Saga of a seventeen year old

 

What does a 17 year old normally do?

Hang out with friends, party and look forward to an enjoyable future.

Vishala, a 17 year old bright girl was doing just that, when she suddenly noticed that she had lost her appetite, not relishing her namkeens and snacks as she used to earlier. Slowly she found that her eyes have started turning yellow. Obviously this is a sign for worry and her parents got her investigated with the usual blood tests for jaundice thinking it is ‘hepatitis’. This was not hepatitis as ultrasound showed that the bile ducts were getting dilated (if there is jaundice, get sonography because it differentiates between hepatitis and obstructive jaundice). She was found to have obstructive jaundice and a series of investigations and imaging followed – CT Scan,MRI etc.

She was sent to Mumbai because she was found to have a tumour in the liver hilum a very delicate, complex area. As I tweeted earlier, we really had to plan carefully for this young girl. The team was determined to do our best for the girl and we spent nearly 7 weeks planning out the procedure and consulted a colleague from Japan. The procedure meant that we had to remove three-fourths of the liver from Vishala and the balance 25% would not be sufficient for carrying on the liver functions.

You may be surprised to know that 60% of normal liver can be removed and the liver regrows in just TWO weeks . Amazing !!

I had the privilege of knowing a Japanese surgeon,Prof Makuuchi, who first described a method of enhancing the volume of the liver which we applied in her case. We then proceeded to do the complex procedure which took almost 8 hours.

Things can go right or   horribly wrong especially in such complex surgeries. The family and the patient  had complete faith in us. We also said that we will do everything possible for getting her all right. Fortunately for us the recovery was relatively smooth and now you see that she is ready to go home.

I asked her what she wanted to do now and she said, “I want to learn dancing”, which is natural for a girl of her age. She with her doctor didis post a happy picture.

It is great to have a wonderful team and a faithful patient. Certainly in this case it makes us feel happy that we could save the life of this teenager. Wish and hope she has many years of bright life!

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Does Age matter?

I had written earlier on surgery for a 79 year old gentleman. Now a true story about an 85 year remarkable old  lady.

When I was coming to my clinic I saw an elderly lady in a wheel chair.

I thought to myself, whatever it is, I just have to counsel her that she would not be suitable for any major surgery and send her back home for some supportive care.

Her son is a Paediatrician in the US. He came in and I started saying, “How old is your mother? She is 85 and too old to undergo any surgery”.

Then he stopped me and said, “I also know that, but I just want you to talk to her once before making up your mind”.

I said, “Oh! Certainly, let me just talk to her”. So she came in and I said, “You see Maaji, you are 85 and surgery at your age would be problematic because of complications”. She had a colon cancer with obstruction.

She said, “I am Mrs. Dikshit,( she insisted that I use her real name). There are 15 doctors in our family. So I know what I am talking. Do you know that I never went to a hospital so far? I do not have any heart problem or any other issue and this is the first time I am getting surgery done. YOU ARE GOING TO OPERATE ON ME. I know that I will survive”.

I was amazed that this lady who is so certain about her outcome. I said, “ but…” and she cut me short and said, “ NO ‘BUT’, YOU ARE GOING TO OPERATE ON ME, IT IS FINAL, IT IS MY DECISION”.

I said, “Okay, things may go wrong”.

She said, “So what if things go wrong. I am 85 as you know and lived my life well. Even otherwise I am not going to have much of a chance, so I’d rather take a chance with your surgery”.

Reluctantly I said, “Okay, let me try”.

My team was looking at me as if to say ‘Don’t do this, you will operate and we are going to have a problem’. We carefully evaluated her and every single test was normal. There was no way we could refuse surgery and taking high risk consent we went ahead with surgery. Believe it or not, on the 8th post-op day she literally walked home. When she came for suture removal she was walking and insisted that she will not come on a wheel chair.

I was so happy that I hugged her and said, “You are really remarkable, bless us that we would be like you at your age, so positive and so full of life”.

with mrs dikshit

More and more senior citizens are getting operated. As we know, longevity is increasing and we see more and more elderly patients. We are extending our boundaries of surgery with better assessment and anesthesia. Earlier I used to feel 65 is the limit, then 70, then 75 and now it is nearly becoming 85 which is really pushing the boundaries.

But more than anything else, I think it is not just the chronological age but physiological age as to the other co-morbid conditions, how active was their life and whether they had multiple other problems. I think all these factors have to be taken into consideration while planning surgery for elderly. The mental attitude is important There are many articles on surgery in elderly. Elderly patients have same outcomes for cancer if they don’t have postoperative complications says Dr Preston “ Geriatric surgery is about the disease and not the age”.

The most fascinating story is of Dr. Michael deBakey, the pioneer heart surgeon of Baylor college, Houston who was the father figure of cardiac surgery. In December 2006, at the age of 97, he had chest pain and was diagnosed with Dissecting aneurysm of Aorta. He had treated 10000 such patients. But as with many patients of his age, he was in denial and then refused surgery. After a month the chest pain was unbearable and he nearly collapsed. His partner for 40 years Dr. Noon said, ”Either surgery or death, what will you choose”. His wife then intervened and consented for surgery. Anaesthetists were not willing to put such an elderly and important person to sleep for a complex cardiac surgery and were literally forced. The surgery went on for 7 hours and with exceptional care of HIS OWN team, Dr Debakey was discharged from the hospital. He himself could not believe that he survived the surgery. The whole story is interesting NY Times article

It will be great if all of us can age without co-morbid conditions. Yes, at some point of time there will be some illness but at least if you are fit by that time you are more likely to come out fine.

The engine has to be kept running in good condition and then you can cover long distances.

Good ‘Old’ generation!

 

Yesterday was a very interesting day. I saw 4 patients who are over 70. When I started my surgical career, more than 3 decades ago, we had a fairly unwritten rule that above 50 years be careful and after 60 avoid risky surgery. Some of the major surgeries which we performed on the younger patients were not offered to the elderly patients as there was a fear that there would be some complications and they would not be able to stand the complications.

In the west it has been proven recently that even older patients have the same kind of resistance and power to heal  and tt does not really depend on the age.

‘Physiological age’  is more important than the ‘Chronological age’

Mr. Mehrotra came into my room with a spring in his step. The first thing I asked was “Are you really 79”? He said, “Of course I am 79 and I even have great grandsons.”

I generally do not base my assessment on the biochemical values or numbers.

So I asked him “What do you do in a day and what time do you get up in the morning?” He said, “I am up by 5 in the morning”.

“Oh, and then ? “.

“I go for a walk for about an hour”,

I asked, “how much distance” and he said, “about 5 km.”

(I said to myself “I don’t do that”)

He said, “then I come back and may be have some juice and fruit, a bit of yoga and then I have my breakfast”.

I said, “Fantastic routine, what else do you do, can you go up a flight of steps?” He said, “of course I can because when I go for a swim in the evening, I do go up and down the steps.”

So I said,”oh oh, that means you swim also?”

He said, “of course I swim or go to the gym.”

Well this man is certainly great, at 79 he is fit and is definitely not overweight. I look at the people who came with him, his nephew (who well certainly looked pretty uneasy with the whole conversation) because it was clear that he never walked, forget about gymming and swimming and he was easily 10 kg overweight.   I had to do a major liver surgery for him so I said, “there is a risk in surgery”, he said, “so what, I am ready for it.” I think it is not only the physical fitness but also the mental attitude of the older generation which is remarkable.

Second gentleman was again 75, the same story except that he does not gym and does all the things which normally should have been done by someone who is much younger than him.

I had no hesitation in clearing both the patients for both liver and pancreatic surgeries respectively. Yes, there are some risks involved but it depends on how you take care of your body.

Then came a 75 year old whom I had operated upon for rectal cancer. He said, “doctorsaab, can I go for my walks?” I said, “of course, you can.” He said, “what about the treadmill?”

( Oh, I also have a treadmill but I do not seem to be using it much).

“Yeah, why treadmill, why not just go for a nice walk in the lawns or outside?”

He said, “yes, that I do everyday, I used to do for an hour but now it is 1/2 an hour, but in the monsoon season, if it is raining, I still want to do my exercise and that is why I am asking if I can go on the treadmill”

I said, “of course you can do it but just be careful”.

So, in short, when I look at the older generation it is so enlightening. They are right in front of us- they take care of their health. Their physical fitness is far far better than the younger generation. In fact, I feel that the ‘father’ coming from a small town will do far better than the ‘son’ who is a busy executive in the city. In small towns and villages the people have to walk, there are no fancy cars. They have fresh vegetables, fresh produce, plenty of clean air and certainly they are far healthier than their city bred sons who are either stressed out, stuck in the traffic, no exercise and plenty of excuses not to do so.

Are we going to see a kind of reversal of the longevity which we have achieved over the years and have younger people having lifestyle related diseases in their prime. May be yes, unless we take quick corrective steps. There is no great science involved in this. Just see your father. Ultimately it is the genes which determine your own health and see your father and follow his habits and that itself is going to make you a healthier person.

Old is gold is a saying which is worth remembering every time. It is so true!