A joint effort that became handy in successfully dealing with … · 2020-01-18 · common case,...

BLK Super Speciality HospitalPusa Road, New Delhi-110005 (India)

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Nanavati Super Speciality HospitalSwami Vivekanand Road, Vile Parle WestMumbai, Maharashtra-400056 (India)24-Hour Helpline: +91-22-26267500marketing@nanavatihospital.orgwww.nanavatihospital.org

Radiant

PULSEFEBRUARY 2018 | ISSUE 23

RARE BUT NOT UNCURABLE A joint effort that became handy in successfully dealing with Carotid Body Tumour

SAVING INSTEAD OF SEVERING Doctors helped elderly lady with acute diabetes to keep her foot despite challenges

Radiant Life Care | Newsletter

03Radiant Life CareBLK, New Delhi | Nanavati, Mumbai

Dear Reader, Prevention is better than cure. With increased awareness about various life-altering diseases such as Cancer, more and more people are now coming forward to avail various prevention options available to them. We will be observing February as the Cancer Awareness month and have planned many programs and campaigns for raising awareness on prevention, detection and treatment of Cancer in both the Group hospitals. The cover story in this edition of your newsletter features a very rare case of Carotid Body Tumour where a 36 year old lady came to the hospital with complaints of sore throat, which later turned out to be a lot more serious. The story has a happy ending thanks to the team of doctors at BLK Super Speciality Hospital who showed exemplary skills and coordination in this case. You will also come across some more interesting stories in this issue such as the case of a 57 year old lady from Turkmenistan who had a close shave from foot amputation or the story of an elderly lady from Jammu who got a new lease on life after a Transcatheter Aortic Valve Replacement (TAVR) procedure. We have engaging stories from Nanavati Super Speciality Hospital, Mumbai as well including the successful treatment of hernia in a little girl. In continuation of our efforts to bring the best-in-class technology for providing world-class healthcare services; we plan to introduce Robotic Surgery System for Advanced Surgical Interventions at BLK and Nanavati in the month of April. The introduction of this technology will not only benefit our patients but will also improve the precision and success rate of our surgical interventions. Lastly, I would like to congratulate Dr. Mihir Bapat and his entire team at Nanavati for completing more than 450 successful Spinal Surgeries, thus, starting the year on a high note. I am sure the year 2018 has many such milestones waiting for us to achieve. I, on behalf of the editorial team, thank all the contributors for their valuable inputs. We hope you will continue to share stories which are not only informative but inspiring to read. If you have any information that you feel should be ideal for this newsletter, please do share with us through mail that can be sent to: [email protected]. Stay Healthy, Stay Happy!

EDITOR-IN-CHIEF PARUL CHHABRA

CREATIVE CONCEPT PARUL CHHABRASHIKHA GIRGLA

SUNIL KUMAR

DESIGN & VISUALISATION

SUNIL KUMAR

CONTENT SHIKHA GIRGLA MAMTA SINGH

Nanavati Super Speciality HospitalMumbai, Editorial Team

PRAJAKTI SHIRSEKAR

SHYAM SHIRSEKAR

February 2018

FROM THE DIRECTOR’S DESK

Dr. Mradul KaushikDirector-

Operations and PlanningRadiant Life Care

C O N T E N T S

FINDING THE BEST SOLUTIONby Dr. Ajay Kaul

4

BEATING THE INCURABLEby Dr. Mihir Bapat

11

BLK & NANAVATI IN NEWS

14-15

PAIN NO MOREby Dr. Pankaj R. Shroff

5

EVENTS AND ACTIVITIES

12-13

RARE BUT NOT UNCURABLEby Dr. Kapil Kumar& Dr. Sandeep Mehta

6-7

SAVING INSTEAD OF SEVERINGby Dr. Vivek Aggarwal &Dr. Ajay Kumar Ajmani

10

MUCH MORE THAN HEARTBURNSby Dr. Chandragouda

9

BENIGN OR MALIGNANT : SOLVING THE MYSTERY

by Dr. Mitusha Verma

8



CT Scan

Suturing the defect

Cocoon Formation

THE CASE

Pritpal Kaur Chadha, a 72-year old lady from Jammu was diagnosed with a life threatening disease called Aortic Valve Stenosis (degenerative) and was experiencing multiple syncopal episodes (loss of consciousness). Since she was also suffering from other ailments like Diabetes, Hypertension and Severe Obstructive Sleep Apnea (OSA), she could not be treated for Aortic Valve Stenosis through conventional procedures. On the advice of a family friend, she visited BLK Super Speciality Hospital in New Delhi to undergo Transcatheter Aortic Valve Replacement (TAVR) surgical procedure.

Aortic Valve Stenosis is a serious problem of valves wherein the valve gets narrow and obstructs the flow of blood to the heart. Considering the age and fragile health of the patient, TAVR came as a boon for the lady. TAVR is a well-proven surgical procedure for Aortic Valve Replacement in people who are considered as high risk patients for Open Heart Surgery.

THE PROCEDURE

On admission, the lady underwent several investigative tests like Coronary Angiography (CAG) which revealed that she had a double vessel disease. A pre-anaesthetic evaluation clearly indicated that she was unfit for Open Heart Surgery and Valve Replacement. The team of doctors led by Dr. Ajay Kaul and supported by Dr. Dheeraj Kumar Gandotra, Dr. Amit Kumar Chaurasia from CTVS and Dr. Jasbir Singh Khanuja from Cardiac Anaesthesia decided to go with minimally invasive strategy and did the Percutaneous Coronary Intervention (PCI) which is a non-surgical method used to open narrowed arteries. They replaced her decreased Aortic Valve percutaneously through the femoral route and MY VAL 23mm was deployed without Open Heart Surgery.

THE RESULT

The patient was kept in the ICU after surgery for a day. She was discharged after two days and is now living a much healthier life.

Finding The Best Solution72-year lady from Jammu gets new lease of life with advanced surgery

Dr. Ajay Kaul

Chairman & HODCardio Thoracic and Vascular Surgery (CTVS) BLK Heart CentreBLK Super Speciality Hospital, New Delhi

“The patient was kept in ICU after surgery for one day. She was discharged after

two days and is now living a much healthier life.”

− Dr. Dheeraj Kumar Gandotra, Consultant,

Cardiology BLK Heart Centre

Dr. Pankaj R. ShroffSr. Consultant- Paediatric SurgeryNanavati Super Speciality Hospital, Mumbai

THE CASE

An 8-year old girl was admitted in Nanavati Super Speciality Hospital with complaints of pain in the abdomen in periumbilical area. She was experiencing the pain for 8 days prior to admission, which was intermittent in nature and subsided temporarily on medication. Four days prior to admission, the patient had a paroxysmal attack of pain. An ultrasound was done which was suggestive of an ileo-ileal type of intussusception in the right iliac fossa which was of intermittent type. A CT scan (A + P) was also done showing transient small bowel obstruction with cocoon formation in the left upper quadrant suggestive of a left para duodenal internal (now known as mesocolic) hernia causing anterior displacement of colon, and multiple reactive mesenteric lymph nodes.

A diagnostic Laparoscopy was advised in the event of any further attack of pain. The patient had a second paroxysmal attack of pain the day she was admitted for further surgical management.

THE PROCEDURE

The doctors found a defect in the medial side of the descending colon near the splenic flexure with around 80% of the intestines herniating through the defect. The left inferior mesenteric vein was found to be very close to the edge of the defect, hence a decision was taken to perform a Laparotomy and close the defect through a small incision made possible because of Laparoscopy.

All the intestines were reduced, the edge of the defect was sutured with the fourth part of the duodenum in the upper part and to the mesentery in the lower part.

THE RESULT

Post-operative recovery was uneventful. An ultrasound follow-up was made seven days after the procedure to confirm absence of recurrence.

DISCUSSION

Mesocolic Hernia, a rare cause of intestinal obstruction in children, with a reported incidence of 0.2-0.9%, may present as an acute surgical emergency, or maybe an incidental finding on Laparoscopy or Laparotomy and should be looked into.

A correct diagnosis together with prompt surgical intervention is essential for achieving patient cure and preventing future complications.

Pain No More Dealing with Mesocolic Hernia successfully

February 2018



Dr. Kapil Kumar

Director - BLK Cancer Centre & HOD - Surgical OncologyBLK Cancer CentreBLK Super Speciality Hospital, New Delhi

Rare But Not UncurableA joint effort that became handy in successfully dealing with Carotid Body Tumour

The carotid body is a neural crest cell-derived chemoreceptor located in the medial portion of the carotid bifurcation. These receptors detect changes in oxygen, carbon dioxide, and pH concentration, and are involved in neurogenic physiologic adaptation to changes in these parameters. They have been commonly referred to by a variety of names including Carotid Body Tumour (CBT), Paraganglioma, Glomus, or Nonchromaffin or Chemodectoma Tumours.

Head and neck paragangliomas are very rare Tumours that have an incidence of 1 in 30,000 to 1 in 1,00,000 cases. CBT is the most common case, accounting for 65% to 80% of these Tumours. CBTs characteristically splay the carotid bifurcation, and depending on their size, can encapsulate the external or internal carotid artery, or both.

CBTs are usually asymptomatic and discovered to be a painless mass or fullness in the neck at the level of the carotid bifurcation. They may be present with pain, dysphagia, odynophagia, hoarseness, stridor or cranial nerve deficit. Sometimes these Tumours may be functional and may present with symptoms compatible with sympathetic hyperactivity. CBT are identified by clinical examination or found incidentally on imaging studies. CT Angiography (CTA) or MRI is the preferred modality for surgical planning of Tumour resection. They are seen as hypervascular masses that characteristically splay the carotid bifurcation, a characteristic that is pathognomic. Octreotide Scintigraphy may be used if there is suspicion of synchronous lesion elsewhere in the body. Complete surgical resection is the preferred treatment for CBTs. The two major challenges encountered are the preservation of adjacent cranial nerves and maintaining the integrity of the carotid arteries. Intra-arterial embolisation, direct embolisation are some of the strategies used to reduce blood loss during surgery.

In cases of surgical resection where segment of carotid artery has to be resected, reconstruction with saphenous vein graft or prosthetic patches or grafts may be needed.

THE CASEA 36-year old lady was brought to BLK with complaints of sore throat. On examination, there was an ill-defined painless swelling over left side of her neck. Ultrasonography of the neck was done to ascertain the cause, which revealed a lesion at carotid bifurcation. She was further evaluated with MRI of the neck and diagnosed with Carotid Body Tumour arising from left carotid bifurcation causing splaying and partial encasement of left proximal ICA, ECA. She then underwent CT angiogram of neck and brain, which showed well marginated highly vascular lesion of size 31.3 mm in (AP) x 26.4 mm (TR) with both CCA, ICA, ECA appearing normal in entire extent with normal brain circulation.

THE PROCEDURESurgical intervention was planned for the patient in the form of neck exploration with excision of mass. Intraoperatively, there was a well circumscribed Tumour of 4 cm x 3 cm at the bifurcation of the left carotid artery, splaying the internal and external carotids, adherent to the vessels but not encasing it. Carotid vessels (CCA, ICA, ECA), IJV, Cranial nerves - X, XI, XII were identified and preserved.

THE RESULTPost-operatively the patient had an uneventful recovery without any cranial nerve deficit. She recovered well under normal conditions in an uneventful manner.

DISCUSSION

Carotid Body Tumour, although rare, is a surgical challenge in view of its close proximity to important neurovascular structure in the neck. These kinds of Tumours are potentially curable disease and are better managed in a set up with multidisciplinary team of specialists.

Dr. Sandeep Mehta

Assistant DirectorSurgical OncologyHOD-Onco-Reconstructive SurgeryBLK Cancer CentreBLK Super Speciality Hospital, New Delhi

MRI Angiography showing splaying of external and

internal carotid artery left side

February 2018

Surgical Intervention of Carotid Body Tumour



Much More Than HeartburnsFrequent heart burns increases risk of Cancer in elderly people

Dr. ChandragoudaDodagoudar

Consultant- Medical Oncology, BLK Cancer CentreBLK Super Speciality Hospital, New Delhi

With growing age the ability to properly digest food and absorb vital nutrients declines. Surprisingly, one of the most common age-related causes of impaired digestive function is the reduction of hydrochloric acid produced by the stomach which helps in the digestion process. And this results in heartburn, indigestion and bloating. Those who have frequent heartburns or two/three times a week and haven’t consulted a doctor are ignoring one of the biggest Cancer risk factors around.

This burning discomfort may be a sign of acid ref lux, which involves stomach acid f lowing back into the esophagus and irritating the lining of the esophagus. Heartburn, or Gastro-Esophageal Reflux Disease (GERD), is a common condition where stomach acid leaks out of the stomach and into the gullet.

GERD is the top cause of ulcers, or sores in the lining of the esophagus. Symptoms include painful swallowing, nausea and chest pain. Your doctor will prescribe medicine to control your GERD and treat the ulcer. A common symptom is uncomfortable warm and burning sensation in the chest, usually just behind the sternum. Although the pain starts in the chest area, it can make its way upto the neck, throat and jaw.

About 5 to 10% of people with GERD develop Barrett’s esophagus where stomach acid causes pre-cancerous changes in cells. Some people with Barrett’s esophagus will not require immediate treatment but will need to have their progress monitored by a Gastroenterologist. For others with pre-cancerous changes, treatment may require endoscopic ablation of the Barrett’s esophagus.

A small percentage of people with Barrett’s esophagus will develop Cancer, more often of the throat, tonsils and upper digestive tracts in the elderly age groups. The incidence of these Cancers is rising worldwide. Hence early detection of Cancer, improves patient care and outcome. Even if the heartburn is for a few months or less one should check with a primary care provider.

Cancer that is limited to only inner layers of esophagus can be removed using minimally invasive endoscopic techniques. When the Cancer is localised to esophagus and is not amenable to endoscopic procedures, primary surgery is required. If the Cancer is more advanced, chemotherapy and radiotherapy modalities are required before definitive surgery.

February 2018

Dr. Mitusha Verma

Consultant RadiologistMRI Department of Radiodiagnosis Nanavati Super Speciality Hospital, Mumbai

Uterine Leimyomas are the most common pelvic neoplasm in women. These may be completely asymptomatic or may cause patient discomfort, dysmenorrhea, menorrhagia, infertility like symptoms. MRI is the modality of choice for fibroid mapping prior to surgical management for better planning. One of the key issues to address is whether the fibroid has undergone sarcomatous change, which might change the treatment plan. Uterine Sarcoma are rare but have a poor prognosis.

THE CASEPatient 1: A 37-year old female with complaints of menorrhagia underwent pre-operative MRI of the pelvis.

Patient 2: A 39-year female with a similar clinical profile and complaints of dysmenorrhea underwent MRI of the pelvis.

THE PROCEDUREHigh resolution MRI Pelvis was performed using 3 Tesla GE Discovery 750W scanner. In addition to morphologic T2, pre and post contrast T1 weighted images, Diffusion Weighted Images (DWI) with a high B value were also obtained. Both patients had fibroids with nearly similar morphologic appearance as well as enhancement pattern. The feature of note was the striking difference on DWI. The fibroid with restricted diffusion was interpreted to have undergone sarcomatous change while one with no restriction was reported benign with cystic degeneration.

THE RESULTBoth patients underwent surgery. Later, histopathology confirmed the imaging diagnosis.

Benign or Malignant :Solving The Mystery

Patient 1: A. Cor T2 showing well defined fibroid B. Restricted dif-fusion C. Reduced ADC value as seen with sarcomatous change

Patient 2: D. Cor T2 showing well defined fibroid with heterogenous appearance E. No area of restricted diffusion

Discussion: The challenge of differentiating a Benign Uterine Fibroid from a Uterine Sarcoma

is one part of the diagnostic process for all women with a uterine mass. Besides the

routine MRI imaging protocol, diffusion weighted images with appropriate B values

must be obtained in all cases of pelvic masses. As, though

sarcomatous change may have discrete routine morphologic as well as post contrast features, these may get obscured with

concomitant features of degeneration. Restriction on

diffusion weighted images has a higher specificity and sensitivity to identify sarcomatous change.

Therefore, as per the recent literature review, if Uterine Sarcoma is suspected based upon clinical characteristics

of the patient or mass or upon sonographic findings, MRI with DWI and gadolinium contrast

may aid in assessing the likelihood of malignancy.



Dr. Mihir Bapat

DirectorInstitute of Spine SurgeryMinimal InvasiveSpine SurgeryNanavati Super SpecialityHospital, Mumbai

Beating the IncurableDealing with the challenges of Spine Cancer

The spine is one of the most frequent location where medical professionals are seeing metastatic disease. Complications related to spine are many and spinal cancer, though rare, is a major concern. A Spinal Tumour is a cancerous (malignant) or noncancerous (benign) growth that develops within or near spinal cord or within the bones of spine. Unfortunately, these Tumours are not preventable. However, with new treatments, Spinal Cancer can be managed effectively.

It is prudent to note that among all the body Tumours, nearly 5% involve Spine Tumours and most occur sporadically. Most common age group for primary Spine Tumour is 3-40 years and for secondary Tumour it is more than 60 years. Spine Tumours are diagnosed with the help of MRI and CT scan. Biopsy is gold standard test for diagnosis. Newer advances in Spinal Tumour treatment offer more options than ever before.

SYMPTOMS OF SPINAL TUMOUR

Signs and symptoms of Spinal Tumours may include back pain, loss of sensation or muscle weakness, especially in legs, difficulty in walking, decreased sensitivity to pain, heat and cold, loss of bowel or bladder function. Paralysis that may occur in varying degrees and in different parts of the body, depending on which nerves are compressed.

TREATMENT OPTIONS FOR SPINAL TUMOUR

Surgery: Surgical removal is the best option for many intramedullary and intradural-extramedullary Tumours, yet large ependymomas at the end of the spine may be impossible to extricate from the many nerves in this area. Although noncancerous Tumours in the vertebrae can usually be completely removed, metastatic Tumours are less likely to be operable. When a Tumour has spread to the spine, radiation alone is usually the treatment of choice. However, research has found that surgery combined with radiation may be more effective at preventing loss of nerve function in people who are healthy enough to tolerate an operation and who have Tumours that have spread from an unknown location, have some evidence of nerve injury, have Tumours resistant to radiation or have recurrent Tumours that were previously irradiated.

Standard Radiation Therapy and Stereotactic Radio surgery (SRS) which is a newer method, capable of delivering a high dose of precisely targeted radiation, is being studied for treatment of Spinal Tumours. This is important because some Tumours, benign or malignant, may reoccur. Analgesics are given to control post-operative pain and Cancer pain. Cancer pain may be difficult to control (e.g. ‘break through pain’). A pain management specialist may provide assistance if conventional drugs (e.g. pill, skin patch) do not provide relief. Any surgery, radiation treatment, or chemotherapy can drain the patient nutritionally. Therefore, a proper diet is important to regain strength, lost weight, and a measure of health. Through exercise and modalities the patient can build strength, endurance and flexibility.

“Hospitals such as Nanavati Super Speciality Hospital are

providing Spinal Tumour surgery in India, offering

end-to-end solution for life-threatening diseases and

facilitating the highest standard of quality medical treatment & patient care for domestic and

international patients.

At Nanavati Hospital, we had done more than 450 Spinal

Surgeries last year itself . To create more awareness on Spine

related issues, we would be organising ‘Back to Health’, a

spine support group programme at the hospital on 17th February

from 2:00 PM-4:00 PM.”

February 2018

THE CASEA 57-year old lady from Turkmenistan was suffering from Diabetes for the last 10 years. One fine day, she found redness on the last toe of her left foot. The next day that redness worsened and the entire toe was swollen. She consulted local doctors in Turkmenistan and they detected the problem as left diabetic foot with gangrene affected toe and cellulitis. The condition was quite aggressive as in less than 24 hours it became worse. Local doctors then advised her to go for foot amputation.

The family then decided to visit BLK Super Speciality Hospital in New Delhi as many of their relatives had earlier undergone satisfactory treatment here. They were aware about comprehensive and specialised Diabetic Foot Clinic at the Hospital. When the patient reached BLK, she was suffering with breathlessness, uncontrolled Diabetes and Septicemia. She was immediately admitted in the emergency unit of the hospital.

THE PROCEDUREThe patient was first stabilised with medication for her high sugar levels and Septicemia under supervision of Dr. Ajay Kumar Ajmani – Sr. Consultant, Endocrinology, BLK Super Speciality Hospital. The Endocrinology team along with the intensive care unit was successful not just in controlling the sugar level but also in saving the patient from a coma like situation.

Once her sugar levels were controlled, Dr. Vivek Aggarwal – Consultant, Endocrine Surgery, investigated the patient and systematically planned the management of her diabetic foot. She was then taken to operation theatre for optimal limb saving surgery. Foot debridement with toe excision was done and rest of the foot was saved from amputation.

THE RESULTPost surgery, the patient gradually improved and her foot became healthy as the infection settled down. The surgery was followed by wound closure, foot reconstruction and grafting. The patient was fine after the procedure. Following that she was educated for diabetic foot care and provided with special offloading footwear for future prevention.

Saving Instead of SeveringDoctors salvage gangrenous foot of elderly lady with severe Diabetes despite challenges

Dr. Vivek Aggarwal

Consultant Endocrine SurgeryBLK Super Speciality Hospital, New Delhi

Dr. Ajay Kumar AjmaniSr. Consultant Endocrinology and Endocrine SurgeryBLK Super Speciality Hospital, New Delhi

“Diabetic foot is a very challenging situation.

Patients with long standing Diabetes develop Neuropathy

and Foot Ischemia. Lower immunity and other

co-morbidities predispose them to frequent foot ulcers

and infections leading to gangrene and foot loss. We

at BLK Diabetic Foot Clinic provide end-to-end solution to all kind of diabetic foot

diseases.”



EVENTS AND ACTIVITIESEVENTS AND ACTIVITIES

BLK Super Speciality Hospial had hosted a New Year Get Together for Doctors at Habitat World, India Habitat Centre on 20th January, 2018.

The winners of the BLK HR Employee Recognition Award for December 2017 were recently commemorated by Mr. Ajay Sharma, VP -Administration; Dr. Pradeep Sharma- Director & Head, Orthopaedics; Ms. Rosamma Jose- Head, Nursing.Left to Right: Dr. Lester Pereira (Doctor of the Month); Ms. Surbhi Gupta (GDA of the Month); Mr. Rajneesh Kumar (Contractual Worker of the Month); Ms. Vandana (Employee of the Month), Ms. Gigi Grace Shaji K (Nurse of the Month).

Robotic Surgery System for Advanced Surgical Interventions will soon be implemented to further enhance the set of advanced technologies that BLK has come to be known for. The new system provides various advantages including greater precision, shorter hospitalisation, reduced pain and discomfort for patients as well as reduced blood loss and transfusion. Procedures and surgeries done through the Robotic Surgery System will also have smaller incisions resulting in reduced risk of infection and minimal scarring along with faster recovery time.

Welcoming Latest Technology

New Year Get Together & Employee Recognition

Nanavati Hospital in association with IMA − Mumbai West Branch, had participated in National Annual Conference of IMA (NATCON) 2017 which witnessed more than 1000 delegates.

NATCON, 2017 in association with IMA, Mumbai

Dr. Gayatri Deshpande − Sr. Consultant, Gynaecology gave a Health Talk on PCOD & Hygiene along with Ms. Preeti − Dietician at SNDT University, Santacruz. The talk highlighted the importance of nutritional food in our daily lives.

Health Talk at SNDT University, Santacruz (W)

(Prof.) Dr. Pradeep Bhosale − Director, Arthritis & Joint Replacement Surgery, Nanavati Super Speciality Hospital, delievered a health talk on Arthritis & Joint problems for members of Shree Bisa Humad Jain Samaj, Borivali (W). More than 200 people attended the event and were benefitted from this health talk.

Health Talk for Shree Bisa Humad Jain Samaj

February 2018



BLK & NANAVATI in NEWSFebruary 2018

A joint effort that became handy in successfully dealing with … · 2020-01-18 · common case,...

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