Wednesday,
October 27, 1999
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Laparoscopic surgery A challenge to the anaesthetist By Dr Suman Sharma Grover The improvement in surgical procedures has led to reduced trauma to the patient, minimised morbidity, mortality and hospital stay and finally reduced health-care costs. The development of better equipment and facilities, along with the increased knowledge and understanding of anatomy and pathology, has allowed the development of endoscopy for diagnostic and operative procedures. Consequences of abuse Concept of primary health-care Rhythm and order by a new way |
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Laparoscopic surgery The improvement in surgical procedures has led to reduced trauma to the patient, minimised morbidity, mortality and hospital stay and finally reduced health-care costs. The development of better equipment and facilities, along with the increased knowledge and understanding of anatomy and pathology, has allowed the development of endoscopy for diagnostic and operative procedures. Laparoscopic surgery, popularly known as buttonhole surgery, has come into routine practice for the past 20 years or so. Most developments in surgery have been related to new applications of the existing skills but laparoscopy entails the learning of new skills. Once these skills are mastered, the evolution of new applications can resume. Though laparoscopic surgery was initially started for gall-bladder removal, it is now being used for appendicectomy, hernia repair and even for the removal of the kidney, the spleen, the uterus and the ovarian cysts. Since laparoscopy developed in the early part of this century as a diagnostic tool, its use is not being developed in the traditional way by study in academic laboratories. The community development of laparoscopic surgery has arisen by default and has been spurred by the tremendous public demand. Jules Verne said: "What one man can conceive, another man can achieve". It appears that this is becoming the case in laparoscopy and general surgery today. Laparoscopy is stimulating not only technology in the area of optic lasers and instrumentation but also in the minds of enterprising anaesthesiologists and surgeons. The rapid growth and development of laparoscopic surgery have also raised a number of complex issues, problems and opportunities. Since laparoscopic is considered more or less a closed abdominal procedure, many in the general public might think that anaesthesia techniques for such procedures would also be much easier and simpler. This is far from the truth. In fact, the rapidly increasing numbers of laparoscopic upper abdominal procedures being performed necessitate, on the part of the anaesthesiologist, a thorough understanding of the pathophysiological changes that can occur. Based on this understanding the anaesthetist must design a system for monitoring and maintaining the well-being of the sicker as well as healthier patients. There is a progressive depression of the heart muscle and narrowing of the blood vessels following the induction of general anaesthesia, insufflation of the abdomen with gas, that is, carbon dioxide and the institution of the position for a specific laparoscopic procedure. Carbon dioxide filled in the abdomen for laparoscopic gets absorbed into blood and affects the functioning of the heart and other organ systems. These changes may be of sufficient magnitude to affect adversely patient with pre-existing cardiovascular diseases like high blood pressure, myocardial infarction and angina. So, careful attention to cardiovascular measurements is required during laparoscopic in this group of patients. During laparoscopic surgery, changes in the lungs are secondary to the upward movement of the diaphragm (muscle which separates the chest and the abdomen) during insufflation of carbon dioxide. In addition, insufflated carbon dioxide gets absorbed through the peritoneum. Thus the measurement of the peak airway pressure and the level of carbon dioxide in the blood is essential during the operative period. In the post-operative period also, pulmonary changes are qualitatively similar to but less than those of, open upper abdominal surgery with restrictive breathing and the, decrease in vital capacity. Lung collapse occurs in some 10 to 40 per cent of the patients. These changes become more significant in patients who are in the elderly age group, already suffering from lung or heart disease and at high risk for any kind of surgery. Surgeons may have to work under the constraint of the poor position of the patient and with lesser insufflation of carbon dioxide. Because of its nature, laparoscopic surgery has some inherent risks. There is a greater dependency on advanced technical instruments and the user of these instruments. Thus more skill is required by all those involved in the operation: anaesthesiologist, surgeon, assistant surgeon, camera operator, scrub nurse and the circulating nurse who must coordinate the reservation of the operating room, the personnel and the specialised equipment. Operating with two-dimensional images and without tactile and proprioceptive orientation is a familiar ground to few. Even the anaesthesiologist has to get used to working in the dark room. He has to administer drugs, intravenous fluids and monitor his patient in a not-so-routine dark environment. The limited expertise and experience of some anaesthesiologists and surgeons with these new procedures also contribute to the magnitude of pathophysiological changes and increase the rate of complications. Finally, the duration of some operative laparoscopies , the risk of unsuspected visceral injury and the difficulty in evaluating the amount of blood loss are other factors that make anaesthesia for laparoscopic a potentially high-risk procedure. With the development of laparoscopy for gastrointestinal surgery, we must now care for the older patients who are more likely to have known or latent disease. Furthermore, because of the multiple benefits reported after laparoscopy, the laparoscopic approach tends to be readily proposed for ill patients. Thus there is a growing need to teach surgeons as well as anaesthesiologists the skills and problems associated with laparoscopic surgery in an approved residency programme. The
challenge for quality assurance organisation —
either hospital based or otherwise — will be to
discriminate between complications that arise from the
inherent limitations of the technique and those that
arise from its inappropriate use or application. Instead
of a lot of people losing a little and a few gaining a
great deal, a lot of people will gain substantially (in
decreased pain and rapid recovery) and a few will lose a
great deal by sustaining a major complication. |
Consequences of abuse Intemperate consumption of alcohol is discredited for many social, medical and neuropsychiatric problems. They are directly related to the frequency and volume of the alcohol consumed, the duration of alcohol consumption, the concomitant nutritional deprivation, alcohol contamination and a combination of alcohol with other substance abuse. Of the many social evils, the loss of marital harmony and child abuse on the verge of causing physical harm and sex-abuse, a high rate of divorce, job losses due to absenteeism at work, an increase in proneness to accidents at home, at the work place and on the roads are of immense concern. An alcoholic, by definition, fails to honour his social obligations and family roles as a parent, a partner or a provider. How wives cope with their alcoholic husbands has been the subject of intense psychoanalytical studies. They revealed discord, avoidance, indulgence and fearful withdrawal as the common coping reactions while marital breakdown, taking corrective actions, assertion and sexual withdrawal as less common responses. The low marital breakdown in the Indian context is attributed to the passive, timid and dependent personality of an average Indian housewife who is culturally nurtured and motivated to keep the marriage intact. For her, the husband is God-incarcinate and his house is a temple which she can ill-afford to quit. This is also compounded by the economic dependence, sympathy for the husband and the social stigma attached to separation from the husband. This is quite in contrast to Western society where walk-outs by wives or woman partners may take place on the spur of the movement. Times are, of course, changing. Many women organisations are taking these family concerns to the streets to draw the government's attention for banning alcohol outlets in the community environment. Medical complications of alcoholism are many, affecting all body systems. Alcohol induces injury to the gastrointestinal mucosa, the liver and the pancreas. The mucosal injury manifests in dyspepsia, ulceration and the shrinkage (atrophy) of the gastric mucosa. Liver injury is exhibited through hepatitis and the development of cirrhosis. One in five individuals consuming over 80 g of alcohol for over eight to ten years develop cirrhosis. They develop jaundice, enlarged liver and spleen, ascites and, may bleed to death or die in hepatic coma. Patients with hepatitis B or C virus infections indulging in alcohol abuse run the risk of developing liver cancer, otherwise uncommon with alcoholism. Pancreatic injury with alcohol abuse ends up with acute and chronic pancreatitis. With chronic pancreatitis, patients experience chronic diarrhoea and develop anaemia and a low protein state from nutrient malabsorption. With continued alcohol abuse, one may develop alcoholic heart disease where the heart is enlarged, functions poorly and fails. They may also have life-threatening cardiac rhythm abnormalities. Anaemia and a low blood platelet count are common amongst alcohol-abusers. Anaemia is multifactoral, beginning with nutritional deprivation, malabsorption and ending up with acute blood loss from bleeds due to liver cirrhosis. Hormone disorders with alcohol abuse are many. They include diabetes, proneness to low blood sugar, impotency, the loss of facial, body and sexual hair, subfertility from anovulation and low-sperm counts, breast enlargement in men, menstrual irregularities, obesity, skin bruises, hypertension and/or low blood pressure on standing, decrease in bone calcium and tetany. Besides, subtle abnormalities in secretion of many hormones without clinical abnormalities are observed. The recognition of alcohol-induced lowering of blood glucose in emergency is life-saving. Truck and passenger vehicle-drivers indulging in alcohol abuse cause traffic accidents not only from alcohol intoxication but also from the effect of low blood sugar. The neuropsychiatric effects of alcohol abuse include tremors, slurred speech, unstable walk, flushed face, abnormal sex and aggressive behaviour and chronic brain syndromes. The loss of both recent and past memory, intellectual impairment from brain atrophy, violent sleep and behaviour disturbances from alcohol withdrawal, hallucinations, anxiety and depression are features of chronic alcoholism. Oft-repeated information on small brains of Punjab road accident victims provides emphasis to alcohol-induced brain atrophy. Under the effect of high alcohol in blood, glucose fails to enter the brain cells to provide nutrition and this induces atrophy. Acute alcohol inebriation is a major cause of suicide. It is the primary diagnosis in 25% of the suicide incidents. Alcoholics also attempt suicide after the loss of their spouses or close relatives. This can be avoided by an effective watch by members of the family. The treatment of patients with problems of alcohol abuse and alcohol dependence is not easy. Although effective management strategies have been known, their implementation and adherence are difficult. The attitude of the physician and the psychiatrist treating such individuals should be warm but authoritarian. In alcohol dependence, relapses after successful alcohol abstinence as a rule occur within six months, after which they are infrequent. The physicians treating alcoholics should avoid anger or excessive pessimism. Family support for alcohol abstinence is essential. The role of Alcoholics Anonymous groups is immense. It provides a forum for the patient to reduce the sense of isolation and imbibe the feelings of belonging. The reformists in the group convey understanding and provide role models for responsible behaviour. Although
many alcoholics contact such help groups as the
Alcoholics Anonymous, it is not clear how many of them
actually derive full benefits. |
Concept of
primary health-care On October 13, Mr Atal Behari Vajpayee, just after having been invited by the President to form the government, while responding to the media representatives on his priorities, mentioned the social sector. And after a pause, he continued: universal primary education, drinking water and primary health-care. On October 16, Dr Satnam Singh, a long-term expert of the WHO, invited as the guest of honour at the inaugural function of the tenth annual conference of the Punjab and Chandigarh Psychiatric Society, was addressing the participants on the subject: Drug-abuse— can the primary health-care system cope with it? Here are some excerpts from his address. "For an effective response to drug-abuse and drug-trafficking the active participation of the people at risk is needed. And as well building partnership among communities, governments, professionals, NGOs and civil society! Can our public health system, of which PHC is the foundation, meet such challenges?" He believes that health workers, though they should cooperate with the authorities charged with the responsibility of reducing drug trafficking and illicit use of drugs, their primary responsibility and that of the health system is to address the demand-reduction side of the problem. After mentioning studies done in the 90s in some of the villages of Ludhiana and Ropar districts where drug abuse (alcohol), opium, tobacco, psychotropic drugs and more than one substance) prevalence among the adults ranged between 7 and 15 per cent with the commonest age of onset of heavy drug usage between 15 and 24 years and the Scheduled Castes rate being double that of others, he touched upon the policy and strategy changes needed to contain the problem. For decentralisation to be effective, the capacity of the district-level personnel to develop sound and realistic integrated plans of action based on local situations need to be enhanced. He regretted that Punjab missed the opportunity to strengthen the organisation and management of the District Health System based on PHC. In June, 1996, the then Principal Secretary (Health) was persuaded and he agreed to start with Ropar district but no follow-up action resulted. More recently, in January, 1999, the WHO Regional Director for the South-East Asia Region invited the attention of Chief Minister of Punjab to the WHO's interest in seeing the following two programme initiatives succeed in the state: —the strengthening of health services in one district by placing a health systems research team in staff position at the district level, and —the essential drugs programme to make available, all the time, good quality medicines at affordable prices at every level of the state health system. Eight main tasks are seen as essential to the PHC programme: health education, food supply and nutrition, water and basic sanitation, maternal and child health (including family planning) immunisation, communicable disease control and prevention, basic curative care, provision of essential drugs. Five principles are central to the PHC concept: equity (equitable distribution of services and all other resources), community involvement, focus on preventive care, appropriate technology and intersectorial approach. Dr Harish Shetty, Consultant Psychiatrist at the National Addiction Research Centre, is of the view that "detoxification is a simple procedure that can be carried out at any primary health-care centre; only those addicts having multiple physical problems need to be referred to the district-level hospitals. While the professionals and health administrators in Punjab may review the feasibility and effectiveness of this approach, PHC centres in Punjab are not ready yet to carry out functions such as follow-up and support of detoxified cases to minimise relapses, primary prevention together with other sectors of development to enable young people to see a future for themselves in the countryside, a future that includes opportunities not only for economic security but also for social and cultural fulfilment. Dr Singh
felt that in a federal republic like ours it was
imperative that in health, education and social welfare
sectors, the Centre's role should be limited to policy
guidelines, evaluation of programmes, research and
training and funding support. While appreciating the
efforts of the Union Ministry of Social Justice and
Empowerment in supporting nearly 500 detoxification,
counselling and rehabilitation centres across the
country, he felt that the implementation for better
coordination and coverage needs to be decentralised to
the State level and in particular to the district level.
He urged the district-level psychiatrists to take the
lead informing societies as has been promoted by the
government for containing problems like HIV/AIDS,
blindness, leprosy, etc, to utilise the resources
available with the government and in the communities in a
professional and effective manner. "This would be a
step forward in strengthening PHC approach." |
Rhythm and order by a new way About 90 per cent of sudden deaths are caused by cardiac tachyarrhythmia — ventricular tachycardia/fibrillation — a condition in which the pumping chambers of the heart start beating at a very fast pace leading to a fall in blood pressure. If such a condition is not corrected immediately by an electric shock (cardioversion), it leads to death. Despite tremendous research in the field of cardiology, these tachycardias (fast beating of the heart) remain unconquered. The only cure for these arrhythmias is to find the focus from where they arise and produce minute burns through catheters using radiofrequency currents to abolish them, a technique called radiofrequency ablation (RFA). Although this technique is well established at the Escorts Heart Institute, New Delhi, it is less effective for ventricular arrhythmia and some supraventricular arrhythmia. The first National Workshop on Electroanatomical Mapping and Catheter Ablation of Cardiac Arrhythmias was organised at Escorts in the second week of this month. The workshop was meant to introduce a new cardiac arrhythmia mapping method called the “Carto system” for the first time in the country and available only at a few centres worldwide. This computer-based system helps to find the focus and circuit (called mapping) of the arrhythmia, thereby ablating them and curing the patient. During the three-day workshop live operations were performed under Dr T.S. Kler, chief electrophysiologist and senior consultant, Interventional Cardiology, at the hospital along with Dr Jasbir Sra, a world renowned electrophysiologist from St Luke’s Hospital, Milwaukee, USA, in the presence of leading cardiologists of the country. The process in performed without any incision and the patient is totally conscious. The process is painless and takes about two hours. The patient is released after nearly six hours. The treatment will provide an option for patients who are advised Implantable Cardiovertor Defibrillator (ICD) but cannot afford it. The ICD is a pacemaker- like device having the capability of delivering electric shocks to correct ventricular arrhythmia. It is known to prevent sudden cardiac deaths. But the cost of the ICD is forbiddingly high (about Rs 9 lakh) whereas the new treatment is expected to cost nearly one tenth of the sum. — Gopal
Sharma |
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