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Global Journal of Medical,

Pharmaceutical, and Biomedical Update

Medical Innovator

Pankaj Garg: A Community Doctor to a Master

Innovator to a Global Icon
David N. Armstrong1 , MD, FASCRS, Iwona Sudoł-Szopińska2 , MD, PhD, Vincent de Parades3 , MD, PhD,
Francesco Litta4 , MBBS, MD, Manuel Limbert5 , MBBS, MD, Khaw C. W. James6 , MB, BCh, BAO, MRCS
1
Department of Colorectal Surgery, Georgia Colon and Rectal Surgical Clinic, Lawrenceville, United States, 2Department of Radiology, National Institute of
Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland, 3Department of Medico Surgical Proctology, Institut Léopold Bellan, Hôpital Paris Saint-
Joseph, Paris, France, 4Proctology Unit, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome, Italy, 5Department of Colorectal Surgery, Portuguese
Institute of Oncology of Lisbon, Lisbon, Portugal, 6Department of Colorectal Surgery, Penang General Hospital, Penang, Malaysia.

ABSTRACT
Pankaj Garg’s story is an interesting one and is a source of inspiration for all physicians and budding
innovators. He started his career as a community doctor about two decades back in the year 2001, then
changed gears in between to become an avid researcher and innovator. He progressed to become a leading
international figure in his field. Garg has exemplified three important points. First, with proper temperament,
it is possible to achieve academic excellence and conduct research even in a primary care setting. Second,
*Corresponding author:
every specialist should fulfill the role of a family physician as well. While pursuing any specialty, the role of
Khaw C. W. James, a “general physician” should never be ignored. Third, innovation is a state of mind, and big institutions and
Department of Colorectal well-equipped laboratories with costly gadgets are not a prerequisite to it. This is clearly exemplified by Pankaj
Surgery, Penang General Garg’s story that it is possible to excel in research, academics, and clinical work at the global level without any
Hospital, Penang, Malaysia. research budget, big institute tag, or the help of government or non-government organizations. Garg has more
than 175 publications in high-impact journals. He has 30 innovations to his name, in and outside his field of
[email protected]
expertise, all of which have been published in international journals. The innovations include new operative
procedures, successful non-operative management, the discovery of new anatomical spaces, new concepts in
Received : 17 July 2023 disease understanding and management, and finding non-operative treatment for diseases for which surgery
Accepted : 04 August 2023 is routinely performed. It is impressive that seven of his innovations are popularly known by his name - Garg
Published : 24 August 2023 classification, Garg space, Garg protocol, Garg cardinal principles, Garg scoring system, Garg phenomenon,
and Garg incontinence scores. Due to 30 innovations done single-handedly, Garg has been certified as a
DOI “doctor with maximum innovations” by several record books. Due to his ability to think “out-of-the-box” and
10.25259/GJMPBU_59_2023 his immense contribution to advancements in the field of proctology, he is recognized as a global icon in his
field. Garg is a master teacher. He has taught surgical skills and the art of scientific paper writing to hundreds of
Quick Response Code: surgeons and doctors. In spite of limited resources at his disposal, Garg goes out of his way to help poor people.
He performs about 30–40% of operations free of cost. He has successfully treated patients from 41 countries
and several patients from royal families of the Gulf who offered him lucrative money to move to the Middle
East. However, Garg flatly refused all offers because his priority was to serve his country and countrymen
first. Hence, a simple doctor working in a small city was never discouraged by the lack of resources, and the
fear of working alone in a small set-up and without any help from the government has carved out a tale that
can motivate professionals in any corner of the world. Dr. Garg’s story provides immense inspiration to every
practicing physician in the country to innovate whether he/she is practicing in a primary healthcare center or
a rural area.

Keywords: Medical research, Exemplary, Pankaj Garg, Community doctor

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Global Journal of Medical, Pharmaceutical, and Biomedical Update • 2023 • 18(16) | 1

 Armstrong, et al.: Community doctor becoming a global icon

ACADEMIC AND RESEARCH IN PRIMARY compared with the unaffected proximal segment of the vessel),
CARE SETTINGS and attenuated fibrous caps (cap thicknesses of <65 μm).

Doctors working at the community level seldom publish or When he returned to India, Garg started implementing what
become national leaders in their field but does this mean that he had learned in the USA. It was an uphill task to use his
community doctors cannot excel in their field, professionally newly acquired experience; he had none of the sophisticated
and academically? The answer is “No” because there are facilities the faculty of academic institutes or medical colleges
many doctors who are practicing in the community and have have namely, patient availability, access to published papers,
excelled academically as well as in research. Pankaj Garg is availability of infrastructure (in terms of manpower [junior
one such doctor [Figure 1]. doctors, residents, etc.] and logistics), big institution tag, grants
or funding for research and article sharing with colleagues.
Garg did undergraduate and post-graduate education in However, this did not discourage him. He worked hard and
Surgery from 1990 to 1999 at AIIMS, N. Delhi, which is the relentlessly. He set up an eponymous institute, Garg Fistula
top-ranking medical institute in India. Upon completion,
Research Institute (GFRI). Even though the institute was small,
he started community practice as a general surgeon in
the vision was big. His initial five papers were the most difficult
Panchkula, Haryana, India. Professionally, what made him
to publish. However, once the initial barrier was broken, there
stand out was that he always fulfilled his role as a family
was no looking back. It took him only 10 years (2008–2018)
physician along with his surgical practice.
to have more than one hundred publications to his name!
A community practice devoid of academics and research Summarizing the whole experience, he wrote in his book,
made Garg was uncomfortable because he was keen on doing DECISIONS, that “The biggest barricades in my road to success
research. Unfortunately, he had no experience in doing research were my own thoughts. My biggest enemy was my own mind.
or writing scientific papers. In 2007, he specially went to the Once you determine that you have to excel, then nobody has the
University of California, Irvine, USA, to learn about research. power to stop you!” (https://www.amazon.in/Decisions-How-
As there were no slots available in the surgery department, he Master-Art-Decision-Making-ebook/dp/B083QKBXZY)
got an opportunity in the Cardiology department. However,
this did not deter Garg. Being a colorectal surgeon, he HEALTH-CARE PROVIDER
learned the basics of research in Cardiology. After a month
of training, he wrote a review article that got published in Family physicians form the backbone of the healthcare
Nature Cardiovascular Reviews![1] In this article,strategies system of any country. In India, the value of family
were discussed to identify and localize “vulnerable plaques” physicians is undermined by the lure of the trend to become
(atherosclerotic plaques vulnerable to rupture and cause a specialist., Therefore, it is paramount for every specialist to
sudden heart attack). The plaques that are vulnerable to rupture fulfill the role of a family physician in the community. Garg
demonstrate distinct histological characteristics, which include is a perfect example of this commitment. Even though he
large plaque and necrotic core volumes (necrotic core >25% is a colorectal surgeon, he always takes his role as a family
of plaque area), extensive positive remodeling of the vessel at physician seriously. Several innovations of Garg (listed
the lesion site (positive remodeling is defined as a 5% increase below) exemplify this. He often says, “Specialties are made
in the luminal cross-section of the artery at the lesion site by humans, God made only one body, and everything is
interlinked. To treat a patient completely, you always have to
look at the complete picture.” Several concepts on physician’s
behavior and doctor–patient interaction published by Garg
have become guiding lighthouses for the budding doctors.[2]

INNOVATIONS
Some of the innovations done by Garg in his role as a family
physician (outside his domain of expertise) [Table 1] are
briefly discussed below:

Traction exercise for the neck in domiciliary setting

(TRENDS)

Neck pain is increasing, especially in the younger generation,

due to the over usage of electronic gadgets. A simple domiciliary
Figure 1: Dr. Pankaj Garg. exercise, TRENDS, gives controlled traction to the neck and has

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 Armstrong, et al.: Community doctor becoming a global icon

Table 1: Some of the innovations of Dr. Garg across different specialties in prominent international journals.
Name of innovation Type Brief description
TROPIS. [11]
New surgical procedure To treat complex anal fistula
Garg classification[13] New classification For anal fistulas that was much more useful than
the existing classifications
Garg protocol[14] A new management protocol To manage anal fistulas in which the internal
opening is not locatable
Garg cardinal principles[20] Management principles To manage complex anal fistulas
Garg space[12] (outer‑sphincteric space) New discovery A new anatomical space where anal fistula spreads
Garg scoring system[15] A new scoring system Applied at 3 months after fistula surgery accurately
predicts long‑term fistula outcome
Garg incontinence score[16] A new scoring system A scoring system to clinically assess fecal
incontinence
TRENDS[3] New treatment concept To treat neck pain due to over usage of mobile
phones and computers
ECLIPS[4] New epidemiological concept New concept to detect breast cancer early
MUSTARD New epidemiological concept To detect persons with uncontrolled diabetes
and to control Mucormycosis during COVID
pandemic
FEED[5] New treatment concept To treat chronic constipation without medicines
LOCULA New surgical procedure To treat complex pilonidal sinus and pilonidal
abscess
IRIP New treatment concept To treat urinary retention without catheterization
after pelvic surgery
TONE[6] New treatment concept To treat hemorrhoids without surgery
RIFIL New discovery A new type of complex anal fistula
TROPIS: Transanal opening of intersphincteric space, TRENDS: traction exercise for neck in domiciliary setting, ECLIPS: Early cancer lump is painless,
MUSTARD: Mass urine sugar testing to assess and regulate diabetes, LOCULA: Laying open and curettage under local anesthesia, IRIP: Inability to raise
intra‑abdominal pressure

shown to be highly effective in treating and preventing cervical this has its own side effects. Garg advocated a physiologic
pain. In this exercise, the person lies on the edge of the bed in method (FEED):
a supine position for 1–2 min. The head lies at the edge of the F - Fiber supplement intake (20 g of Psyllium husk to be
bed and the feet toward the center of the bed. The head and taken with 500 mL of water per day),
the upper torso are then lowered from the edge of the bed so E - Elevation of feet in the toilet seat during defecation
as to hang the head free from the bed. This traction exercise is by keeping a small bench (of 12–16 inches in height)
simple, easy to learn, and reproducible. It can be done at home below the feet to increase hip flexion,
without involving any extra cost or gadgets.[3] E - Exercises of the abdominal muscles while sitting on
the toilet commode,
Early cancer lump is painless (ECLIPS) D - Drinking 500–600 mL of water, empty stomach in
the morning.
Many women with breast cancer lumps presented quite late
in outpatient care because they did not take it seriously as it The FEED regimen combines the benefit of many physiologic
was painless. As can be expected, most lay people associate methods and is highly effective in treating chronic
pain with danger and vice-versa. In a large epidemiological constipation without medicines or laxatives.[5]
study, Garg highlighted that even in an urban and educated
city like Chandigarh, 82% of women did not know that an TONE (To treat even advanced degree hemorrhoids
early breast cancer lump is painless. The recommendation by without surgery)
Garg to raise awareness about ECLIPS has saved thousands
of lives was published in a high-ranking U.S. journal.[4] Hemorrhoids affect 20–30% of the world’s population. Many
of these patients, especially those with advanced hemorrhoids,
FEED (To treat chronic constipation physiologically) are operated on. Garg innovated the TONE concept, which
removed the root cause of the disease and was shown to be
Chronic constipation affects 15–20% of the population. Most effective in preventing surgery in >90% of patients with even
of these patients must take laxatives on a long-term basis and advanced hemorrhoids. The TONE concept is

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 Armstrong, et al.: Community doctor becoming a global icon

T - Three minutes at defecation (spending 3–5 min in abdominal radiology journal in the world. This further led
the toilet) to the discovery of a new type of complex fistula, fistula at
O - Once a day (frequency of defecation to be once a day) roof of ischiorectal fossa inside levator-ani muscle (RIFIL)
N - No straining (no compulsive defecation or excessive [Figure 2].[12]
straining while defecating, not to take a newspaper
or mobile phone in the toilet) Garg classification
E - Enough fiber (4–5 tablespoons of psyllium husk with
500 mL of water)[6] Garg published a new classification for anal fistulas that is
much more useful than the existing classifications because
Water jet in toilet seat as a cause of anal fissure it is more accurate and is the first classification that guides
and helps in the management of these fistulas. Garg’s
Garg discovered that the water jet in toilet seats commonly classification is extensively used across the world and has
used in India is one of the leading causes of anterior anal been published widely in international medical journals and
fissures. This discovery was published in a leading UK textbooks [Figure 3].[13]
journal.[7]
Garg protocol
Physiological treatment of irritable bowel syndrome (IBS)
Garg innovated a new protocol to manage anal fistulas in
A lot of treatment regimens are being tried for IBS, but none which the internal opening is not locatable. This protocol has
of them has been shown to be effective. Garg demonstrated been shown to be highly effective in achieving high cure rate
that intake of psyllium husk by proper method (20 g of and preventing the recurrence of the disease.[14]
psyllium husk taken with 500 mL of water per day) along
with the FEED regimen (Point 4 above) is effective in treating Garg scoring system
IBS physiologically, that is, without any medicines.[8]
Anal fistulas are notorious for recurrence even years after
Post-defecation cleansing method: Tissue paper or water? the surgery. This causes a lot of uncertainty in the minds of
patients as well as doctors. Garg innovated a new scoring
Half of the world uses water as a post-defecation cleansing system which, when applied at 3 months after fistula surgery,
method while the other half uses tissue paper. No research accurately predicts the long-term fistula outcome (positive
has been done to find a better method between the two. predictive value >98%).[15]
Garg did the first detailed research on this topic which was
published in the topmost colorectal journal.[9] Garg incontinence score

GLOBAL INNOVATIONS Fecal incontinence is a common problem and the existing

scoring systems to clinically evaluate this problem had several
Some of the remarkable path-breaking innovations by Garg lacunae. Garg devised a new improved scoring system which
in his specialty (colorectal surgery), which earned him is statistically sound and more scientific [Figure 4].[16,17]
recognition as the top-most expert at the global level, are
listed below [Table 2]. All these were done in a modest center Local and oral antibiotics and avoidance of constipation
in a small district place (GFRI, Panchkula, India) with a zero (LOABAC) treatment to treat anal fissures without surgery
research budget [Table 1].
Garg innovated a new treatment for anal fissures, which is
Transanal opening of intersphincteric space effective in treating >90% anal fissures with medicines only
and without surgery.
A new procedure innovated by Garg for highly complex
anal fistulas has been highlighted by a large meta-analysis Lay open and curettage under local anesthesia (LOCULA)
as the most effective sphincter-sparing procedure among procedure for a pilonidal sinus
all procedures invented to treat anal fistulas in the past
100 years.[10,11] Routine surgery for pilonidal sinus results in an extensive
wound, a hospital stay of 2–4 days, and a bed rest of
Garg space 15–20 days. LOCULA can be performed under local
anesthesia, requires no hospital admission, and the patient
Garg has discovered a new anatomical space, outer can resume his/her normal activities after 1–2 hrs. This
sphincteric space (Garg space), where the fistula usually is a major advancement and reduces patient suffering
spreads. This discovery was published in the top-most significantly.[18]

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 Armstrong, et al.: Community doctor becoming a global icon

Table 2: Path‑breaking and pioneering research work in the field of anal fistula by Dr. Garg.
1. Largest series of anal fistula in the medical literature (1250 patients)
2. Largest series of exclusive complex high fistulas with long‑term follow‑up (408 patients)
3. Largest series of supralevator fistulas with long‑term follow‑up (129 patients)
4. Largest series of preoperative and postoperative MRI in anal fistulas (2404 MRI)
5. Largest series of anorectal tuberculosis (776 patients, 1336 samples)
6. Largest series of fistulotomy to treat anal fistulas (611 patients)
7. New useful classification of anal fistula (Garg classification)[13]
8. New cardinal principles to treat complex anal fistula (Garg cardinal principles)[20]
9. New protocol to treat anal fistula with no obvious internal opening (Garg protocol)[14]
10. First guidelines to interpret MRI in the postoperative period after fistula surgery
11. New anatomical space where fistula spreads (outer sphincteric or Garg space)[12]
12. New type of highly complex fistula (RIFIL fistulas)
13. New parameter‑HOPE‑ As a parameter in MRI reporting of anal fistulas
14. Innovation of TROPIS procedure‑ Highly effective to treat high complex and supralevator fistulas (healing rate>90% over
long‑term)[10]
15. Innovation of tube in tract and PERFACT procedures for anal fistula
16. The first paper on the management of circumrectal fistulas (completely encircling the anorectum)
17. The first paper on the management of additional supralevator rectal opening in supralevator fistulas
18. First proportional meta‑analysis on VAAFT and anal fistula plug
19. A new phenomenon‑ IRIP phenomenon as a cause of urinary retention after fistula surgery
20. The first series of anal fistula and pilonidal sinus disease coexist simultaneously
21. The first paper to objectively demonstrate the role of MRI to confirm long‑term healing in complex high cryptoglandular anal fistulas
(151 cases)
22. The first guidelines on postoperative MRI in patients operated for cryptoglandular anal fistula (2404 MRI)
23. A new scoring system to accurately predict long‑term healing in cryptoglandular fistulas[15]
24. A new scoring system to clinically assess fecal incontinence[16]
TROPIS: Transanal opening of intersphincteric space, IRIP: Inability to raise intraabdominal pressure, MRI: Magnetic resonance imaging

Figure 3: Garg classification for anal fistulas.

Figure 2: Garg space and RIFIL fistula.

STATEMENT OF STATURE
It is rightly said that when you pursue excellence, everything
else follows suit. After entering the medical field in 1990,
Garg could not publish any research paper till 2008. But
with determination, between 2008 and 2022, he published
more than 175 articles in high-impact international
journals.[21] This includes a full spectrum of articles from
case series, prospective controlled studies, randomized
controlled trials, systematic reviews, meta-analyses, and
even guidelines. Overall, Garg’s research has been cited more Figure 4: Garg incontinence scores: A scoring system to clinically
than 2600 times, and the H-index and i10-index are 26 and assess fecal incontinence.

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 Armstrong, et al.: Community doctor becoming a global icon

55, respectively. Apart from receiving top international and Use of artificial intelligence (AI)-assisted technology for
national awards (https://fistulacure.com/about-us/), Garg has manuscript preparation
been ranked number one in Asia in the field of rectal fistulas,
pilonidal sinus, and fissure-in-ano by a leading USA medical The authors confirm that there was no use of Artificial
monitoring site, expertscape.com. (https://expertscape.com/ Intelligence (AI)-Assisted Technology for assisting in the
ex/fissure+in+ano/c/asi). His name has been included among writing or editing of the manuscript and no images were
the top 10 innovators and contributors in the field of anal manipulated using the AI.
fistula in the past 500 years.[19] Several record books including
the Limca Book of Records, Asia Book of Records, India Book REFERENCES
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history of surgery for anal abscesses and fistulas: Everything Litta F, Limbert M, James KC. Pankaj Garg: A Community Doctor to a
has been tried. and it’s not over yet! Hépato Gastro Oncol Dig Master Innovator to a Global Icon. Glob J Med Pharm Biomed Update
2023;18:16.
2022;29:1229-38.

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