Tuesday, January 19, 2016

Endovascular management of internal Carotid Artery Aneurysm

Endovascular management of Intracranial aneurysms is gaining popularity worldwide. It is especially useful in the management of Cerebral Aneurysms that are difficult to access or whose surgery has a high morbidity rate. It is also very useful in elderly patients and patients who are in a poor neurological state. 

Microcatheters placed in the carotid and vertebral arteries through the femoral route outline the aneurysm and then deliver coils which are placed into the aneurysmal sac. The size and configuration of the aneurysm determines the number and type of coils used. 

A 65 year old lady presented with repeated attacks of unawareness and loss of vision suggestive of TIA and TMB. An MRI with MR angiogram revealed an Internal Carotid artery aneurysm. A Digital Subtraction Angiogram (DSA) was done which showed the aneurysm to be arising from the ventral wall of the Cavernous Sinus segment of the ICA. Embolisation of the Aneurysm using 3D coils was performed after placing a balloon across the neck of the aneurysm to prevent distal embolus of the coil. 

The procedure was successful with the post-coiling angiogram showing complete obliteration of the aneurysm. 

The lady was discharged three days after the procedure without any symptoms or deficits.

Special points of interest
  • Aneurysms can present in many ways including TIA
  • All symptomatic aneurysms and some incidental aneurysms require treatment
  • The choice of management between surgery and endovascular management depends on many factors
  • A microcatheter placed in the carotid and vertebral arteries through the femoral route helps delineate the configuration of the aneurysm
  • The size and configuration of the aneurysm decides the type and number of coils used
  • It is essential that the Neurosurgical team be on stand by during the pro-cedure in case of any eventuality

Wednesday, January 13, 2016


Now we are in a SMART world, SMART CARD, SMART PHONE, SMART DOCUMENTATION etc. Perhaps it is time for Physicians to be SMART. It is not that they are not SMART hitherto. But the SMART what we perhaps intend to say is with regard to the modern Medical Practice. There is virtual explosion in the technology and to keep abreast is difficult within the current resources and ambiance. It is equally true that both media and Government have special focus always on medical professionals, often not so pleasant. Legal issues against medical professionals are growing in geometrical proportions. Society adores doctors but recently, there is increase in the admonishes for the practitioners many times for no fault. Medical professionals, no longer enjoy the unequivocal faith of their patients. Further, unhealthy practices, unethical competitions are leading to annihilation of the people involved. Sometimes, we wonder, whether we have evolved as human race in right direction. Hence we need to be SMART PRACTITIONERS, what do we mean by that? 

To be a SMART Physician, we need to follow the following FIVE: 

AWARE: One must be aware of their skills, limitations and the availability of the resources. A patient can never be over promised and the doctor under performing. 

BEHAVIOUR: A physician’s conduct is a model for society. He is simple, soft, sensitive and compassionate. Behavior should be socially acceptable and exemplary. 

CONFIDENCE: Whatever one says and commits one should be courageous to implement, and practice. Real courage lies just not in righteous practice but also in skillful management. 

DEDICATION: Dedication is a word that reflects the comprehensive submission of skills and knowledge in the service of the patients. 

ENDURANCE: Lasting endurance is hall mark of a good physician. Trying to control one self in all adversities is an inevitable virtue of medical professionals. 

FRIENDSHIP: Trying to be friendly with peers is part of professionalism. Gaining friends is strength and losing them is weakness. If we note and practice the above grammar rules for a Physician, we are bound to be SMART.

Saturday, January 9, 2016

Professionals and Promotions

Ethics have always been an issue, now-a-days in every field, more so in medicine. When we repeatedly speak of ethics, means we are stepping out frequently. If not checked at right times, some of the actions of the professionals become objectionable by public. It is unfortunate, that professionals take oath, more as ritual than a conscious affirmation. This is seen in every sphere; public or private, proportions may vary.

Recently, from Harvard to Stanford a notable instruction was sent out to medical professionals, banning them from receiving samples, participation on behalf of pharmaceuticals as promoters of their products etc. This is welcomed by all, though not totally. The issue of ethics is only a small part but the umpteen numbers of related issues that amount to intellectual or monetary corruption. It may be rude to conclude and many professionals are innocent and see only the scientific part of it. It is not universal, the higher the cadre, greater is their role in the promotion of a given product. What is that Professionals who indulge get, pleasure trips, rewards, continuous support of the company, including some personal gains. Managements of Harvard noticed the malady of such practices. Weeks of absence from the place of work by travelling to several places across the continents, promoting the products cause serious inconvenience to the services.

Apart from this is the greatest damage caused by identification of the said professionals with some companies. Let us not dwell on the quality of the products, which is a different issue. Medical professionals opting to write protocols, promotional literature, release product information, and above all making some claims that are intended to attract peers, are all questioned by both public and colleagues. The image of the entire professional fraternity is at stake sometimes. To have a bias for a product may not be objectionable but selection and dropping any product irrationally creates problems. This is not restricted to drugs, but to many biomedical equipment, disposables, catheters etc.
Medical ethics is categorical in admonishing such practices.

But, unfortunately, they continue in some form or other. For example advertising, particular professional or services as information is different from publishing photos and pictures. Medical Profession is noble, no doubt, are the professionals noble?, is the question asked by public. As responsible citizens, Medical professionals need to practice and project up-right personality. In Greek, persona means, Mask, at the same time, Persona in Latin is divine. I do not know what becomes applicable in this situation.

Friday, January 8, 2016

Patients and/or Patents? – The Saga of Drug Molecule from Bench to Bedside

Patents are given to protect the interests of the inventor(s) for a period of 17-20 years and the patent shall not be exploited or copied by anybody else during this period for commercial purposes. It is expected that this period gives enough time to realize the value of the invention/patent. Pharmaceutical companies which own patents for new drug molecules enjoy an exclusive marketing right during this patent period and usually some such drugs become block-busters for the company. Drug discovery is expensive and time consuming.

Unless the new drug fails in the market due to unexpected fatal side effects, the company makes a premium in the first few years of sales. To maintain a monopoly on the drug and prevent other companies from introducing similar or better drugs many companies have resorted to what is called “ever-greening” of block buster drugs. This means the original drug molecule is re-patented claiming under the existing patent law, some unique features and presumed benefits, the sole intention being to extend the monopoly on the original drug.

This practice is in vogue in many advanced countries and hence it is possible to “ever-green” and to extend monopoly on the original drug, albeit under a new “dress-up”. India is extremely good in reverse engineering and it showed the world how basic chemistry skills could be used for the benefit of the (economically poor) society. Till today, India is the largest manufacturer and supplier in the world of drugs which have gone-off patent (the generics), the largest beneficiary being HIV-AIDS patients in the world. Indian companies ventured to extend this strategy for anti-cancer drugs, the costs of which are prohibitive throughout the world. This practice is being opposed by the patent holding companies. In 2005 our parliament introduced Indian Patent Act with some modifications to protect the interest of the poor people. One such modification introduced as section 3(d) emphasizes that “mere discovery of a new form of a known substance which does not result in the enhancement of the known efficacy of that substance” is not an invention — for the purpose of patenting.

The Swiss pharmaceutical giant, Novartis, has been fighting a case, for seven years now, against Government of India and other stakeholders for the anti cancer drug the beta crystalline form of “Gleevec” or “Glivac” as superior and better compared to originally patented as Imatinib mesylate. No data was submitted to substantiate “better or improved therapeutic efficacy” and hence the Supreme Court rejected the petition and denied patent to the newer version. This is a landmark judgment and it will open the gates for Indian pharmaceutical companies to go for generic version of all off-patent drugs and make them affordable to the society. The generic version of the drug Glivac is made available by Indian pharmaceutical company at “a tenth” of the cost to the patients. The cry of “end to R & D”, “drug discovery”, “innovation” have no basis and on the contrary this judgment will ensure that money is spent on original inventions and entirely new drugs and not on frivolous claims on existing molecules for newer specifications. Many countries, I am sure, will follow India in this and make drugs affordable to poor people in their country.

Saturday, June 20, 2015

Rare Minimal Access Spine Surgery performed at Global Hospitals, Mumbai

Rare Minimal Access Spine Surgery performed at Global Hospitals
First time in India Minimal Access Surgery performed on Ankylosing Spondylitis patient
82 year old patient given new lease of life
 Was in paralytic state before the surgery

Mumbai May 27, 2015: Global Hospitals Mumbai - one of the fastest growing chains of tertiary care, multi-super specialty and multi-organ transplant hospitals in India, has yet again achieved a rare feat in spine surgery. 

For the first time in India, expert team of doctors in Global Hospitals performed minimal access spine surgery on 82-year-old Ankylosing Spondylitis (Bamboo Spine) patient. The surgery was conducted by implanting 14 screws in the spinal cord.

Ankylosing Spondylitis, commonly known as Bamboo Spine is a form of rheumatic arthritis that’s associated with long-term inflammation of the joints in the spine. Symptoms include pain and stiffness from the neck down to the lower back. The spine's bones (vertebrae) may grow or fuse together, resulting in a rigid spine. At times these changes might be severe, and may lead to a stooped-over posture. 

In this case the 82 year old patient having Ankylosing Spondylitis had a fall in November 2014. Post the fall he was constantly complaining of excruciating back pain. In Feb 2015 he became totally bed ridden. He was paralyzed in the legs. 

He came to Global Hospitals in first week of March. Upon investigations the team found that had developed 3 Andersson Leisons (AL). It is a known complication in patients with Ankylosing Spondylitis. AL may result from inflammation or (trauma) fractures of the ankylosed spine. After carefully examining his case and meticulously weighing all the options, Dr. Peshattiwar decided that there was no option but to perform surgery on the patient. The surgery was all the more challenging as the patient had other complications as well. He had fluid in both his lungs commonly known as pleural effusion. He was also found to have very low protein levels which could have resulted in further complications. 

There was no chance of performing a traditional surgery, as "open surgery," means the area being operated on is opened with a long incision to allow the surgeon to view and access the anatomy; It would have led to loss of blood and the chance of patient not surviving post the surgery would have been very high.

The team decided to conduct a minimally invasive surgery.  A minimally invasive spine surgery does not involve a long incision; it avoids significant damage to the muscles surrounding the spine and results in less pain after surgery and a faster recovery. 

Dr. Vishal Peshattiwar, Consultant, Consultant - Endoscopic & Minimally Invasive Spine Surgeon, Global Hospitals, Mumbai, carried out the complex surgery in second week of March.
Dr. Peshattiwar said, “We were delighted when post the surgery patient said that pain he is feeling after the surgery is much less as compared to the one he was in prior to the surgery. It was gratifying to see him go home walking as he had come to us on a stretcher and was on bed a month prior to that. He has recovered well and now has started performing all his daily chores by himself. It was a huge risk as there is always a danger of life involved in the surgery, and spine is extremely sensitive area.” “What boosted our confidence was the fact that we had performed a similar surgery successfully on a liver failure patient who had TB of the spine,” added Dr. Peshattiwar.

Talking about the benefits of minimally invasive surgeries, Dr. Peshattiwar added, “Recovery post surgery is faster. There is negligible blood loss, so, the patient doesn’t require any blood transfusion. Even patients who have undergone prior surgical procedures or have stents can be operated via minimal access surgery successfully.”

At Global Hospitals Mumbai, the highly specialized team of Spine Doctors treats slip disc in neck and/or lower back, spondylosis with pressure on nerve, spinal stenosis, abnormal curvature, degenerative disc disease, osteoporosis of the spine, tuberculosis of the spine and many other spine problems. The team performs day care spine & neck surgeries, non-surgical slip disc removal, minimally invasive spine surgery, stitchless spine surgery and high risk spine surgeries with precision and care.

Monday, June 15, 2015

Western India’s first Auxiliary Liver Transplant performed at Global Hospitals Mumbai

  • 14-yr-old suffering from Crigler–Najjar Syndrome (CNS) successfully operated upon
  •  Liver transplant gives a new lease of life to CNS type I patients
  • CNS is a very rare disease estimated at 0.6-1.0 per million
Mumbai June 12, 2015: Global Hospitals Mumbai - one of the fastest growing chains of tertiary care, multi-super specialty and multi-organ transplant hospitals in India, has added one more feather to its cap, by performing Western India’s first auxiliary liver transplant on a 14 year old patient from Mumbai suffering from Crigler–Najjar Syndrome (CNS). The liver was donated by Yash’s aunt.
Crigler-Najjar Syndrome Type I is a very rare inherited disorder in which bilirubin (a substance made by the liver) cannot be broken down. It occurs when the enzyme that normally converts bilirubin into a form that can easily be removed from the body does not work correctly. Without this enzyme, bilirubin can build up in the body and lead to jaundice (yellow discoloration of skin and eyes) and damage to the brain, muscles, nerves and loss of life in extreme conditions. This is a very rare disease (estimated at 0.6–1.0 per million live births).

The syndrome runs in families (inherited). A child must receive a copy of the defective gene from both parents to develop the severe form of the condition. Parents who are carriers (with just one defective gene) have about half the enzyme activity of a normal adult, but do not have symptoms.
Lifelong light treatment (photo therapy), blood transfusion and liver transplant are used for CNS treatment.

The 14 year old resident of Oshiwara, Yash Ranjit was detected with CNS, 14 days after he was born and was on photo therapy since then. Yash had to undergo daily photo therapy for 6 hours a day which increased to 12-14 hours a day as he grew up, to keep his bilirubin under control; else he would have suffered brain damage.

Yash’s parents were very disturbed with his condition, but were  reluctant to undergo a liver transplant due to various reasons and fear. They imported a photo therapy machine to keep Yash under light. Due to this condition, Yash could not lead a normal life like  other children of his age, as he had to compulsorily take  photo therapy, and was confined to the four walls of his home.
During this course, one day Yash got seizure and his parents could not see the plight of their son.  That’s when they decided to go for liver transplant. 

It was not an easy choice for the parents. Both his parents turned out to be unfit for a liver donation. They were in a state of flux, and then his aunt came forward and agreed to donate part of her liver to Yash. Yash came to Global Hospital and the team of experts at Global Hospital decided to perform the rare complex auxiliary liver transplant on him. The transplant was successfully performed and Yash has been discharged from the hospital and now can lead a normal life, but will have to be on immunosuppressant medications.

Prof. Mohamed Rela, Group Director, Institute of Liver Diseases, HPB Surgery and Transplantation said, “Auxiliary liver transplant is a complex procedure, unlike a normal liver transplant, wherein a complete liver is transplanted. The procedure is a technically demanding one. In this we remove a part of the liver and replace it with a part of the donor liver. Once the patient's own liver regenerates, then the need for donor liver no more exists. In most cases, the donor liver shrinks and becomes a small tissue. In some, another surgery is needed to remove it.”

Dr. Ravi Mohanka - Chief Surgeon and HOD, HPB Surgery and Liver Transplantation Global Hospitals, Mumbai said, “Yash is  suffering from a  rare genetic disorder due to which, his liver was not able to produce a certain enzyme, which is needed for detoxification, due to which his bilirubin was always shooting up and he had to be under photo therapy constantly. However, Phototherapy does not work after an age because the thickened skin blocks the light. With the successful transplant, the other part of his liver has started producing desired enzyme and his liver function has become normal. ” 

Dr. Parijat Gupte, Consultant Hepatologist, Hepatology, Liver Intensive Care & Transplant Hepatology Deaprtment, Global Hospitals, Mumbai said, “The patient was on high risk of getting severe brain damage due to the high bilirubin levels, had he been not operated upon quickly. As soon as Yash came to Global Hospitals, the doctors decided to perform auxiliary liver transplant, as it was the only option to save him. The patient is doing good and has been discharged from the hospital and will be able to lead a normal life hereafter.”

Yash’s liver transplant took place on 28th May. During the surgery a portion of Yash’s liver was removed and replaced with a small portion of his aunt’s liver. Post – operative complications were managed by liver intensive care team. He got discharged on 10th June with a normally functioning liver. 

Also known as Auxiliary Partial Orthotopic Liver Transplantation (APOLT); the procedure entails attaching part of a donor liver to the failing liver in the recipient, where it supports the patient, clears toxins, and prevents brain injury during recovery. After the patient's native liver recovers, the donor liver withers in most patients and the majority of patients are able to withdraw from immunosuppressant medications.

The expert team of doctors comprised Dr. Samir Shah, Dr. Guruprasad Shetty, Dr. Somnath Chattopadhyay and Dr. Vishal Sachde. Yash’s parents are extremely thankful and relieved post the surgery and are very happy with their decision. Global Hospital Mumbai has already established itself in the transplant space and has handled many complex liver surgeries in the past, including the successful Dual Lobe Living Donor Liver Transplant in the past. With the first ever auxiliary liver transplant in Global Hospital Mumbai, the hospital as yet again reiterated its commitment to provide world class health care facilities to the patients. 

Tuesday, May 26, 2015

ENDOSCOPIC DISCECTOMY: Minimum surgery, Maximum relief…

The SPINE lends structural stability and balance to our body helping us stand upright, while allowing flexibility in various movements. Moreover, it forms a protective canal in which the SPINAL CORD, the most important part of the neural network, flows down from the brain to the rest of our body. The spinal column is an interconnected structure of bony (vertebrae) and cartilage tissues (intervertebral discs) and it is prone to age related wear and tear. Read through to learn more about a HERNIATED DISC, its manifestations and treatment options, with special reference to a minimally invasive surgical technique called Endoscopic discectomy.
What is a herniated disc?
First, let’s understand an intervertebral disc. It is essentially a disc shaped, rubber like tough and flexible structure made of outer layers of fibrous cartilage with a softer gel like tissue in the center. A disc lies between two adjoining vertebral bones of the spine and acts as a shock absorber. This disc undergoes wear and tear changes (degeneration) after a certain age. When the degenerated disc is subjected to any external strain or injury, the substance from the central part of the disc comes out through the tears in the outer fibrous layers. This condition is called a herniated disc. It is also referred to as prolapsed or slipped disc. A disc prolapse can occur in any part of the vertebral column; but, mostly observed in the lumbar (lower back) or in cervical (neck) region.
What happens when an intervertebral disc herniates ?

When the inner disc material protrudes through the disc surface, it may pinch or irritate the nerve roots it comes in contact with. It also elicits a severe inflammatory chemical response in that area. If this happens in the lumbar spine, it induces symptoms such as:

  1. Pain in the back,
  2. Pain running down the leg,
  3. Weakness of the muscles in the leg supplied by the affected nerve root,
  4. Numbness or tingling sensation in the respective part of the leg.
  5. Loss of bladder and bowel control if a large disc prolapse compresses multiple nerve roots.

If you feel recurring radiating pain in any of the body parts, it would be a good call to see a Spine specialist. 

What causes disc herniation?
Disc herniation happens as a result of degeneration that is mostly related to the genetic composition of the person. Smoking is another well established factor that causes disc degeneration. Other factors also play a role in the process of wear and tear of the discs. Though the exact reason is hard to pick, disc herniation may be precipitated by strain on the spine during physical work, certain kind of frequent body movements or spinal injury due to any accident. Sometimes adopting improper body posture for physically demanding jobs of time may result in this condition.

What are the treatment options for herniated disc condition?
Most cases of disc herniation can be treated medically with rest, pain relievers, anti-inflammatory medication and physiotherapy. But, if the symptoms persist or the pain is severe or if it is affecting the nerve function causing numbness and weakness, it needs surgical intervention. 

Minimally Invasive (Endoscopic) Spine Surgery
Spine surgery is generally adopted as the last resort to treat painful disc prolapse that do not respond to medication for a longer period (usually 3 months). Rarely, a severe nerve compression causing weakness of muscles or severe sciatica may need surgical treatment straight away. Conventional open surgery involves cutting the muscles and removing some portion of bone in the spine, which has its own complications and disadvantages. But, the advent of high definition image guided systems and surgical tools, now-a-days spine surgery for herniated discs can be done with minimal invasion. 
Endoscopic Discectomy for herniated disc is a minimally invasive spine surgery carried out through a one centimeter incision on the back. It involves removal of herniated disc material that protrudes and compresses the adjacent nerve roots, through specially designed spine endoscopes that help in clear visualization of the structures. Instead of cutting the muscles in an open surgery, endoscopic surgery involves dilation of the muscles causing much less damage and procedure related pain. It can also be performed under local anesthesia as a day care procedure in suitable patients. 
It is a complicated procedure requiring high degree of expertise and long years of practice. Though endoscopic spine surgeries like TED have become common place in western countries, in India it is still in a nascent stage. 

The procedure of Endoscopic Spine Surgery are:

  • The patient is positioned lying face down.
  • On table x rays are taken to locate the entry point for the affected disc
  • A small injection is given to anesthetize the skin at the entry point
  • The track to the disc is found with a needle and the track is dilated without cutting muscles
  • Endoscope inserted into the disc and structures visualized
  • Prolapsed disc fragments removed under direct clear vision.
 The advantages of Endoscopic Spine Surgery are:
  • A small incision of less than one centimeter is made on the back
  • Minimal muscle or bone damage
  • Minimal  blood loss
  • Can be done as a day care procedure.
  • Minimal risk of infection
  • Less painful then open surgery
  • Cost of treatment and recovery comparatively low.

Though it is fast emerging as a procedure of choice for herniated disc conditions, Endoscopic Discectomy may not be suitable for everyone. The patient selection for suitability of the procedure is very crucial and the decision is best made by an experienced spine surgeon who understands the pros and cons of the procedure.

Dr. Phani Kiran S
Consultant Spine Surgeon
Global Health City, Chennai