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Department of Surgical Gastroenterology Jawaharlal Institute of Postgraduate Medical Education & Research Puducherry India Department Manual Department Manual S.No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 0 Issue No. 1.0 Date 01/01/2016 Contents summary History Department profile Mission and vision Department policies Organogram Faculty and staff details Job description Responsibilities and role of HOD Responsibilities and role of consultant Responsibilities and role of senior resident Responsibilities and role of chief resident Page No 2 3 4 5 6 7 9 10 11 13 Departmental administration Policies on documentation Services Inpatient services Outpatient services 14 17 Clinical programmes Classification of diseases and conditions Academic schedule and review meetings Fire safety plan Standard operating procedures Information materials for patients Inpatient and outpatient statistics 31 34 36 40 45 74 94 Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head 19 24 Control Status Page 1 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 1 Issue No. 1.0 Date 01/01/2016 History The department of Surgical Gastroenterology has been conceptualized with three sanctioned faculty posts - one professor/additional professor and two assistant professors and six senior resident posts. The Department was started on 03/03/2010 with the joining of Dr V Ranjit Hari as Assistant Professor. Dr. Vikram Kate, Professor of Surgery was appointed as faculty in charge. Dr Vishnu Prasad, Additional Professor in General surgery, was deputed to the department in May 2010. Dr Biju Pottakkat, joined as Assistant Professor on 30/06/2011. Dr V Ranjit Hari resigned from the post and was relieved on 14th June 2013. Dr R Kalayarasan joined as Assistant P r o f e s s o r o n 15/07/2013 on adhoc basis and later joined on regular basis on 26/11/2013. Dr. Biju Pottakkat was promoted as Associate Professor on 01/07/2014 and later recruited as Additional Professor on 09/09/2014. Dr Vikram Kate was relieved from the post of faculty in charge and Dr Biju Pottakkat was appointed as Head of the department on 01/12/2014. Dr Sandip Chandrasekar A joined as Assistant Professor on 02/02/2015 on adhoc basis. Dr Alwin Gunaraj and Dr Senthil Kumar joined as senior residents on 01/06/2010. MCh Surgical Gastroenterology course was commenced on 16/08/2011 with two sanctioned seats per year. Dr Pradeep Joshi and Dr Salil Kumar Parida were the first MCh trainees of the department. From January 2015, select ion of MCh candidates is taking place in two sessions one candidate each in January & July session. There are two junior residents working in the department currently. The outpatient clinics started during March 2010 and the inpatient facilities started with eight general beds including two intensive care unit beds. Operation theatre services were initiated from 02/06/2010. The dedicated surgical gastroenterology ward was begun with 16 beds on 01/08/2012. Dedicated ICU with six beds started functioning from 06/08/2012. Endoscopy services were also initiated at the same time. Additional four general and four pay wards were included to expand the services. Dedicated ostomy services were begun by 06/06/2013. Specialized dietary services started on 01/11/2014. Obesity & metabolic surgery programme was started on 24/03/2015 and has been catering bariatric surgery services to those who could only dream of such surgeries which involve high costs elsewhere. The department office commenced functioning from 09-03-2011. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 2 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 2 Issue No. 1.0 Date 01/01/2016 Department Profile The department of surgical gastroenterology at JIPMER was established in the year 2010 with an aim provide advanced treatment, for training and extend research in the area of surgical gastroenterology. The department aims to act as a leader in this domain in the country. It is located in the JIPMER superspeciality block. It is a 32 bedded clinical unit with 3 full time faculty, 6 resident doctors, 2 junior residents, 33 nursing staff and other supporting staff. The department manages patients with complicated surgical problems in the GI tract and has outpatient clinics, general and special wards, intensive care unit and operation theatre. Superspeciality degree programme is running with two trainees per year. Regular residency teaching programmes and continuing nursing programmes are ongoing. The department runs a simulation laboratory, stoma clinic and a diet clinic. State of the art facilities and equipment’s are available to fulfil the needs of complicated patients. Patient centered research in various arenas is one of the foremost priorities of the department. The planned expansion in terms of new services, programmes and infrastructure development are ongoing. Patients are treated at a highly subsidized rate. Quality and safety of high order is maintained in patient care. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 3 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 3 Issue No. 1.0 Date 01/01/2016 Mission and Vision The department of surgical gastroenterology at JIPMER is envisioned to act as the leader in the specialty in the country. The goal is to act as a department of excellence in patient care, teaching and research. Patient care- The aim is to develop innovative strategies in diagnosis and treatment of common surgical diseases in the gastrointestinal tract which are common in southern India. The core areas include cancer of liver, chronic pancreatitis, portal hypertension and cancer of esophagus. The innovations include new concepts in etiology, re-look in to the existing definitions and descript ions, novel diagnostic and evaluation algorithms and new management strategies. Existing standard operating procedures for a particular disease will be relooked and modifications will be suggested. Developing new concepts in equipment and instrument designs will be a priority. Teaching- The aim is to include new systems of teaching in superspeciality training. Endoscopy and percutaneous interventions will be part of the training. Simulation methods will be used in a big way in training the procedures. Short and long term goals of training in MCh curriculum will be specified with due emphasis to the recent advances. Specialty nursing at the departmental level rather than nursing college level will be explored adopting the methodology of ‘post qualification nursing training’ and the curriculum will be developed as ‘qualified in specialty’ concept. Research- Lacunae in available scientific information in the specialty will be kept as a prerequisite for new research initiatives in clinical management. Research in nursing care will be given top priority. Research into systems and practices will be performed so as to create new models for the country in care delivery. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 4 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 4 Issue No. 1.0 Date 01/01/2016 Department policies Quality and safety in patient care Patient first approach in services Inter area co-ordination Equipment mutual sharing policy Unit wise concept in department as well as area functioning Transparency in concepts, plan and executions Policy of internal audit of systems and practices Faculty consultant system in individual patient care Paper less policy, electronic transfer and storage policy for information and communication Ecofriendly policy Promotion of research and development in all areas Promotion of Hindi and Tamil among staff Policy of staff wellness Extra mile project – work beyond duty apart from duty Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 5 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 5 Issue No. 1.0 Date 01/01/2016 Organogram Head of Department Senior Residents (6) Year I (2) II (2) Department In-charge ANS Medico social worker Ward, OPD, OT, ICU, Endoscopy Sister In-Charge Dietician Stoma nurse III (2) Junior residents (2) Faculty: Assistant Professors (2) Staff nurses Store keeper Office assistant Multi-tasking staff Multipurpose worker Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 6 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 6 Issue No. 1.0 Date 01/01/2016 Faculty and staff details S. No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Name Dr. Biju Pottakkat Dr. Kalayarasan. R Dr. Sandip Chandrasekar. A Dr. Gourav Kaushal Dr. Gajendra Bhati Dr. Shahana Gupta Dr. Kapil Nagaraj. P Dr. Santhosh Anand. K.S Dr. Pavan Kumar. V Mrs. Thilagavathi. T Mrs. Uma Prakash Babu Mrs. Sumathy. M Mr. Midhun K Mrs. Priyankamol. V.C Mr. Dhinakaran. S Mr. Biji. K Mrs. Mangaleshwari. M Mr. Gopalakrishnan. G Mrs. Kiruthigadevi. E Mrs. Rajakumari. R Mr. Shine. P.S Mrs. Lanit ha. N.T Mrs. Divya. K.S Ms. Vyshnavi. M Ms. Anju jose Mrs. Neda. S Mr. J. Muktatman Pandya Ms. R. Yogaramya Mrs. Indirani. M Mrs. Aruna Sundari Devi. V.G Mr. Mudavath R. Nayak Mr. Binny George Ms. Pavithra. M Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Designation Additional Professor & Head Assistant professor Assistant professor Senior Resident Senior Resident Senior Resident Senior Resident Senior Resident Senior Resident Assistant Nursing Superintendent Nursing sister in charge (OT) Nursing sister in charge (OT) Staff nurse (OT) Staff nurse (OT) Staff nurse (OT) Staff nurse (OT) Staff nurse (OT) Staff nurse (OT) Nursing sister in charge (ward) Nursing sister in charge (ward) Staff nurse (ward) Staff nurse (ward) Staff nurse (ward) Staff nurse (ward) Staff nurse (ward) Staff nurse (ward) Staff nurse (ward) Staff nurse (ward) Nursing sister in charge (ICU) Nursing sister in charge (ICU) Staff nurse (ICU) Staff nurse (ICU) Staff nurse (ICU) Control Status Page 7 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 34 35 36 37 38 39 40 41 42 43 Ms. Saranya. S Ms. Nithyakalyani. C Mr. Sreevalsan. K Mr. B. Ramshankar Naik Ms. Tency George Mrs. Krishnaveni. N Mrs. Priya Grace Prakash Mrs. Thilagavathi Sasikumar Mrs. Vijaya Balasubramanian Mrs. Punidavathi. A 44 Mrs. Navamani 45 46 Mrs. Priyadarsini. B Mrs. Amirthavalli. A 47 48 49 50 51 52 53 54 Mrs. Dhilshath Begum. A Mrs. Hena Melya Mr. Sivasubarmanian. K.R Mr. Lalan Kumar Ray Mr. Ajeesh Sathyan Ms. Saranya. R Mrs. Ramya Esther Rani Mr. Tamaraselvane Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Section No. 6 Issue No. 1.0 Date 01/01/2016 Transplant co-ordinator Staff nurse (ICU) Staff nurse (ICU) Staff nurse (ICU) Staff nurse (ICU) Staff nurse (ICU) Ostomy nurse Ostomy nurse Nursing sister in charge (OPD) Nursing Sister in charge (Endoscopy) Nursing Sister in charge (Endoscopy) Technician (Endoscopy) Nursing sister in charge (Liver Transplant) Dietician Medical Social Worker Store keeper (Office) Multi-Tasking Staff Multi-Tasking Staff Office Assistant Multi-Purpose Worker Nursing Assistant Control Status Page 8 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 7 Issue No. 1.0 Date 01/01/2016 Job description Responsibilities & Role of HOD 1. To be responsible for the overall functioning of the department 2. To develop mission and vision for department after consulting with all staffs 3. To be an example by setting good standards in teaching, research and patient care 4. To take active steps in fostering cordial interpersonal relationships in the department and ensuring that there is a smooth working relationship among all the members of the department. 5. To co-ordinate teaching and research programmes of the department 6. To plan, conduct and monitor quality management systems of the department 7. To be known for humility, transparency and integrity 8. Conduct weekly departmental academic meetings and regular mortality and audit meetings. 9. Conduct monthly gastro pathology and gastro radiology meetings 10. Conduct monthly staff in-charge meetings 11. Conduct faculty meetings once in 3 months 12. Conduct MCh residents review meetings once in 6 months 13. Conduct annual departmental meeting 14. Interact with the administrators and external agencies on behalf of the department 15. Conduct model theory and practical exam for all MCh residents annually 16. Evolve direct ion plan and programme for the department 17. Attend inter departmental and other meetings with administration 18. Operate departmental funds 19. Interact with all groups of staff to ensure smooth functioning of department 20. Acquire, maintain and ensure optimal utilization of equipments 21. Plan and approve capital budget requests 22. Organize functions in department Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 9 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 7 Issue No. 1.0 Date 01/01/2016 Job description Responsibilities & role of Consultant 1. To be responsible for the care of patients admitted 2. Supervise, guide, teach and assist the trainee residents in the care of patients 3. Supervise and guide the residents in various procedure 4. Required to teach the residents on daily rounds 5. Carry out research work 6. Participate in the departmental training program and other training courses that will enhance personal development, skills, knowledge and practice requirements 7. Co-ordinate and moderate seminars and journal clubs 8. To ensure implementation of the quality assurance programme &conducting clinical audits. 9. Formulating Guidelines & protocols 10. Support the HOD in all management responsibilities of the department Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 10 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 7 Issue No. 1.0 Date 01/01/2016 Job description Responsibilities & role of Senior Resident The department admits one candidate biannually for the superspeciality degree, MCh in Surgical Gastroenterology (SGE) through a national eligibility written test. They are considered as temporary employees of the institute and are assigned as senior residents. They are involved in dedicated full time surgical training, research and academic activities. Surgical training is self-motivated and directed towards the needs of the community. They are involved in identifying ailments relevant to GI tract and associated basic sciences. The residents perform diagnostic and therapeutic GI endoscopic procedures, basic and advanced GI (open and minimal access) operations independently and with the guidance of a senior surgeon. They also undertake comprehensive GI perioperative intensive care management. The trainees complete a dissertation during their curriculum. The conduct of this dissertation is in accordance with institutional ethical and research monitoring committee. They acquire basic knowledge of statistics to understand and critically evaluate published article. They also prepare research paper for publication. Attending few lectures related to research, human behavior studies, pharmaco-economics and non-linear mathematics are included in their training period. Senior residents study standard text books of GI surgery and keep updating themselves with recent publications and journals. They have scheduled ongoing academic sessions including monthly audit, case presentations, seminar in assigned topics and discussion of complex multidisciplinary cases. They attend national and international GI surgery conferences and update themselves with recent advances in the field. Residents maintain record of important activities during the training in the log book. They also have periodic assessment of their theory and practical knowledge. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 11 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 7 Issue No. 1.0 Date 01/01/2016 In addition, the trainees are expected to demonstrate empathy and humane approach towards patients and their families in accordance with the societal norms and expectations. They also play the assigned role in the implementation of national health programme, effectively and responsibly. They acquire the ability to organize and supervise the health care services demonstrating adequate managerial skills in the clinic/hospital or the field situation. The residents develop skills as a self-directed learner; recognize continuing educational needs; select and use appropriate learning resources. They evolve as an effective leader of a health team engaged in health care, research and training by the end of training programme. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 12 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 7 Issue No. 1.0 Date 01/01/2016 Job description Responsibilities & role of chief resident The concept of chief residency was introduced in department of surgical gastroenterology, so that residents will be well trained with responsibilities of a consultant and able to run a department immediately after completion of their three year residency. Chief resident is the resident who is in third and final year of his residency. He is virtual consultant bearing all responsibilities of the department. He is key link between senior residents and the faculty. Chief resident is expected to make all decisions regarding patient management and to discuss with consultant as and when required. He is expected to involve in teaching of first and second year senior resident and to coordinate all department and patient related work with them. Daily evening ward round is conducted by chief resident which includes daily progress of patients presented to him by senior residents. It includes comprehensive case by case discussion and formulation of treatment plan on the basis of best available current evidence. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 13 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 8 Issue No. 1.0 Date 01/01/2016 Departmental Administration Surgical gastroenterology department office Surgical Gastroenterology office shortly called as SGE Office is located at fourth floor of SS Block IPD, Complex No.551. SGE Office complex comprising of ten rooms viz., offices of the head of the department, three consultants, one female doctor, one male doctor, one seminar room, one office staff room, one data room and one stores. Department office functions as the link between the departmental and institute administration. All the institute and external communications are channeled through the office. SGE -Office plays the role of back end office administration for the main wing of the department viz- outpatient clinics, in patient facility, intensive care unit, operation theatre and endoscopy besides auxiliary wings like stoma clinic, diet clinic, skills lab & SGE office itself. Office administration activit ies include human resource management (HRM) of 50 personnel (including doctors, nursing staff & para medical staff), continues medical education (CME) to doctors & nurses, conducting symposiums & training Programmes, MCh Courses & exams etc. Three national conferences, 07 regional level seminars, 20 departmental level training programs are conducted. Office is manned by two multitasking staff and one assistant. The departmental store, manned by a storekeeper, provide logistics support to above main & auxiliary wings of this department as regards to equipments, consumables, nonconsumables, information technology infrastructures, office contingencies, etc. Store activities include forecasting of requirements, project ion, budgeting, procurement, and technical/price bids evaluation, receipts of stores/ equipment, storing, distributions to its wings, maintenance contracts for equipments etc. The department hosts equipment assets to the tune of Rs.10 crores and has been procuring consumables/non-consumable products to the tune of one to two crores every year. A separate procurement scheme is in place for those patients covered under insurance scheme. Surgical gastroenterology store has a model smart bin location system and also taken a lead of compiling a partial study report on JIPMER Inventory Management System called “JIMS” which is likely to be integrated into upcoming hospital information system. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 14 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 8 Issue No. 1.0 Date 01/01/2016 Departmental Administration Head of the department (HOD) The department is headed by a senior faculty in the cadre of professor or additional professor. Dr Biju Pottakkat is currently the head of the department. The head of the department is acting as the chief executive officer of the department. As the staff in the department are working in diverse do mains, each faculty is allotted various areas for the betterment of services, teaching and research. Head of the department is responsible for all the academic and administrative activities. Clinical services are designated to individual consultants to ensure better patient care through individualized approach. Head of the department is the chairman of all the academic programs and courses running in the department. He is the convener of the MCh exit examination. All research proposals need clearance from the head of the department. As the chairman of the department purchase committee, HOD has to generate all the purchase requirement for the department and conduct the committee meetings. HOD is the member of institute council and infect ion control committees. HOD chairs faculty meetings, in charge nurses meetings and all other meetings in the department. Head of the department initiates system changes taking inputs from ongoing feedbacks and discussions. Annual performance of each employee will be assessed by HOD and will be forwarded to the director. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 15 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 8 Issue No. 1.0 Date 01/01/2016 Departmental Administration Nursing administration 36 nurses are working in the department. Mrs. Thilagavathi. T, Assistant Nursing Superintendent (ANS) heads the nursing services. Mrs E Kiruthiga Devi and Mrs Rajakumari R are acting as nursing in charges in the ward and ten staff nurses are working under them. Mrs. Indirani Mohanraj and Mrs Aruna Sundari Devi VG are heading the Intensive Care Unit (ICU) and eight nurses are working there. Operation theatre services are supervised by Mrs Uma Prakash Babu and Mrs M Sumathi and eight trained operation room nurses are involved in operation theatre management. Mrs Vijaya Balasubramanian is heading the outpatient services including ostomy care and diet clinic. Mrs. Amirthavalli is heading the liver transplant unit. ANS oversees the systematic functioning and acts as a link with the institute nursing administration. She acts as the representative of nursing services of the department in all the hospital and departmental meetings. All the nursing training and academic programmes are conceptualized and co-chaired by ANS. ANS is the in charge of nursing education and nursing research. Interdepartmental co-operation in nursing services are ensured through ANS. All the institute and hospital policies in patient and personnel care regarding quality control, staff welfare etc. are communicated to all nurses through ANS. ANS convenes nursing in charge meetings on a monthly basis and attend all the care review meetings. Nursing in charges are responsible for overall wellbeing of the patients and ensures smooth running of all services in their respective areas. They are actively involved in education and training. All store indents from department store, central store, pharmacy, laundry and linen section are handled by in charge nurses. Duty scheduling are effected in respective service areas by in-charge nurses. In charge nurses are responsible for implementing all the institute guidelines like infection control, workforce safety, JIPMER quality council guidelines etc. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 16 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 9 Issue No. 1.0 Date 01/01/2016 Policies on Documentation Documentation in OP chart Only faculty and senior residents can make entries in the OP chart Whenever a patient is seen, the date, time and name of consultant is noted in the OP chart. List out the chief complaints, personal, past and family history. The drugs the patient is on is listed. Any new changes are marked A relevant clinical examination is documented A clinical impression and a plan of management is clearly written, along with the list of tests ordered Other details, if applicable that are documented are: Instructions or education given to the patient, follow up instructions, health tips and diet instructions. Documentation of assessments in IP Visit summary is prepared by the senior resident as soon as the patient arrives. It is typed and print out is kept in patient file The chief complaint and clinical examination is documented and provisional diagnosis written A plan of action is outlined based on entries made in the OP chart/discussion with the consultant Blood and other investigations sent are documented Follow up of investigations and appropriate treatment is started and documented Treatment, investigation & patient monitoring charts are prepared for ward & ICU separately which furnishes the necessary progress of the patient. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 17 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 9 Issue No. 1.0 Date 01/01/2016 Policies on Documentation Discharge summary Contains the name of all consultants & residents in department with department contact number Contain name of treating consultant, SGE number, Diagnosis, date of admission, date of operation and date of discharge Should contain visit summary Investigations – biochemical, microbiological, radiological Operation record Hospital course Plan, follow up, advice on discharge and drug slip Discharge summary delivery procedure Discharges are decided at least one day prior and informed to patient and relatives in advance The patient-in-charge doctor prepares the discharge summary by filling in details on a typed standard format available in the department The discharge summary has patient’s clinical history, findings, diagnosis, investigation results, treatment given/procedure done, condition at discharge, advice on medication and other instructions on discharge Discharge summary also contains the details of follow up visits and whom to contact in case of emergency In case a patient dies in the ward a death summary is g iven stating the cause of death Discharge summaries are prepared by resident doctors and the consultant verifies and signs before handing over to patient and is kept in the depart mental folder for future reference A copy of discharge summary and letter about the course of patient in hospital is send to the referred doctor A folder is maintained in departmental computer which includes complete detail of patient including visit summary, discharge summary, operative photographs, clinical photographs, representative radio logical imaging, operative videos and follow up details Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 18 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services In-patient services Surgical gastroenterology Ward (46/47) Surgical Gastroenterology ward is located in the fourth floor of Super specialty block, with 20 sanctioned general beds, and four individual special pay rooms. Ward is well equipped with the upgraded infrastructure for patient care needs, run by trained nursing staff who have special interest in gastro intestinal care and round the clock doctors to extend the best health care support to patients. Infrastructure includes adjustable cots with side railings, cardiac tables, separate oxygen and vacuum pipelines for individual patients, water heater systems, water purification systems, cold storage systems, non-touch infrared thermometers, separate digital weighing machines including a 200 Kg machine used exclusively for bariatric patients. Procedure room hosts an examination table with all essential equipments. Adjustable trolleys have made transfer of patients comfortable and safe. Also equipped with desktop computer, high definition display, printers to facilitate digital data maintenance and cordless phones to support staff at work. With infusion pumps, pulse oximeters, automated BP apparatus, the infrastructure is state of the art for perusal of doctors and nursing staff. Safety mechanisms like fire safety are periodically checked and monitored. Technical and mechanical support has always been prompt and service expedious. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 19 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services Intensive care unit (ICU) Surgical Gastroenterology intensive care unit shortly called as SGE ICU (146A/SSB18) is a state of the art surgical care facility. It is situated in the first floor ICU Complex of Super specialty Block. It is an air conditioned 6 bedded intensive care unit exclusively for critically ill patients and post-operative patients with gastrointestinal surgical ailments. SGE ICU provides individualized continuous medical attention. It has the facility of cardiac respiratory monitors for each bed along with oxygen, air and suction supply. Apart from this it has three mechanical ventilators (Carefusio n USA, Neumovent Schiller), infusion syringe pumps, aerosol nebulizers, bair-hugger warmer & thermocare disposable warmer blankets, PCA syringe pump & disposable ambulatory PCA pumps to manage all the needs of a critically ill patient. It also has 12 lead ECG equipment & defibrillator for cardioversion. A state of art Motorola EPOC cartridge based portable Arterial Blood Gas (ABG) machine with blue tooth printer helps in management of critically ill patients. The prosound HITACHI ultrasound machine helps in bed side imaging. CT and MRI Image viewing through PACS helps for quick decision making and interventions for critically ill patients. Fully equipped emergency cart makes it possible to face any kind of medical emergencies that may arise in the ICU. Appropriate storage of medicines is ensured by a 277 liter storage capacity refrigerator. To maintain proper anti septic measures, 500ml hand rub is placed outside entrance of ICU and its made mandatory to use hand rub for all entering inside and a coat stand to place coats. Besides a 500ml hand rub is placed in all bedsides, segregation of biomedical wastes at source, needle burner and sharp container help to fight against hospital acquired infect ions and ensures personnel safety. Patient’s nutritional needs are calculated by a full time dietitian. Enteral feeding is promoted, parenteral nutrition support is provided when needed. SGE ICU is provided with an induct ion cooker and a mixer grinder for customized food preparation. The SGE team including the faculty rounds twice a day that helps in early interventions and treatment planning. One senior resident is stationed in ICU round the clock. There are totally ten staff nurses, two in charge sisters and one nursing orderly in ICU who render excellent nursing care. Nursing rounds are done three times a day apart from continuous nursing care. Many standard operating procedures (SOPs) and checklists including quality rounds checklist (QRC) are being followed. Learning atmosphere is created among staff nurses by promoting continuing nursing education by formal presentations weekly and bed side teaching daily. Handover protocols ensures effective information transfer during duty shifts. HIS (Hospital information system) connectivity in ICU helps to retrieve real time information, digitalize patient records and foster patient’s privacy. Twice daily status report of the patient’s condition will be provided to the relatives. The Notice board outside ICU displays the ongoing events as well as provides patient family education regarding disease conditions, management, and home care. Resources are optimized to save the cost without compromising care, efficacy and safety. All the events in the ICU are audited through weekly morbidity mortality meetings at the departmental level. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 20 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services Surgical gastroenterology operation theatre Surgical Gastroenterology operating room (OR No. 10) is located in the OT complex in the first floor inpatient block of super specialty block. It is a dedicated operating room exclusively for surgical gastroenterology patients. Endoscopic procedures and percutaneous interventions are performed in OR No 6. Operation room is functioning five days a week. This is a centrally air conditioned modular OT with laminar flow, HEPA filters and positive air pressure system. Temperature is maintained at 20± 3°C and humidity between 40 – 60% which will be constantly monitored in control panel display inside the O.R suite. Two fully equipped emergency carts and a defibrillator make possible any kind of emergency arising pre operatively or intra-operatively to be managed effectively. Appropriate storage of medicines, blood products and hemostatic agents are ensured by a refrigerator. Advanced anesthesia machine incorporates a ventilator, suction unit and a cardio respiratory monitoring device. Infusion pumps, Blair hugger patient warmer, blood & fluid warmers (Ranger and EnFlo) prevent hypothermia. HIS and PACS are available inside OT. Myrian XP liver radiology workstation helps in virtual reconstruction and effective contemplation of liver resections. Complex hepatopancreatobiliary, gastrointestinal and advanced laparoscopic procedures are being performed in this department. Basic instruments, retractors, different types of vascular and special instruments are available for performing simple to complex cases. Recording systems are used to record the operative procedures. Stryker modular laparoscopic console and all laparoscopic instruments are available to perform advanced laparoscopic and bariatric surgeries. New version Harmonic generator, Ultrasonic liver dissection workstation from Soring, Karl storz choledochoscope, radio frequency ablator and advanced electro cautery from ALSA makes the OT state of the art. OT store ensures adequate supply of consumables like staplers and hemostats. Focusing on patient safety and ensuring quality, use of WHO surgical safety checklists, patient transfer slips, visible white boards for counts, patient strapping, shifting trolleys with side rails etc. are well in practice. To prevent infect ion, strict procedures for surgical scrubbing, gowning, gloving, and use of three layered water resistant surgical gown/drapes are followed. Systems for segregation of bio medical wastes at source, needle burning and containers for sharp item disposal are in use. Autoclaving, ETO and Plasma sterilization are ensured as per protocol. Weekly washing, AC vent cleaning and fumigation processes are being done strictly. Focusing on personnel safety, orientation sessions on hand hygiene, infect ion control, needle stick and fluid splash injuries and hepatitis B vaccination are conducted regularly. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 21 of 94 Private Circulation only Section No. 10 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Services OT-6 OT-6 is utilized by both Medical and Surgical Gastroenterology units. It is fully equipped with advanced endoscopic and fluoroscopic gadgets. Diagnostic and therapeutic endoscopic procedures including endoscopic ultrasound and Endoscopic Retrograde Cholangio Pancreatography (ERCP) are done in a regular basis by Medical Gastroenterologists. Percutaneous interventions including Percutaneous Transhepatic Biliary Drainage (PTBD) and Percutaneous Catheter Drainage (PCD) are done under fluoroscopic guidance by Surgical Gastroenterologists. Surgeries requiring endoscopic assistance including Intraoperative enteroscopy are done there. Rendevous procedures combining use of endoscopic and percutaneous approach for difficult biliary strictures, endoscopic ultrasound guided aspiration cytology and drainage, percutaneous endoscopic gastrostomy and other advanced interventions are also being done. Protective measures against radiation hazard are ensured. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 22 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services Endoscopy Endoscopy suite of surgical gastroenterology department is shared with the department of medical gastroenterology and 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 lower GI scope. Both diagnostic and therapeutic scopies are performed. The therapeutic procedures include esophageal stricture dilatation, variceal ligat ion, variceal injection, glue inject ion and biopsy. One nurse, one endoscopy technician and one nursing assistant helps in performing endoscopies. A recovery room is situated nearby where pat ients are kept for a while after endoscopy. Endoscopies and therapeutic procedures are mostly performed on a day care basis without admission. Strict asepsis is followed during the procedure. Prior appointment is given for endoscopy. Intervention services 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 radio logy and TACE is done in collaboration with cardio logy. The biliary intervention procedures include PTBD, internalization, stenting, trans-PTBD biopsy a n d stricture dilatation. The biliary intervention procedures are being performed as pre-operative biliary drainage or 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. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 23 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services Out-Patient Services Outpatient clinic Surgical Gastroenterology OPD (SGE OPD) is situated in the second floor of superspeciality OPD block room No 305. Initially OPD was started with 2 working days (Monday and Friday). From 2013 it was increased to thrice weekly (Monday, Wednesday and Friday). In 2015, it was extended to 6 days a week (Monday to Saturday). Working hours: Monday to Friday: 9 AM to 1 PM Saturday: 9 AM to 11 AM The Department faculty and MCh residents takes care of OPD patients after registration in OPD reception. Separate consultation rooms are allotted for consultants and residents. OPD dressing room is equipped with instruments for dressings and stoma dressing room is available to take care of stoma patients. OPD complex also has separate stoma clinic, diet clinic and MSW clinic on all OPD days to cater needs of ever y patient. OPD is equipped with audio visual system in the waiting hall which plays department introductory video and other health awareness videos in local language for the benefit of patients Procedure for admission of patient Our department policy is to admit and evaluate patients visiting OPD if there is any suspicion of malignancy. This is to avoid waiting period during evaluation on OPD basis. Patients are admitted in SGE ward which is located in 4th floor of superspeciality IP block. Patients are given choice of either general ward or special ward. General ward is completely free and special ward is having minimal charges. Patients are admitted on priority basis with malignancy patients getting first priority. Significant proportion of patients are transferred from various specialities too for further expert management. Every effort will be made to borrow beds from other departments on a temporary basis in case of shortage of beds. Emergency admissions Those requiring admission urgently will be admitted depending on the intensity of care required in the ICU, General Ward or Private Ward as the case requires and availability of beds. In case of need for emergency surgical intervention, emergency anaesthesia team is informed and patient shifted to emergency OT in the 3rd floor of casualty block for surgery Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 24 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services Ostomy services 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 involves 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. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 25 of 94 Private Circulation only Section No. 10 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Services Nutritionist services 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 patient’s 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 postoperative patient’s nutritional needs by offering nutritional support counseling to the patients and their attenders. 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 feeding patients. Dietician is available in SGE OPD during the OPD days for consultation and counseling of new cases and follow up cases. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 26 of 94 Private Circulation only Section No. 10 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Services 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 treatment through comprehensive psychosocial support and care. The Patients are assessed for emotional wellbeing, mental health, social support, financial problems for focused intervention. The services include supportive 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 units are 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 structured 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 appraised 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. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 27 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services 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 staffs 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 infect ions, 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. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 28 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services 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 Trans-Eurasia 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 w ith well renowned national and international surgical gastroenterology centers. Patient information materials and videos Information materials are made available in departmental website for various diseases like Anterior Resection, distal pancreatectomy, esophagectomy etc. for the benefit of patient which includes details of various diseases, risk factors, preventive measures, symptomatology, diagnostic measures and management options in a simple language for better understanding. Patient information videos are being prepared for 20 common gastrointestinal disorders in their local language. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 29 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 10 Issue No. 1.0 Date 01/01/2016 Services Policies for assessment of patient When patients are admitted, they are seen by a nurse and housekeeping instructions given along with any stat orders if any The doctor in charge of the bed or the duty doctor will see the patient as early as possible The doctor will do an initial work up, write the care plan and the medications and send necessary investigations required Reports of blood investigations are available online through HIS from ward and radio logical investigations through PACS Dangerously abnormal results are intimated by concerned lab personal to treating resident or consultant directly through telephone. Patients are shown to respective consultants and plan discussed and decided in the round Drug prescript ions are written in drug chart and it is changed daily or as and when required. Standard operating procedures prepared by the department according to Evidence based surgery is used for managing the patients. All the patient information’s are kept confidential and online access is restricted by password Patients are seen at least twice a day by the resident doctors. During each visit the clinical status is recorded in the progress notes along with date, time and signature When the concerned doctor is not available, the responsibility is handed over to another doctor of the same unit or the duty doctor Dietician will see, evaluate and advice diet for the admitted patient Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 30 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 11 Issue No. 1.0 Date 01/01/2016 Clinical programmes Hepato-pancreato-biliary (HPB) surgery The department has established itself as a center of excellence for HPB surgery in the region of Puducherry, Tamilnadu, Kerala, Andhra Pradesh and Telangana. Benign and malignant disorders of HPB system are being managed according to the standard operating procedure protocol of the department. Advanced HPB surgeries performed in the department include Hepatectomies (Major & minor) for Hemangioma of liver, Hepatocellular carcinoma, Intra hepatic & hilar cholangiocarcinoma, Colorectal & neuroendocrine liver metastases, intra hepatic stones, radical cholecystectomy for carcinoma gallbladder, choledochal cyst excision, common bile duct exploration, Whipples pancreatoduodenectomy for periampullary carcinomas, head coring & duodenum preserving pancreatic head resection, distal pancreatectomy for chronic pancreatitis, cystoenterostomy for pseudocyst of pancreas and procedures for cystic neoplasm of pancreas, necrosectomy for acute necrotizing pancreatitis. The energy devices required for advanced HPB surgeries like Harmonic scalpel, CUSA, vessel sealer are available in the state of art operation theatre of the department. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 31 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 11 Issue No. 1.0 Date 01/01/2016 Clinical programmes 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 cardio myotomy, laparoscopic fundoplicat ion, 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 and robotic simulators were used for these minimally invasive surgical skills courses. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 32 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 11 Issue No. 1.0 Date 01/01/2016 Clinical programmes Obesity and metabolic surgery 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. Obesity and metabolic surgery programme was inaugurated on 24/03/2015 by Dr S C Parija, Director, JIPMER. 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 and laparoscopic Roux En Y gastric bypass are 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. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 33 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 12 Issue No. 1.0 Date 01/01/2016 Classification of diseases and conditions Organs • Esophagus • Stomach • Duodenum • Small bowel • Colon and rectum • Liver • Gall bladder and biliary tract • Pancreas • Spleen • Abdo minal wall Diseases and conditions • Esophagus- cancer, achalasia, hiatus hernia, corrosive injuries, stricture, perforation, foreign body • Stomach- cancer, stromal tumors, peptic ulcer, bleeding lesion , gastric outlet obstruction, obesity • Duodenum- cancer, ulcer, obstruction, malrotation, duplicat ion • Small bowel- cancer, lympho ma, tuberculosis, perforation, obstruction, bleeding, fistula, and acute appendicit is • Colon and rectum- cancer, lymphoma, obstruction, vo lvulus, bleeding lesions, stoma • Liver- cancer, cirrhosis, hydat id 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 condit ions • Abdo minal wall and hernias- Incisio nal hernia, inguinal hernia. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 34 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 12 Issue No. 1.0 Date 01/01/2016 Classification of diseases and conditions 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 hemicolectomy, 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 Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 35 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 13 Issue No. 1.0 Date 01/01/2016 Academic schedule and Review meetings of the Department Our department has regular scheduled programme for academic and monthly audit meetings. This helps in improving scientific knowledge of the staffs and to review the shortcomings, thereby overcoming them subsequently. The adverse events are promptly reported and a record of such incidences are maintained. There are various academic activities involving faculties and senior residents held in the department. Journal club involves critical analysis of a published research paper, appraising its limitations and finding its applicability. Seminars on selected topics, current evidence in advances and future perspective are held in regular basis. Case presentations in a structured format helps senior resident trainees well versed for their practical exams. Exclusive monthly lecture by faculties provides in depth theoretical and practical concepts in particular topics. Review of inpatients individually, their morbidities and follow up are recorded and reviewed in monthly basis. We also have discussion of cases which have multidepartmental role in management by conducting interdepartmental meets. Monthly Academic schedule Academic activity Journal Club Case presentations Case capsule Seminars Individual patient audit meet Mortality audit meet Faculty lecture Gastro Pathology meet Gastro Radio logy meet Numbers 4 4 3 2 1 1 1 1 1 The department monitors academic and research activities periodically, to assess progress of senior residents. Review meetings with associated health care professionals regularly helps to implement day to day practical shortcomings, thereby providing better patient care. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 36 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 13 Issue No. 1.0 Date 01/01/2016 Academic schedule and Review meetings of the Department Review meetings schedule Review meeting Schedule Annual department meeting Once in a year Faculty meeting Once in three months Resident progress meeting Once in six months Resident committee meeting Once in six months Sister in charges meeting (Dr Biju) 1st Friday of month ICU meeting (Dr Sandip) 1st Tuesday of month Ward meeting (Dr Kalayarasan) 2nd Tuesday of month OPD and stoma meeting 3rd Tuesday of month OT meeting (Dr Biju) 3rd Friday of month Office meeting 4th Tuesday of month Department quality cell (Dr Biju) Nursing research cell (Dr Biju) Once in three months Once in three months In addition, we have regular teaching schedules at various levels including Continuous Medical Education (CME), Continuous Nursing Education (CNE), workshops in basic ventilator management, infect ion control, hospital waste management, postoperative ICU care and transfusion guidelines, which helps our staffs to stay in line with current practices according to international guidelines. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 37 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 13 Issue No. 1.0 Date 01/01/2016 Department quality cell Quality cell was formed in the year 2015 with the aim of improving the quality of care provided to the patients. Functions of quality cell are 1. Reporting of adverse events in department 2. Root cause analysis & auditing of such events 3. Implementation of corrective measures 4. Implement Jipmer Quality Council protocols in department Department quality cell meets once in three months. Members of quality cell are: 1. Dr Biju Pottakkat – Additional Professor & Head 2. Mrs. Thilagavathi. T – ANS Nursing incharge 3. Ms. Vyshnavi. M – Staff nurse (Ward) 4. Mr. Dhinakaran. S – Staff nurse (OT) 5. Ms. Pavithra. M – Staff nurse (ICU) Nursing research cell Research forms a major part of our nursing faculties in the department. In order to further promote and motivate research among nursing faculties, nursing research cell was formed in the year 2014. This body meets once in three months. Research topics are selected and ongoing which ultimately helps in providing better patient care. Members of nursing research cell are 1. Dr Biju Pottakkat – Additional Professor & Head 2. Mrs. Thilagavathi. T – ANS nursing incharge 3. Ms. Saranya. S – Staff nurse (ICU) Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 38 of 94 Private Circulation only Department Manual Section No. 13 DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Co-ordination of extra departmental training and orientation programmes Following will act as organizing secretaries 1. Basic laparoscopic skills courses for doctors 2. Advanced abdominal surgery skills courses 3. Basic laparoscopic skills courses for nurses 4. All intensive care and infection related programmes 5. All quality and care related programmes 6. All stoma and wound care related programmes 7. All nutrition orientation programmes 8. All staff and patient communication orientation programmes Dr Sandip Dr Kalayarasan Sr. Uma Sr. Indirani Sr. Kiruthiga Sr Priya Grace Ms Dhilshat Ms Hena HOD will act as organizing chairman of all programmes. ANS will act as convener of all programmes except 1 and 2. All organizing teams are requested to organize a minimum of four programmes in a year aimed for JIPMER staff and outside delegates. Simulation laboratory Simulation laboratory in the department is one of the best in the country in surgical simulation. The skills lab room is located in OPD hall complex near Room No 305, second floor, OPD block, superspeciality complex. Basic laparoscopy simulation room and advanced surgical simulation room are located in two different halls. Basic laparoscopy simulation centre: Equipped with three box simulators (Ethicon endo-surgery) with hand instruments for training. Advanced laparoscopy simulation centre: Equipped with following: • • • • • • Two laparoscopic haptic simulators- Lap mentor express One Virtual reality laparoscopic simulator- CAE RoSS robotic surgery simulator – first of its kind in India Ultrasound and echocardiography simulator- CAE Myrian liver radio logy simulation work station Ostomy trainer The simulation centre in the department is pioneer in the country in initiating curriculum based simulation surgery programme. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 39 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 14 Issue No. 1.0 Date 01/01/2016 Fire safety plan- Superspeciality Block (SSB) Fourth Floor 1. Resources: i. Human resource: All staff working in the fourth floor of SSB. ii. Firefighting resources in the fourth floor of SSB: a. Active: i. ii. iii. iv. Fire alarms -smoke detectors as well as manually activated alarms. Fire extinguishers. Fire sprinklers. Fire hydrants and hose reel. b. Passive: i. ii. Fire exits are provided on either side in each floor. Emergency power back up. 2. Common meeting place at the time of evacuation: Open ground located near the garage of the EMS department. 3. Floor plan of the Wards in the Fourth Floor of SSB (See diagram) Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 40 of 94 Private Circulation only Department Manual • DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 14 Issue No. 1.0 Date 01/01/2016 The Ward in the fourth Floor of SSB has a main corridor leading to exit corridors on either end – the northern end corridor has the emergency (fire) exit on the eastern end.There is also one elevator (lift) next to the emergency exit. The southern end of the main corridor leads to the main landing elevators (lift) and staircase. There are four cubicles, two nursing stations, pantries, four bathrooms, toilets, and special wards on the eastern side of the corridor. • There are six cubicles, three nursing stations, pantries, six bathrooms, toilets and procedure rooms on the western side. • There are six cubicles, three nursing stations, pantries, six bathrooms, toilets and procedure rooms on the western side. • There are six cubicles, three nursing stations, pantries, six bathrooms, toilets and procedure rooms on the western side. • There are six cubicles, three nursing stations, pantries, six bathrooms, toilets and procedure rooms on the western side. • The main entrance to the ward is fro m its southern end where the lift s and staircase landing are located. • There is an Emergency (Fire) Exit on the eastern side of the north end of the main corridor. • There are signs indicating direct ion of the nearest exit along the corridors. • The emergency exits should be opened at all times. DO NOT LOCK. If locked keys should be easily available. 4. Fire Extinguisher location • Available all along the corridor of the fourth floor and in the pantries. 5. Action to be taken for containing and extinguishing fire The senior most nursing staff on duty in the ward opposite the one where fire event occurred and on hearing the alarm ‘Code red’ must take the measures for containing and extinguishing fire and act as the leader of the ‘fire control team’. She/he will: Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 41 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 14 Issue No. 1.0 Date 01/01/2016 • Remove or direct the nearest available staff member(s)to remove patients and other persons, valuable records and equipment to the extent possible as well as any inflammable articles in the vicinity of the fire. • Close or direct closing of all windows and doors after essential items and people have been removed • Call the nearest person to retrieve the nearest fire extinguisher. Operate or direct the operation of the fire extinguisher using the ‘PASS’ technique to extinguish the fire. • Fire extinguisher is best carried by two persons. • Instruct the switching off of the electrical mains supply of that section as early as possible after informing the ‘fire marshal’ and the ‘ward medical care team’ leader. • Instruct the switching off of the medical oxygen supply of that section as early as possible after making sure from the ‘fire marshal’ and the ‘ward medical care team’ leader that patients needing oxygen support have been shifted to oxygen cylinders. • Not leave the fire unattended. • If fire occurs in one of the pantries, treatment/ procedure rooms, store rooms, linen rooms, lab, special wards or doctors’ / nurses’ counter or duty rooms, then the door of that room must be closed if the fire cannot be contained after confirming that all people, valuable records and equipment and inflammable articles to the extent possible have been removed. There is no door in the ward, hence the question of closing doors do not arise. • If patient is on fire Follow Stop, Drop and Roll. Wrap the person in a blanket before rolling. • She / he will keep the ‘fire marshal’ informed time to time regarding the gravity of fire and ask for fire additional fire controlling resources including material and manpower. • She will also inform the ‘fire marshal’ regarding the need to order evacuation in the event that fire is not getting contained. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 42 of 94 Private Circulation only Department Manual DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 14 Issue No. 1.0 Date 01/01/2016 Evacuation procedure • The instruction for evacuation will be given by the ‘fire marshal’ after receiving communication from the ‘fire control team’ that fire is not getting controlled and she / he will assign such staff as are available for the purpose to the evacuation team. • A scout(s) should first check safety of evacuation route(s) and report back the safe route available Prepare and evacuate the building by way o f the nearest emergency exit. Walk as fast as possible but do NOT run. Do NOT use elevators. • The elevators (lift s) should not be used for evacuation. • Before exiting through any closed door, check for heat and the presence of fire behind the door by feeling the door with the back of your hand. If the door feels very warm or hot to the touch, advise everyone to proceed to another exit. • Once instructions for evacuation are given the senior most nursing staff of the ward adjacent to the one on fire must coordinate evacuation. • He / she will act as the leader of the ‘evacuation team’ and keep the ‘fire marshal’ informed. • First all visitors and attendants of patients not in need of assistance are asked to leave the ward immediately. • Next patients who are stable and ambulatory are asked to walk down the corridor to nearest exit leading away from the cubicle on fire i.e. the main exit, the fire exit, and from there walk down the stairs and out of the building and assemble at the ‘common meeting point’ located near the garage of the EMS department. • Thereafter non-ambulatory i.e. wheel chair patients and bed bound patients (in that order) will be physically lifted and evacuated through staircases to the third floor and thereafter, if possible, will be wheeled out through the corridor connecting to the EMS. Use trolley / slings made of bed sheet /blanket for carrying the patients or the patients must be physical carried out. For this purpose at least two persons are needed to carry one patient. Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 43 of 94 Private Circulation only Department Manual • DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Section No. 14 Issue No. 1.0 Date 01/01/2016 All hospital staff will assist the different teams and will leave last after ensuring that all patients have been evacuated on the instructions of the ‘fire marshal’. • The ‘evacuation team’ leader will assign a nursing staff for coordinating with the help of hospital security the assembly of patients, other staff and the ‘common meeting point’. Only patients and staff shall assemble at the ‘common meeting point’. Visitors must be asked to leave. • In the event you are unable to exit the building: Remain calm; do not panic In a smoky room or corridor remain low; crawl if necessary. Place a cloth, wet if possible, over your mouth to serve as a filter If trapped in a room signal for help from a window. Use a towel, clothing, sign etc. • Do not block any driveways and approach to casualty, as Fire Department personnel will need access to these areas. • The cessation of an alarm/departure of the fire department is not an "all clear" to re- enter the building as corrective measures may still be in progress. • Stay clear of the building until your designated Fire Safety Officer has advised you to reenter the building/area. • In the event of an evacuation order, the priority is to evacuate patients. Visitors must be asked to leave even before the evacuation order. However, once all patients are evacuated, do assist visitors in need. Visitors may not be aware of exits/alternative exits and the procedures that should be taken during alarm situations. Employees should calmly inform visitors of the proper actions to be taken and assist them with the evacuation. • At the end of evacuation a roll call must be performed by the ‘fire marshal’ to make sure that all patients and staff having been evacuated. In case someone is left behind, the fire service teams that would have arrived by then must be informed to take steps for their search and rescue Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 44 of 94 Private Circulation only STANDARD OPERATING PROCEDURES (SOPs) FOR DISEASES Section No. 15 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Achalasia cardia Achalasia cardia Evaluation with Barium swallow/ UGI endoscopy Low surgical risk High surgical risks Laparoscopic Myotomy +Fundoplication Medical Management Failure Pneumatic dilation/ Esophagectomy Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 45 of 94 Private Circulation only Section No. 15 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Acute Pancreatitis Acute Pancreatitis USG/Serum Amylase/CECT General: Pain relief; Fluid resuscitation; Nutrition (Enteral preferred); Antibiotics (Controversial) Non Gallstone Pancreatitis Local Complications Gall stone pancreatitis Mild Severe with cholestasis Conservative Pancreatic Necrosis Peripancreatic fluid collection ERCP +Stone extraction Infected necrosis Conservative management Delayed Intervention weeks) (>4 Laparoscopic cholecystectomy Step-Up approach Step-Down approach Open necrosectomy with: 1)Closed packing 2)Open packing 3)Continuous closed postoperative lavage 4)Programmed open necrosectomy Percutaneous / Endoscopic/Laparoscopic Drainage with necrosectomy If no improvement Percutaneous Radiological Drainage of residual collections Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Open Surgical Drainage with Necrosectomy Control Status Page 46 of 94 Private Circulation only Section No. 15 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Benign Biliary Stricture (BBS) Benign Biliary Stricture (BBS) Clinical Features: Jaundice, Recurrent cholangitis, Portal Hypertension Complete Blood Count, Liver Function Tests, Kidney Function Tests, Ultrasound abdomen(USG) Magnetic Resonance Pancreatography (MRCP), Contrast Enhanced Computed Tomography(CECT) in cases of suspected atrophy hypertrophy complex and malignancy Cirrhosis Present Absent Early Late Modified Bismuth Classification of BBS Liver Transplantation Types IIIB, IV& V Types I,II,IIIA Atrophy- Hypertrophy Complex Roux- En Y Hepaticojejunostomy with HeppCouinaud approach Absent Drain all atrophic ducts during surgery Present Preop biliary stenting Liver resection if stricture extends into subsegmental ducts Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 47 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 15 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Benign Gastric Outlet Obstruction Benign Gastric Outlet Obstruction (GOO) Stomach decompression and wash Malnourished /Nutritionally depleted Upper GI Endoscopy and antral biopsy Anti H pylori treatment H. pylori Parenteral nutrition No improvement After conservative Treatment Laparoscopic/open Truncal vagotomy and Gastrojejunostomy Endoscopic balloon dilation Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 48 of 94 Private Circulation only Section No. 15 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Carcinoma colon Carcinoma Colon Non obstructed obstructed Contrast enhanced CT abdomen & pelvis; Carcinoembryonic antigen (CEA), Complete blood count, Liver & kidney function tests, Colonoscopy Emergency surgery Resectable (metastatic/ non metastatic) Unresectable (metastatic/ non metastatic) Metastatic Non metastatic Surgery Resection adjuvant chemotherapy Resectable metastasis Unresectable Adjuvant chemotherapy Staged resection/ combined resection Palliative chemotherapy Stoma/ bypass Adjuvant chemotherapy Palliative chemotherapy Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 49 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. 15 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Carcinoma Esophagus Esophageal cancer Most common presentation - Dysphagia Evaluation UGI endoscopy and biopsy, USG abdomen and CECT neck thorax and abdomen Carcinoma middle and lower third esophagus and within 5 cms of GE junction Carcinoma upper third (Within 4 cms of cricopharynx) Severe dysphagia (grade III- VI) Definitive chemo radiation Feeding jejunostomy Fit patient Unfit patient Neoadjuvant chemoradiation Reassessment with CECT scan C T 1-3/ N 0-1, MO T4,N2-3,M1 Esophagectomy Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 50 of 94 Private Circulation only Section No. 15 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Carcinoma Rectum Carcinoma Rectum Non- obstructed Obstructed Sigmoid colostomy CECT abdomen & MRI pelvis, CXR, CEA Contrast enhanced CT abdomen & MRI pelvis, CXR, Carcinoembryonic antigen Metastatic Early cancer/ lymph node negative on imaging Neoadjuvant chemoradiotherapy Lymph nodes +/ locally advanced Surgery Surgery Neoadjuvant chemoradiotherapy Unresectable Resectable Surgery Neoadjuvant chemotherapy Palliative chemotherapy Surgery for primary & metastasis: combined or staged Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 51 of 94 Private Circulation only Department Manual Section No. 15 DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Carcinoma Stomach Carcinoma Stomach Upper GI endoscopy/ CECT abdomen and pelvis No metastasis Metastasis SymptomaticBleeding/obstruction Asymptomatic Palliative Resection/bypass Palliative CT Site GE junction and the Cardia Proximal Gastrectomy with partial esophagectomy Body and fundus Total Gastrectomy Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Antrum and pylorus: Distal Gastrectomy Control Status Page 52 of 94 Private Circulation only Section No. 15 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for CBD Stones Choledocholithiasis +Cholelithiasis Evaluation by USG/MRCP Laparoscopic cholecystectomy +IOC/LUS Open Surgery Jaundice,cholangitis Multiple stones/Dilated CBD/impacted ampullary stones/ampullary stenosis ERC/ES CBDE/T Tube Transcystic CBDE Retained stones Choledochoduodenostomy Laparoscopic choledochotomy and CBDE Remove via TTube Laparoscopic cholecystectomy Multiple(>8) or large (>1cm)stones; stones in CHD Debililated or elderly patient Failure/Retained stones Follow up Postoperative ERC/ES Open CBDE CBDE: Common Bile Duct Exploration; ERC:Endoscopic retrograde cholangiography; ES:Endoscopic Sphincterotomy; CHD: Common Hepatic Duct; IOC: Intraoperative cholangiography; LUS: Laparoscopic Ultrasound Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 53 of 94 Private Circulation only Section No. 15 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Chronic Pancreatitis Established Chronic Pancreatitis Trail of conservative therapy, analgesics, alcohol avoidance & enzyme replacement therapy Persistent symptoms Additional symptoms / Complications Differentiate duct morphology by USG abdomen or CECT abdomen Small duct disease - More aggressive pain management - Izbicki procedure Large duct disease - Duct drainage procedure mostly Frey’s procedure Only tail involved - Distal pancreatectomy +/- splenectomy Symptomatic pseudocyst Bile duct stricture – LFT, MRCP Pancreatic head mass – Pancreatic protocol CT Pseudoaneurysm – CT angiogram Cystogastrostomy / cystojejunostomy usually with added duct drainage Roux-en-Y Hepaticojejunostomy with Frey’s procedure Malignancy / suspicious of malignancy / head dominant disease Pancreatoduodenectomy Massive GI bleed angioembolization followed by Surgery later Persistent pain even after Surgery Pain management, celiac plexus block Portal hypertension Endoscopic duct drainage preferable Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Pancreatic ascites and pleural effusion Bowel rest, parenteral nutrition and octreotide Control Status Page 54 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Corrosive Injury Esophagus Corrosive Injury Esophagus Early admission (48-72hrs) Late admission (> 3 weeks) Delayed admission (72hrs- 3 weeks) Early Endoscopy Endoscopy and dilation No endoscopyFJ- if severe dysphagia Mild lesions Severe lesions Endoscopy +/dilation every 3 weeks Discharge and follow up Feeding jejunostomy Successful Endoscopy +/dilation every 3 weeks Endoscopy Follow up Unsuccessful Feeding jejunostomy Esophageal bypass Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 55 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Crohns disease Crohn’s disease Medical management [e.g. Budesonide/ 5-aminosaliclic acid (5-ASA) and its derivatives] Remission Complications: obstruction, abscess, perforation Moderate to severe Mild to moderate Systemic steroids +/_ azathioprine, 6mercaptopurine (6MP) Surgery No remission Maintenance 5ASA/ observation Remission Relapse No remission Maintenance azathioprine, 6-MP, methotrexate, 5-ASA Relapse Anti TNF alpha +/_ Azathioprine/ 6-MP Remission Newer biological agents/ surgery Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Relapse Maintain on Anti TNF alpha, azathioprine/ 6MP Control Status Page 56 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Esophageal Perforation Signs and symptoms of esophageal perforation Contrast esophagography /chest X ray and CECT Contained perforation Uncontained perforation Broad spectrum antibiotics and parenteral nutrition No improvement <24 hrs Cervical Thoracic Abdominal Drainage Surgical repair tolerable Evaluation of perforation Surgical repair Intolerable Malignancy Primary repair Controlled fistula Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Exclusion and diversion Resection Control Status Page 57 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for GERD GERD symptoms Atypical GERD symptoms Typical GERD symptoms Esophagogastroduodenoscopy (EGD), Barium swallow +/- Reflux Scintigraphy study Symptoms persist Life style modification & trail of Proton pump inhibitors (PPIs) +/Prokinetics Symptoms resolve Associated with dysphagia /chest pain No esophagitis or reflux Manometry + / esophageal motility scintigraphy studies GERD complications like Barrett’s esophagus, Peptic stricture 24 Hr – pH monitoring Continue life style modification and taper PPIs If symptoms recur - EGD, Barium swallow +/- Reflux Scintigraphy study Associated motility disorders, then treat accordingly GERD present No GERD Seek alternate diagnosis Antireflux surgery + / Hiatus hernia repair Maintenance therapy with PPIs Option of antireflux surgery considered even if medical management is successful (quality of life considerations, lifelong medication, expense of medications etc.) Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 58 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for GIST GIST Primary GIST, Resectable Primary GIST, Unresectable Primary GIST, Metastatic Recurrent GIST Imatinib therapy Biopsy Biopsy Surgery Neoadjuvant Imatinib therapy Low risk of recurrence or metastases (<3 cm and <5 mitoses/ hpf) Imatinib therapy Moderate to high risk of recurrence or metastases ( >3 cm or >5 mitoses/ hpf) Responsive Progressive Imatinib +/_ Surgery Sunitinib Reimaging Surveillance Imatinib therapy Resectable Unresectable Surgery Imatinib therapy Imatinib therapy Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 59 of 94 Private Circulation only Department Manual Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Ileo caecal tuberculosis Ileocecal Tuberculosis Non- obstructed Obstructed X ray abdomen, CXR, baseline blood investigations, resuscitate CXR; Sputum AFB & culture Sputum AFB/culture- +ve AFB Negative Emergency surgery: Resection anastomosis/ stoma CECT abdomen with oral and rectal contrast IC thickening Yes No Colonoscopy & biopsy Negativee Diagnostic Laparoscopy & biopsy Anti tubercular treatment Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 60 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Lower GI bleed Acute lower GI bleed Ruleout upper GI bleed by esophagogastroduodenoscopy Ruleout low anorectal disorders by DRE and proctoscopy Intermittent or mild to moderate persistent bleed Persistent or severe acute bleeding Assess severity & Resuscitate Unstable Stable Emergency surgery Colonoscopy Source not identified, continued bleeding Source identified Source not identified Treat lesion accordingly Serial clamping or Intraoperative enteroscopy and identification of lesion – treat accordingly Tagged RBC scan Positive Angiography and embolization or surgery Negative Repeat Colonoscopy, small bowel studies & CECT abdomen Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 61 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Liver Abscess Suspected liver abscess USG abdomen* U Un-ruptured Ruptured Free peritoneal rupture Peritonitis Contained rupture Per cutaneous drainage (PCD)/ percutaneous needle aspiration (PNA) of the abscess PCD of collection if not communicating with abscess Surgery Laparoscopy laparotomy Pyogenic liver abscess (PLA) likely When secondary biliary causes identified Recent biliary intervention Multiple small abscesses Negative amoebic serology Positive culture Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Start empirical antibiotics against gram negative and anti amoebic drugs (eg- third generation cephalosporins + Metronidazole or ampicillin + aminoglycoside + Metronidazole) Amoebic liver abscess (ALA) likely Single large abscess Recent history of diarrhea/ Dysentery (within 6 months) Stool for ova cyst positive Nested PCR for E. Histolytica DNA positive in stools/ saliva/ pus aspirate (if done) Positive amoebic serology (poor positive predictive value in India) Control Status Page 62 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 ALA PLA Indeterminate etiology Continue anti amoebic drugs Early drainage of abscess PNA if multiple small abscesses < 5 cm in size PCD if abscess > 10 cm For abscess 5- 10 cm both can be used with more likelihood of multiple procedures with PNA Identify secondary causesadditional investigations as indicated* Improvement Culture based antibiotics for 23 weeks Treat secondary causes if present Metronidazole for 2 weeks Luminal amoebicide (eg diloxanide furoate) for 10 days No improvement in 3-4 days Impending rupture (< 1mm overlying liver parenchyma) Subcapsular/ contained rupture Secondary bacterial infection suspected > 10 cm size especially in left lobe Abscess drainage PNA if small abscess < 5 cm in size PCD if abscess > 10 cm For abscess 5- 10 cm both can be used Inability to positively identify any of the two types Continue empirical antibiotics and anti amoebic drugs for 2 weeks followed by luminal amoebicides Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 63 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Liver space occupying lesion (SOL) SOP-Liver SOL Complete Blood Count, Liver Function Tests, Kidney Function Tests, Serum .alphafetoprotein, Upper Gastrointestinal Endoscopy, Ultrasound abdomen, Triple phase Computed Tomogram abdomen Typical features of Hepatocellular Carcinoma (HCC) on imaging Atypical features on imaging percutaneous biopsy Typical features of Non HCC tumor on imaging Follow HCC Protocol Follow Non HCC Protocol HCC Protocol Features of chronic liver disease Present CPT score >8 or S. Bilirubin > 2 mg% or FLR< 80% Absent FLR <30% FLR>30% CPT score < 8 and FLR> 80% Can Tolerate Major surgery Good performance status No Yes Present Absent Lesions size TransarterialChemoem bolisation Resection > 5 cm supportive therapy Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head < 5 cm Radiofrequency Ablation(RFA) Control Status Page 64 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Liver SOL – Non HCC Non- HCC Protocol Asymptomatic benign lesions Symptomatic benign and premalignant lesions Metastasis in liver Intrahepatic cholangiocarcinoma Chest XRay, Serum.CEA Observe Liver only mets with Resectable primary colorectal ca and genitourinary malignancy Surgery for primary malignancyand 5 FU based Chemotherapy for colorectal ca Unresectable colorectal primary or otherprimary sitewith liver metastasis Functional liver Remnant (FLR)>30% Fit for major surgery FLR<30% Performance status Good Yes Poor No Resection Palliative chemotherapy Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Supportive therapy Control Status Page 65 of 94 Private Circulation only DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Liver Trauma Liver trauma Initial resuscitation Grouping and cross matching Unstable Stable Associated injuries requiring surgery (eg. Hollow viscus perforation) Operating room CECT Isolated liver injury No contrast blush Contrast blush present Conservative management ICU care 6 hourly hemoglobin estimation Heart rate and blood pressure monitoring Watch for compartment syndrome/ peritonitis Watch for sepsis Successful Clinical deterioration Unsuccessful Angioembolisation Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 66 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Morbid Obesity BMI >40 kg/m2 or BMI >35 kg/m2 with an associated medical comorbidity worsened by obesity Failed dietary therapy Psychiatrically stable without alcohol dependence or illegal drug use Knowledgeable about the operation and its sequelae Motivated individual Ambulating patient Prader-Willi syndrome ruled out Age group (> 18yrs & < 65 yrs) Cardiovascular evaluation • Pulmonary assessment - obstructive sleep apnea, reactive asthma, pickwickian syndrome Renal function. Musculoskeletal conditions Diabetes control Clinical examination for umbilical or ventral hernias USG abdomen to R/O cholelithiasis UGIE to R/O GERD, Barrett’s & Hiatal hernia BMI > 50 (Super Obese) YES MALABSORPTIVE PROCEDURE 1) Biliopancreatic diversion 2) Duodenal switch NO Failure of surgery Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head RESTRICTIVE PROCEDURE 1) Sleeve gastrectomy 2) Roux en Y gastric byepass Control Status Page 67 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Portal hypertension Complete Blood Count, Liver Function Tests, Kidney Function Tests, UpperGI Endoscopy, Ultrasound abdomen, Doppler Ultrasound portal axis Portal cavernoma Present Absent Extrahepatic Portal Vein Obstruction (EHPVO) Chronic Liver Disease(CLD),Noncirrhotic Portal Fibrosis(NCPF) Moderated to massive splenomegaly Computed Tomogram(CT)portovenogra m if portal venous anatomy not clear or Portomesenteric venous thrombosis suspected or pseudoaneurysms in the portomesenteric circulation or if Rex shunt is planned Present NCP F Patient on chronic endoscopic therapy for varices Symptoms of hypersplenism and no Varices Absent CLD If varices ,endoscopic therapy for variceal eradication Splenectomy and introp portal pressure If portal pressure> 12 cm H2O Left portal vein > 3 mm in EHPVO Diffuse splanchnic venous thrombosis Prepared By Rex shunt Compatible splenic vein anatomy Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Gastroesophageal devascularisation Assistant Professor Proximal Splenorenal Additional Professor Shunt & Head If portal pressure <12 cm H2O, Observe Spenicvein not available but patent SMV or portal vein Control Status Interposition mesocaval or portocaval shunt Private Circulation only Page 68 of 94 DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Section No. Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Rectal Prolapse Rectal Prolapse Clinical Features: mass protruding per anum, mucus discharge per anum, difficulty in evacuation of stool, History of constipation, history of prolonged/ difficult labour Complete Blood Count, Liver Function Tests, Kidney Function Tests, Examination in squatting position, History of constipation Absent Present Laparoscopic mesh rectopexy Laparoscopic anterior resection and mesh rectopexy Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 69 of 94 Private Circulation only Department Manual Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operating Procedure for Surgical Obstructive Jaundice Painless progressive jaundice Associated with anorexia/weight loss Short duration of symptoms No Yes Suspect malignant cause cause Suspect benign cause Initial investigation: liver function test and ultrasound abdomen - To confirm obstructive nature of jaundice, to identify etiology (benign or malignant), if malignant - level of obstruction (lower end or hilar) and stage the disease Choledocholithiasis ERCP & stone extraction followed by laparoscopic / open cholecystectomy Or laparoscopic / open cholecystectomy with CBD exploration Malignant lower end obstruction and no evidence of metastasis Malignant hilar obstruction Follow treatment algorithm for lower end obstruction Follow treatment algorithm for malignant hilar obstruction Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 70 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operative Procedure for Malignant lower end obstruction Malignant lower end obstruction – periampullary and pancreatic head carcinoma Assess indications for biliary drainage – cholangitis, severe malnutrition and Total bilirubin > 15mg/dl Yes No Dual phase CECT (Pancreatic protocol) or MRI with MRCP for accurate staging followed by ERCP & stenting Side viewing endoscopy +/- biopsy followed by cross sectional imaging with CECT or MRI abdomen Metastatic disease Rescetable disease Locally advanced disease Palliative therapy metallic biliary stenting or triple bypass Pancreatoduodenectomy Neoadjuvant chemotherapy therapy and reassess with imaging If unresectable disease If resectable disease Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Control Status Page 71 of 94 Private Circulation only Department Manual Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operative Procedure for Malignant hilar obstruction Malignant hilar obstruction Assess for resectability using Triple phase CT abdomen or MRI with MRCP abdomen carcinoma Rescetable disease Unrescetable disease Assess indications for biliary drainage – cholangitis, severe malnutrition, Total bilirubin > 10mg/dl and prolonged jaundice > 4 weeks irrespective of bilirubin level Palliative biliary drainage No Yes ERCP and stenting if hilar confluence is patent, PTBD if hilar confluence is not patent Adequate > 40 % Surgical resection Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Assess future liver remnant Inadequate < 40 % Portal vein embolization Control Status Page 72 of 94 Private Circulation only Section No. DEPARTMENT OF SGE JIPMER, PUDUCHERRY Department Manual SGE/JIPMER/DM/01 Issue No. 1.0 Date 01/01/2016 Standard Operative Procedure for Ulcerative colitis Ulcerative colitis Complications e.g: perforation, massive hemorrhage or toxic megacolon Moderate to severe Mild to moderate severity Proctitis Extensive Left sided Oral 5- ASA Aminosaliclic acid (ASA) suppositories Urgent surgery: total abdominal colectomy and end ileostomy ileal pouch anal anastomosis (IPAA) at later stage Response yes yes Rectal 5-ASA maintenance NO NO Oral 5- ASA maintenance Surgery: Total proctocolectomy and ileal pouch anal anastomosis Oral steroids Yes Response Taper steroids, consider oral 5ASA NO Cyclosporine or infliximab Prepared By Approved By Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat Assistant Professor Additional Professor & Head Refractoriness/ dependence/ toxicity to medical therapy or carcinoma/ DALM Control Status Page 73 of 94 Private Circulation only