Intensive care unit (ICU)
Endoscopy suit of surgical gastroenterology department is situated at Room No 304 near the surgical gastroenterology OPD. Endoscopies are routinely performed on Wednesdays and Fridays. Endoscopy room is equipped with upper GI scope, side viewing and lowe GI scope. Both diagnostic and therapeutic scopies are performed. The therapeutic procedures include esophageal stricture dilatation, variceal ligation, variceal injection, glue injection and biopsy. Endoscopic retrograde cholagio-pancreatographies (ERCP) are performed in the operation theatre complex. One nurse, one endoscopy technician and one nursing assistant helps in performing endoscopies. A recovery room is situated nearby where patients are kept for a while after endoscopy. Endoscopies and therapeutic procedures are mostly performed on a day care basis without admission. Strict asepsis if followed during the procedure. Prior appointment is given for endoscopy.
Intervention services provided by the department include percutaneous drainage of abdominal collections, percutaneous trans-hepatic biliary drainage (PTBD) and trans-hepatic arterial chemoembolization (TACE). The department has ultrasound machine and image intensifier. Feasible procedures are done bedside. PTBD is done in collaboration with radiology and TACE is done in collaboration with cardiology. The biliary intervention procedures include PTBD, internalization, stenting, trans-PTBD biopsy stricture dilatation. The intervention procedures are being performed as a part of pre-operative biliary drainage or as permanent palliation. Facility for metallic stenting is also available. Angiographic interventions include TACE and trans-hepatic arterial chemotherapy (TAC). Macro aggregated albumin (MAA) scan is done in the department of nuclear medicine before TACE to rule out significant systemic shunting. Pre-operative portal vein embolization both through ileocolic and trans-hepatic approaches are being performed. In patients with big tumors, pre-operative therapies help to reduce the size of tumors so that they can be resected later.
Patient information materials and videos
Quality and safety
Maintaining Quality and safety in patient care is one of the foremost priorities of the department. This is continuously maintained through various mechanisms. JIPMER quality council (JQC) guidelines in the JIPMER manual on patient safety are followed in all patient care areas. All staff in the department are motivated in patient safety and are given regular training by quality managers of various domains. Standard operating procedures (SOPs), checklists and guidelines are developed, followed and audited. WHO surgical safety checklist, patient transfer SOP, quality rounds checklist (QRC), medication prescription-administration chart etc. are followed. Patient identification accuracy is maintained before all interventions. Hospital acquired infections, medication safety, operation room safety, workforce safety, blood transfusion safety etc. are given prime importance. The department has an event reporting system in which all adverse events are recorded and reported. Root cause analysis (RCA) are done for all significant adverse events.
The department of surgical gastroenterology was the first department to establish a comprehensive departmental clinical auditing system in JIPMER in 2011. Electronic patient record and data keeping are given care and precision. All the discharges are presented in weekly morbidity-mortality meetings (MNMs). Clinical auditing is done at doctors and nurses levels. Service area wise auditing system (OPD, ward, ICU, OT) was initiated in the year 2015. Annual MNMs and audit meetings help us in identifying the system performance and areas of improvement. The department supports other departments to establish good clinical auditing systems.
Two research studies in the area of patient safety are ongoing in the department. Surgical gastroenterology ICU is acting as the nodal station for needle stick injury reporting and body fluid exposure management for staff in the superspeciality block. Monthly orientation programme on various aspects of patient safety is a regular affair.
Best efforts are put in place to maintain quality and safety of the highest order matching international standards.
Hepato-pancreato-biliary (HPB) surgery
Advanced laparoscopic surgery
Advanced minimally invasive surgery has been one of the thrust areas of the department. Majority of the benign and malignant disease affecting the gastrointestinal tract, liver, pancreas and biliary tract were managed laparoscopically/thoracoscopically in the department. Minimally invasive surgery is the procedure of choice and no longer an option for the majority of the gastrointestinal disorders treated in the unit. The department is establishing itself as a center of excellence for minimally invasive surgery in the region of Puducherry, Tamilnadu, Kerala, Andhra Pradesh and Telangana.
The department faculty received minimally invasive surgery training from best centers in India and abroad. The operation theater is equipped with state of art full high definition Stryker laparoscopic camera system with the video monitor. High-end energy devices like laparoscopic harmonic ace plus probe, enseal devices, and laparoscopic CUSA are available to perform complex laparoscopic and thoracoscopic procedures. In addition, the department is equipped with advanced laparoscopic instruments like laparoscopic vascular clamps, flexible trocars, gel port system, autosuture device etc. All types of laparoscopic staplers and cartridges are available in the department.
Advanced minimally invasive procedures performed in this department include thoracoscopic esophagectomy, thoracoscopic assisted esophagogastrectomy, laparoscopic total gastrectomy, laparoscopic sleeve gastrectomy, laparoscopic cardiomyotomy, laparoscopic fundoplication, laparoscopic retrosternal gastric bypass, laparoscopic right hemicolectomy, laparoscopic anterior resection, laparoscopic low anterior resection, laparoscopic intersphincteric resection, laparoscopic abdominoperineal resection, laparoscopic splenectomy, laparoscopic distal pancreato-splenectomy. JIPMER is one of the few centers in India to perform the most complex laparoscopic procedures like laparoscopic pancreatoduodenectomy and laparoscopic liver resection.
Research projects are underway to study the feasibility and significance of thoraco-laparoscopic radical surgery in esophageal cancer and laparoscopic preconditioning procedures which can minimize the complications after this radical surgery. The department had taken a lead in minimally invasive training by conducting multiple minimally invasive surgery skills courses for trainee surgeons, practicing surgeons and staff nurses. Basic and advanced laparoscopic simulators including those with haptic feedback were used for these minimally invasive surgical skills courses.
Obesity is increasing in an alarming proportion and it is no longer a cosmetic concern and is a risk factor for diabetes, hypertension, coronary heart disease and multiple other non-communicable diseases. Although the surgery for obesity was originally developed as a weight reduction therapy, it has been reported to improve type 2 diabetes and to reduce rates of cardiovascular diseases and death. Hence, the term metabolic surgery is preferred over bariatric surgery to highlight the metabolic benefits of these surgical procedures. JIPMER is one of the few major Government institutes in the country to have an established metabolic surgery programme.
The successful metabolic surgery program requires a comprehensive care that includes adequate pre-operative education, nutrition and lifestyle counselling, challenging perioperative care, as well as post-surgical support. A multidisciplinary expert team of Surgeons, Endocrinologists, Pulmonologists, Cardiologist, Psychiatrist, Anesthesiologists and Nutritionists ensures comprehensive care for these patients. The department faculty trained in advanced laparoscopic gastrointestinal surgery performs these complex operations.
The Surgical Gastroenterology operation theater is equipped with the battery powered operation table with adequate width, weight capacity, leg separation and lithotomy facilities. In addition a full high definition Stryker laparoscopic camera system with the video monitor, long trocars and cannula, long laparoscopic instruments, vessel sealing systems and endoscopic staplers are available to perform these operations. In the postoperative period these patients are managed in a dedicated intensive care unit with real time monitoring of blood pressure, oxygen saturation, and electrocardiogram. In addition ventilators and continuous positive airway pressure mask for the management of obstructive sleep apnea.
Currently, laparoscopic sleeve gastrectomy is the preferred metabolic surgical procedure offered to these patients. Patients are advised to bear the cost of the consumables used in operation which is 20% of the expenses in corporate hospitals.
The Stoma Clinic in the Department of Surgical Gastroenterology was conceptualised and commenced from June 2013.Two staff nurses were sent for ostomy training at Tata Memorial Hospital Mumbai in 2013 and 2014 (three months each). Initially, stoma services were provided thrice a week. From 05.05.2014, these services are available 5 days a week. Along with OPD services, the ostomy nurses pay daily visit s to all stoma inpatients in the Department of Surgical Gastroenterology. They also receive direct references from other Departments in JIPMER like Surgical oncology, Pediatric surgery, Urology, General surgery, Radiotherapy, Medical oncology, Emergency Department, PMRC, Neuromedicine, Neurosurgery and Gynecology for stoma care and also care of pressure sores. The services provided by the Ostomy nurses include pre-operative stoma counselling, stoma marking, select ion of stoma appliances, application of appliances, stoma wash, care of bedsore and intestinal fistula management. They also provide advice to patients with stoma during discharge for stoma care and provide follow up care. The types of stoma managed by the team includes colostomy, ileostomy, jejunostomy, bowel fistula, duodenostomy, caecostomy, esophagostomy and urostomy. They also manage stoma related complications like peristomal skin excoriation and allergic dermatitis. Till date, the team has paid a total of 1613 visits to patients with stoma with a median of 3 visits per patient. 40 percent patients had more than 5 visits. Since November 2015 Ostomy nurses have been dedicated full time to ostomy service, provided from 7.30 am -3.30 pm. There is one ostomy nurse posted in OPD and another ostomy nurse for IP service. On call emergency services are also available. An Ostomy support group has also been formed recently and is scheduled to meet once in 3 months.
Their main area of services invo lves Superspeciality block (35%),Old block (56%);others being EMSD,RCC,WCH,PMRC (1-3% each).The stoma in-patients are provided with free stoma appliances. The process of provision of free appliances to OPD patients is in the pipeline. Various activities like ostomy and wound care training programmes, stoma product demonstration programmes and two stoma day celebrations have been conducted by ostomy nurses in JIPME R. The team has been involved in mentoring Ostomy clinic at Stanley Medical College, Chennai.
In future, augmentation of education material, extending advisory and training services outside JIPMER, care of all bedsores in JIPMER, organizing monthly in service training for other nurses and initiation of ostomy training course to make JIPMER a training centre for ostomy care is planned.
A full time Dietician is available in the SGE Department in all working days. Dietician rounds is done once in a day regularly in SGE ICU and Ward. Separate diet order sheets are used in ICU and Ward to communicate patients nutritional needs to the staffs. Assessment of patients nutritional status is done on the first day of admission and appropriate intervention is carried out based on the nutritional status. Special attention is given to all Preoperative and post-operative patients nutritional needs by offering nutritional support counseling to the patient and their attender. Diet chart are prepared according to patients individual nutritional needs and regular monitoring is carried out to check the nutritional intake of patient. Special blenderized feeds are prepared for achieving the nutritional needs of enteral feedings patients.
Dietician is available in SGE OPD during the OPD days for consultation and counseling of new cases and Follow up cases.
Medical social services
Medical Social worker acts as an intermediate link between the medical team and the patients in order to make the patient at ease and well informed. The Patients, care givers and family members are assisted to cope with problems resultant to illness and treatmentthrough comprehensive psychosocial support and care. The Patients are assessed foremotional wellbeing, mental health, social support,financial problems and other support needed for focused intervention and services.
The services includesupportive and adjustment counselling, pre and post-operative counselling, health education and clarifications on disease conditions and treatment procedures,counseling on treatment adherence,Individual, couple and family counselling, group therapy, palliative support, crisis intervention, financial assistance,guidance on availing community resources and referrals. The patients are regularly consulted in the OPD, the In-patients in the ward and intensive care unitsare provided bedside counselling and support. Assessments and interventions are done systematically and are being documented.Frequent surveys are conducted to assess the patients’ satisfaction to the care delivery system.
Medical social worker ensures that the informed consent is being provided both to the patient and the relatives in a structures way using comprehensive educational materials. Diagnosis, the need of the operation, its antecedent advantages, possible complications, the post-operative recovery and follow up plans are discussed in detail.
The availability of various government schemes and insurance schemes to get treatment are apprised to the patient. They were motivated and guided to the insurance cell for quick approval for support.
Medical social service extends to staff wellness as well. Various surveys are conducted to assess the staff satisfaction and the departmental administration is appraised about possible interventions.
The Medical Social Worker can be consulted in all working days in the OPD.
Research projects aimed at perception and interventional counseling are also conducted.
Telemedicine and telehealth
JIPMER has been designated as Regional Resource Centre for telemedicine activities in South India with an infrastructure of high speed (1Gbps) internet connectivity and satellite connectivity with various national and international networks including the Telemedicine Development Center of Asia (TEMDEC), Asia Pacific Advanced Network (APAN) and TransEurasia Information Network (TEIN) which enable JIPMER, a tertiary care Institute of National Importance, to share knowledge with different countries. Our department participates in telemedicine programmes and webinars at frequent intervals with well renowned national and international surgical gastroenterology centers.
Classification of Diseases and conditions
• Small bowel
• Colon and rectum
• Gall bladder and biliary tract
• Abdominal wall
Diseases and conditions
• Esophagus- cancer, achalasia, hiatus hernia, corrosive injuries, stricture, perforation, foreign body
• Stomach- cancer, stromal tumors, peptic ulcer, bleeding lesions, gastric outlet obstruction, obesity
• Duodenum- cancer, ulcer, obstruction, malrotation, duplication
• Small bowel- cancer, lymphoma, tuberculosis, perforation, obstruction, bleeding, fistula, acute appendicitis
• Colon and rectum- cancer, lymphoma, obstruction, volvulous, bleeding lesions, stoma
• Liver- cancer, cirrhosis, hydatid cyst, benign liver tumors, stone disease, abscess, portal hypertension
• Gall bladder and biliary tract- cancer, benign tumors, stone disease, cholangitis
• Pancreas- cancer, benign tumors, acute pancreatitis, chronic pancreatitis, cyst
• Spleen- tumors, spleen in hematological conditions
• Abdominal wall and hernias- Incisional hernia, inguinal hernia
• Esophagus- Transthoracic esophagectomy, transhiatal esophagectomy, thoracoscopic esophagectomy, esophageal bypass ,esophageal replacement laparoscopic esophageal bypass,laparoscopic cardiomyotomy, laparoscopic fundoplication
• Stomach- Radical gastrectomy, simple gastrectomy, laparoscopic gastrectomy, laparoscopic gastric bypass, laparoscopic vagotomy
• Duodenum- Duodenal resections, laparoscopic perforation closure
• Small bowel- Laparoscopic segmental resections, laparoscopic feeding jejunostomy, laparoscopic adhesiolysis
• Colon and rectum- laparoscopic right hemicolectomy, laparoscopic left hemicolectomy, laparoscopic anterior resection, laparoscopic abdominoperneal resection, total colectomy, ileal pouch anal anastomosis, sphincter preserving surgeries, stoma, stoma closure,laproscopic appendicetomy
• Liver- right hepatectomy, left hepatectomy, trisectionectomy, segmental liver resections, laparoscopic left lateral sectionectomy, portal vein embolization, trans arterial chemoembolization (TACE), percutaneous transhepatic biliary drainage (PTBD), splenorenal shunts, mesocaval shunts, devascularisation
• Gall bladder and biliary tract- Laparoscopic cholecystectomy, laparoscopic CBD exploration, radical cholecystectomy, extended radical cholecystectomy, hepatopancreatoduodenectomy
• Pancreas- pancreatoduodenectomy, Frey’s procedure, Beger’s procedure, Duodenum preserving pancreatic resections, lateral pancreatojejunostomy, laparoscopic distal pancreatectomy, spleen preserving pancreatectomy, pancreatic pseudocyst drainage,necrosectomy
• Spleen- Laparoscopic splenectomy, partial splenectomy
• Abdominal wall- laparoscopic incisional hernia repair, laparoscopic inguinal hernia repair.
Surgical procedures performed
• Esophagus- Transthoracic esophagectomy, Trans hiatal esophagectomy, thoracoscopic esophagectomy, esophageal bypass, esophageal replacement, laparoscopic esophageal bypass, laparoscopic cardio myotomy, laparoscopic fundoplicat ion
• Stomach- Radical gastrectomy, simple gastrectomy, laparoscopic gastrectomy, laparoscopic gastric bypass, laparoscopic vagotomy
• Small intestine - Duodenal resect ions, laparoscopic perforation closure, laparoscopic segmental resections, laparoscopic feeding jejunostomy, laparoscopic adhesio lysis. • Colon and rectum- Laparoscopic right hemicol e c tomy, laparoscopic left hemicolectomy, laparoscopic anterior resection, laparoscopic abdominoperineal resect ion, total colectomy, ileal pouch anal anastomosis, sphincter preserving surgeries, stoma, stoma closure, laparoscopic appendicetomy. • Liver- Right hepatectomy, left hepatectomy, trisectionectomy, segmental liver resections, laparoscopic left lateral sectionectomy, portal vein embolization, Trans arterial Chemo Embolization (TACE), percutaneous transhepatic biliary drainage (PTBD), splenorenal shunts, mesocaval shunts, devascularisat ion.
• Gall bladder and biliary tract- Laparoscopic cholecystectomy, laparoscopic CBD explorat ion, radical cho lecystectomy, extended radical cho lecystectomy, hepatopancreatoduodenectomy • Pancreas- pancreatoduodenectomy, Frey’s procedure, Beger’s procedure, Duodenum preserving pancreatic head resect ions, lateral pancreatojejunostomy, laparoscopic distal pancreatectomy, spleen preserving pancreatectomy, pancreatic pseudocyst drainage, necrosectomy
• Spleen- Laparoscopic splenectomy, partial splenectomy • Abdo minal wall- laparoscopic incisio nal hernia repair, laparoscopic inguinal hernia repair.
Standard operating procedures for diseases