1. Major surgeries for benign and malignant conditions of oesophagus, stomach, intestines, liver and pancreas are carried out routinely.
2. Minimally invasive Cholecystectomy, Appendectomy, Splenectomy and Intestinal Resections are also routinely performed.
3. Surgery for Hiatus Hernia is another commonly performed procedure.
4. The other specialty of the centre is that complex Biliary reconstruction surgery for bile duct strictures is performed on par with any other centre in the world with excellent results.
5. Our Minimally Invasive Surgery Division is one of the centers performing the largest number of laparoscopic procedures in the country, performing not only basic laparoscopic procedures but also most of the advanced laparoscopic procedures like laparoscopic esophageal surgery, gastric resections, colorectal surgery, pancreatic surgery and small bowel surgery. We have a state of the art Aida Touchscreen facility, and DVD recording facility and a newer version of the Harmonic Scalpel for bloodless surgery.

With the use of advanced technology and surgical methods, patients now have more options than ever for the treatment of Hepatobiliary disease. Apollo Hospital's Centers for Hepatobiliary surgery offers comprehensive specialty care for diseases of the liver, pancreas and bile duct.

For patients requiring hospitalization, we have a dedicated Hepatobiliary critical care unit, a heptobiliary physician on-call, anesthetists and a specialized O.R. nursing team. At the Liver Center, our focus is on providing experienced, personalized care for all our patients. Our doctors are trained at the world's most renowned centers in Hepatobiliary surgery and Liver Transplantation and are actively involved in clinical research.

Our team of surgeons, interventional endoscopists, radiologists and hepatologists work together to provide surgical treatment for the following disorders:

Biliary disorders

• Carcinoma of the gallbladder
• Malignant tumors of the bile duct
• Bile duct injuries and strictures
• Choledochal cysts
• Recurrent pyogenic cholangitis

Disorders of the Pancreas

• Pancreatitis
• Pancreatic pseudocyst
• Malignant neoplasms of the pancreas
• Cystic neoplasms of the pancreas
• Pancreatic islet cell tumors

Liver disorders

• Hepatic trauma
• Metastatic neoplasms of the liver (Cancer originated elsewhere & spread to liver)
• Benign (Non cancerous) tumors and cysts of the liver
• Portal hypertension (portasystemic shunts)

KEY HEPATOBILIARY PROCEDURES

Radiofrequency ablation and chemoembolisation of liver tumours and cancers

Dedicated to providing the highest quality medical and surgical liver care services, Apollo offers a broad range of effective treatments for cancer that have shown promising results. Radiofrequency ablation and Chemoembolization are highly successful treatment options available for select patients, whose suitability is recommended after meticulous evaluation by skilled doctors. Radiofrequency ablation, sometimes referred to as RFA, is a minimally invasive treatment for cancer. It is an image-guided technique that heats and destroys cancer cells. Imaging techniques such as ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) are used to help guide a needle electrode into a cancerous tumor. High-frequency electrical currents are then passed through the electrode, creating heat that destroys the abnormal cells. Some common indications for RFA are: 1) hepatocellular carcinoma, which is a primary liver cancer; 2) colon cancer that metastasizes or spreads from the colon to the liver.

Chemoembolization is a combination of local delivery of chemotherapy and a procedure called embolization to treat cancer, most often of the liver. Anti-cancer drugs are injected directly into the blood vessel feeding a cancerous tumor. In addition, synthetic material called an embolic agent is placed inside the blood vessels that supply blood to the tumor, in effect trapping the chemotherapy in the tumor.

RFA and chemoembolization are done at Apollo Hospitals Delhi and Chennai.

Pancreatic transplantation

A pancreas transplant is an organ transplant that involves implanting a healthy pancreas (one that can produce insulin) into a person who usually has diabetes. Because the pancreas is a vital organ, performing functions necessary in the digestion process, the recipient's native pancreas is left in place, and the donated pancreas is attached in a different location. The healthy pancreas comes from a donor who has just died or it may be a partial pancreas from a living donor. At present, pancreas transplants are usually performed in persons with insulin-dependent diabetes, who have severe complications that are usually of a renal nature. The majority of pancreas transplantations (>90%) are simultaneous pancreas-kidney transplantions. Over the recent years, long-term success has improved and risks have decreased. One year after transplantation more than 95% of all patients are still alive and 80-85% of all pancreases are still functional. After transplantation patients need lifelong immunosuppression. Pancreatic transplantation procedure performed at Apollo offers a new lease of life to patients with insulin-dependent diabetes and other severe complications, related to kidney function.

Pancreatic transplantation is done at Apollo Hospitals Chennai.

Other hepatobiliary system surgeries

The most common operation performed on the liver is a resection (removal of a portion of the liver). The most typical indication for liver resection is a malignant tumor. Tumors can be primary (developed in the liver) or metastatic (developed in another organ, then migrated to the liver). The single tumor or more than one tumor confined to either left or right side of the liver can be successfully resected with 5-year survival as high as 60%. Benign tumors of the liver (cyst, adenoma, hemangioma) can be successfully managed by liver resection as well.

Some of the other hepatobiliary system surgeries are:

• Pancreatic Surgery
• Bile Duct Surgery
• Gall Bladder Surgery
• Portal Hypertension Surgery and Liver Cirrhosis

Minimal access surgery too has a role in hepatobiliary surgical treatment

Hepatobiliary system surgeries are performed at Apollo hospitals Delhi, Chennai, Bangalore, Hyderabad, Ahmedabad and Kolkata.

Adult Hepatology and Gastroenterology services

The centres also have state of art Hepatology and Gastroenterology services. Endoscopic procedures for the care of liver patients are performed by well qualified and trained gastroenterologists. Complex endoscopic procedures like band ligation for bleeding varices in a cirrhotic, ERCP for a variety of biliary problems, sclerotherapy for control of ulcer bleeding etc are done. We also have capsule endoscopy and liver dialysis system (MARS) under the ambit of Hepatoenterology.

Apollo's comprehensive liver transplant care programme aims to provide effective health care by connecting to people dealing with liver disease. The Centers for Liver Diseases and Transplantation, Apollo Hospitals, are equipped with the state-of-the-art technology for liver surgery using the laparoscopic Argon Beam Laser as well as Tissue Link™ in combination with other methods of liver resection like CUSA™ and Laparoscopic Vascular Stapling. Bloodless Liver Surgery is also performed with high success rates.

Milestones

• First successful:
  • Pediatric liver transplant in India
  • Adult liver transplant in India
  • Cadaver liver transplant in India
  • Transplant in acute liver failure in India
  • Liver-kidney transplant in India
• Fastest growing Liver Transplant program in India with the biggest cadaver program for liver.
• Over 400 Liver Transplants performed with a success rate of 90%.
• Multi-organ Transplant Programme at Delhi performed as many as 250 Liver and Kidney transplants in the year 2009.
• First of its kind Comprehensive Organ Transplant program being commenced at Apollo Hospitals Chennai.
• One of the country's busiest and rapidly growing Pediatric Liver transplant programmes at Apollo Hospitals New Delhi.

FACILITIES

The ideal facilities which are required for Liver Transplantation, are present at multiple hospitals across the group, notably , Indrarastha Apollo hospitals New Delhi and Apollo Hospitals Chennai

• Liver transplant surgeries require meticulous aseptic measures. In keeping with this, we have separate OT facilities with laminar flow.
• The centres are equipped with the state-of-the-art technology for liver surgery such as the laparoscopic Argon Beam Laser as well as Tissue Link™ which are used in combination with other methods of liver resection like CUSA™ and Laparoscopic Vascular Stapling. Bloodless Liver Surgery is performed with high success rates
• Blood Bank facilities are available round the clock, to take care of both routine and emergency cases.
• Specialized Pathology and Immunology facilities are available at our laboratories for the investigation of patients of liver transplantation- both donors and recipients.
• For patients requiring hospitalization, we have a dedicated Hepatobiliary Critical Care Unit, a heptobiliary physician on call, anesthesia staff and a specialized OR nursing team.
• For postoperative convalescence and monitoring of donors and recipients, dedicated ICU facilities and Multi Organ Transplant Unit (MOTU) facilities are available.

Who is eligible for liver transplant?

While a liver transplant is the best cure for most patients with non-metastatic liver cancer, the limited organ supply may make this option unviable. The eligibility criteria for transplantation is the presence of a single HCC tumor 5 cm or less in diameter, or fewer tumor nodules, each 3 cm or less in diameter. Both living relative and cadaveric liver transplants are options for patients at the Center for Liver Diseases & Transplantation, Apollo Hospitals,India. Patients who will obtain maximum benefit from liver transplantation include those who are estimated to have less than one to two years of life and have no alternative medical or surgical therapies. The liver transplant procedure helps prolong the patient's life for at least five years and/or to restore the patient to a normal or near normal functional status. Thus, the overall goals of liver transplantation are to prolong life and improve the quality of life.

Pediatric liver transplantation is now an established and successful modality of treatment worldwide for children with acute and chronic end stage liver disease. The advent of new surgical techniques, immunosuppressive drugs, sophisticated peri and postoperative care has tremendously improved the survival rates in pediatric patients over the last four decades. In the current era, pediatric liver transplant has one and ten-year survival rates of 90 and 80% respectively.

Till a few years back, in the absence of liver transplant facilities in India, a patient with liver failure had only two options, certain death or travel abroad for a transplant. In 1998, India's first successful pediatric liver transplant was performed in our unit. The recipient is now a healthy teenager. The youngest baby in India was successfully transplanted in August 2008 at the age of 7 months. We have now performed over 43 pediatric liver transplants. We have recorded 90% survival rates. Our results are now comparable with the best centers in the west. The surgical expertise gained over the last few years combined with the lessons learnt in the medical management have contributed considerably to this achievement.

When is a pediatric liver transplant indicated?

The indications of pediatric liver transplant include biliary atresia, fulminant hepatic failure, chronic liver failure, metabolic disorders like Crigler-Najjar syndrome type I, primary hyperoxaluria type 1, urea cycle disorders and non-resectable hepatic tumors.

For more details visit www.apollolivercare.com

Endoscopy is routinely performed at the Centers for Medical and Surgical Gastroenterology, Apollo Hospitals, India for the following conditions:

• For patients who suffer from gastrointestinal bleeding ,both Banding / injection of esophageal varices and control of bleeding with adrenaline injection / argon plasma coagulation are routinely performed.
• For patients with swallowing difficulty due to esophageal stricture or achalasia, endoscopic dilatation can be carried out under fluoroscopic guidance. Similarly dilatation of pyloric and colonic strictures can also be carried out. In patients with esaphageal tumours, metallic stent placement is done, after dilatation.
• For patients for whom feeding is a problem either due to neurological disorders or altered consciousness levels, endoscopic placement of nasojejunaltube or PEG (Percutaneous Endoscopic Gastrostomy) tube is done.
• Endoscopic removal of gastric / colonic polyps is routinely done.
• For patients with obstructive jaundice, ERCP / papillatomy / stone extraction from CBD/biliary stenting (plastic as well as metal stents) can be performed.
• Placement of pancreatic stents in patients with severe pain due to chronic calcific pancreatitis is done.
• Esophageal manometry, pH studies and rectal manometry, which are available in only limited centres, are done routinely and help not only in diagnosis, but also in deciding which patients with gastro-oesophageal reflux or achalasia are likely to require surgery.
• Other routine procedures like liver biopsy, aspiration of liver abscess and diagnostic and therapeutic paracentesis are done through endoscopy.

Obesity and Bariatric Surgery

Obesity - A Growing Health Hazard

Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults and children, and health organizations view it as one of the most serious public health problems of the 21st century. Obesity is stigmatized in much of the modern world (particularly in the Western world), though it was widely perceived as a symbol of wealth and fertility at other times in history, and still is in our part of the world.

Obesity dramatically increases the risk of Type 2 diabetes, high blood pressure, high levels of cholesterol, Heart disease, Stroke, Arthritis, Obstructive sleep apnea, and Polycystic ovarian syndrome. Higher body weight is also associated with cancer, infertility, depression, asthma and early death.

India has the second largest diabetic population in the world. We have 7 Crore diabetics at present with a prediction that it would cross 11 crore in 2030. 25.4% urban & 25.2% rural obese populations are diabetic.

We are also the second largest hypertensive population in the world with 11 Crore hypertensives and a prediction of 21 crore hypertensives in 2025. This will make us the hypertension capital of the world by 2025.

20 % of all present deaths are either obesity or metabolic related.

Most weight loss programs are based on a combination of diet, behavior modification, and regular exercise. However, published scientific papers report that these methods do not help resolve morbid obesity because they fail to help people maintain weight loss. In fact, more than 90% of people regain the weight they lose within a few years after treatment.

Several factors can contribute to weight gain. Diet and exercise programs address factors that can be modified, such as lifestyle and behavior. However, because these methods fail to help people achieve and maintain a healthier weight, a strong link between our genetic makeup (which we're born with) and obesity are postulated.

Facts about Morbid Obesity

What is morbid obesity?

Obesity is a condition in which one has too much body fat (adipose tissue). Obesity is determined by calculating the Body Mass Index (BMI), which measures weight for height and is stated in numbers.

BMI =	Weight (in kg)
	Height (in m2)

BMI Status

Below 18.5Underweight

18.5 - 24.9Normal

25 - 29.9Overweight

30 - 34.9Obese

35 - 39.9Severe Obesity

> 40Morbid Obesity

> 50Super morbid Obesity

Health Hazards of Morbid Obesity

Severe obesity damages the body by its mechanical, metabolic and physiological adverse effects on normal body functioning. These "co-morbidities" affect nearly every organ in the body in some way, and produce serious secondary illnesses, which may also be life threatening. The cumulative effect of these co-morbidities can interfere with a normal and productive life and can shorten life as well. The risk of developing these medical problems is proportional to the degree of obesity.

• People who are obese do not live for as long as those who are not obese and the earlier a person become obese; the more years of life are lost.
• Heart Disease- Severely obese persons are approximately 6 times as likely to develop heart disease as those who are of normal weight. Heart disease is the leading cause of death today and obese persons tend to develop it earlier in life.
• High Blood Pressure- Hypertension is much more common in obese persons and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries.
• Diabetes Mellitus- Overweight persons are 40 times as likely to develop Type 2, Adult-onset diabetes. Once diabetes occurs, it becomes even harder to lose weight, because of hormone changes which causes higher fat accumulation in the body.
• Sleep Apnea Syndrome- Sleep apnea - the stoppage of breathing during sleep - is commonly caused in the obese, by compression of the neck, closing the air passage to the lungs.
• Respiratory Insufficiency
• Heartburn - Reflux Disease and Reflux Nocturnal Aspiration
• Asthma and Bronchitis
• Gallbladder Disease -Gallbladder disease occurs more frequently in the obese, in part due to repeated efforts at dieting, which predispose one to this problem.
• Stress Urinary Incontinence.
• Degenerative Disease of Lumbo-Sacral Spine (Backbone)
• Degenerative Arthritis of weight bearing joints like knee and hip
• Venous Stasis Disease in the lower extremities.
• Emotional/Psychological Illness- Extremely overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, and remarks from strangers. They often experience discrimination at work. Stereotypes of obese people - such as that they are lazy - may result in lower self esteem and poor body image.
• Social Effects- Severely obese persons suffer inability to qualify for many types of employment and there tends to be a higher rate of unemployment among them. There is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness.

Bariatric Surgery For Obesity

Over the last decade, weight loss or Bariatric surgery has been continually refined to improve results and minimize risks. Today, bariatric surgeons have access to a substantial body of clinical data that supports the use of surgery as a safe and effective weight loss treatment when other methods have failed.

Compared to other weight loss methods, such as dieting, surgery provides the longest period of sustained weight loss in patients for whom all other therapies have failed. It has also been shown to improve many obesity related health conditions, such as type 2 diabetes and high blood pressure.

Many patients who have had bariatric surgery report improvements in their quality of life, social interactions, psychological well-being, employment opportunities, and economic conditions.

Surgical options for treating Morbid Obesity

The morbidly obese have to seriously consider surgery for reducing weight to avoid its ill effects. Surgery for Morbid Obesity is for the following situations:

• The person's BMI is over 40, or is 35 or higher and a serious medical problem (hypertension, diabetes, heart disease, joint problems, reflux) that is made worse by obesity is present
• If it has not been possible to reduce or maintain weight under a medically supervised program
• If the person has been obese for at least 5 years

Surgical Treatment options available are :

1. Laparoscopic Adjustable Gastric Banding:

• An Inflatable Gastric Band is used, thus creating an Hourglass structure to the Stomach.
• This procedure may lead to about 39% of the excess weight being reduced within 18 months after the surgery.
• This procedure needs a high level of compliance from patient regards lifestyle and diet post surgery.
• There is always a risk of the Band eroding into the stomach, slipping out of place, and can also produce vomiting, development of GERD or sometimes the device can also fail to function.

2. Laparoscopic Sleeve Gastrectomy:

• Laparoscopic Sleeve Gastrectomy is safer than other procedures.
• In this procedure, 80% of the stomach is stapled and removed which induces weight loss by restriction in food intake and early satiety, due to loss of hunger producing hormones.
• Digestion and absorption is normal.
• By eating less the body draws the required energy from its own fat stores and thus you lose weight.

3. The R oux-en-y Gastric Bypass - The Gold Standard procedure:

• In this procedure, a small, 15 to 20 cc, pouch is created at the top of the stomach.
• The small bowel is divided. The bilio-pancreatic limb is reattached to the small bowel and the other end is connected to the pouch, creating the Roux limb.
• The small pouch releases food slowly, causing a sensation of fullness with very little food intake.
• The bilio-pancreatic limb preserves the action of the digestive tract.

4. Bilio-pancreatic Diversion with Duodenal Switch:

• In this procedure, greater weight loss can happen with less dietary compliance from the patient.
• There may be an increased risk of malnutrition and vitamin deficiency and intermittent diarrhea can also occur.
• Constant follow-up is needed for this procedure in order to monitor for complications.

Apollo Hospitals -A Pioneer in Bariatric Surgery

Apollo group of hospitals has been one of the earliest centers in the country to start Bariatric Surgery way back in 2005. We have successfully performed more than 1000 surgeries across the entire group so far with highest safety rate, with very minimal morbidity and no mortality. Apollo Hospitals Chennai has performed more than 300 surgeries so far , which include all varieties and techniques available with the least amount of morbidity and no in-house mortality.

Highlights

We are proud to have performed all types of Bariatric surgeries including Gastric Band, Sleeve Gastrectomy, Gastric Bypass, Minimal Gastric Bypass and Metabolic surgeries for control of Diabetes.

Apollo Chennai performed the world's first scarless endoscopic revision gastroplasty for failed bariatric surgery in association with Apollo Endosurgery, USA and has tied up with them for its clinical studies on Endoscopic Bariatric surgeries.

Apollo Chennai has also performed World's first Single Incision Revision Bariatric Surgery, India's first Single Incision Gastric Bypass and is one of the few centers in the country to perform Single Incision Bariatric surgery on a regular basis.

Apollo Chennai is the first hospital in India to perform Robotic Gastric Bypass & Sleeve gastrectomy in the country through its Apollo Robotic Surgery department.

Institute for Bariatric Surgery

An exclusive center for Bariatric Surgery has been launched at Apollo Hospitals Chennai on 26 November 2012, aimed at holistic healthcare for patients dealing with obesity & metabolic syndromes. Every obese individual's needs are different and our group of highly trained specialists will analyze and tailor the management protocols that best suits them. With literally all modalities of surgical and non-surgical options available at the Centre, , coupled with our enviable safety record, our patients are indeed assured of a safe journey with us during their weight loss process.

With department guidelines based on international standards, we will soon have India's first integrated theater system for laparoscopy, Robotics, SILS and NOTES surgeries all under one platform, specially designed rooms and patient facilities including cots, chairs and transport devices to help our obese patients have a comfortable experience with us.

With a dedicated team of specialists, nursing and support staff, Apollo Bariatric Institute is indeed a world class facility and one of the most advanced Bariatric centers in the country.

For more details, call Apollo Bariatric Institutes Helpline: 72999 52999