SAFE EXIT - IndiaMore than 800 Bone Marrow Transplants, India’s first DCD Liver Transplant,...

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: +91-22-26267500www.nanavatihospital.org

Radiant

PULSEJANUARY 2018 | ISSUE 22

SAFE EXIT A life saved by performing a challenging Exit procedure

CONSCIOUS CALL Brain surgery of a marine engineer while he was awake

Radiant Life Care | Newsletter

03Radiant Life CareBLK, New Delhi | Nanavati, Mumbai

Dear Reader,

The beginning of a new year is always a good time to start afresh. This time of the year is also a good time to introspect upon the past twelve months. We have had a great year with many significant milestones for ourselves in both the group hospitals. More than 800 Bone Marrow Transplants, India’s first DCD Liver Transplant, Tanzania’s first ever Kidney Transplant, India’s first successful EXIT procedure, successful cardiac surgery of a young athlete were some of our achievements in the year gone by.

The first issue of Pulse for the year 2018, encapsulates some of our milestone cases. The cover story features a highly challenging Exit procedure which saved the life of a new born child. The case of Tanzania’s first ever Kidney Transplant, carried out by the team of BLK doctors in partnership with the experts at Muhimbili National Hospital, is also detailed out in this issue. From our group hospital in Mumbai, you will also come across this intriguing case of a marine engineer’s brain surgery where he was awake and conscious throughout the procedure. Some of the other cases include that of a young man who was brought to the hospital with complaints of sudden loss of control of his lower limbs but it turned out to be a lot more serious condition, bringing to fore the necessity for timely check-ups.

The editorial team sends its gratitude to all those who have contributed stories and articles which enable us to bring out this newsletter in time. Our special thanks to the first time contributors with the hope that they will regularly share their pieces with us. Our editorial team will be happy to connect with you through email at: [email protected].

Wishing all of you a very Happy New Year!

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

January 2018

C O N T E N T S

A BOND TO LIVE FORby Dr. H. S. Bhatyal,Dr. Sunil Prakash & Dr. Rajesh Kumar Pande

4

CATASTROPHE AFTER TKR PERIPROSTHETIC FRACTUREby Dr. Pradeep B. Bhosale

9

MORE THAN MEETS THE EYEby Dr. Chandragouda Dodagoudar

11

BLK & NANAVATI IN NEWS

14-15

REGAINING THE STRENGTHby Dr. Harshad Limaye &

Dr. Pradyumna J. Oak

5

PRESERVING HOPES OF MOTHERHOOD

by Dr. Sanjay Dudhat

8

EVENTS AND ACTIVITIES

12-13

SAFE EXITby Dr. Prashant Jain

6-7

CONSCIOUS CALLby Dr. Rajan Shah

10

FROM THE DIRECTOR’S DESK

Dr. Mradul KaushikDirector-

Operations and PlanningRadiant Life Care



January 2018

Dr. Sunil Prakash

Sr. Consultant & Director Nephrology & Renal Transplant ServicesBLK Super Speciality Hospital, New Delhi

Dr. H. S. Bhatyal

Advisor & Sr. ConsultantUrology, Andrology & Renal Transplant BLK Super Speciality Hospital, New Delhi

Dr. Rajesh Kumar Pande

Director & Sr. ConsultantBLK Centre for Critical CareBLK Super Speciality Hospital, New Delhi

Regaining The StrengthElderly man bounces back to normalcy after experiencing weakness on the right side with slurring of voice

A team of experienced doctors from BLK Super Speciality Hospital in partnership with Muhimbili National Hospital at Dar Es Salaam performed the first ever Kidney Transplantation in Tanzania. This is one of the most significant milestones in Tanzania’s medical history.

In line with Prime Minister Narendra Modi’s vision that India will stand ‘shoulder to shoulder’ with the continent in its race towards a brighter future, BLK Super Speciality Hospital has been working towards knowledge sharing, transfer of skills and capacity building with the objective of building the African region as an advanced healthcare destination.

THE CASEA 30-year old Tanzanian lady was suffering from end stage kidney disease and was on haemodialysis for over a year. Her only hope for survival without dialysis was a Kidney Transplant, something that has never ever been performed in her country. Luckily for her, she didn’t have to struggle to find the donor as her 27-year old brother stepped up selflessly to donate one of his kidneys to save her life. As BLK Super Speciality Hospital has been working with Muhimbili National Hospital, Dar Es Salaam, it decided to take up the herculean task of performing what would become the first ever successful Kidney Transplant in Tanzania.

THE PROCEDURELed by Dr. H. S. Bhatyal, Advisor & Sr. Consultant, Urology, Andrology & Renal Transplant along with Dr. Sunil Prakash, Sr. Consultant & Director, Nephrology & Renal Transplant Services and supported by Dr. Rajesh Kumar Pande, Director & Sr. Consultant, Critical Care; Dr. Anil Handoo, Director, Lab Services and Dr. Manu Varshney, Associate Consultant, Anaesthesia from BLK Super Speciality Hospital and Dr. Jacqueline Shoo and Dr. Kisanga from the Nephrology Department at Muhimbili National Hospital, the painstaking task of the transplantation was conducted without any complication.

THE RESULTBoth the donor and the recipient recuperated well under supervision. After explaining the care that the recipient and the donor need to take and the importance of taking timely medicines, the brother and sister got discharged and both of them have now resumed their normal activities.

The Health Minister of Tanzania Ms. Ummi Mwalimu expressed that the success of this Kidney Transplant laid a noble foundation for the introduction of other organ transplantations in the country, bringing hope to a number of patients waiting for transplant operations in the African nation.

A Bond To Live ForBLK doctors perform Tanzania’s first ever Kidney Transplant

THE CASE

A 62-year old male hypertensive since 5 years was brought to Nanavati with mild right sided weakness and slurring of speech for 12 hours and focal convulsion of right side just before he was brought to the emergency department. He was an ex-smoker, with no other significant co-morbidities. His vitals were also stable and the blood pressure was 150/90. His right sided power was 2/5 and he had right UMN facial palsy. On further examination, no other neurological and systemic abnormality was found. His CBC, LFT, renal function and lipid profile were normal.

Basis the findings, the stroke protocol was activated. His MRI revealed a space occupying lesion in left parietal lobe. The lesion showed restricted diffusion with peripheral enhancement and perilesional oedema. MR Spectroscopy revealed, presence of lipid lactate peak and diffusion tensor imaging showing displaced tracts.

THE PROCEDURE

Based on MRI finding the differentials were an abscess, neoplasm/ metastasis. The patient had progressed to power 0/5 by the time he was wheeled in to the OT within 36 hours of hospitalisation. Left parietal craniotomy with intra opt USG Sonography guided aspiration and excision of the mass was done. The necrotic aspirated material was sent for pathological and microbiological investigations. The histopath revealed the presence of sulphur granules and VITEK based culture revealed presence of Actinomyces israelii.

THE RESULT

The patient was treated with IV Ceftriaxone 1gm twice a day for 6 weeks. He was also given antiepileptic medications. He showed a remarkable recovery over a period of next few months. His power improved to 5/5 in right lower limb and 4/5 in right upper limb when he was last seen after 6 months of surgery.

T2 weighted Image Gram Stain - Histopath Slide

“Actinomyces israelii is a species of gram-positive,

rod-shaped bacteria within the Actinomyces. Known to live commensally on and within humans. It is an

opportunistic pathogen and a cause of Actinomycosis.”

Dr. Harshad Limaye

Sr. Consultant Internal Medicine Nanavati Super Speciality Hospital, Mumbai

Dr. Pradyumna J. OakSr. ConsultantInterventional NeurologistNanavati Super Speciality Hospital, Mumbai


Radiant Life Care | Newsletter January 2018

Safe ExitA life saved by performing a challenging Exit procedure

“BLK’s team of deft Surgeons and Neonatologists

successfully bridged the critical gap between the baby and the oxygen and delivered the baby after a challenging

procedure.”

A new born baby with a large neck mass blocking his airways was able to have a safe access and new lease of life owning to a rare and difficult procedure called Extra Uterine Intra Partum Treatment (EXIT) performed by the Paediatric Surgery and Neonatology team of BLK Super Speciality Hospital.

THE CASEA 29-year old lady, 30 weeks pregnant from Bihar was diagnosed on antenatal ultrasound scan to have a large neck mass in foetus. The patient was referred to BLK Super Speciality Hospital for further management. The patient was further evaluated and a foetal MRI was done which was suggestive of large neck mass of an approximate size of 10 x 9 cm. The infant’s airways could not be visualized as the giant cervical mass was compressing it.

The infant’s normal exit from the womb would have been life threatening as the wind pipe was blocked due to the giant neck mass, obstructing the oxygen passage despite its abundant presence. The odds were stacked against his survival, as his wind pipe had to be decongested by intubation while he was still in the uterus, keeping the umbilical circulation intact throughout the intervention.

THE PROCEDUREA multidisciplinary team comprising Paediatricians, Neonatologists, Paediatric Anaesthesiologists, Obstetricians, Paediatric Cardiologist, Paediatric Pulmonologist, Paediatric ENT specialists and dedicated nursing staff and other operating room personnel was formed to perform this rare and critical procedure.

A special caesarean section was performed, only the head and shoulder of baby were delivered out of uterus and intubation was done. Intubation procedure was swiftly done within a record time of 1 minute 32 seconds. Every step during the caesarean and after delivery operation of Giant Cervical Lymphangioma was performed with precision and the end result was quite satisfying as the baby was breathing safely. The case also required a special C-section to keep the foeto-placental circulation intact. This can only be made possible under general anaesthesia with uterine relaxants. But again this carries a high risk of maternal bleeding. After the successful windpipe procedure and delivery of the new born, the non-cancerous Tumour in the neck was also operated. Intubation was also done away with as his windpipe was decongested thoroughly.

THE RESULT

The baby and mother were well post operation and recuperated without any complication. The mother and baby duo got discharged after a few post-operative days.

DISCUSSION

When the baby is in womb, mother breathes for him through the umbilical cord. But once out of the womb, the baby needs to breathe for himself as all babies do. It would have been fatal for the baby had he exited without going through the ‘EXIT’ procedure. Securing airway after the child is delivered could have been difficult because of distorted anatomy of neck and the intubation time cannot exceed more than 25-30 seconds to prevent brain hypoxia. So EXIT procedure was the only option left with the doctors wherein they could have comparatively more time to perform the intubation procedure.

Exit procedure being performed on the new born baby

Exit Procedure Team

Dr. Prashant Jain

Sr. ConsultantPaediatric SurgeryBLK Centre of Neonatal, Paediatric & Adolescent Medicine BLK Super Speciality Hospital, New Delhi


Radiant Life Care | Newsletter January 2018

Preservation of fertility is an extremely important issue for many women diagnosed with a gynaecologic malignancy. Approximately 21% of gynaecological malignancies occurs in women of reproductive age who wish to start a family. It has been reported that between 3-17% patients with ovarian cancer including Germ Cell Tumours are younger than 40 years of age at the time of diagnosis and 7-8% of all stage I epithelial Ovarian Cancers occur in women more than 35 years.

THE CASEA 17-year old female with history of heaviness and pain in lower abdomen for the past 3 months visited Nanavati Super Speciality Hospital. Her menstrual cycles were slightly irregular. Sonography of abdomen pelvis showed a large pelvic solid mass arising from left ovary. Tumour markers AFP, Beta HCG, CA-125, LDH were done. AFP, Beta HCG showed higher values indicating Germ Cell Tumour. CT scan of abdomen pelvis showed solid large pelvic abdominal mass lesion (18.9 x 8.4 cm) arising from the left ovary without any evidence of ascitis, lymphadenopathy, omental or peritoneal deposits.

THE PROCEDURELaparotomy with excision of left ovarian mass and removal of left fallopian tube and salpinx was done. The ovarian mass was removed intact without spillage in the peritoneal cavity. Frozen section showed Germ Cell Tumour possibly Yolk Sac Tumour. Considering the age of the patient, decision was taken to preserve opposite ovary and uterus. Final histopathology revealed Yolk Sac (Endodermal Sinus) Tumour.

THE RESULTPost operatively patient was given 4 cycles of Chemotherapy (BEP). For the past 6 years, the patient has been doing well and her menstrual cycles has also become regular after 2 years of chemotherapy.

DISCUSSIONYolk Sac (Endodermal Sinus) Tumour is a second most common Malignant Germ Cell Tumour of the ovary. As all Germ Cell Tumours are chemo sensitive, we can perform fertility preservation surgery in place of radical / debulking surgery. Even if post-operative chemotherapy is given in such Tumours, patient can also conceive. The prognosis for patients with Low-Malignant Potential (LMP) Tumours is generally excellent and patients still have the ability to bear children and can be treated with conservative surgery to preserve fertility. But it is very important to define and differentiate between Low Malignant, Potential or Border Line Tumours and also invasive carcinomas. It is also essential to define stage IA Tumour − which is confined to the ovary with no capsular infiltration, no papillary excrescences on the surface and no ascitis. Close observation is required as recurrence rates are 9%.

Preserving Hopes of Motherhood Catastrophe after TKR Periprosthetic FractureDoctors saved an ovary of an adolescent girl with

Yolk Sac Tumour

Germ Cell Tumour

CT scan

Treated Successfully at Nanavati Hospital

Dr. (Prof.) Pradeep B. Bhosale

Director, Arthritis & Joint Replacement SurgeriesOrthopaedics & Joint ReplacementNanavati Super Speciality Hospital, Mumbai

Dr. Sanjay Dudhat

HeadDepartment of Oncosurgery Nanavati Super Speciality Hospital, Mumbai

“Fertility preservation surgery for early stage disease can

be advocated in young patients desirous of child

bearing provided they have low Malignant Potential

Tumours/ Cell Differentiated Tumours (Stage IA)/Germ Cell

Tumours.”

THE CASEA 78-year old female who had undergone Bilateral Total Knee Replacement 6 months ago from another hospital, sustained an accidental fall and developed Supracondylar Periprosthetic Fracture.

THE PROCEDUREAfter pre-operative planning, the team of doctors at Nanavati Super Speciality Hospital performed the reconstruction Revision TKR surgery. They reconstructed the crumbled bone with specially made Tantalum Metal cone (TMcone) which has bone forming capacity with structural support as a replacement distal condylar part of femur. It is manufactured specifically for such reconstruction. It has exclusive feature of bone forming ability as per modern international research apart from providing mechanical stability. It is available in various sizes specific for left or right sides. It fits accurately to the residual available bone. It needs reinforcement with bone graft to help biological bone formation. Strength and shape is specially designed to fit revision TKR prosthesis having intramedullary stem support for femur and tibia. Since it is cemented, stability and mobility is achieved immediately. The patient is permitted to walk full weight bearing with stable mobility upto 120 degree knee movement.

THE RESULTPost operation the patient was discharged after 5 days. Follow up after one year post operation shows excellent fitting of revision TKR with functional mobility and stability.

Stable reconstructioinin right knee

Pre-op peri-prosthetic

Post-operative followup images of the patient

(Top Left) Intra-op Reconstruction with TM Metal Augment, (Top Right) Intra-op Stable Revision TKR complete



January 2018

More Than Meets The EyeLack of control of lower limbs reveals a set of much more deeper problems

THE CASE

A 25-year old man was brought to the Emergency Department of BLK Super Speciality Hospital with complaints of sudden loss of power in both his lower limbs. The MRI spine revealed multiple vertebral lesions with spinal cord compression. He was taken up immediately for decompression surgery. Medical oncology opinion was sought for testicular swelling and bone metastasis. The patient needed further assessment and treatment for advanced stage Testicular Malignancy, Septicemia, Tumour Lysis Syndrome, Renal Dysfunction and Paraplegia.

All his tumour markers (AFP, beta HCG, LDH) were elevated. PET-CT non-contrast revealed right Testicular Tumour with metastasis to liver and multiple bones. The family was counselled for the treatment and prognosis.

THE PROCEDURE

The patient was started under high risk consent on low dose chemotherapy with all supportive care measures for his conditions. Gradually he started showing improvement. Renal function showed improvement and complete recovery over 2 weeks. Once his general condition started improving, he was administered complete two courses of chemotherapy. In view of deep vein thrombosis, IVC filter was inserted by the Cardiologist.

Re-evaluation after two cycles of chemotherapy revealed complete remission of his disease. The patient was given two more cycles of chemotherapy and he continued to be in complete remission. He started showing improvement in controlling his lower limbs after 2 cycles of chemotherapy.

He underwent right orchiectomy after the complete treatment. The histopathology of specimen showed pathological complete remission.

THE RESULT

The patient showed tremendous improvement after 4 cycles of chemotherapy and he could come to the follow-up OPD walking on his own with support. He is under regular follow-up now. It has been more than 18 months and he is currently disease free.

Brain surgery of a marine engineer while he was awake

THE CASEA 49-year old non-diabetic, non-hypertensive, right-handed, gentleman of Indian origin, Master Mariner by profession was on a holiday in US when he developed sudden onset symptoms of speech impairment with letters / numbers recognition difficulty. The patient could not even do simple calculations. This impaired his professional life as well, since as a Mariner number recognition was of utmost importance. He was admitted to the Hospital and a CT scan was done which revealed a Tumour. His MRI only confirmed that Tumour was present in the left frontal lobe of the brain. The Neurosurgeon there advised immediate surgery.

THE PROCEDUREThe patient visited Dr. Rajan Shah at Nanavati Super Speciality Hospital. After a battery of pre-op tests and a functional MRI, DTI (tractography) with Navigational protocol. The patient was subjected to Awake Craniotomy, ie surgery under local anaesthesia and is ‘awake’ during the surgery, so as to assess his neurological functions in real time during surgery. The patient’s speech functions and calculations were monitored for further worsening. The patient withstood the procedure without any untoward event. The patient was asked several questions during surgery which were answered correctly by him. On completion of the surgery, the patient was transferred to CCU for a day under observation.

THE RESULT24 hours later the patient was shifted to the room. The following day, he was discharged. On follow-up the patient was found to be neurologically intact with complete recovery of the speech and calculation functions. The patient was then suggested to resume his profession.

Conscious Call

“Awake Surgery is a neurosurgical technique

and type of craniotomy that allows a surgeon to remove a Brain Tumour while the patient is awake to avoid

brain damage.”

Dr. Rajan Shah

Director and Head Department of NeurosurgeryNanavati Super Speciality Hospital, Mumbai

Dr. Chandragouda Dodagoudar

ConsultantMedical OncologyBLK Cancer CentreBLK Super Speciality Hospital, New Delhi



EVENTS AND ACTIVITIESEVENTS AND ACTIVITIES

January 2018

BLK Super Speciality Hospital had participated in the Times Health & Wellness Expo held from 16th to 17th December 2017 at Ambience Mall, Gurgaon, Haryana.

The expo was organized by The Times of India Group and witnessed participation of leading brands from the health and wellness sector.

Main activities of the Expo included knowledge sharing sessions, healthcare tips, body fat analysis etc. BLK showcased the facilities available at the hospital with a primary focus on Bariatric Surgery, Plastic Surgery and Physiotherapy.

BLK Super Speciality Hospital was the official Medical Partner for Jashn-e-Rekhta, a 3 day annual festival organized under the aegis of Rekhta Foundation to celebrate the quintessential spirit of Urdu language. BLK was also the track partners for: musical rendition by Shubha Mudgal and an interactive session by Imtiaz Ali on 9th December.

Jashn-e-Rekhta – Celebration of multi-faceted nature of Urdu – its beauty and versatility through poetry, prose, drama, art, cinema, performances, recitations, mushairas, panel discussions, debates, conversation on films and calligraphy.

BLK Super Speciality Hospital had organised a multi-speciality health camp in Rishikul Vidyapeeth School, Sonepat in Haryana on 10 December 2017. Over 500 people, mostly comprising of students, parents and teachers, attended the camp and were screened for BP, Blood Sugar, Weight, ECG, BMD and Dental check-up. Expert consultations for various specialities such as Cardiology, Internal Medicine, Child Psychology, Dental, Orthopaedic, Physiotherapy and Dietetics were given out by senior consultants.

The health camp was organized with an aim to provide specialized healthcare facilities coupled with raising awareness about health issues, prevention of diseases and general well-being of the students, parents and the teachers. Speaking about the camp, Dr. Mradul Kaushik said, “the success of the health camp has inspired the hospital to organise similar activities at other schools in Delhi NCR.”

Event Sponsorship and Health Camp

Times Health & Wellness Expo, Gurgaon

Nanavati Hospital had organised a CME & Live Surgical Workshop on Bariatric Surgery in association with Lab Guru. Dr. Jaydeep Palep − Director & Head, Department of Bariatric & Minimal Access Surgery, conducted this surgery while interacting with the doctors present at the auditorium. The surgery was live telecasted from the operation theatre. More than 100 doctors were in attendance to witness this unique surgery.

A CME on Neurosurgery & Bariatric surgery was organised in Surat, Gujarat. Dr. Rajan Shah − Director & Head, Department of Neurosurgery and Dr. Jaydeep Palep − Director & Head, Department of Bariatric & Minimal Access Surgery gave informative lectures to the local doctors of Surat. The event was attended by close to 80 doctors.

Live Bariatric Surgery at Nanavati Super Speciality Hospital

CME for Doctors in Surat



BLK & NANAVATI in NEWSJanuary 2018

SAFE EXIT - IndiaMore than 800 Bone Marrow Transplants, India’s first DCD Liver Transplant,...

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