BREACHING BARRIERS& Liver Transplant BLK Super Speciality Hospital, New Delhi “In our endeavor to offer the state-of-the-art clinical services to our patient, we saw an opportunity

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

Radiant

PULSEAPRIL 2018 | ISSUE 25

BREACHING BARRIERS ABO Incompatible Living Donor Liver Transplant

IN SAFE HANDSSalvaging a nearly amputated finger

Radiant Life Care | Newsletter

03Radiant Life CareBLK, New Delhi | Nanavati, Mumbai

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

April 2018

FROM THE DIRECTOR’S DESK

Dr. Mradul KaushikDirector-

Operations and PlanningRadiant Life Care

Dear Reader, Month after month, we feature some of the unique cases from our group hospitals which reflect our passion for healing. In keeping that tradition alive, we bring to you this month few intriguing and challenging cases along with some good to know medical facts, among others. The cover story features the case of a man with a terminal liver disease who got a new lease on life after a team of doctors at BLK Super Speciality Hospital performed the first ABO-Incompatible Living Donor Liver Transplant. This case is a milestone achievement that has the potential to turn around the stories of thousands of people living with end stage liver diseases like Cirrhosis. Other stories in this issue include the case of an elderly gentleman from the Netherlands who had a sudden attack of Community Acquired Pneumonia and that of four obese ladies who underwent Single Incision Laparoscopic Sleeve Gastrectomy and got back to shape with just a tiny scar below the belly button. There is also a poignant case of a man who nearly got one of his fingers cut off by the Chinese Manjha on the day of Makar Sankranti but was saved in the nick of time by the Plastic Surgery team at Nanavati Super Speciality Hospital. It is always a matter of great pride for us when one of our group hospitals is recognised for its contribution in driving excellence for quality health care delivery. Last month, BLK had the privilege of being conferred with the AHPI Award for Quality Beyond Accreditation for the second consecutive year. Congratulations to the entire BLK family for this momentous achievement! To our contributors, the editorial team shares its gratitude. Our special thanks to the first time contributors with the hope that they will regularly share their pieces with us. If you have any feedback on any of the stories featured here or if you would like to share any thought related to this newsletter, you can write to us at: [email protected]. Stay Healthy, Stay Happy!

C O N T E N T S

CARE IN TOTALITYby Dr. Shikha Halder

4

BACK ON THE FEETby Dr. Puneet Girdhar & Dr. Bhupendra Bharti

9

TOO BIG TO BE GOODby Dr. Salil Shirodkar & Dr. Jaideep Rajebahaddur

11

BLK & NANAVATI IN NEWS

14-15

TROUBLE UNANNOUNCEDby Dr. Navneet Singh & Dr. Ravi Charan S

5

IN SAFE HANDSby Dr. Anshuman Manaswi

8

EVENTS AND ACTIVITIES

12-13

BREACHING BARRIERSby Dr. (Prof.) Sanjay Singh Negi & Dr. Rasika Setia

6-7

FIT BODY, FIT MINDby Dr. Jaydeep H. Palep & Dr. Nidhi Khandelwal

10

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300



April 2018

Indications for TBI

◆ Certain Indications: Leukaemias in adults and childhood

• Acute Lymphoblastic Leukaemia (ALL)

• Acute Myeloid Leukaemia (AML)

• Chronic Myeloid Leukaemia (CML)

• Myelodysplastic Syndrome (MDS)

◆ Optional Indications: Solid Tumours in childhood

• Neuroblastoma• Ewings’ Sarcoma• Plasmocytomas / Multiple

Myeloma• Non-Hodgkin’s Lymphoma

(NH)

Total Body Irradiation (TBI) is an important component of Haematopoietic Stem Cell Transplant (HSCT), with the goal of eradicating residual malignant cells and modulating the immune system of the transplant recipient. TBI is advantageous because biologic effects can be exerted uniformly, without sparing of “sanctuary” sites like the nervous system or testes and without interference from metabolic or resistance processes. It also reduces graft versus host disease.

TBI differs from conventional radiation therapy in several unique ways. The limited maximum apertures available from teletherapy machines complicate it. Dose uniformity is compromised by tissue in homogeneities (i.e., variations in both body parts, thickness and tissue density). If the skin and the bone marrow are targeted for treatment, then the build-up region becomes a concern, especially for linac energies. Critical organ shielding must balance toxicity and control of circulating leukaemic cells. Thus, protocols often specify low dose rates to minimise toxicity.

Although the haematopoietic system is the target of TBI, normal tissues effectively limit the dose that can be safely delivered. The sparing of normal tissues with fractionated TBI was proposed by Peters and colleagues, showing less lung injury with fractionated TBI regimens.

Early reversible toxicity of radio-chemotherapy (partly with high risk of lethality) include nausea and vomiting, mucositis (oropharyngeal, gastro-intestinal), bone marrow aplasia, infections, haemorrhage, interstitial pneumonitis, alopecia, nail growth disorder and parotitis. Late toxicity of radio-chemotherapy include endocrine and reproductive gonadal insufficiency, growth disorders (in childhood), hypothyreosis, lung fibrosis, cataract, secondary malignancies, irreversible alopecia and cardiomyopathy.

BLK ExperienceSince 2009, BLK has treated 180 patients with TBI for various conditions ranging from aplastic anaemia to peripheral T cell Lymphoma. Of these, 98 patients were treated with short course - single fraction TBI of 2 Gy and 82 patients were treated with long course – 12 Gy in three days TBI i.e. 2 Gy per fraction BD, 12 hours apart. For long course, lung shield and kidney blocks were used.

Care In TotalityTotal Body Irradiation Post Stem Cell Transplant

Dr. Shikha Halder

Director & Senior Consultant Radiation OncologyBLK Super Speciality Hospital, New Delhi

Thymus Shielding in Total Body Irradiation (TBI) After Treatment

Before Treatment

Dr. Navneet Singh

Director Accident and Emergency Nanavati & BLK Super Speciality Hospital

Dr. Ravi Charan S

In charge and Coordinator Accident and Emergency Nanavati Super Speciality Hospital, Mumbai

Trouble UnannouncedAn Unusual Case of Community Acquired Pneumonia

THE CASE

A 57-year old Dutch national on a business trip to India was brought to the emergency department of Nanavati with a history of high grade fever for the past 4 days which was not subsiding with oral medications. He also had complaints of breathlessness which had started a day before the date of admission. On examination, he was found to be Tachycardiac, Tachypnoeic and was in Type 1 respiratory failure. Chest X-ray was done immediately and it showed opacities all over the left lung.

THE PROCEDURE

The patient was resuscitated using IV fluids and started on a broad spectrum of antibiotics. HRCT of chest was done which showed lobar consolidation in the left upper lobe and patchy consolidation in bilateral lower lobes and right upper lobe with surrounding ground glass attenuation. The patient was started on non-invasive ventilation in view of worsening Tachypnoea. As the patient didn’t respond to IV fluids he was started on vasopressor support and was intubated and ventilated in view of respiratory acidosis and worsening respiratory distress.

The patient was admitted to the ICU under Dr. Sudhir Nair − Pulmonologist. Lab results showed raised creatinine, CRP and Pro BNP levels. In view of raised creatinine and reduced urine output with mixed acidosis, the patient was started on Renal Replacement Therapy. 2D echo was normal with good LVEF of about 60%. The patient had developed severe ARDS secondary to community acquired pneumonia and was consequently started on steroids and as sepsis worsened, more antibiotics were given. He had metabolic encephalopathy, possibly due to sepsis. The patient developed critical care neuropathy and metabolic encephalopathy and would have needed prolonged ventilatory support, hence Tracheostomy was done on Day 11 of admission. He subsequently got better and vasopressors were discontinued. However, he still needed Renal Replacement Therapy. He was on weaning from ventilator trials. Subsequently the patient developed central line associated sepsis with resulting septic shock, hence antibiotics and lines were changed. He was started on CRRT in view of haemodynamic instability with need of dialysis. He started having drop in haemoglobin with occult blood in stool requiring multiple blood transfusions. An OGD Scopy was done which showed multiple esophageal ulcers. He was started on valganciclovir for the same.

THE RESULT

Gradually the patient’s condition improved, he was weaned off vasopressors and subsequently from the ventilator too. Biopsy from ulcer revealed Herpes Simplex Virus. A repeat OGD Scopy revealed complete resolution of ulcers. He was still requiring intermittent dialysis at discharge and his motor power had also improved significantly. He was transferred in an air ambulance to the Netherlands where he was decannualted the very next day.


Radiant Life Care | Newsletter April 2018

“Living Donor Liver Transplantation (LDLT) expands the organ donor pool for patients with life-threatening diseases who cannot be supplied with a

cadaver organ.”

Dr. Rasika Setia

Sr. Consultant & HODTransfusion MedicineBLK Super Speciality Hospital, New Delhi

Breaching Barriers ABO Incompatible Living Donor Liver Transplant

Living Donor Liver Transplant provides a new lease of life to patients with end stage liver disease. Although immunologically, liver is a privileged organ, ABO compatibility is still a barrier for successful Liver Transplant. This deprives many unfortunate patients who do not have a compatible liver donor in their family the benefit of transplant. Their only hope is a deceased donor organ but they are few to come by in the Indian scenario. The percentage of patients who have benefitted from deceased organ donation is few, while the majority succumb to their disease waiting for an organ.

THE CASEThe patient was suffering from chronic liver disease with Cirrhosis diagnosed 4-5 years back and was staring at certain death with life expectancy less than a year despite best medical treatment. During the intervening period, he was in and out of the hospital multiple times with poor quality of life and his family in complete disarray. Diagnosed as advanced Cirrhosis (Child C) with poor prognosis, the family was counselled regarding the need for Liver Transplant at the earliest possible. Blood groups of all prospective donors were checked and found to be incompatible. The patient and his family were counselled about the ABO-Incompatible Living Donor Liver Transplant protocol and all their queries were answered.

Some very important relevant issues of the case were prolonged pre-operative planning, increased risk of immediate post-operative complications, increased financial implications, prolonged and more intensive follow-up as compared to routine Living Donor Liver Transplant. The patient’s wife was identified as the prospective donor, and apart from the ABO incompatibility, she was found to be an adequate donor. Multidisciplinary planning with inputs from Transfusion Medicine were instrumental in the smooth execution of the treatment protocol.

THE PROCEDUREThe patient’s blood group was B and the donor’s blood group was A. The patient also had pre-formed anti-A IgM and IgG antibodies circulating in the blood. If transplanted, these pre-formed antibodies would pre-dispose to hyperacute rejection. To prevent this, ABO-Incompatible Liver Transplant protocol was developed at BLK Super Speciality Hospital. All timelines and interventions were meticulously planned to the last detail as far out as 3-4 weeks before transplant. The strategy was to reduce the levels of these circulating antibodies to bare minimum and to knock-out the cells producing these antibodies namely the B-cells and plasma cells. This would allow the liver to be safely transplanted when these immune elements are at a favourable level and provide a milieu where the liver graft could adapt leading to chimerism.

Total Plasma Exchange (TPE) is utilised to wash out the antibodies in the immediate perioperative period. This leaves the patient intensely immunosuppressed and predisposed to complete wrath of even the mildest of infections. It is the most critical phase just prior to the transplant when the immunity is at its weakest and antimicrobials are liberally utilized to provide empiric treatment. The patient was administered Rituximab, anti-CD20 monoclonal antibody that destroys the B-cells responsible for production of antibodies against ABO antigens. This was done 3 weeks before the intended day of the transplant to reduce the Anti-A IgM, Anti-A IgG, CD19+ and CD20+ cells to an acceptable level. Serial monitoring of these levels were done over a period of three weeks. The patient was also built up nutritionally and physically in the intervening period. Two sessions of TPE was done before the transplant- 6 days and 1 day prior.

THE RESULTThe actual surgical procedure of Living Donor Liver Transplant was uneventful and the patient was extubated on POD1 as per protocol. Anti-A IgM, IgG, CD-19+ and CD-20+ were monitored. TPE was utilized a few times in the post-operative period to pre-empt any rising immunoglobulin levels. CD19 and CD20 cells did not show any rise. The patient was discharged on the 19th post-operative day. The patient has been on regular OPD follow-ups and has had stable immunoglobulins, CD19, CD20 levels and normal liver function tests. No plasmapheresis was required after the discharge. Meticulous planning with constant clinical vigilance was instrumental in successfully overcoming the barrier of ABO incompatibility and pushing the benchmark of excellence a notch higher.

Dr. (Prof.) Sanjay Singh Negi

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

“In our endeavor to offer the state-of-the-art clinical

services to our patient, we saw an opportunity to innovate and grow.

With earnest efforts, we performed the first ABO-

Incompatible Living Donor Liver Transplant at BLK

Super Speciality Hospital. We proudly consider this arduous achievement a

milestone in BLK’s journey and one that will bring

renewed hope to patients who have none left.”


Radiant Life Care | Newsletter April 2018

THE CASE46 year old Santosh Shetty was driving his bike on a highway on the day of Makar Sankranti, when the string (Chinese manja) of a flying kite coated with powdered glass entangled his neck. He reflexly brought his hand in front of his face to save himself and what followed was profuse bleeding from his middle finger which was nearly amputated. A passerby helped him ride the bike and took him to a nearby hospital, where he was given first aid and was then referred to Nanavati Super Speciality Hospital. On examination it was found that all the tendons, nerves and arteries of his middle finger were cut and the finger was not viable. Except for bone and a small part of the skin, all the structures had been cut.

THE PROCEDUREThe patient was immediately operated upon in emergency setting by the Plastic Surgery team of Nanavati Hospital led by Senior Consultant Dr. Anshuman Manaswi and Dr. Parag Vibhakar with micro vascular plastic surgical techniques. All the structures including minute nerves and vessels were joined to save his finger. The operation lasted for 6 hours. The chemical content of string caused more severe injury in the lining of the blood vessels making the surgery more challenging.

THE RESULTAfter about one and a half months of healing and post-operative physiotherapy, Mr. Shetty’s finger is almost back to normal. The sensation and strength will take a few more weeks to recover.

In Safe HandsSalvaging a Nearly Amputated Finger

Back on the FeetA Successful Case of a Back Deformity Correction

Dr. Anshuman Manaswi

Sr. ConsultantPlastic & Cosmetic SurgeryNanavati Super Speciality Hospital, Mumbai

Dr. Puneet GirdharDirector − Spine Surgery

Dr. Bhupendra Bharti Associate ConsultantBLK Centre for Orthopaedics, Joint Reconstruction & Spine SurgeryBLK Super Speciality Hospital, New Delhi

“We have been reading and seeing in media about the

injuries caused to birds due to kites especially when the manja string is coated with powdered glass, but human

injuries are also possible and are equally fatal. This article

highlights the dangers of irresponsible kite flying.”

Before & After Treatment

THE CASEA 12-year old girl with ‘hunched back’ deformity since birth was brought to BLK Super Speciality Hospital. She had undergone surgery with a failed attempt at correction of her deformity in her native place almost a year back. Following the surgery, few months later she started having immense back pain with progressive increase of hump and difficulty in walking. Radiological investigations showed broken implants in situ with protrusion and tenting of the skin with evidence of progressive kyphotic deformity and congenital formation defect in spine (hemi vertebrae D11,12).

THE PROCEDUREUnder neuro monitoring guidance, the following procedures were performed for back correction - implant removal, posterior extended instrumentation of dorsolumbar spine and corpectomy of D11 and D12 with expandable cage implantation and spinal column reconstruction with attempted fusion.

Revision of deformity correction surgery is always more critical than the first surgery. Removal of broken implants and spinal defect (hemi vertebrae) excision while preserving spinal cord function throughout to prevent future reoccurrence was not an easy task. Possibility of excessive blood loss due to previous scarring was also a big challenge. But the doctors ensured 360 degree straightening with zero error approach to achieve alignment correction of the spine while protecting the spinal cord.

THE RESULTPost-operative X-ray reports showed significant correction and excellent restoration of alignment. The patient was ambulated within 2 days post surgery and is back to her school 4 weeks later.

720

Pre-Operative

300

Post-Operative



April 2018

Dr. Jaydeep H. Palep

Director & HeadDepartment of Bariatric and Minimal Access SurgeryNanavati Super Speciality Hospital, Mumbai

Dr. Nidhi Khandelwal

Associate Consultant Department of Bariatric and Minimal Access SurgeryNanavati Super Speciality Hospital, Mumbai

How SILS Bariatric Surgery Helps Regain Confidence

Fit Body, Fit Mind Too Big to be GoodA Brief Discussion on Enlarged Heart

Dr. Salil Shirodkar

Sr. ConsultantCardiology Nanavati Super Speciality Hospital, Mumbai

Dr. Jaideep Rajebahaddur

Clinical Associate Cardiology Nanavati Super Speciality Hospital, Mumbai

Is having an enlarged heart serious? Enlargement of heart is a serious condition which is always pathological and can cause progressive cardiac deterioration. It may lead to symptoms of breathlessness, palpitations, chest pain or swelling over the body.

What does it mean when your heart is enlarged? This means that there is abnormal dilatation (enlargement) of normal chambers of the heart. There are four chambers in the heart, the most common one to be involved is the left ventricle.

Can you die from an enlarged heart? Enlarged heart is associated with increased morbidity and mortality which may shorten or hamper the quality of life.

Can an enlarged heart subside?There are certain reversible conditions like hyperthyroidism, certain infections which if treated promptly and adequately can cause regression of an enlarged heart.

What are the causes and different types of enlarged heart? There are various reasons that cause heart enlargement. It can be caused by coronary artery heart disease, abnormalities of cardiac muscle (cardiomyopathies), structural defect in heart valve causing narrowing or leakage of heart, some defects from birth (atrial septal defect). Sometimes, rare condition after pregnancy and abuse of alcohol and chemotherapy drugs can also cause enlarged heart.

Explain the treatment options for enlarged heart?Treatment options differ as per primary cause. They can vary from medical management which includes diuretics, anti-hypertensives, anti-anginals etc, to surgical correction (CABG, valve replacements, closure of heart defects etc) including cardiac transplantation.

Can enlarged heart be prevented? Enlarged heart can be prevented only in specific condition like hypertension wherein one has to keep the blood pressure under control. Most of the times it is a sequela of underlying heart disease and may not be totally preventable.

What are the chances of occurrence of enlarged heart and are there any specific symptoms involved with enlarged heart?Certain group of population are more susceptible to develop enlarged heart like those with congenital heart disease. Symptoms like breathlessness, palpitations, chest pain, syncope, swelling over the body may be present.

THE CASEFour single young women, aged 25, 29, 30 and 32 years, were all morbidly obese with BMI ranging between 32.5 kg/m2 and 38.4 kg/m2. Two of them were also pre-diabetic. The four women approached Nanavati Super Speciality Hospital seeking solutions to their weight issues. However, like most young women, cosmesis was a major concern for all these four women.

THE PROCEDUREAll four women were individually counselled for a Single Incision Laparoscopic Sleeve Gastrectomy. After a thorough pre-operative evaluation and preparation, they all underwent SILS Gastrectomy at Nanavati Super Speciality Hospital. The surgeries were done with one single incision, just below the umbilicus, measuring about 2.5 cm. A special single port device was used in each case, along with standard bariatric length instruments, energy devices and staplers.

THE RESULTThe patients recovered very well and were discharged within 48 hours of surgery.

The procedure left just a single thin scar below the belly button of the patient which will gradually recede into the umbilicus as they lose weight. All four women were extremely satisfied with the result of the procedure.

“SILS Bariatric Surgery is proving itself to be a very fruitful tool, achieving not only

healthy bodies, but also scar free ones!”



EVENTS AND ACTIVITIESEVENTS AND ACTIVITIES

April 2018

− Left to Right

Mr. Ajay Sharma − VP, Administration, Ms. Anumol Joseph − Deputy Nursing Superintendent, Dr. Anil Vardani − Senior Consultant, Internal Medicine, GDA of the Month − Ms. Pooja, Employee of the Month − Ms. Kiran Bisht, Contractual Worker of the Month − Mr. Lal Singh Rawa, Doctor of the month − Dr. Anil Kumar, Nurse of the Month − Ms. Rinsu Raju, Dr. Chander Mohan − Director, Interventional Radiology, Dr. W V B S Ramalingam − Director, ENT, Dr. Neha Sood − Senior Consultant, ENT

BLK Super Speciality Hospital has taken an initiative to provide world class high quality treatment to the people of Tuvalu and Island of Fiji. For years, BLK has been providing medical assistance to a large number of patients from Tuvalu and Fiji. Our eminent doctors also visit Tuvalu and Fiji on a regular basis to provide super speciality consultations and also offer training assistance to their doctors, nurses and paramedic staff with an aim to strengthen their knowledge and skill base.

Awards and New Initiative

Employee Recognition

Free Obesity Camps organised by Nanavati Hospital

We are very delighted and honoured to have received the AHPI Award for ‘Quality Beyond Accreditation’ at the AHPI Global Conclave held on the 16th and 17th of February 2018, at Hotel Le Meridien, Kochi, Kerala.

Nanavati Super Speciality Hospital in association with DATRI had organised a Blood Stem Cell Donation camp and lecture to create awareness on fatal blood disorders. Mr. Darasingh Khurana (Mr. India International) showed his support for the cause by accepting to be the Guest of Honour at the event.

Awareness on Blood Stem Cell Donation

Senior Citizen Group Live 360@60 Monthly Get-together

Dr. Navneet Singh − Director, Accident & Emergency, conducted awareness lecture on health emergencies for around 200 senior citizens. The program provided information on handling health emergencies while alone at home. Later CPR training was imparted to the attendees in batches.

As part of the ongoing health awareness initiative of Nanavati Super Speciality Hospital, several health camps on Obesity and Diabetes were organised. The programmes were spearheaded by Dr. Jaydeep Palep − Director and Head and Dr. Nidhi Khandelwal − Consultant (Department of Bariatric & Minimal Access Surgery). These camps and lectures were conducted at Ulhasnagar, Titwala, Uran and Vasai to create awareness amongst people on lifestyle disorders and importance of healthy living.

On his recent visit to India, Mr. Enele Sopoaga − The Prime Minister of Tuvalu, met with the top medical experts of BLK Super Speciality Hospital and discussed the mode of collaboration with his country for providing better medical services to his people and neighbouring Islands of Fiji. The meeting paved the way for an agreement between the Ministry of Health, Tuvalu and BLK for setting up a dialysis centre in Tuvalu. The Hospital is now in the process of signing an MoU with the Ministry of Health, Tuvalu.

Mr. Enele Sopoaga, Prime Minister of Tuvalu with Dr. Mradul Kaushik and Dr. Sanjay Mehta



April 2018

BLK & NANAVATI in NEWS

Documents

BREACHING BARRIERS& Liver Transplant BLK Super Speciality Hospital, New Delhi “In our endeavor to offer the state-of-the-art clinical services to our patient, we saw an opportunity