Perfecting Pancreatic Surgeries with Prof Omar Javed Shah

Prof Omar Javed Shah retired as Director Sher-e-Kashmir Institute of Medical Sciences (SKIMS) Soura. His innovative techniques in performing advanced Hepatobiliary, Pancreatic and Portal Hypertension surgeries have gained currency in the International arena and are recognized the world over. His contributions are referenced in major text books of Hepatobiliary and Pancreatic surgery. In an exclusive interview with Greater Kashmir Correspondent Zehru Nissa (ZN), Prof Shah (OJS) talks about the present and future of pancreatic surgeries.

ZN: First things first: Why is lapro-surgery preferred?

OJS: Laparoscopy is a type of surgical procedure that allows a surgeon to access the inside of the abdomen (tummy) and pelvis without having to make large incisions in the skin. This procedure is also known as keyhole surgery Large incisions can be avoided during laparoscopy because the surgeon uses an instrument called a laparoscope. This is a small tube that has a light source and a camera, which relays images of the inside of the abdomen or pelvis to a television monitor.The advantages of this technique over traditional open surgery include:

·         a shorter hospital stay and faster recovery time

·         less pain and bleeding after the operation

·         reduced scarring (scarless surgery)

The emergence of minimally invasive techniques is a revolutionary advance in surgery. Since the laparoscope was firstly applied in cholecystectomy in the 1980s, minimally invasive surgery has spread all over the World. Many open procedures have been replaced by minimally invasive procedures because of the faster recovery, better cosmetic effect, and less post-operative pain. Despite the profound advances of minimally invasive techniques, the common utilization of Minimally Invasive Pancreatic Surgery (MIPS) has underwent a hard process as a result of the complexity of the procedure.

Another type of minimally invasive surgery is robotic surgery. It provides a magnified, 3D view of the surgical site and helps the surgeon operate with precision, flexibility and control.Continual innovations in minimally invasive surgery make it beneficial for people with a wide range of conditions.

ZN: How far has our health sector kept pace with the advances in surgery?

OJS: Recently concluded Uro-Surgery 2023 conference at the Govt Medical College Srinagar showcased the current scenario and future of MIS in Jammu and Kashmir. More than 300 delegates all across the country and abroad were involved for 3 days in demonstrating live workshops  involving Robotic and advanced Laparoscopic  surgery from few of the best centres in India. Senior doctors at GMC who have  shown positive advancements in Laparoscopic procedures are striving hard to achieve better results for the patients and benefit the society at large. The audience were enthralled by a feast of various laparoscopic procedures. These deliberations stimulated extensive discussions within experts. Amongst these advanced procedures, laparoscopic and Robotic operations were also undertaken.

Many surgeons at  Government  Medical College Srinagar have shown outstanding performance in performing adventurous Pancreatic surgery by the use of Laparoscopic methods. This clearly highlights the dedication and commitment of these doctors for bringing these advanced procedures to the J&K. Their efforts will go a long way for the future progress of such surgery in this region of the country. High volume centre of Pancreatic surgery in J&K located at SKIMS  which has been involved in making continuous scientific progress in this field. I have had Pancreatic Surgeries as my passion throughout my career and have been, thanks to Almighty, recognised internationally for my contributions in the field. My work has paved way for the super-speciality of GI surgery in this region.

ZN: What is your take on the advanced pancreatic surgery in J&K?

OJS: Pancreaticoduodenectomy (PD) is a complex, high-risk surgical procedure used to treat pancreatic head or periampullary region tumours. Earlier, PD was associated with high rates of morbidity and mortality. However, over the years, advances in surgical techniques, critical care facilities, post-operative complications management, and, most importantly, the emergence of specialised centres of excellence at regional levels have caused a phenomenal decrease in the post-operative morbidity and mortality rates of PD patients. Patients treated at such centres have better chances of survival and increased life expectancy,  which has altered the situation globally.

ZN: Tell us something about the start of pancreatic surgery at SKIMS ?

OJS: My professional journey started at  SKIMS at the surgical division of gastroenterology, where senior colleagues advised me to focus solely on the abdominal cavity and keep pancreatic-related problems at bay. Though I tried, I could not follow this counsel for long and soon I found myself looking forward to an opportunity to tread the forbidden territory. Opportunity presented itself, when a separate department of Surgical Gastroenterology was established within the premises of SKIMS in 2005. A team of skilled and experienced hepatobiliary surgeons was formed out of the then-existing in-service human resources of the institute. I became part of the team entrusted with the responsibility of creating and organizing the performance profile of the future department.

The “touch-me-not” approach was permanently abandoned in our effort to provide high-quality tertiary care to a referral stream of patients, and PD became a routine surgical procedure. With the skilled assistance of my colleagues, we eventually succeeded in developing a “Superior Approach Technique” (SAT) for PD, having numerous advantages over the traditional Whipple’s Technique.

ZN: How did your technique shape up?

OJS: By switching over to SAT, I was able to offer a secure and comfortable process to patients in need of PD.  SAT further lowered the morbidity and mortality rates and shortened the hospital stay; further it yielded double dividends, it boosted the patient load of the department and simultaneously it also contributed to the skilful and dexterous management of such cases. Thus, SKIMS got transformed  into a reputable high-volume centre for PD operations.

ZN: Great work is done by great teams. Is that right?

OJS: Team work is the underlying principle of any successful project. The experience and expertise of operating surgeons must be backed with assistance from trained multidisciplinary team so as to ensure favourable outcomes. Poor operational outcomes are attributed mostly to a lack of teamwork, poor decision-making and inappropriate behaviour patterns. In fact, these immeasurable elements are frequently considered to be even more important in ensuring optimum operational outcomes. Their devotion and commitment equally contribute to better surgical performance.

ZN: How do you see pancreatic surgery at present ?

OJS: Pancreatic surgery is undergoing a revolution. Boundaries for indications of radical resection are continuously being pushed, and vascular resections with reconstructions are becoming standard procedures. The safety of the procedure is improving not only because of innovative methods discussed above but also because of the centralization of pancreatic surgery.

ZN:What is your opinion about present status of minimal invasive pancreatic surgery?

OJS: Owing to its numerous advantages, laparoscopy was applied to pancreatic surgery in the 1990s. Initially, enucleations and distal pancreatic resections were mainly performed, which was eventually followed by pancreaticoduodenectomy. The findings indicated that the laparoscopic procedure took longer time but reduced intra-operative blood loss, shortened the hospitalization stay, and is associated with almost same number of postoperative complications as that with traditional surgery. Having said this, I reiterate that, laparoscopic  pancreaticoduodenectomyshould be performed only in centers specialized in pancreatic surgery and having experts with extensive experience in laparoscopic surgery.

ZN: What is your advice to  surgeons involved in minimal invasive pancreatic surgery ?

OJS: The procedure should be performed in specialized high-volume pancreatic centers with extensive expertise in minimally invasive surgery. The laparoscopic approach, with all its benefits, is feasible only when performed by highly experienced surgeons. Perhaps, increased implementation of robotic surgery will facilitate vascular reconstruction during minimal invasive pancreatic resection and thus widen its application. However, as of now, the open approach remains the mainstay when it comes to vascular involvement.

ZN: How do you see the future for laparoscopic surgery?

OJS: Any innovation in surgery must be easy to implement, reasonable in cost, and have comparable, if not improved, outcomes compared to conventional therapies. Once these innovations have been tested and proven, only then should they become a widely adopted standard.

Future generations will undoubtedly view the way we currently perform surgery as antiquated. Many diseases that currently require surgical treatments may no longer need them. For example, surgical treatment of peptic ulcer disease has now been mostly replaced by antibiotic treatment. Moreover, with more advanced, diverse and miniaturized robotic technologies being produced by multiple companies, surgical robotics will become more widely available, and as competition increases, the price will decrease. This will make robotic platforms accessible to more surgeons and patients, and by default, it will improve surgical technique. Until then, the combination of advanced flexible endoscopy and laparoscopy will continue to be at the forefront of everyday surgeries. Mobile technologies have already affected the way we conduct or daily lives, and without a doubt, they will be implemented in digital or mobile health care, which includes surgery. Ultimately, economic factors will always play a role, as no innovation will succeed unless it makes economic sense.

ZN: Are robotic surgeries really the future?

OJS: The main advantages of robotic surgery are a three-dimensional image which gives greater operative freedom to the surgeon and allows greater precision. Operation with a robot is closer to the open technique than traditional laparoscopy; hence, it is considered a safe procedure. However, there are yet  only few reports on long-term follow-up after pancreatic resection via robotic surgery, which includes the assessment of long-term survival. Robotic surgery also involves high costs, and at present its availability is limited to large centers.