo effect after the procedure. Some people will say that yeah, I am feeling a little better, but for how long you don't know. The straighter part of it has come in mainly for reflux barrettes, also to some extent, and so on and so forth. To be honest, when I get a difficult patient like that, I don't like to experiment too much. So, if I have a good reliable surgeon, I usually have a talk with him. And I think that a time-tested procedure which can now be delivered laparoscopically, yeah, I tend to prefer that. So uh quite a few of them leave me, but that doesn't matter to me as long as I think that the long-term outcomes are bad. Track record of new procedures coming in in endoscopy and then uh getting shut down have been very high, both with reflux procedures and with bariatric procedures.
SPEAKER_00Yes.
SPEAKER_02So that we have to be cautious before we tell the patient, look, this is a good option for you.
SPEAKER_01So, I mean, continuing in the same vein, like you know, you have for reflux, I'm sure you know this better than I want to hear from you, the lifestyle changes, medications, then endoscopy and surgery. I mean, these are all the interventions or options. What is your uh take on long-term PPIs? Now we are seeing a lot of problems with uh PPIs. So, what is your take on long-term PPI? And how do you decide that when is the time that now these guys should go for surgery?
SPEAKER_02I think that uh the list of complications associated with long-term PPIs are going up, you know. So it's about 40 years that the PPIs came into the market. So the list is growing. So there are three types of complications. One is related to long term acid suppression, one is related to uh the drug itself, you know, uh causing certain things like hypomagnesemia, iron deficiency, and so on. And the third is that you really don't know uh whether long term PPI would be very safe, some of them have. Come in for a bit of questioning, like the kidney issues and the heart issues and all that. The problem, on the other hand, is that it's easy to take, it is cheap. In general, if you look at the uh frequency of serious side effects, it is a bit low. And in fact, if I might tell a small story for the audience, so there is this uh lady, she was I think around uh 75 or 80, and incidentally she came from Calcutta, you know, the business family. And every now and then at night she would get a reflux and it would cause panic, and her husband, who was around 80, would have to drive her to the hospital. Yes, and then they would get a pantocid or a rantac injection, she would be okay and come back. You know, it was so traumatic for them. They came and I said, Look, the problem is of reflux, so either you continue with PPI or you get a surgery done. You know, she opted for surgery because she said that the panic and inconvenience is so much and we are getting older, I would much rather get it done. So then I told her that look, your age is not exactly on the favorable side, you know. But you know what she said? She said that I am willing to take the risk, and if I can get the surgery done, if I live for another five years, I want a better quality of life. And she went through the surgery and she came back from Calcutta to tell me that she was doing much better and to thank me. So I think that you know sometimes we have to individualize and see how the patient wants it, but to a large extent, one has to be very fair with giving both sides of the coin. And if it is a younger person, for example, say in his 40s, requiring high dose PPIs, I would have a lower threshold for sending for surgery. The reason is he has got 30 years ahead, you know, yes, and he is going to pop that pill all along. So he has to be a little more, shall we say, pushed to accept it. There's another difficulty also, and the difficulty is that uh you mentioned lifestyle. Yes, lifestyle does work. The problem is it's very easy for the doctor to advise lifestyle and for the patient to nod and say, yes, yes, but it doesn't get that.
SPEAKER_01Sustain it for a long period.
SPEAKER_02That's the problem.
SPEAKER_01That's the problem. So, I mean uh you brought this uh about uh the procedures and all, and I want to just uh dwell a bit on that. You know, generally what I've seen, and it's not to any specific procedure, but in general, uh we like a particular procedure has taken a period of time to uh for us to develop skills on that, know what are the issues, do it properly over a period of time, and now you've sort of so-called mastered the procedure or you know how to do it. And then uh this new kid on the block comes and says, Oh, but we are going to do this in this manner, endoscopic or whatever. Now there is a learning curve. There is a period of establishing the uh veracity of that procedure, the long-term uh results of that. So how do you counsel the patients? I mean, in real real life scenarios, uh that one is established procedure, other is we don't know how it is work, because what I feel generally is patients are taken in simply by the fact that it is a lesser invasive procedure, irrespective of what is the outcome and the credibility of it.
SPEAKER_02I would agree with you. So, what happens now uh, you know, Sadik, you also trained as a surgeon, I also trained as an endoscopist. So initially, na we were also in a way trying to develop our skills, you know, and our psychomotor skills. So I guess that that was a time when if there was any opportunity of a procedure, we would put the case in a way that would be a little more convincing for the patient to accept the procedure. And you know, that is how we all learned. I mean, in the sense fair or unfair, but those were young days, and we all learned. Now, what has happened is that particularly in the West, I'm telling you, in the Western world today, the opportunity for trainees to get a hands-on to do procedures is quite low. And that is the reason why they would actually grow go and grab the uh patient and the procedure opportunity. And unfortunately, you know, many of them come to India now for doing hands-on in the RCP. Some people do it for a fee and all that. Uh ethically, I think it is wrong. The reason being that I think uh your the procedure is probably risky, you have not yet been established or adequately trained, you're trying to kind of uh pick up or hone your skills, psychomotor skills, and you have patients who are not likely to be very demanding, you know. So that combination worries me a bit. And I have a feeling that one of the things that is evolving but not has evolved enough. You know, when we were learning, we were learning directly on the patients. Yes. Which I think was unfair. See, today I think that for training you have to have very good uh models on of training. For example, today if you look at airlines, and airlines is one of the safest industries, you know. Yeah, they actually have to practice a lot on a module and then see how simulate it is and then move forward, yes, which did not happen adequately with medical and surgical teams.
SPEAKER_01Absolutely, absolutely. I think uh that's a very important point because uh now hands-on is becoming more and more difficult, and uh you know you brought the aviation industry, they have simulation for each airport and each condition, and uh it may not be that difficult to have for each clinical condition and even the complication with that. So I agree with you that that needs to be done. But uh I'm glad that we under because it's the same with surgery, that there are people who are embarking on new procedures without having established this credibility. And just because it is new, people are sometimes gullible and they accept that. So I think we need to be careful about that. Uh that's an important point. One more thing I want to talk about uh in uh GERD GC is Barrett's esophagus. Now, this always confuses me and it worries me also. Two things about it. One, Barrets, is it an absolute indication for surgery? And B, does it reverse or revert post surgery? What is your experience?
SPEAKER_02So when we talk about barrets, there are two parts to it. One is, you know, these are these tongue-like uh projections of the gastric mucosa into the esophagus, you know, which is associated with long-term uh reflux. Those barrets are not necessarily always precancerous or dangerous, and that is where the problem comes. So as soon as a person gives a label of a barrels, you know, it almost sounds like a death nail, you know, that you might as well desperately get something done. So now I think the studies have adequately shown that only if it shows persistent high grade dysplasia, then it is an indication because the chances are high that it will move on to cancer. So excess panic is a problem. So a lot of my patients come because they have had endoscopy in a remote place, they have been told bad it's and they have it. Um, incidentally, let me put the other side of the coin also into the picture. So lower esophageal cancer is one of the cancers which has been on the rise in recent decades.
SPEAKER_00Yes.
SPEAKER_02But when we say on the rise and you look at percentages, if it was say three out of ten thousand and it becomes six out of ten thousand, it doesn't mean it is going to be uh World War III.
SPEAKER_00Yes. So you have to put things in perspective. So it could be increased, yes.
SPEAKER_02Yeah, it could be doubling, but you know the chances are still quite low. So I think that that we have to be more factual and tell it to the patients also. If the suppression of inflammation is good, that is a good amount of PPIs if the person is not symptomatic, most of the dysplasia part regresses. This has been well shown. If it is a dysplasia which is more than 50 to 70 percent not regressing, that is a matter of worry because usually what happens is the inflammation due to acid reflux, if it comes down with the acid suppressant, generally they do well here. I mean, I have a whole lot of 75-year-old who are continuing and they are likely to die of a heart attack or Alzheimer's, but not due to sufficient cancer. Okay. So the thing is you have to put it in perspective. The other thing is that for some unknown reason, Barrett's the typical Barrett's, which is a pre-cancerous Barrett, yeah, is a little less common in India than what it is reported in the West. So if that be so, and you know, I usually look at the patient in a very individualistic manner. So if this fellow has got a coronary artery disease, he has got diabetes, he's uh uh has got an endoscopic barrels but no significant dysplasia, and he is doing reasonably well, and he probably has five years more to go, you know, going by life expectancy statistics. I wouldn't push him to get a major procedure done. But if it is a youngish fellow, 45-50, with a pretty bad barrels, with some degree of dysplasia, unlikely to change his habits, and if he is willing to go in for some kind of a surgery for Barrett's, so many of them actually do reasonably well even with a fundoplication because once the reflux part comes down, now you don't actually have to cut the barrels part. The barrels part needs to be cut only if there is significant display. I think they do pretty well.
SPEAKER_01So you you brought about how to counsel and talk about these patients. So you've written a book recently on uh human touch in modern medicine, right? Bringing patient care back into healthcare. That's the title. So GC, very interesting. What prompted you to write this book? Do you think there's a you've felt and you've uh experienced or seen that there is a tremendous decline in compassion, empathy in the interaction between patients and doctors?
SPEAKER_02So there has been a decline. I mean, whether it's a huge decline or not, I won't like to comment on that. But there has been a decline because let me put it this way uh when you joined Ames, you know, to do your MBBS, I think the motivating factor was probably not money.
SPEAKER_00Yes.
SPEAKER_02You like the job. I mean there was a certain amount of call it altruistic feeling or a glamour associated with being a doctor.
SPEAKER_00Yes.
SPEAKER_02Today, if you look at people joining medicine and why it is so much in uh demand, it's because they look upon it as a lucrative profession. And if you go by the simple logic that you know there are seats which are going on sale for one crore per seat, see obviously whosoever is going to pay that money, uh, his parents or his family is going to expect the returns quite quickly.
SPEAKER_01Sometimes I feel if I have so much money, why be a doctor?
SPEAKER_02Quite right. But you see how we can sometimes be unfair, I'll tell you. Yeah, uh, if you inject the idea that, oh, this is a bad, but you know, if you Google badets, you will find it's a pre-cancerous condition. You know, obviously the fellow is going to take whatever advice you give to tackle the badts, although the actual chances are going to be very low. So, this is what is called as a subtle fear-mongering, which also many of us tend to do to suit our convenience.
SPEAKER_01Going back to this book, so I'm very enamored by this uh concept. There is uh a tremendous uh uh decline in the how we interact and the compassion and empathy in that. But how do you think we can bring that back in the system?
SPEAKER_02You know, uh this empathy and understanding of human relations primarily occurred in the earlier generations. I mean, I would put you also in that category, although you're not a vintage. It is basically by reading storybooks. You see, books now usually tell stories about individuals' lives, and that is what brings in empathy. Today, there is very little of reading in the sense most of it is social media. So social media would be creating an impression, giving you information, but it doesn't always convey the emotion in a long, let's say longitudinal manner.
SPEAKER_00Yeah.
SPEAKER_02So today, one of the methods which is used everywhere that you must read stores storybooks because you know it is through stories that you understand human emotions. Second thing is role modeling. So if you have a role model who does it that way, the chances are that the student would also think about it if he has to deviate.
SPEAKER_00Yeah. Well said.
SPEAKER_02These are two things. And and and to be honest, today now our yardstick of success has also come down. If you see a fellow who's got two swanky cars and he's going to Europe for holidays, you know, a very successful surgeon or a physician. Um, many people would actually like to emulate that model rather than actually say that look, I'll do less but be happy with less. It doesn't work. It sounds altruistic, but it doesn't work.
SPEAKER_01Yeah. Absolutely. Well said, GC. And I think uh it's something which we all need to be worried about if it's uh declining this aspect. Let's come back to the science a little bit more. Another one which I feel has a constant tussle is the inflammatory bowel disease. Now, from the surgeon's perspective, we don't want to operate Crohn's. That's right. And the second part is we don't want ulcerative colitis to go on for very long on medical treatment in terms of surgery, having uh sort of become proficient at doing a pouch and so on and so forth. Now, in this era of the anti-TNFs and all, do you think there is a change because we have these in our hands and we can prolong the patients to go for surgery? And is that beneficial or is that approach the appropriate approach?
SPEAKER_02So, my best teachers are patients. So I'll tell you about this lady, very, very intelligent lady, very well to do. She had uh ulcerative colitis, which was picked up in Bangalore because she had iridocyclitis, and the ophthalmologist said, get your gut checked up, you know. She had a little looses, and this was, I think, almost 15 years back. And then she has been on steroids, she has been on five amino salicillates, then she has been on biologics, adolemy mab, and all that. And you know, when she came to me, because she got transferred from she was in some fancy school, you know, uh mistress uh director. So she was in good now, and then we tried all the things, you know, Remy Kid and this and that. She developed uh plastidium difficile infection that got treated, blah blah blah. To cut a long story short, you know there has been a huge evolution in the medical therapy for ulcerative colitis and Crohn's, and I think it has been a good thing. The reason I'll tell you in our time it was primarily corticosteroids, and today corticosteroids is something which we really hate to give because it does produce long-term side effects. Okay. So now you have gothacetinab, upadacetinab, biologicals, and so on and so forth. Even azuran, I don't give much. The results are pretty good, and interestingly, IBD occurs in young people at the very productive phase of life. And as soon as you diagnose ulcerative colitis, the next question they ask is, So, sir, is it an incurable disease? Now, how do you answer that? Uh, it is a manageable disease, to be honest. But is it curable? The answer is probably no, it will keep coming back, and they're not happy. So, what's the alternative? The alternative is to do a surgery and get the colon out if colon is the source of the problem. But again, this concept of illeostomy and a three-stage procedure is something which doesn't appeal to a lot of people. I mean, let me be very upfront.
SPEAKER_00Yeah.
SPEAKER_02Now, this was a patient in whom we tried everything, and she was in one of my clinical trials where I was using it mod, it was a global trial. For two years, she did well, and then after that, itracy mod stopped working, and again she tried everything, including Stellar and all that. Very frustrated. So, when I get into these situations, I usually take a second looking. He also went through, scratched his head, and said that look, I can't see anything more. If this doesn't respond, then a collectomy is a good answer. I said it's good. So she's probably thinking, but is going in for it. These types of cases, I think that you know, maybe we should pick up more often, a bit earlier, and hopefully things would be good. On the other hand, I would say that the number of patients that we used to see of severe IBD have actually come down because of early institution of many of these therapies, which are pretty good. The second part of it is that Crohn's. Once diagnosed to be Crohn's, we were very worried that look, if you cut and reset, it will come back.
SPEAKER_03Yes.
SPEAKER_02And sure enough, I see a lot of recurrence, but I'll tell you which are the patients who come with recurrence. These are patients who have had a uh resection after getting some control, and then they were made to believe that the problem is over for good and they were not on any maintenance therapy, so the disease record restrictured. So some of them have got three surgeries done. You have to put the patient on a therapy so that it doesn't recover. Crohn's, I'll tell you that with my surgical colleague, we have done, I think, about 40 patients. The results are pretty good. The only thing that he writes, he tells me, and I tell him, is that get the disease in good remission with biologics or whatever it is, and then you do a clean dissection anastomosis, even primary anastomosis holds, yeah, and therefore I have found that the outcomes are pretty good. Ulcerative colitis, the pouches have actually come down there, but they are still occurring. And maybe that debate which we had earlier on that are we delaying too much, that debate was a little more relevant when we were pumping too much steroids. But now, if the patient can afford the other medicines and they're tolerating it, it's not such a bad deal.
SPEAKER_01Say, for example, patients are on biologics and all, and then they come for surgery, and then we have a good meta-analysis which says that you know, complications, all these are much more in these patients. And then when they come for surgery, perhaps the results are not as good as we would like it to be, and then it is ascribed to oh, that's why surgery should not be done and all. So my point is, and I come back to the first question, that is there a time now for multidisciplinary management of benign diseases? We know it is important in cancer care, but in benign diseases would help the patient to get the right option at the right time.
SPEAKER_02I I would agree with you. One thing which I think is a little dangerous, Sadhg, is. To quote international data.
SPEAKER_03Yes.
SPEAKER_02I'll tell you why. Because those are done by the best of people under the best of circumstances. For example, emergency ERCP in patients with suspected biliary pancreatitis. And 130 patients, there were no complications. Okay. Now, if you use that data to support the fact that doing emergency ERCP in biliary pancreatitis is safe, it's a disastrous interpretation. So we also have to assess our own individual expertise, team expertise, and what works best. But I agree with you.
SPEAKER_01Sometimes the diseases spectrum is also very different, and we see this most of the time. But I feel that in this speciality, there is a lot of scope of working together. I think being together and having confidence in each other's ability would help us sort of sift out the right option for each individual patient.
SPEAKER_02I couldn't agree more with you, Sadiq. There were good old days when we used to dream. If you have a team of a good endoscopist, a good surgeon, a good radiologist, and a good interventionist.
SPEAKER_00Yes.
SPEAKER_02You can almost tackle anything here. The fact is that you have to know each other, trust each other, and be compatible.
SPEAKER_01So, GC, it was good fun talking to you on these things, but uh any parting words? Uh why I ask is how do you motivate yourself? I mean, you've had such a long career, you have had uh forays in various things, in uh uh you know preventive medicine, in writing, in endoscopy, in uh uh academics. So, what motivates you?
SPEAKER_02So I do my reading, I still, because of my background career, I am called to give talks or attend conferences, which I think is good because much of the learning also occurs when you listen to people sitting in the audience as to what is going on, which way the you know the winds are blowing.
SPEAKER_03Yeah.
SPEAKER_02So this book that I wrote, I put my heart to it. I actually describe the situations where I think we need to be different. And uh whether things will change or not, I have my doubts because there is a you know sometimes it's a wave, it goes in a direction, you can't actually stem the tide.
SPEAKER_01This is how you get inspired, and I think your book uh would probably bring back at least a realization that what we are missing.
SPEAKER_02This is the one which you are referring to. Yeah, yes, yeah, so the the human touch in modern medicine putting care back at the center of healthcare.
SPEAKER_01Fantastic. It's a great talking to you, GC. I'm glad we got you on this podcast and thank you very much for sparing your Sunday morning.
SPEAKER_02Pleasure, Sadi.
SPEAKER_01Thank you.