Treating a woman with rarest reported Broad Ligament Fibroid...Dr. Raina Nahar Consultant Cosmetology and Dermatology Nanavati Super Speciality Hospital, Mumbai Gain the Mane Successful

Radiant

PULSENOVEMBER 2017 | ISSUE 20

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

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

www.blkhospital.com

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

AN EXTRA-ORDINARY CASE

Treating a woman with rarest reported Broad Ligament Fibroid

GAIN THE MANESuccessful transplant

of 9000 hair strands

Radiant Life Care | Newsletter

03Radiant Life CareBLK, New Delhi | Nanavati, Mumbai

Naresh Kapoor

Executive DirectorRadiant Life Care

FROM THE ED’S DESK

Dear Readers,

As a responsible healthcare organisation we have always stressed on the importance of prevention thereby enhancing health outcomes which becomes even more imperative during these months of changing weather. Preventive measures and early detection can go a long way in avoiding extreme health complications.

The cover story from BLK Super Speciality Hospital chronicles the extraordinary case of a woman with arguably the rarest reported Broad Ligament Fibroid. Other featured articles include a challenging case of a 97 year old nonagenarian who survived a hip fracture despite multiple health concerns and an informative article on heart ailments. The case of a man regaining his self-esteem by getting 9000 strands of hair in Nanavati and the classic case of Corneal Reinnervation Surgery also make for an interesting read.

We have also presented the heartfelt message left by a team of 10 critical care nurses from Muhimbili National Hospital, Tanzania who were at BLK for over two months on an observership course. Our thanks and appreciation to all those who have taken time out to contribute stories for this issue. We look forward to receiving more articles and stories from our regular contributors as well as the first timers. Our editorial team will eagerly await your pieces at [email protected]. Stay Healthy, Stay Happy!

EDITOR-IN-CHIEF PARUL CHHABRA

CREATIVE CONCEPT PARUL CHHABRASHIKHA GIRGLA

SUNIL KUMAR

DESIGN & VISUALISATION

SUNIL KUMAR

CONTENT SHIKHA GIRGLA MAMTA SINGH

Nanavati Super Speciality HospitalMumbai, Editorial Team

AVANTI PAWAR

PRAJAKTI SHIRSEKAR

SHYAM SHIRSEKAR

C O N T E N T S

WALKING AGAIN AT 97by Dr. Ishwar Bohra

4

AN EXTRAORDINARY CASEby Dr. Poonam Khera Dr. Laxmi Mantri & Dr. Niti Chaturvedi

6-7

GAIN THE MANEby Dr. Raina Nahar

9

THE RIGHT SIGHTby Dr. Sunil Morekar

11

BLK & NANAVATI IN NEWS

14-15

DEFEATING SEARING PAINby Dr. Manmohan Kamat

5

THE HEART OF THE MATTERby Dr. Neeraj Bhalla

8

READING THE WARNING SIGNSby Dr. Gayatri Deshpande

10

EVENTS AND ACTIVITIES

12-13

November 2017



Dr. Manmohan KamatSr. Consultant General Surgery, Minimal Access and Laparoscopic SurgeryNanavati Super Speciality Hospital, Mumbai

Defeating Searing PainHelping an elderly gentleman deal with Internal Hernia

Internal Hernias (IH) are a rare cause of acute abdomen and intestinal obstruction in adults. Among different types of Internal Hernias, Paracecal Hernia is a rare type. It is present as a lump in right iliac fossa with features of small bowel obstruction. Due to its rarity, non specific clinical findings and small window period to take action, a differential diagnosis of Internal Hernia must be kept in mind while approaching a patient with small bowel obstruction features. An urgent CT scan is advised before operating as it is a valuable aid to diagnose and operate subsequently. There might not be any previous history of herniation, strangulation or any specific risk factor / indication preceding herniation.

THE CASE A 68-year old man came to the emergency unit of Nanavati Super Speciality Hospital, walking with difficulty while experiencing severe pain in the right iliac fossa since morning. The pain was mild at first but increased in severity since that morning with a score of 10/10 at admission. The pain was associated with nausea and vomiting. He had 3 episodes of vomiting during that day which was non projectile in nature and mostly food particles as the content. He had no history of fever or cough or trauma and didn’t display any co-morbidities such as: Diabetes Mellitus / Hypertension / Cardiac problems / chest condition.

There was no recent history of any drug use / abuse. On examination,the patient was febrile with blood pressure of 150/90 mm Hg, pulse rate of 112/min and a saturation of 98%. Patient was conscious and oriented. Systemic examination of cardiovascular system, respiratory system and central nervous system did not reveal any impairment. On abdominal examination, a tender, palpable mass in the right iliac fossa was noted. Guarding rigidity was present but abdominal scar or indication of previous trauma was absent. A computerized tomography (CT) scan of abdomen and pelvis was immediately taken.

THE PROCEDUREIn view of the clinical and imaging findings, the patient was shifted to the operation theatre immediately. Starting with a midline incision, ascending colon and cecum was pushed up. Small bowel and omentum were found to be adherent in RIF. The omentum was separated and the band of defect strangulating the bowel segment was released. Adhesiolysis was performed, detortion of bowel was done and approximately 2.5 feet of gangrenous segment was resected followed by end to end anastomosis in 2 layers. Thorough exploration of the contaminated cavity and peritoneal cavity was performed.

THE RESULTThe patient was not allowed to take anything orally for 2 days and was on IV fluids and medications. He was then started on liquids, gradually progressing to normal diet with removal of drain. His recovery was uneventful and was discharged on fifth post operative day with no complication.

Intra-operative image

November 2017

Dr. Ishwar Bohra

Sr. ConsultantBLK Centre for Orthopaedics,Joint Reconstruction& Spine SurgeryBLK Super SpecialityHospital, New Delhi

THE CASEYashila Jamir, a 97 year old lady from Nagaland was battling with several old age diseases like Diabetes, Hypertension, Hypothyroidism, Osteoporosis, Cardiac and Kidney ailments and had recently suffered a severe hip bone fracture. The old lady was first taken to several hospitals in Nagaland, however, considering her age and critical condition the doctors refused to operate on her. The lady’s will to live and her determination even motivated the family to transport her by means of an air ambulance to BLK Super Speciality Hospital, New Delhi to avail advance care and treatment. When she reached BLK, she was in severe pain due to the fractured hip bone and existing co-morbidities. Her condition started deteriorating while she was undergoing her preliminary tests and examinations. It was then decided to take her up for an immediate surgery.

THE PROCEDURETo salvage the damaged bone was a real challenge, keeping in mind the age and fragile health of the nonagenarian. Administering anaesthesia for the surgery was another challenge considering her age and other complications related to anaesthesia. She is probably the eldest lady in the country with a fractured hip, multiple health concerns and still fighting for survival. The aim of the procedure was to repair the fracture and to make her walk again. Extra care was taken to avoid the complications which could have aroused for a bed ridden patient. With all expert opinion, the patient was optimized for surgery and the fracture was repaired with proximal femoral nail for early mobility.

THE RESULTThe patient was kept in ICU after surgery for one day. She was discharged after five days and started walking with the support of a walker. Presently, she is doing well and is in good health.

Walking Again At 97Fixing a hip fracture in an almost century old patient

“ To salvage the damaged bone was a real challenge, considering the age and

fragile health of the nonagenarian”

CT Scan - Obstructed Paracaecal Hernia



“Although extra uterine fibroids are rare and

histologically benign, they may mimic Malignant Tumours clinically and

on imaging may present a diagnostic challenge.”

An Extraordinary CaseTreating a woman with rarest reported Broad Ligament Fibroid

Fibroid or Leiomyomas are the most common pelvic Tumours present in 20% of women in the reproductive age. These are composed of smooth muscle with a variable amount of fibrous connective tissues. They may be uterine or extra uterine in origin. Extra uterine fibroids are rare and may arise in broad ligament or at other side where smooth muscle exist. Broad Ligament Fibroid are mostly epithelial in nature, whereas Mesenchymal Tumours of the broad ligament are Leiomyomas. They may cause variety of symptoms such as menstrual irregularities and pressure effects. The case at hand is that of a 54-year old patient with true Broad Ligament Fibroid which is quite rare and has been the largest reported till date.

THE CASEA 54-year old post-menopausal patient was brought to BLK with complaints of increasing abdominal distension and pain for a year and a half. The mass in her abdomen was gradually increasing in size for about the same time. There was no history of bleeding, fever or bowel or bladder complaint.

Abdominal examination revealed a mass of 36 week size arising from the pelvis with regular margins, firm in consistency and was non-tender. The patient looked like someone with a full term pregnancy.

Ultrasound of the abdomen showed the large well circumscribed mass lesion of approx. 29x26x2 cm in the abdominopelvic region which was superiorly extending up to the epigastrium and was inseparable from the uterus.

THE PROCEDUREThe patient was taken up for total abdominal Hysterectomy and intraoperatively a true Broad Ligament Fibroid mass of approx. 32x30x16 cm and 10 kg weight was detected in the abdominal cavity. The bladder was advanced which was separated and Broad Ligament Fibroid mass was dissected out and separated from the uterus with capsule intact. Uterus was menopausal size, the left tube and ovary was normal and atrophic. Right tube and ovary were adherent. TAH with LSO was done in a usual manner and specimen was sent for HPE leaving behind the right tube and ovary. Bilateral ureters were traced and normal peristalsis of both ureters were seen with adequate urine output.

THE RESULTWith timely diagnosis and management of pressure symptoms like hydroureter, hydronephrosis and rectal symptoms were avoided. The post-operative period was uneventful and the patient was able to lead a normal healthy life.

DISCUSSIONAlthough extra uterine fibroids are rare and histologically benign, they may mimic Malignant Tumours clinically and on imaging may present a diagnostic challenge. The symptoms and imaging feature depend on the location and size of lesion. During surgery, one should be very careful about the ureteric course and surrounding organs.

Dr. Poonam Khera

Sr. ConsultantObstetrics and GynaecologyBLK Super Speciality Hospital, New Delhi

Dr. Laxmi Mantri

Sr. ConsultantObstetrics and GynaecologyBLK Super Speciality Hospital, New Delhi

Dr. Niti Chaturvedi

Associate ConsultantObstetrics and GynaecologyBLK Super Speciality Hospital, New Delhi

November 2017

Broad Ligament Fibroid



Before Hair Transplant

After Hair Transplant

Follicular Unit Extraction is one of the two widely used methods of Hair Transplant, wherein follicular units consisting of 2-4 hair strands are extracted from the donor site and implanted, creating appropriate openings with accurate angulation to match the natural hairline. The procedure is performed under tumescent local anaesthesia, so no hospital stay is required. Utmost precision is required while extracting hair units to avoid transection and wastage of grafts. 0.8-0.9mm motor punches are used to minimise scarring. While implanting, openings are created in such a manner that gaps in between is almost similar to natural hairline.

THE CASEA 23-year old man with male pattern baldness grade 3 with generalised diffuse Alopecia visited Nanavati Super Speciality Hospital. He had been experiencing gradual thinning of his hair for the past 6 years and had tried medical modalities like Mesotherapy, PRP, Laser sessions with limited results and long term maintenance. His condition had led him to develop very low self esteem. After evaluating his case it was decided to go ahead with FUE technique of Hair Transplant.

THE PROCEDUREWe had decided to implant around 4000 grafts i.e around 8000 to 9000 hair spread over a 2 day surgery to cover atleast 80% of the scalp. It was a day care procedure with minimal scarring and bleeding.

THE RESULTPatient resumed his work on the 4th day of surgery with few precautions. After a month, Derma Roller and Mesotherapy sessions were started once a month to enhance the hair growth for 6 months. Thereafter, the patient required only negligible maintenance with life-long results.

Dr. Raina NaharConsultant Cosmetology and DermatologyNanavati Super Speciality Hospital, Mumbai

Gain the ManeSuccessful transplant of 9000 hair strands

November 2017

Dr. Neeraj Bhalla

Director & Sr. Consultant CardiologyBLK Heart CentreBLK Super Speciality Hospital, New Delhi

When dealing with the matters of the heart, terms like Heart Attack and Cardiac Arrest are often thrown around interchangeably. However, when you come down to the semantics of these terms, you learn how different they are from each other.

Heart Attack: Your heart has intricate plumbing, with different blood vessels carrying blood to specific body parts. The coronary arteries, which are branches of the aorta, are the main supply for oxygenated blood to the heart. A blockage in these arteries would mean partial or complete cut off in the blood supply, which may result in a Heart Attack. Sometimes, the coronary arteries will have a brief, sudden narrowing of the arterial wall, which is known as a coronary spasm. During this spasm, there is a constriction of the oxygenated blood supply to the heart; which if it lasts long, can lead to a Heart Attack.

The most common reason for coronary blockages are plaque buildup – crystals of cholesterol that accumulate in the arteries, clogging them up. Coronary spasms may occur irrespective of any evidence of plaque buildup. Signs and symptoms of a Heart Attack include pain in chest or abdomen, pain radiating in the arm or jaw, feeling of tightness, heaviness or burning sensation in the chest, feeling light headed or dizzy, sweating profusely, having difficulty breathing and feeling nauseous or vomiting. Women may not necessarily have these typical symptoms.

Cardiac Arrest: Your heart is also an electrical marvel. For your heart to supply blood to the body, it must follow a rhythmic contraction-relaxation. A Cardiac Arrest occurs when your heart cannot contract properly, leading to a sudden stop in effective blood flow. The heart, in trying to make up for the decreased blood flow, starts beating faster which results in muscle fatigue and eventually the heart is unable to pump at all. The causes of Cardiac Arrest are varied including coronary artery blockages, pulmonary embolism, congestive heart failure, overdose, drowning and severe physical stress.

Signs and symptoms of Cardiac Arrest include, unconsciousness, loss of response and loss of palpable pulse. In some cases, Cardiac Arrest may be preceded by fatigue, chest pain, vomiting, dizziness and blackouts.

Angina: Angina is chest pain due to decrease blood flow to the heart. It is not a disease, rather a symptom of an underlying cause. It ranges from discomfort to severe chest pain, that may radiate to the arms, jaws and back. Sometimes, it may manifest as indigestion.

Unlike the portrayal often seen in movies or television, where every instance of a Heart Attack is shown as a person in severe pain, clutching their chest, a Heart Attack differs from person to person.

The Heart of the MatterKnowing the difference between a Heart Attack, Cardiac Arrest and Angina

“Understanding the difference between the heart ailments makes you more informed

about the treatment of choice and helps you to prepare for

the unknown.”



The Right SightElderly diabetic patient gets back his vision with Corneal Reinnervation

Dr. Sunil MorekarSr. Consultant Ophthalmology Nanavati Super SpecialityHospital, Mumbai

THE CASE A 64-year old man with a history of Diabetes, Thyroid abnormality and Diabetic Corneal disease visited Nanavati Super Speciality Hospital. In his case, the corneal sensation was affected as the cornea became opaque due to loss of corneal nerves.

THE PROCEDUREAn upper eyelid incision was made and the sural nerve attached to supra orbital or alternatively a transferred supra orbital nerve fibres were tunnelled into the palpebral incision. Lid split full thickness was made medial to the medial horn of the levator aponeurosis. The levator aponeurosis is a thin, tendon-like sheath that connects the eye’s main opening muscle, the levator muscle, to the upper eyelid’s supporting structure (tarsal plate). The skin and nerves were further tunnelled through incision into the superior conjunctival fornix. A conjunctival incision was made at the 10 o’clock- 8mm above the corneal sclreal limbus, and an atraumatic forceps was used to access the space under tenon’s capsule to pull out the branches of the nerves which are then placed below the sub-tenon’s space and sub sclera tunnels around the limbus.

THE RESULTThe patient’s vision recovered to 6/18 in one eye and 6/9 in the other, also the nerve density increased to near normal. Corneal nerves and the corneal sensations which were absent were restored to near normalcy post surgery.

DISCUSSIONCorneal Reinnervation surgery is a simple surgery that can be used to return corneal sensations which is vital for prevention of neurotrophic ulcers and survival of grafts. This procedure can be used in Diabetic Neurokeratopathy, Traumatic Corneal Neuropathy and may have potential even in cases where corneal nerves are lost in Herpectic disease. Corneal Transplants which have failed due to neurotrophic reasons may stay transparent after reinnervation.

Pre-operative

Post-operative

“American Journal of case reports acknowledged that such kind of surgery was

first performed in India at Nanavati Super Speciality

Hospital.”

What, when and why of postmenopausal bleeding

Menopause is defined by WHO as permanent cessation of menstruation resulting from the loss of ovarian follicular activity. From clinician’s perspective, any occurrence of vaginal bleeding after 12 months of amenorrhea (cessation of menstrual cycle) should be considered as postmenopausal bleeding. This condition is prevalent in 3% to 5% of postmenopausal women and definitely warrants investigations.

The cause of these symptoms may be benign lesions like Vaginal Atrophy, Endometrial Polyps, Endometrial Hyperplasia, Submucous Fibroid etc. However, primary aim in investigation is to rule out Endometrial Cancer and Cervical Cancer. There are other conditions like unopposed estrogen therapy (without progesterone) or prolonged tamoxifen administration in women suffering from breast cancer.

The risk of endometrial carcinoma with PMB rises with age from 1% at the age of 50 years to 25% at the age of 80 years. The high risk factors are: Age of menarche < 10 years, late Menopause > 55 years, Nulliparity, Obesity, co-morbidities like Diabetes Mellitus, Liver disease and Hypertension. Use of unopposed estrogen and addition of > 2 risk factors increases the risk.

The examination must rule out local causes like Atrophic Vaginitis, Vulvar Lesions, Cervical Lesions as well as Endo-cervical Polyp. A cervical smear (PAP smear) must be done to rule out cervical pre-cancer lesions. The incidence of CIN III (pre-cancerous lesion of cervix) is 11 per 1 lakh in well screened women but 59 per 1 lakh in those who are not regularly screened (PAP smear).

Important modality of investigation is trans-vaginal ultrasound. The endometrial thickness more than 4 mm is suspicious and warrants biopsy. Those who undergo tamoxifen therapy, the thickness more than 9mm should be the cut off. Hystero-sonography (Transvaginal Ultra sound with instillation of normal saline) helps to delineate lesions line Endometrial Polyps and Submucous Fibroid. MRI helps to identify size and site of primary Tumour (Endometrial), any evidence of myometrial invasion and presence of lymph node metastases. To confirm the diagnosis, the retrieval of endometrium by Hysteroscopically guided Endometrial Biopsy is the Gold standard. A blind D & C is known to miss more than 40% of endometrial tissue. Hysteroscopy offers an advantage of diagnostic as well as therapeutic benefit to the patient.

Endometrial Hyperplasia is an estrogen dependent condition. It can bea simple Endometrial Hyperplasia – 1 to 5% progression to cancer and complex Endometrial Hyperplasia – 5 to 25%. Management of simple Hyperplasia could be administration of long term progestogens and strict monitoring by ultrasound. Levonorgestrel IUCD (Mirena) is also proved to be effective in converting the Hyperplastic Endometrium into Atrophic type. However atypical Hyperplasia warrants Hysterectomy.

Reading the Warning Signs

• Any woman with complaints of postmenopausal bleeding needs

immediate attention• Benign lesions represent most

frequent causes which may include Endometrial Polyps or

Submucous Fibroid• However, primary aim is to

rule out Endometrial Carcinoma which goes on increasing with

advancing age• Histopathological diagnosis

can be best obtained by Hysteroscopy guided biopsy

which is Gold Standard

Dr. Gayatri Deshpande

Sr. ConsultantGynaecologyNanavati Super SpecialityHospital, Mumbai

Hysteroscopic Polypectomy

November 2017



EVENTS AND ACTIVITIES

BLK Diwali Celebration

CME on Managing Obesity

BLK Event Calendar

BLK Super Speciality Hospital had recently organized a grand ‘Diwali Celebration’ for the entire BLK family.

Mr. Abhay Soi, CMD, Radiant Life Care presided over the event as the Chief Guest. The event witnessed enthralling performances by the staff members, felicitation of star performers and other engaging activities.

Nanavati Event Calendar

Word of thanks and appreciation for BLK staff“We would like to thank BLK Super Speciality Hospital for the special gratitude shown to us.

We have met all our objectives, acquired knowledge and skills on standard critical care nursing practice for the best implementation in our country. We don’t have anything to pay you back except for extending our heartfelt thanks for your kindness. Dhanyavaad”.

A team of 10 critical care nurses from Muhimbili National Hospital, Tanzania visited BLK Super Speciality Hospital for a two month course. At the end of their course, they left behind a note to express their gratitude. An excerpt from the note:

BLK Super Speciality Hospital had recently participated in FICCI Advantage Healthcare Exhibition held at Bengaluru International Exhibition Centre from 12th – 14th October.

The exhibition witnessed visitors and delegates from over 60 countries including, Uzbekistan, Kazakhstan, Tazakhstan, 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 200 visitors over a period of 3 days.

CME on Women’s Bone and Joint Health: Cradle to Grave was held on 15th October, 2017. The event was inaugurated by a special lamp lighting ceremony by Padma Shri Dr. N. S. Laud – Past President IOA, Dr. Rajendra Patankar – COO, Dr. Deepak Patkar – Director, Medical Services & Head, Department of Radiology from Nanavati Super Speciality Hospital. Lectures were delivered by Dr. Rujuta Mehta – Sr. Consultant, Paediatric Orthopaedics, Dr. S. S. Mohanty – Sr. Consultant, Orthopaedics, Dr. Nikhil Arbatti – Sr. Consultant, Spine Surgery, Dr. Sanjeev Shah – Sr. Consultant, Endocrinology, Dr. Aspi Irani – Sr. Consultant, Paediatrics, Dr. Ali Irani – HOD, Physiotherapy and Ms. Nirva Desai – Dietician. The event was attended by 125 delegates comprising of Doctors and Physiotherapists.

CME on Managing Obesity was conducted on 11th October, 2017 for doctors of ‘General Practitioners Association’ by Dr. Jaydeep Palep – Director, Bariatric & Minimal Access Surgery, Dr. Pradeep Bhosale – Director, Arthritis & Joint Replacement Surgery, Dr. Mihir Raut – Sr. Consultant, Diabetology, Dr. Salil Bendre – Sr. Consultant, Chest Medicine, Dr. Gayatri Deshpande – Sr. Consultant, Obstetrics & Gynaecology. The event was attended by close to 75 delegates.

November 2017



BLK & NANAVATI in NEWSNovember 2017

Documents

Treating a woman with rarest reported Broad Ligament Fibroid...Dr. Raina Nahar Consultant Cosmetology and Dermatology Nanavati Super Speciality Hospital, Mumbai Gain the Mane Successful