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SURGEON’S DIARY: Patient who was way ahead of his time in ulcer treatment

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By Yusuf K. Dawood
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I have often mentioned in this column how surgery is making progress at supersonic speed in all specialities. In the process, newer diagnostic methods are coming up and management of surgical diseases is changing on the basis of evidence-based research.

In my own speciality of breast, we have reverted from radical surgery to breast preserving procedures, mainly driven by our patients who impressed upon us the femininity they attribute to their breasts and how they considered it as an expression of their sexuality.

We heard their wailings and proved with sound evidence that lumpectomy of malignant tumours in early cases produces the same result in survival and disease-free period as radical mastectomy where the whole breast is removed with the muscles it lies on.

This conversion took almost a century to happen because radical surgery held sway on the mistaken belief that the more radical a surgery on cancer is, the less possibility of it coming back!

I confess to having done a few radical mastectomies in my time because it was statistically connected to longer survival. That obviously was a misconception.

In general, in cancer the progress is phenomenal because, even in the developing world where the mortality was high from infection, other communicable and deficiency diseases, deaths from cancer of lungs, liver and colon, prostate in men and breast and uterine cervix in women, seem to be going up. The incidence is going up too.

In non-cancerous groups, a classic example is the treatment of duodenal ulcer, located in the spout of the stomach through which food goes to the small intestine. For many years, the surgical treatment was removal of a major part of the stomach on the basis that the stomach lining produced excessive acid which was responsible for ulcer formation. I remember teaching my students for many years that the causes for excessive formation of acid in the stomach are stress, spirits, spices and smoking.

The spices as a cause was verified by a British surgeon who worked in south India for many years where people eat a lot of chillies and the high incidence of duodenal ulcer there is attributed to it.

To help their memory, I even put them in easy alliteration. I also remember telling them that there were only two indications for surgery. “They are failed medical treatment and onset of complications.” To complete my sermon from the pulpit of surgery, I then rattled the four recognised complications, counting them on the fingers of my outstretched hand. “They are,” I added, using melodious alliteration again: “Burst, bleed, block and turn malignant.”

We were naturally deflated and highly embarrassed when fresh research proved that duodenal ulcers are caused by tiny bacteria which reside in the pylorus and cause ulcer next door in the duodenum and the bacteria can be eliminated by simultaneous administration of three oral drugs and therefore called “triple therapy”.

I heard of this earth shattering discovery at the annual conference of Association of Surgeons of East Africa and the research paper was read by a young surgeon working at Tenwek Mission Hospital, newly arrived from USA, where he had picked up the material for his paper.

In time, drugs were discovered to arrest haemorrhage from ulcers so that surgical treatment for complications whittled down to three, perforation, blocked stomach from fibrosis in a healed ulcer and malignancy, supervening on a benign ulcer. After this long introduction, I want to narrate the story of Rael whose dread of a surgical operation unwittingly took advantage of this progress.

Like many of us, Rael was scared stiff of a surgical operation and went to great lengths to avoid it. His one measure in this direction was to visit various surgeons, here and abroad, which he could easily afford to do. He suffered from a benign duodenal ulcer proved by barium meal, endoscopy and biopsy.

In his relentless search for a surgeon who would not recommend surgery, I was the seventh surgeon he consulted. When he came to see me, I could recognise his type instantly by the pile of X-rays and the thick file, with typed reports he carried with him as he entered my office.

He stuck to his typical category as he embarked on his long history, in the course of which, he dropped the names of distinguished ulcer specialists he had seen in London, Hyderabad, Mumbai and Chenai in India and New York.

He then proceeded to show me all the X-rays and reports written by stomach specialists from all over the world, at his behest. They had all recommended surgery on the basis that adequate and repeated medical treatment given by eminent physicians had failed to get rid of the ulcer permanently. He admitted as much. “I am free of pain as long as I am on treatment which boils down to antacids and dietary restrictions.”

In reply I said. “In a case like yours, surgery is the only answer because at operation, we remove the acid producing part of the stomach and since there is no acid produced after surgery, there is no recurrence of the ulcer.”

After a session which lasted at least half an hour during which time my secretary rang me a few times on the intercom to say that other booked patients were complaining about the delay, as Rael picked up his X-rays and reports in very slow motion, he gave me an impression that I had convinced him about the need for surgery and that he was instantly going to discuss with me a mutually convenient day for operation. Instead, he said. “Let me think about it and I will ring you about my decision.”

Knowing the type, I reckoned that he was not going to ring me but he was going to see me again and pick my brain on the same subject. So after he left, I told my secretary. “If Rael rings to make an appointment, despite the fact that he is an old patient, please allot him 15 minutes instead of the usual five so that we don’t have the same problem as we had today.”

True enough, he was in my office a month later. I kept my cool despite the same questions Rael asked. There was one positive aspect — I learnt from him what Google said all about duodenal ulcer on the internet!

When the breakthrough came, I decided with glee that Rael was going to act as my first guinea-pig under the supervision of my medical colleague. So on Rael’s next visit, which fortunately took place after the ASEA conference, I said to him with mutual delight, mine exceeding his. “Duodenal ulcer has become a medical disease to be treated by the physicians in the future.”

As I saw the relief on his face, I went on. “The disease is caused by bacteria, according to the latest research, and my medical friends have devised tests to confirm the presence of these bacteria in the pylorus, the spout which connects the stomach to the duodenum where the ulcer is formed. They have also found a combination of drugs to eliminate the bacteria and allow the ulcer to heal. Since there are three drugs. It is known as ‘Triple Therapy’.” I concluded.

“Good news!” exclaimed Rael. “Strange I didn’t see it on the Internet or Google. You know I religiously check if there is any progress in medical treatment for my disease.”

“They are being over cautious.” I explained. “The information is hardly in our professional journals.”

I sent Rael to my medical colleague after making sure he knew of the breakthrough. “Of course, I know.” He said proudly. “I always thought that it was an overkill to take most of the stomach out for a tiny ulcer in the duodenum.”

Rael had fresh and additional tests done on him and once the diagnosis was confirmed, he was put on a course of ‘Triple Therapy’ for a week and to his amazement and mine, he lost the pain in his upper abdomen after food and hunger pains or pain in the epigastrium when he was hungry, two cardinal symptoms of the disease.

He did get one recurrence of his symptoms which was attributed to re-infection, a common occurrence but soon settled down with another course of medication.

Rael is now a patient of my physician friend, who does not mind Rael taking half an hour every time he comes to see his doctor.

I keep a proxy eye on him and occasionally Rael pops into my office to say a quick jambo to me when I am doing my desk work without a patient in front of me.

To end this story, physicians in general don’t mind engaging with their patients for longer time than I do because they have more patience than surgeons. In fact, they have a different personality altogether. I should know because when I was searching a career for myself after qualifying as a doctor, I wanted to be a physician because it is considered a cerebral speciality. Why eventually I ended up as a surgeon is a story for another day.

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