blk performs country’s first successful dcd liver … a life even after death blk performs...

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

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Nanavati Super Speciality HospitalSwami Vivekanand Road, Vile Parle West,Mumbai, Maharashtra- 400 05624-Hour Helpline: +91-22-26267500www.nanavatihospital.org

Nanavati

GIFTING A LIFEEVEN AFTER DEATH

BLK performs country’s first successfulDCD Liver Transplant

LUXURY OFWALKING REGAINED

An international patient fromNigeria fights odds to walk again

JUNE 2017 | ISSUE 15

Radiant

PULSE

Radiant Life Care | Newsletter June 2017

03Radiant Life CareBLK, New Delhi | Nanavati, Mumbai

Naresh Kapoor

Executive DirectorRadiant Life Care

Dear Readers, Our group has always put innovation and adoption of new techniques in treatment on top of all the programs. We are very proud to announce that BLK Super Speciality Hospital, New Delhi has been able to prove itself equal to all the challenges and has earned another incredible feather on its cap when our doctors from department of Liver Transplant led by Dr. Sanjay Singh Negi successfully conducted a Liver Transplant surgery after harvesting liver from a donor post his cardiac death, which is possibly the first reported case of successful DCD Liver Transplant in India. The current issue covers this transplant story and we feel that going forward more and more patients would be benefitted from this technique as we spread awareness about the same. We have other intriguing stories from our team of doctors at Nanavati which includes the case of a Mumbai-based businessman who had to be airlifted from a European country as he suddenly developed uncontrollable fever, which was later diagnosed as Lyme’s Disease and the case of a 35 year old lady from Nigeria who had been left immobile due to Sickle Cell Disease as well as hip disability but was able to regain movement again post her Total Hip Replacement surgery. In the month of May, BLK has entered into a strategic agreement with Ministry of Health -Khartoum State, Republic of Sudan. The bilateral agreement aims to set up a platform for mutual sharing of medical, scientific and educational collaborations, which will further help to strengthen the healthcare system of Sudan. This will benefit people of Sudan through regular outreach programs by BLK doctors and also enhance the presence of BLK in other African countries. Nurses being the backbone of our healthcare delivery system, we very proudly celebrated International Nurses Day at both the Group hospitals and glimpses of celebrations can be seen in the Events and Activities page. If you have any story to share, our editorial team would be happy to receive them. Ideas to improve the newsletter along with other opinions and feedback are welcome at [email protected], as always. Stay healthy, stay happy!

FROM THE ED’S DESK

EDITOR-IN-CHIEF PARUL CHHABRA

CREATIVE CONCEPT PARUL CHHABRA / SHIKHA GIRGLA /

SUNIL KUMAR

DESIGN & VISUALISATION

SUNIL KUMAR

CONTENT SHIKHA GIRGLA /

MAMTA SINGH

Nanavati Super Speciality HospitalMumbai, Editorial Team

AVANTI PAWAR

PRAJAKTI SHIRSEKAR

SHYAM SHIRSEKAR

C O N T E N T S

SOUND TREATMENT THAT REVIVES HOPEby Dr. Vikash Kumar

4

GIFTING A LIFE EVEN AFTER DEATHby Dr. Sanjay Singh Negi

6-7

DEALING WITH A MYSTERIOUS CONDITIONby Dr. Harshad Limaye

9

SQUAMOUS CELL CANCERby Dr. Sudeep Sarkar

11

BLK & NANAVATI IN NEWS

14-15

LUXURY OF WALKING REGAINED

by Prof. Pradeep B. Bhosale

5

TAKING A FREE KICK AGAINby Dr. Mrinal Sharma

8

RAREST OF THE RAREby Dr. Pankaj Kumar Pande

10

EVENTS AND ACTIVITIES

12-13

Luxury of Walking RegainedAn International patient from Nigeria fights all odds to walk again

Sound Treatment That Revives HopeCyberknife Radiosurgery in a case of Bilateral Acoustic Neuroma

THE CASEA 43 year old male from Nigeria, a known Hypertensive, was admitted to BLK Super Speciality Hospital, New Delhi with a history of diminished hearing from the left ear and gait instability. On evaluation, the MRI brain revealed extra-axial mass in bilateral cerebello-pontine (CP) angle with mass effect in left side and upstream ventricular dilatation, suggestive of Acoustic Neuroma. He underwent decompression surgery in 2010 in Nigeria. He was advised for Radiosurgery but could not undergo the same due to logistic reasons. He was well until May 2016 when he suddenly experienced severe headache. The MRI revealed increase in the size of lesion with hydrocephalus. Subsequently, he underwent VP shunt placement in June 2016 followed by microsurgery for the left CP angle tumour in July 2016 elsewhere. After surgery he developed diminished vision in both the eyes, facial deviation and incomplete closure of the left eye.

He was brought to BLK in April 2017. On examination, his higher mental functions were normal with ataxia and left sided facial palsy. The MR scan showed heterogeneously enhancing mass lesions in the B / L cerebello-pontine angle cistern extending to the B / L internal auditory meatus causing indentation of the brain stem, pons and extending along the dural margin to the premedullary cistern. The pure tone audiometry showed moderate to severe sensori-neural hearing loss in left side and moderate sensory neural hearing loss in the right side.

THE PROCEDUREHe was planned for Cyberknife Radiosurgery for the right CP angle mass to be followed by interval Cyberknife treatment for the left side CP angle mass after 6 months. After informed consent, the patient was taken for treatment planning. An orfit uniframe was fabricated for immobilisation and reproducibility. The simulation was carried out with CT scan and MR Image fusion was done for target and organs at risk of delineation. A dose of 1650 cGy in 3 fractions was prescribed at 80% isodose level covering 95% of the target volume (GTV). The treatment planning was performed on MultiPlan® ver. 4.6 as per the prescribed dosage and OARs constraints. The dose to 95% of the GTV was 1651 cGy with conformity index (CI) 1.14 and homogeneity index 1.27. The beams were planned in such a manner that there was no entry or exit beams from the eyes and the dose fall off to the brain stem and right cochlea were well below the tolerance limit.

THE RESULTThe patient withstood the treatment very well and there was no acute treatment related complication. He was sent back to his country on the next day of the treatment.

“Cyberknife is a non-surgical, painless, cutting-edge technol-ogy that offers patients treat-ment with significantly fewer complications and lower risk

than open surgery.”

Beam arrangements, dose volume histograms and

dose statistics

Dr. Vikash Kumar

Sr. ConsultantBLK Cyberknife CentreBLK Super SpecialityHospital, New Delhi

THE CASEA 35-year old lady was referred to the Advanced Joint Replacement Centre at Nanavati Super Speciality Hospital, Mumbai from Kenya. She was unable to walk due to restricted hip mobility with a significant difficulty to walk. She was suffering from Sickle Cell Disease (SCD) which entails sickle shape RBCs that are prone to cause blockage of capillaries during blood circulation. Her sickling index was 98% which meant her RBCs were abnormal, being sickle shaped. This condition can lead to sickling crisis causing acute abdomen pain due to vascular blockage of intestinal blood supply and bleeding tendency. Pre-operative meticulous planning is required to bring sickling index below 30% by Blood Transfusion using an ultra-modern exchange transfusion machine.

THE PROCEDUREThe surgery was conducted with proper pre-operative planning for a disease with confirmed sickling index of less than 30% with normal bleeding and clotting profile. The anticipated surgical difficulties were Protrrusio (intra pelvic migration of hip), large Supra-acetabular Bone Cyst 40mm X 20mm in size, poor bone quality, risk of bleeding and higher incidence of infection. Total hip joint was re-structured after reconstructing Protrrusio and Supra-acetabular Bone Defect using Impaction Bone Graft, continuum trabecular metal coated titanium cementless cup (Zimmer) with 3 anchoring screws and 36 mm delta ceramic head. THE RESULTThe Total Hip Replacement (THR) cementless construct was stable enough to allow the patient to be able to walk bearing full weight on the first day of surgery itself. After a year of follow-up, the patient has near normal ambulatory activity with complete Osteo-integration of Hip Implants.

Dr. (Prof.) Pradeep Bhosale

Director, Arthritis & Joint Replacement SurgeryNanavati Super SpecialityHospital, Mumbai

Pre-operative X-ray showing changes of Arthritis, Protrussio

and Supra-acetabular Cyst

One year post – operative X-ray showing complete remodelling of Acetabulum with THR Implant

Supra-acetabularCyst

Protrrusio



Gifting a Life Even After DeathBLK performs country’s first successful DCD Liver Transplant

THE CASEA 45 year old patient, Atul Saluja, underwent successful Liver Trans-plant at BLK Super Speciality Hospital, New Delhi. What made it a milestone case was the fact that the patient received the liver from a donor post his cardiac death, making it a classic example of ‘Donation After Cardiac Death’ or DCD. As per the available data, there are re-ported cases of DCD of kidney in India but none for liver. The degree of complexities involved in this case as against Kidney Transplant, makes it more challenging and special. The success of this case also demonstrates the growing capabilities and expertise of the surgeons in India. What went in favour of Atul Saluja was the readiness of the family of the deceased ― a 60-year-old man who suffered a cardio-respiratory arrest and was surviving on mechanical support. After much consid-eration, the family agreed to go in for the donation. The donor had a history of Hypertension, Diabetes and Coronary Artery Disease. He had suffered one cardio-respiratory arrest already and was awaiting another.

THE PROCEDUREOrgan Transplants in India are usually done from brain dead donors where the blood circulation is intact, cells are normally perfused and organs are still functioning at the cellular level. In case of DCD, blood supply to organ is briefly absent, causing the tissues to become starved of oxygen, a condition known as ischemia. Unlike kidneys which have long warm ischemia time of about 2 hours, the challenge in Liver Transplant is shorter ischemia time of 30 minutes requiring the graft to be re-perfused very fast.

Dr. Sanjay Singh Negi

Sr. Consultant and DirectorBLK Centre for HPB Surgery & Liver TransplantBLK Super Speciality Hospital, New Delhi

“We are glad at having achieved this feat of success-ful DCD, which is certainly

a rare one, and opens up avenues for many needy

patients. This case can, in fact, pave way for a new

trend and go a long way in addressing donor gaps in the

country.”

“At BLK Super Speciality Hospital, we have made a

conscious effort through our flagship initiative Recycle

Life to keep alive the legacy of those who give others a

chance to live. Aligned to our honourable Prime Minister’s appeal for highlighting the need for Organ Donation,

we encourage people to join hands to pledge their organs

and make a difference.”

Since time was of critical significance, the team did not lose any moment and the complex transplant operation was swiftly accomplished. The critical care team led by Dr. Amit Singhal, Associate Director, HPB Surgery & Liver Transplantation, Anaesthesia and Critical Care at BLK Super Speciality Hospital, played a pivotal role through the turbulent intra-operative and post-operative period.

THE RESULTAtul’s body received the donated organ quite well and under the supervision of the doctors, he recovered fast and had since been discharged. He has been advised to take his medicines on time and to lead a near normal life.

DISCUSSIONWhile Western countries have used DCD for a long time, somehow India has been lagging behind due to reluctance of families to donate organs. Donation After Cardiac Death can help bridge the wide gap between demand and supply of organs. In India, less than 5,000 Kidney Transplants are carried out annually against an estimated requirement of over 175,000. Similarly, only 1,000 Liver Transplants are performed every year in a country where over 50,000 die due to end stage liver diseases, mostly related to preventable causes like Hepatitis B and Hepatitis C. The annual requirement of hearts is estimated to be around 50,000 and lungs about 20,000. But the rate of Organ Donation is as low as 0.3 per million population (PMP). BLK Super Speciality Hospital has been at the forefront of Organ Donation. Through its Recycle Life initiative, the hospital has been carrying out campaigns to encourage people to come forward and learn about many aspects of Organ Donation. In India, due to lack of knowledge about Organ Donation, many people ignore to register for Organ Donation with the national registry maintained by National Organ & Tissue Transplant Organisation.

Other factors like myths and misconceptions discourage potential donors from making the decision to donate organs or tissues after death. If more and more people come forward and take the pledge to donate their organs, it can end up saving a lot of lives.


Patient Atul Saluja post surgery


Dr. Mrinal Sharma

Consultant Joint Replacement SpecialistBLK Centre for Orthopaedics, Joint Reconstruction & Spine SurgeryBLK Super SpecialityHospital, New Delhi

THE CASEA 61 year old businessman was brought to Nanavati Super Speciality Hospital, Mumbai with a history of high-grade fever, minor breathlessness, debilitating joint pains associated with significant swelling for a few weeks. In the previous 30 days, the patient had been travelling internationally to Paris and then to Sri Lanka for business-related work. He developed the first fever spike while in Paris and was treated there on an OPD basis with only partial relief. A few days later, he needed hospitalisation for recurrence of fever and breathlessness in Sri Lanka.

He was found to have normal CBC, elevated CRP, Atrial Fibrillation and Left Bundle Branch Block (LBBB) with preserved Ejection Fraction (EF) and interstitial shadows in both lung fields on CT chest. He was investigated for Atypical Pneumonia, but no cause was found. He did not respond to higher antibiotics, amiodarone and supportive treatment and, hence, was airlifted to Mumbai after 4 days. The patient was first admitted to another tertiary care hospital in Mumbai where he continued to have fever spikes and dyspnoea with significant worsening of joint pains.

As his fever and infective markers were worsening, his antibiotics were stepped up to vancomycin and meropenem with no relief to his symptoms. At this point, he was referred to Nanavati Super Speciality Hospital with extensive investigations for pyrexia of unknown origin that had not revealed any specific cause.

In view of his recent history of travel, recurrent fever spells, Cardiac Arrhythmias and Oligoarticular Arthritis, a diagnosis of Lyme’s disease was considered. His higher antibiotics were stopped and the patient was put on Doxycycline. Simultaneously, his borrelia burgdorferi IgM was obtained, which was strongly positive.

THE RESULTWithin 2 to 3 days, the fever and synovitis showed significant resolution and the patient was discharged. The recovery was rather uneventful. The patient was advised for a follow-up visit after two weeks. During the follow-up, doctors observed no fever and joint pains even after stopping the NSAIDs. The patient could resume his normal routine without any difficulty.

Dr. Harshad Limaye

Sr. Consultant Internal MedicineNanavati Super Speciality Hospital, Mumbai

Taking a Free Kick Again Dealing with aMysterious ConditionSoccer player gets back on his feet after being

grounded by a knee injuryLyme’s Disease - a rare phenomenon

THE CASEUinga, a 7 feet tall soccer player from Tuvalu suffered from a debilitating stiffness of joints 5 years ago due to a knee injury which made him bedridden and dependent. He developed deformities and stiffness in his knees, hips and ankle joints. He was suggested to consult Dr. Mrinal Sharma at BLK Super Speciality Hospital, New Delhi.

THE PROCEDUREDue to his condition, Uinga faced challenges while moving his knee joints and any other movement was next to impossible. Dr. Mrinal had to take bone cuts without dislocating the knee joints. Since there was little movement at his hips due to contracture, the flexion and extension was limited. Even the largest size of implant seemed small for this 7 feet tall soccer player. Dr. Sharma had to use special constrained implants (TC3 Depuy) to stabilise and balance the knee.

THE RESULTThe surgery was successful and the patient was made to stand with the walker the very next day. He started walking without pain in next few days and achieved good range of motion in his knees. He underwent rigorous physiotherapy and was quite content with his outcome.

• Lyme’s disease is a bacterial infection caused by spirochete borrelia which is transmitted by tick bite. Its symptoms include multi-system manifestations.

• Diagnosis is mostly clinical with serological confirmation. History of tick bite and presence of erythema marginatum is useful but not present every time (as in the case of our patient, which made the diagnosis more difficult).

• Taking into account the history of the patient, considering clinical manifestations in the right context, minimal but relevant investigations can give a quick diagnosis of even relatively rare conditions.

• Higher antibiotics are not a panacea for all infective PUOs. As in this case, all that was needed was good old Doxycycline + NSAIDs.


Pre operative X-ray

Post operative X-ray


Dr. Pankaj Kumar Pande

Sr. ConsultantSurgical OncologyBLK Cancer CentreBLK Super Speciality Hospital, New Delhi

Rarest of the Rare Squamous Cell CancerA Pathologic Surprise in the form of Neuroendocrine Tumour

Timely detection saves livelihood of a teacher

CT scan showing large mass lesion left lobe liver

Resected left Lobectomy specimen with Tumour

Dr. Sudeep Sarkar

Sr. ConsultantOncosurgeryNanavati Super Speciality Hospital, Mumbai

Pre-operative

Post-operative

Cancer Wing

Primary Hepatic Neuroendocrine Tumours are extremely rare, with only about 150 reported cases in the world. Most primary Hepatic Neuroendocrine Tumours occur mostly in middle-aged females. Effective treatment methods for cure includes, Surgical Resection, Liver Transplantation, Somatostatin Analogues and Chemotherapy.

THE CASEA 58 year old lady from Afghanistan came to BLK Super Speciality Hospital, New Delhi with complaints of pain over her right upper abdomen for the past 4 months with intermittent non-bilious vomiting. On examination she had a palpable lump in the epigastium of about 5 x 4 cms in size. Triphasic whole body PET CT scan revealed a large mass lesion with no abnormal FDG uptake in left lobe of liver measuring 70 x 70 x 72 mm3. Few cystic enhancing areas were seen within. Non FDG avid large heterogeneous mass lesion with associated necrosis, fat, areas of enhancement and calcification were seen in the left side pelvic cavity of 74 x 71 mm2 dimension - which is a likely ovarian dermoid cyst. No other metabolic activity elsewhere were noticed in the body.

THE PROCEDUREThe patient was planned for surgery, i.e. Exploratory Laparotomy. Excision of left ovarian mass with frozen section was done, which revealed a dermoid cyst. Type 1 Hysterectomy and right Salpingoophorectomy along with left Lobectomy liver with excision of hepatic node was performed. Histoptholgy revealed Neuroendocrine Tumour grade 2 and positive Hepatic Node and Cystic Teratoma of ovary.

THE RESULTThe patient withstood the procedure well and had a steady recovery post-operatively. She was discharged on seventh post-operative day. She was advised to undergo a DOTA-PET on her next follow-up to rule out Metastatic Neuroendocrine Tumour.

DISCUSSIONMature Cystic Teratoma of the ovary is almost always benign, but in approximately 0.2-2% of cases, it may undergo malignant transformation. Surgery offers the best chance of cure. Primary Hepatic Neuroendocrine Carcinoma should be considered as a possible differential diagnosis in the management of Hepatic Tumours. The liver can be the primary origin of Neuroendocrine Tumours and if the tumours are diagnosed as primary Hepatic Neuroendocrine Tumours, surgical resection must be considered for curative treatment.

THE CASEA 58 year old lady was diagnosed with an ulcer over the left lateral border of the tongue that hadn’t healed even after being treated by her family physician for 3 months . On examination, a 3 x 2 cm ulcer was seen against her sharp left lower canine. A biopsy from the ulcer confirmed the diagnosis of Squamous Cell Cancer. Additional investigations with MRI of the head and neck were conducted to confirm the extent of the disease. The patient was informed of the need for Hemiglossectomy (removal of left half of the tongue) and dissection of the lymph nodes in the neck.

THE PROCEDUREThe patient underwent left Hemiglossectomy with left modified radical neck (spinal accessory nerve and internal jugular vein preserving) dissection. The defect was reconstructed by microvascular free tissue transfer from the left forearm (free radial artery forearm flap).

THE RESULTThe patient was discharged on the fifth day post operation and was advised a normal liquid and soft diet. At the follow-up two weeks later, the patient was extremely satisfied with the cosmetic and functional outcome (speech and swallowing) after the removal of half of her tongue. She has now resumed her profession as a school teacher.

The advent of modern reconstruction work like the one illustrated above have made a quantum leap towards cosmetic and functional rehabilitation in patients with Oral Cancer and these patients can now confidently resume their daily routine after major cancer operations of the head, face and neck region.



EVENTS AND ACTIVITIES

Collaboration

BLK Event Calendar

International Nurses Day Celebration

NSSH Celebrates World Thalassemia Day

The week long celebrations of nursing week concluded in a grand way on the special occasion of Nursing Day on 12th May, 2017 along with the monthly employee engagement function “Connexions”. The event saw “Pledge taking ceremony” and distribution of “Proud to be a nurse” badges to all nursing staff by the Nursing Superintendent. The celebrations also witnessed various performances by the talented nursing staff. Other than the monthly employee recognition, various other awards and recognitions were also distributed based on the competition held during the week.

Left to RightMs. Rosamma Jose (Nursing Superintendent), Ms. Parul Chhabra (AGM- Corporate Communication & Marketing), Mr. Sunil Kumar (Employee of the Month), Ms. Rita Choudhrie (Chairperson), Mr. Naresh Kapoor (Executive Director), Dr. Brijendra Singh (Doctor of the Month), Mr. Jitender Sharma (Head- F&B), Ms. Jamuna (Contractual Worker of the Month), Mr. Tiju Scaria (Nurse of the Month), Ms. Poonam (GDA of the Month) and Ms. Kanika Saha (Senior Manager- Housekeeping)

On World Thalassemia Day, 8th May 2017, Nanavati Super Speciality Hospital had organised an awareness program ‘Together for Humanity’. Lectures on ‘Thalassemia’ were delivered by: Dr. Niranjan Rathod, Associate Director & HOD, Bone Marrow Transplant & Haemato - Oncology, Dr. Nimish Kulkarni, Associate Consultant, Bone Marrow Transplant and Dr. Rinku Bhatia, HOD, Transfusion Medicine. More than 150 people took part in this event. Special momentoes were presented to Thalassemic patients, who also took stage to express their heartfelt thanks to blood donors and gave inspiring speeches to help promote blood donation.

The International Nurses Day was celebrated with great aplomb on 17th May, 2017 at Nanavati Super Speciality Hospital. Mr. Abhay Soi, CMD, Radiant Life Care presided over the celebration as the Chief Guest whereas Dr. Deepak Patkar, Director - Medical Services was the Guest of Honour. Mrs. Mugdha Lad, the Chief Nursing Officer, while elaborating on this year’s theme “Nurses: A voice to lead and achieve sustainable development goals” spoke about how each nurse can be a voice to lead at the individual, professional and multi-disciplinary team levels. Various nursing teams put up incredible performances that included a fashion show and a group dance. Dr. Ajit Dandekar, HOD - Mental Health Department took a session on stress management.


BLK Super Speciality Hospital has entered into a special pact with three different agencies of Republic of Sudan with the broader aim to promote cooperation and mutual understanding between the two countries and develop educational, scientific and medical cooperation for excellence through knowledge, skills transfer and capacity building.

Speaking on this collaboration, Mr. Naresh Kapoor, Executive Director, BLK Super Speciality Hospital, said, “We are indeed happy to collaborate with these three institutions in Sudan. We shall promote exchange of resources for educational and scientific research programs, besides organising development of joint international projects and conducting research on areas of common interest.”

BLK Super Speciality Hospital, New Delhi, India inks pact with• Ministry of Health,

Khartoum State• Takaful Association,

Ministry of Development and Human Resources and Labor Khartoum State

• Custom Authority, Republic of Sudan


BLK & NANAVATI in NEWSRadiant Life Care | Newsletter June 2017


blk performs country’s first successful dcd liver … a life even after death blk performs...

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