AN AMALGAMATION OF IMUM · 2019. 2. 4. · of Sleeve Gastrectomy corrected with Roux-en-Y Gastric Bypass well detailed in this issue. There is also an intriguing story where experts

RIGHT DIAGNOSIS FOR THERIGHT TREATMENT P6

BACK TO NORMAL P9

PROPORTIONS

AN AMALGAMATION OF

ONE-TO-ONE WITH MR. ABHAY SOI

IMUM

JANUARY 2019 | ISSUE 33

BLK Super Speciality HospitalAccredited by JCI

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

24-Hour Helpline: 011- 3040 3040Email: [email protected]

[email protected]

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

MENDING THE PROBLEM FOR GOOD

by Dr. Manmohan Kamat

7

RIGHT DIAGNOSIS FOR THE RIGHT TREATMENT by Dr. Harshad Limaye

6

HI-TECH INTERVENTION FOR HIGH-RISK SURGERYby Dr. Surender K. Dabas

8

LOOKING AHEAD TO A CLEAR FUTUREby Dr. Vivek Garg

10

BACK TO NORMALby Dr. Amol Joshi

9

UNRAVELLING A COMPLICATION

by Dr. Jaydeep H. Palep& Dr. Nidhi Khandelwal

11

BLK & NANAVATI IN NEWS

14 - 15

EVENTS ANDACTIVITIES

12 - 13

FROM THE DIRECTOR’S DESK

Dear Reader,

First of all, I wish you and your family a happy and healthy New Year!

The outgoing year has been an extraordinarily successful one for our Group and the hospitals, marked by many significant and triumphant moments, foremost of which is the transaction whereby we will be acquiring a majority stake in Max Healthcare Institute Limited. This move will put us amongst the top three hospital networks in India by revenue and the fourth largest in India in terms of operating beds.

Quite naturally, the cover story of our first edition of 2019 is about this acquisition which will create significant value for all stakeholders including doctors, management and our patrons. The merged entity will operate over 3200 beds throughout 16 hospitals across India, including tertiary and quaternary care facilities offering high end critical care and super specialities.

Other stories featured in this edition include the miraculous case of how the advanced technology of the Robotic system gave a new lease of life to a 72-year-old Cancer patient from Nepal. You will also find a story of how experts at BLK Sight Centre restored improved vision in a 58-year-old patient with the help of Vue Permanente technique.

From our group hospital in Mumbai, we have the case of a 31-year-old woman with associated complications of Sleeve Gastrectomy corrected with Roux-en-Y Gastric Bypass well detailed in this issue. There is also an intriguing story where experts at Nanavati successfully closed perforation in a patient caused

02 Radiant Life Care | Newsletter | January 2019 03BLK, New Delhi | Nanavati, Mumbai

by unremoved stent from past surgery. Other stories include that of a 37-year old male patient who underwent an Exploratory Laparotomy to treat his thickened descending colon, sigmoid colon and upper rectum. Another interesting story is of how the expert doctors at Nanavati helped improve the quality of life of a 31-year-old male patient with rare presence of Hodgkin’s Lymphoma.

We are happy that we have come a long way and in the process have grown at an inspiring pace. But most importantly, we feel very fortunate and humbled to be able to make a difference in people's lives.

On behalf of the editorial team, I would like to express my gratitude to our contributors and advisers for their valuable contributions and for guiding the newsletter towards achieving excellence. If you have any more stories which will be perfect for the newsletter, do send them to us at:[email protected]. Once again, I wish you and your family the best for the New Year ahead.

Stay Healthy, Stay Happy!

CONTENT SHIKHA GIRGLA MAMTA SINGH

Nanavati Super Speciality HospitalMumbai, Editorial Team

PRAJAKTI SHIRSEKARSHYAM SHIRSEKAR

EDITOR-IN-CHIEF PARUL CHHABRA

CREATIVE CONCEPT PARUL CHHABRA SHIKHA GIRGLA

SUNIL KUMAR

DESIGN & VISUALISATION

SUNIL KUMAR

CONTENTS

Dr. Mradul KaushikDirector - Operations & Planning BLK Super Speciality Hospital New Delhi

AN AMALGAMATION OF MAXIMUM PROPORTIONS

4-5


CMD, Radiant Life Care, Mr. Abhay Soi in conversation with Editor-in-Chief, Radiant Pulse on the recent development in the group, creating value for the stakeholders and the journey ahead. Few excerpts from the interview-

Editor: As the group embarks on an exciting journey with the acquisition of Max Healthcare, how do you foresee this journey ahead?

AS: This acquisition will immediately put us in the big league. Between BLK and Nanavati, we have a capacity of 1,000 beds, and now additional 2,400 beds are in the pipeline in the Delhi-NCR region. The merged entity will operate over 3,200 beds throughout 16 hospitals across India, including tertiary and quaternary care facilities offering high-end critical and super speciality care. We plan to create substantial value by integrating proven best practices from the group hospitals and build a lasting culture of teamwork leading to expanded access of higher quality care.

We will now be among the top three hospital networks in India by revenue and the fourth largest in India in terms of operating beds.

Editor: Since now you would be a listed entity, how would you see this as a value creation for the organization and stakeholders?

AS: As we continue our mission of providing superior medical services, I believe this step of consolidation will provide substantial potential for synergizing medical and non-medical expertise, technology-in -use, clinical outcomes, geographical reach, thus creating an ecosystem of equal opportunity and growth for all stakeholders. We have achieved significant growth and expansion and with this development, we aim to increase scale by merging with a leading and complementary hospital network.

Editor: Great! How do you see this as an opportunity especially for the management and doctors?

AS: The multiple hospitals that we will now have in our Group’s fold would mean availability of many more specialists,

I believe this step of consolidation will provide substantial potential for synergizing medical and non-medical expertise, technology-in -use, clinical outcomes, geographical reach, thus creating an ecosystem of equal opportunity and growth for all stakeholders.

“

”

Mr. Abhay SoiChairman and Managing DirectorRadiant Life Care Pvt. Ltd.

Going forward, we plan to create substantial value by integrating proven best prac-tices from both the group hospi-tals and build a lasting culture of teamwork that leads to expanded access of higher quality care.

PROPORTIONS

AN AMALGAMATION OF

IMUMONE-TO-ONE WITH MR. ABHAY SOI

combined medical expertise and wider access to advanced technologies. We will continue to focus on more robust capacity building measures for the doctors and other medical professionals. They can also look forward to more intra-group collaborations on unique and challenging cases requiring in-depth expertise and experience.

Editor: BLK and Nanavati are both metro centric hospitals in Delhi and Mumbai, respectively. Does this approach of selecting a metro centric hospital make for a successful business model?

AS: Yes, the location and presence of the hospital make a huge difference. What I understand is a more metro centric model than the non-metro centric one. Having said that there are other factors as well like availability of quaternary care facilities, infrastructure, technology, renowned doctors, etc. which are more viable in metros than in the B and C cities. So, what I am actually seeing is, as smaller nursing homes, single speciality hospitals, labs, so on and so forth mushroom up in smaller cities and towns, less people are coming from

smaller cities to bigger cities for basic primary, secondary and maybe low-end tertiary care. However, as far as quaternary care is concerned, which is transplants, revision surgeries for joints etc., more people from metros are coming to avail such facilities. Again, this business is supplanted by the international medical tourism business that we have been able to attract quite well.

Both BLK and Nanavati are located in arguably the two best micro-markets and the two best metros of India. And this I believe where our capabilities are. With this acquisition now we would have a similar platform.

Editor: Lastly, what is the next milestone for the group?

AS: Though this acquisition will provide us with a large platform to operate but taking into cognizance the challenges that we might face in running a consortium of this size, it is important to have right synergies in place. Our next milestone would be to consolidate and create one comprehensive healthcare ecosystem at par with international standards. Secondly, we would like to be reckoned as the most well-regarded and efficient hospital and not necessarily the largest.

We will continue to focus on more robust capacity building measures for the doctors and other medical professionals. They can also look forward to more intra-group collabora-tions on unique and challeng-ing cases requiring in-depth expertise and experience

“


Xpert MTB-RIF were negative. Lung biopsy revealed no evidence of invasive fungal disease. He was started on Voriconazole. The patient developed itching all over the body and altered sensorium, but no focal deficits or neck rigidity were noted. An MRI Brain with contrast did not reveal any abnormality and CSF studies did not show any abnormality. All aerobic, TB and fungal cultures were negative. Since altered sensorium is a rare but possible side effect of Voriconazole, it was stopped. The patient improved neurologically. However, the fever spikes persisted. Due to high WBC counts, despite antibiotics, a bone marrow biopsy was done, however, histopathological and microbiological studies were normal. A PET-CT was done and it revealed a cavitating lung mass and the presence of metabolically active new left supraclavicular lymph node.

A surgical excision biopsy of the left supraclavicular lymph node was performed and it revealed the presence of classical Hodgkin’s Lymphoma and Reed Sternberg cells. The patient was started on Adriamycin, Vincristine, and Dexamethasone. Bleomycin was omitted in view of lung involvement and poor pulmonary reserve. Antitubercular therapy was stopped. The patient showed remarkable clinical benefits with weight gain, disappearance of fever and significant improvment in PFT. Lymphadenopathy and lung lesions showed near complete resolution at the end of the 4th cycle.

This is an example of atypical and rare presentation of Hodgkin’s Lymphoma as a necrotizing cavitary lung lesion, mimicking an infective pathology. There is a need for extensive investigations including multiple tissue biopsies to pin down the diagnosis.

RIGHT DIAGNOSIS FOR THE RIGHT TREATMENTRare presence of Hodgkin’s Lymphoma and how best to deal with it

A 31-year-old male patient, non-smoker, was admitted to a hospital in Mumbai for a Renal Tubular Acidosis (RTA). A CT scan was done which revealed cavitating Lung Lesion and Hilar Lymphadenopathy. Subsequently, he was put on Antitubercular therapy.

The patient was later referred to Nanavati Super Speciality Hospital with persistent fever, ongoing weight loss (59 to 41 kg) and cough despite taking ATT for 6 months.

Investigations revealed Anaemia, Leucocytosis, and High ESR. Sputum for gram stain culture, AFB smear and Xpert MTB/RIF was negative. An HRCT chest scan was done which showed consolidation with internal cavitation

and necrosis with multiple fibronodular lesions in bilateral parenchyma. A 7.5 x 5 cm necrotic lymph node was seen in the anterior superior mediastinum.

A CT guided lymph node biopsy revealed necrotic tissue. Gram stain, culture, AFB smear, TB gene Xpert MTB/RIF and fungal culture were negative. A bronchoscopy with BAL and lung biopsy revealed Aspergillus flavus in fungal culture. The serum and BAL galactomannan levels were positive. Aerobic / anaerobic culture, AFB smear,

MENDING THE PROBLEM FOR GOODExperts at Nanavati Hospital successfully closed perforation in a patient caused by unremoved stent from past surgery

Dr. Manmohan KamatHead General SurgeryMinimal Access and Laparoscopic SurgeryNanavati Super Speciality Hospital, Mumbai

A 22-year-old patient was rushed to the Emergency Department at Nanavati Super Speciality Hospital, Mumbai with pain in the periumbilical region which had gradually increased in the past 24 hours. The patient was in severe pain at the time of admission and had experienced multiple episodes of vomiting. Initial examination reported the patient's BP was 140/90 mm Hg, pulse rate was 102/min, and respiratory rate was 20/min. On further examination, the abdomen was found to be distended; guarding was present in epigastrium, left hypochondrium and periumbilical region. The patient's condition was a known case of hereditary Spherocytosis. The patient was earlier hospitalised in 2008 with chief complaints of Jaundice and abdominal pain in the right hypochondrium. The patient underwent an endoscopic procedure following which Laparoscopic Cholecystectomy and Splenectomy were done after a gap of 7-8 days.

Contrast-enhanced CT scan showed a sliver of pneumoperitoneum below the right crus of the diaphragm and extraluminal air in the vicinity of DJ flexure. A foreign body was protruding from the jejunum near the DJ flexure. In view of the above findings, an endoscopic retrieval was planned. An Upper Gastroscopy was done, but the foreign

body could not be located. Subsequently, Diagnostic Laparoscopy was performed which revealed dense adhesions. Peritoneal fluid with pus contamination was also found. Adhesiolysis was done, yet, the site of the perforation could not be identified. Finally, an Exploratory Laparotomy was then performed, and perforation with stent projecting out was located in the jejunum,

just distal to the DJ flexure. The stent was removed, and the perforation was closed. Once peritoneal lavage was given, the drain was kept, and the abdominal wall was closed in layers. Post-operative period was uneventful, and the patient was discharged on the 7th post-operative day. Follow up showed good results and the patient is doing well now.

The rate of complications arising from endo-biliary stents have

been reported to be between 8 and 10%, mortality rate of 1%, and distal migrations up to 6%.

It is reported that these stents, which undergo migration, are often expelled through natural means or remain in the intestinal tract without causing symptoms. However, in this case, the patient did not follow up with the Gastroenterologist for stent removal and had approached the hospital after 10 years with perforation peritonitis due to a migrated biliary stent.

Communication to the patient and relatives is important in case of stent placementso that removal of these stents is done in time hence avoiding any complication.

“

”Hodgkin Lymphoma is a rare type of Cancer that develops in the lymphatic system, which is a network of vessels and glands spread throughout your body.

“

”

Intra-operative image

Dr. Harshad LimayeSr. ConsultantInternal Medicine Nanavati Super Speciality Hospital Mumbai

PET CT Scan

X-Ray

A 72-year-old man from Nepal got deeply worried when he started coughing blood. Owing to his old age he was in a very vulnerable state and was desperately looking for the best treatment for his condition. He contacted BLK Super Speciality Hospital where he underwent a thorough evaluation. Additional tests and scans for his diagnosis at BLK confirmed that he had Cancer in his left lung.

Generally, in cases like this, surgery is prescribed. But keeping in view the age of the patient, location of the tumour, anticipated blood loss and delayed recovery, a traditional surgery seemed complicated. So, experts at BLK Super Speciality Hospital decided to operate on the patient with advanced robotic surgery techniques.

The patient underwent Robotic Left Lower Lobectomy with Mediastinal Lymph Node Dissection Surgery under general anaesthesia. Due to excellent magnification, 3D view and minimally invasive surgical technique, his tumour was removed with relatively less blood loss intra-operatively.

The patient was later shifted to ICU post-operatively where he took very little time to recover. Simple analgesics were provided to manage the pain. Soon the patient got discharged in a stable condition. The minimally invasive surgery technique helped the patient recover at a faster rate, which proved beneficial for the patient considering his old age. Finally, the patient went back to Nepal and is now leading a normal life.


Dr. Amol JoshiSr. Consultant General & Laparoscopic SurgeryNanavati Super Speciality Hospital, Mumbai

A 37-year-old male visited Nanavati Super Speciality Hospital, Mumbai with the chief complaint of pain in the left iliac fossa and passing of mucous and blood in stool for the past one year. He had visited other hospitals for the same problem where repeated Colonoscopies were done with no conclusive diagnosis.

The patient was admitted and started on IV fluids and antibiotics. Routine investigation results were all within normal limits. CEA levels were also found to be within normal limits. Clinically the patient was hemodynamically stable. He had tenderness in the left iliac fossa with

lumpy feel. Rectal examination was performed which revealed irregular mucosa about 4cm from the anal verge.

CT scan of abdomen and pelvis suggested of thickened descending colon, sigmoid colon and upper rectum. The patient was managed conservatively and was discharged with directions to take oral antibiotics. However, the patient came back again with similar complaints after 15 days. Abdominal findings were the same as before. As per the rectal examination, previous irregularity of mucosa was not felt.

The patient was posted for Exploratory Laparotomy. There was evidence of thickened descending colon, sigmoid and upper rectum with tethered mesenteric. Resection of the involved segment was done, and descending colon was anastomosed to lower rectum.

Post-operative period was uneventful. Histopathology reports revealed ischemic colitis. Follow up result was also favourable, and the patient is now living a normal routine life. Segmental colonic ischemic stricture in a young patient without predisposing factors or co-morbidities is a rare entity. The patient is being referred to a haematologist to rule out hypercoagulable state.

Dr. Surender K. DabasDirector – Surgical Oncology &Chief – Robotic SurgeryBLK Super Speciality Hospital, New Delhi

Resected part of Colon

An Exploratory Laparotomy is a surgical procedure performed with the objective of obtaining information that is not available via clinical diagnostic methods.

“

”

CANCER IS THE 2ND MOST COM-MON KILLER IN INDIA after cardiovascular diseases. As per the ICMR Study, LUNG CANCER IS NEXT TO BREAST AND HEAD AND NECK CANCER with an estimat-ed 1.14 lakh new cases by 2020.

HI-TECH INTERVENTION FOR HIGH-RISK SURGERYRobotic surgery gave a new lease of life to a 72-year-old Cancer patient from Nepal

BACK TO NORMALExpert team performs Exploratory Laparotomy to help patient with thickened descending colon, sigmoid colon and upper rectum

“In minimally invasive tech-niques of Robotic surgery, doctors can operate with greater control and vision. It provides a magnified, 3-D view of the sur-gical site and helps the surgeon to operate with great precision, flexibility and better control, allowing them to perform safe surgery with less blood loss.”– Dr. Surender K. Dabas

“

An active 58-year-old, Indian origin, US returned businessman, approached BLK Sight Centre with complaints of difficulty in recognising faces during his morning walk, glare while driving, difference in colour perception in both his eyes and inability to focus clearly at near objects while reading. All these problems were gradually causing hindrance in his daily activities and were affecting his confidence levels as well.

After a thorough examination of his eyes by Dr. Vivek Garg, he was diagnosed to be harbouring a cataract in his left eye, which was causing him painless, progressive loss of visual contrast and acuity in the left eye. On further discussion, the patient expressed his desire to be provided with the best, latest and state-of-the-art technology and technical expertise. After all, "the world for a person is only as much as he can see", as often told to his patients by Dr. Vivek Garg.Along with the routine Micro Incision Cataract removal, the patient was

LOOKING AHEAD TO A CLEAR FUTUREVue Permanente technique restores good vision after cataract surgery

operated at BLK Sight Centre using the "Vue Permanente" or bag-in-the-lens technique, a surgical technique that ensures that the quality of vision which is restored after the cataract surgery, is maintained permanently for life .i.e. "fit it, shut it, forget it". This technique was a favourable option for the patient as the patient will never have posterior capsular opacification, will never need any secondary procedure for his lens management like Nd Yag Capsulotomy. He will always have excellent visual contrast, and more importantly, he will be saved from spending a few years of his life harbouring PCO, waiting for it to grow sufficiently enough to be treated.

A limitation of this surgical technique is that at present it can make corrections in the spherical component of far vision only. If the patient has more than 1.5 D astigmatism at corneal plane, or if the patient wants to see near objects without glasses than this is not the procedure of choice for him.


UNRAVELLING A COMPLICATIONSleeve Gastrectomy complications corrected with Roux-en-Y Gastric Bypass

Dr. Jaydeep H. PalepDirector & HODBariatric and Minimal Access SurgeryNanavati Super Speciality Hospital, Mumbai

A 31-year-old woman, weighing 130 kgs with a BMI of 42.6 kg/m2, underwent a Sleeve Gastrectomy procedure. Immediately post surgery, she complained of nausea and vomiting, which is common for a few days post any Bariatric Surgery. After her discharge, she came back within 2 days with complaints of persistent nausea, vomiting and abdominal pain. She underwent a CT scan, which showed oral contrast was not passing down into the duodenum, indicative of Gastric Outlet Obstruction.

An Upper GI endoscopy was done, which showed a twist in the stomach (Gastric Torsion) at the level of the Incisura Angularis. This is an extremely rare complication post

Sleeve Gastrectomy. The patient, then underwent an emergency Laparoscopy, wherein the experts at Nanavati Super Speciality Hospital stapled across the torsion site, similar to a Stricturoplasty.

However, there was no considerable improvement. Subsequently, Sleeve Gastrectomy was converted to a Roux-en-Y Gastric Bypass. The CT scan post Roux-en-Y Gastric Bypass showed a smooth passage of oral contrast down into the jejunum. After almost 11 days of starving since the first surgery, the patient was finally able to tolerate all food orally.

Though complications are rare post Bariatric Surgery, it is important to be alert, and have enough clinical experience to diagnose and treat them appropriately and well in time.

SLEEVE GASTRECTOMY IS A SURGICAL WEIGHT-LOSS procedure in which the stomach is reduced to about 15% OF ITS ORIGINAL SIZE, by surgical removal of a large portion of the stomach along the greater curvature.

Dr. Vivek GargAssociate ConsultantOphthalmologyBLK Super Speciality Hospital, New Delhi

The bag-in-the-lens implant is a monofocal spherical hydrophilic intraocular lens comprised of a 5mm bi-convex optic with two elliptical plane haptics.

“

”

The Laparoscopy was ineffec-tive and we then had to convert the Sleeve Gastrectomy to a Roux-en-Y Gastric Bypass. The CT scan post Roux-en-Y Gas-tric Bypass showed a smooth passage of oral contrast down into the jejunum. After almost 11 days of starving since the 1st surgery, the patient was finally able to tolerate all food orally.

“

Endoscopy: showing twisted & edematous gastric mucosa, with collected mucous

Intra-op picture showing torsion of stomach

Dr. Nidhi KhandelwalAssociate Consultant Bariatric and Minimal Access SurgeryNanavati Super Speciality Hospital, Mumbai


EVENTS AND ACTIVITIES

3

2

A REVOLUTIONARY TREATMENT FOR PARKINSON’SBROUGHT TO INDIA BY NANAVATI HOSPITAL

INTERNATIONAL EVENTS

OPD IN DIBRUGARH

X-MAS CELEBRATION & EMPLOYEE RECOGNITION

Nanavati Super Speciality Hospital in association with Ohio State University, USA held an ‘International Emerging Infectious Diseases Conference’ on 1st and 2nd December 2018. The event was inaugurated by Mr. Edgard D. Kagan – US Consulate General. Renowned national and international speakers exchanged ideas and approaches for the management of infectious diseases in India.

BLK Super Speciality Hospital has recently started Bone and Joint Special OPD Services at Dibrugarh in association with Archana Trauma and Orthopaedics Hospital.

BLK Super Speciality Hospital had hosted a Christmas Day celebration for the entire BLK family. The festivity was marked by entertaining performances by staff members, delectable array of hors d'oeuvres, rewards and recognition. The winners of the Employee Recognition Awards announced at the event were: Employee of the month- Mr. Suraj Walia (Senior Executive- Accounts & Finance); Doctor of the month- Dr. Ajay Kumar Singh (Resident-CTVS); Nurse of the month- Ms. Kirti Koundil (Staff Nurse-Nursing); GDA of the month- Mr. Sita Ram (Shine & Standard); Contractual worker of the month- Mr. Arvind Kumar Jain (Security Guard-Swift Securitas).

Nanavati Super Speciality Hospital in collaboration with the National Parkinson's Centre of Excellence – King's College, London, launched a revolutionary treatment for Parkinson's - Non-Oral Infusion Therapies for the first time in India. The event was inaugurated by Hon'ble Health Minister of Maharashtra, Dr. Deepak Sawant and Member of Parliament, Padma Shri, Paresh Rawal on 5th December 2018. As part of the event a symposium on Continuous Dopaminergic Therapy for Parkinson's Disease was organised by Dr. Nita Shah – Senior Consultant, Neurology, Dr. Anil Venkitachalam – Consultant, Neurology and Dr. Ali Irani – Head, Physiotherapy & Rehabilitation Centre. The symposium had witnessed participation of more than 150 delegates.

BLK Super Speciality Hospital had recently participated in FICCI Advantage Healthcare Exhibition held from 4th – 6th December 2018 at India Expo Center & Mart, Greater Noida.Live session of Dr. Surender Dabas on Robotic Surgery & a Plenary Session on Technology in Indian Healthcare System moderated by Dr. Manav Wadhawan were some of the key highlights.The exhibition witnessed visitors and delegates from over 60 countries including, Uzbekistan, Kazakhstan, Tajikistan, Nigeria, Kenya, Sudan, Ghana, Myanmar, Mongolia, Afghanistan, Oman, Iraq and Bahrain, to name a few. At the exhibition, the BLK stall was visited by close to 300 visitors over a period of 3 days.

BLK EVENT


BLK AND NANAVATI IN NEWS

Documents

AN AMALGAMATION OF IMUM · 2019. 2. 4. · of Sleeve Gastrectomy corrected with Roux-en-Y Gastric Bypass well detailed in this issue. There is also an intriguing story where experts