Embed Size (px)
DESCRIPTION
A monthly newsletter for the medical community
Citation preview
Pre-operative LV angiogram
A60 year old gentleman presented to the hospital with history of progressive
breathlessness now in NHYA III/ IV. He had a previous history of an anterior wall MI around three years ago. There was no significant past his tory. An echocardiogram revealed a left ventricular apical aneurysm with clots and an EF of 30%. A coronary angiogram done on
Vol 2, Issue 7, October 2008
Wockhardt Hospitals l Mumbai l Bangalore l Kolkata l Hyderabad l Nagpur l Rajkot l Surat
INSIDE
him revealed a triple vessel coronary
artery disease and a left ventricular
inject ion confirmed the lef t
ventricular aneurysm.
Surgery was advised and he
underwent a coronary artery bypass
grafting and left ventricular
reconstruction procedure (Dor’s Procedure).
Dor’s Procedure for Left Ventricular Restoration l Unusual Presentation of a Common Neuro Infection l Surgical Arthroscopy for Discoid Meniscus l Laproscopic Meckel’s Diverticulum using Endostapler l An Unusual Cause of Dyspnoea following Blood Transfusion l Implant Restorations in Dentistry l Neurology Services at Wockhardt Hospitals l Management of Movement Disorders l News Room
or’s Procedure for Left Ventricular RestorationD
TM
TM trade mark of Wockhardt Hospital Limited. Copyright (c) 2007 Wockhardt Hospital Limited. All right reserved.
01
Dear Doctor,
Greetings from Wockhardt Hospitals!
Your continuous support and feedback has encouraged us to take the concept of ‘The Specialist’ across our centers in India. With this, we are able to share the skills and achievements of Wockhardt clinicians across the medical fraternity. We have earned numerous accolades in our clinical expertise across specialties in 2008. We became the first hospital in Karnataka to earn the JCI accreditation for quality health care. The Center for Joint Replacement at Wockhardt Hospitals, Bangalore has performed over 1000 joint replacements since the inception of the hospital and its services have now been extended to our Nagarbhavi facility. We have performed some ground breaking work such as the first lumbar disk replacement, removal of brain tumour through the eyebrow, scoliosis surgery performed by a neurosurgeon, joint replacement surgery on a metal allergic patient using a titanium nitrate implant, open heart surgery on a 900 gm baby and a double switch operation on a 13 year old girl. Advanced procedures such as endoscopic brain and spine surgeries, awake brain tumour surgery, complex interventional cardiac procedures and cardiac surgeries (in both adults and children), video assisted thoracic surgeries (VATS) are routinely practiced here. With your trust in us, we continue to surge ahead with such achievements.
An updated Doctors Directory encompassing a complete listing of our specialist doctors and a brief sketch of each of our specialties and centers is enclosed for your reference which could be a handy guide for interacting with our specialists. Also a compilation of some of the selected VATS surgeries conducted at our hospital is attached.
We are sure this will further boost your confidence in the quality and service rendered by Wockhardt Hospitals to your patients.
Best wishes
Dr. Lloyd NazarethCOO – Wockhardt Hospitals
Although, he required an IABP and
Post-operative LV angiogram
inotropes his post-operative stay in
the ICU was uneventful in which he
was weaned of the IABP and
inotropes and shifted to the ward on rdthe 3 post-operative day and was
discharged from the hospital on the th7 post-operative day.
Left ventricular aneurysm is a bulge
or ballooning of the weakened heart
muscle. When the patient has a heart
attack, blood flow to the muscles of
the heart is reduced. Part of the
muscles of the heart die during the
process and healing takes place with
formation of a scar where the heart
muscle dies. Sometimes the scar
tissue becomes thin and bulges out of
the heart muscle causing a left
ventricular aneurysm. Not all
patients with a scar develop a
aneurysm. Up to 25% of people with a
Discussion
large area of heart muscle death from
a heart attack develop aneurysms.
The aneurysms range from very small (thumbnail size) to huge (doubling the size of the heart). Aneurysms usually form and get bigger during the first few months after a heart attack.
The aneurysm causes progressive left
ventricular dysfunction. The scar
tissue is more prone for arrythmias
and over a period of time the normal
left ventricle also shows sign of
dysfunction with chances of
development of mitral insufficiency.
Clots may form in the aneurysm with
increased incidence of dislodgement
of the clots and carried away by the
blood streams to cause strokes and
organ damage.
The Dor’s procedure is one of the complex procedures available for management of such aneurysm. The whole aim of the procedure is to restore left ventricular geometry, exclude the infracted septum, resect the scarred arrytmogenic scarred
ventricular tissue and revascularise the heart with a bypass surgery.Overall five-year survival after the
Dor’s operation is 69%. The pre-operative left ventricular end-systolic volume index (LVESVI) is a critical
measurement in planning the Dor’s operation. Patients with symptoms of heart failure but LVESVI
2<60 ml/m should not undergo ventri-cular remodeling, as ventricular size may become too small.
I n c o n t r a s t , p a t i e n t s w i t h 2preoperative LVESVI >100 ml/m
have a poor long-term outcome from
bypass alone, and the Dor’s procedure is indicated. These patients have been shown to have an increased survival.
Patients with preoperative LVESVI 2<80 ml/m have, however, a five-year
survival of 79%. This value decreases, however, to 72% and 67% for patients
2with LVESVI between 80–120 ml/m , 2and greater than 120 ml/m
respectively.
Mr s . S u d h a ( n a m e
changed) presented to us
with history of headache
and binocular diplopia of three
weeks duration. The headache was
predominantly in the region of vertex
aching, continuous and severe in
intensity. She was treated for pan
sinusitis with little relief. Examination threvealed right 6 nerve palsy with
subtle impairment of sensation in
r ight ophthalmic branch of
trigeminal nerve; possibility of
Gradenigo ’ s Syndrome was
considered and she was evaluated
accordingly.
Investigations revealed fasting and
postprandial hyperglycemia with
elevated ESR. MRI of brain revealed
features suggestive of right petrous
apex osteomyelitis and edema
retropharyngeal muscles. ENT
evaluation was normal; but nasal
endoscopy revealed mucopus
dripping from superior meatus on the
right side. Culture of the mucopus
revealed gram positive cocci. He was
treated with intravenous cefriaxone
for 10 days. Fungal etiology was ruled
out with appropriate investigation.
Despite the treatment, headache and
diplopia persisted. LP was done and
CSF analysis revealed 600 cells with
p r edominan t l y l ymphocy t i c
pleocytosis, elevated protein and low
sugar. CSF PCR for myco TB was
positive. He was started on ATT.
After the introduction of ATT,
headache i n t en s i t y showed
remarkable improvement. Over the
nex t s e ven day s , d i p l op i a
disappeared and euglycemia could
be achieved. Final diagnosis
cons idered was tuberculous
meningitis with apical petrositis and
diabetes mellitus. This case illustrates
a relatively rare presentation
(Gradenigo’s Syndrome) of a
c o m m o n n e u r o i n f e c t i o n
(tuberculous meningitis). It also
teaches us the value of keeping an
o p e n m i n d a b o u t v a r i o u s
possibilities.
Gradenigo’s Syndrome consists of
three components, otitis media, pain st ndin the distribution of 1 and 2
division of trigeminal nerve and
ipilateral abducent nerve palsy. This
syndrome was named after Giuseppe
Conte Gradenigo, an Italian
o t o l a r y n g o l o g i s t . C h r o n i c
suppurative otitis media is commonly
associated with this syndrome.
However, Gradenigo’s syndrome can also arise due to any lesion affecting apex of petrous bone can cause cranial nerve dysfunction.
E x t r a d u r a l a b s c e s s o r pachymeningitis overlying the petrous apex without petrositis per se can also present as this syndrome. Phlebitis from lateral sinus spreading along the inferior petrosal sinus can also produce this. The above case i l lustrates that pat ients s t i l l occasionally present with petrous apicitis and the clinician needs to be aware of the conditions presenting features to prevent possible life threatening complications.
A 17 year old boy presented to our office with complaints of a painful limb for the past 6
months and an inability to straighten out the left leg. Patient and his father denied any history of trauma. There was no history of fever, pain or stiffness in any other joints. The boy complained that his sporting activities were restricted and that quite often he heard clicks from the left knee.
Physical examination revealed flexion deformity of 20 degrees, mild effusion, range of motion 20-140 with pain in terminal part of flexion, anterolateral joint line tenderness, quadriceps
wasting. McMurray’s test was equivocal
and Springer’s test was positive. On ranging the joint a palpable thud could be elicited. X-rays were non contributory. Magnetic Resonance Imaging (MRI) done, revealed a Discoid lateral meniscus.
Pa t i en t unde rwen t su rg i ca l arthroscopy of the left knee and a torn discoid meniscus entrapped in the intercondylar notch was seen. It was decided to proceed with subtotal menisectomy (leaving the peripheral rim) considering the age of the patient. Subtotal menisectomy was carried as there are high chances of meniscus regeneration following subtotal menisectomy. Post-operative course was uncomplicated although
urgical Arthroscopy for Discoid MeniscusS
nusual Presentation of a Common Neuro InfectionU
Dr. Ganeshkrishnan K.T. Iyer
MS, M.Ch
Consultant Cardiothoracic
Surgeon
HEART CARE
Dr. C. Udaya Shankar
DM
Consultant Neurologist
Dr. Chandran Gnanamuthu
MD, DM, FIAN, FAAN
Consultant Neurologist
Department of Neurology
BRAIN & SPINE CARE
Dr. Sheelu Srinivas
M.S (ENT), DLO, RCS
(London)
Consultant ENT Surgeon
DEPARTMENT OF ENT
02 03
The Dor’s procedure is one of the complex procedures available for management
of such aneurysm
LP was done and CSF analysis revealed 600
cells with predominantly lymphatic pleocytosis,
elevated protein and low sugar. CSF PCR for myco
TB was positive.
Post-operative LV angiogram
inotropes his post-operative stay in
the ICU was uneventful in which he
was weaned of the IABP and
inotropes and shifted to the ward on rdthe 3 post-operative day and was
discharged from the hospital on the th7 post-operative day.
Left ventricular aneurysm is a bulge
or ballooning of the weakened heart
muscle. When the patient has a heart
attack, blood flow to the muscles of
the heart is reduced. Part of the
muscles of the heart die during the
process and healing takes place with
formation of a scar where the heart
muscle dies. Sometimes the scar
tissue becomes thin and bulges out of
the heart muscle causing a left
ventricular aneurysm. Not all
patients with a scar develop a
aneurysm. Up to 25% of people with a
Discussion
large area of heart muscle death from
a heart attack develop aneurysms.
The aneurysms range from very small (thumbnail size) to huge (doubling the size of the heart). Aneurysms usually form and get bigger during the first few months after a heart attack.
The aneurysm causes progressive left
ventricular dysfunction. The scar
tissue is more prone for arrythmias
and over a period of time the normal
left ventricle also shows sign of
dysfunction with chances of
development of mitral insufficiency.
Clots may form in the aneurysm with
increased incidence of dislodgement
of the clots and carried away by the
blood streams to cause strokes and
organ damage.
The Dor’s procedure is one of the complex procedures available for management of such aneurysm. The whole aim of the procedure is to restore left ventricular geometry, exclude the infracted septum, resect the scarred arrytmogenic scarred
ventricular tissue and revascularise the heart with a bypass surgery.Overall five-year survival after the
Dor’s operation is 69%. The pre-operative left ventricular end-systolic volume index (LVESVI) is a critical
measurement in planning the Dor’s operation. Patients with symptoms of heart failure but LVESVI
2<60 ml/m should not undergo ventri-cular remodeling, as ventricular size may become too small.
I n c o n t r a s t , p a t i e n t s w i t h 2preoperative LVESVI >100 ml/m
have a poor long-term outcome from
bypass alone, and the Dor’s procedure is indicated. These patients have been shown to have an increased survival.
Patients with preoperative LVESVI 2<80 ml/m have, however, a five-year
survival of 79%. This value decreases, however, to 72% and 67% for patients
2with LVESVI between 80–120 ml/m , 2and greater than 120 ml/m
respectively.
Mr s . S u d h a ( n a m e
changed) presented to us
with history of headache
and binocular diplopia of three
weeks duration. The headache was
predominantly in the region of vertex
aching, continuous and severe in
intensity. She was treated for pan
sinusitis with little relief. Examination threvealed right 6 nerve palsy with
subtle impairment of sensation in
r ight ophthalmic branch of
trigeminal nerve; possibility of
Gradenigo ’ s Syndrome was
considered and she was evaluated
accordingly.
Investigations revealed fasting and
postprandial hyperglycemia with
elevated ESR. MRI of brain revealed
features suggestive of right petrous
apex osteomyelitis and edema
retropharyngeal muscles. ENT
evaluation was normal; but nasal
endoscopy revealed mucopus
dripping from superior meatus on the
right side. Culture of the mucopus
revealed gram positive cocci. He was
treated with intravenous cefriaxone
for 10 days. Fungal etiology was ruled
out with appropriate investigation.
Despite the treatment, headache and
diplopia persisted. LP was done and
CSF analysis revealed 600 cells with
p r edominan t l y l ymphocy t i c
pleocytosis, elevated protein and low
sugar. CSF PCR for myco TB was
positive. He was started on ATT.
After the introduction of ATT,
headache i n t en s i t y showed
remarkable improvement. Over the
nex t s e ven day s , d i p l op i a
disappeared and euglycemia could
be achieved. Final diagnosis
cons idered was tuberculous
meningitis with apical petrositis and
diabetes mellitus. This case illustrates
a relatively rare presentation
(Gradenigo’s Syndrome) of a
c o m m o n n e u r o i n f e c t i o n
(tuberculous meningitis). It also
teaches us the value of keeping an
o p e n m i n d a b o u t v a r i o u s
possibilities.
Gradenigo’s Syndrome consists of
three components, otitis media, pain st ndin the distribution of 1 and 2
division of trigeminal nerve and
ipilateral abducent nerve palsy. This
syndrome was named after Giuseppe
Conte Gradenigo, an Italian
o t o l a r y n g o l o g i s t . C h r o n i c
suppurative otitis media is commonly
associated with this syndrome.
However, Gradenigo’s syndrome can also arise due to any lesion affecting apex of petrous bone can cause cranial nerve dysfunction.
E x t r a d u r a l a b s c e s s o r pachymeningitis overlying the petrous apex without petrositis per se can also present as this syndrome. Phlebitis from lateral sinus spreading along the inferior petrosal sinus can also produce this. The above case i l lustrates that pat ients s t i l l occasionally present with petrous apicitis and the clinician needs to be aware of the conditions presenting features to prevent possible life threatening complications.
A 17 year old boy presented to our office with complaints of a painful limb for the past 6
months and an inability to straighten out the left leg. Patient and his father denied any history of trauma. There was no history of fever, pain or stiffness in any other joints. The boy complained that his sporting activities were restricted and that quite often he heard clicks from the left knee.
Physical examination revealed flexion deformity of 20 degrees, mild effusion, range of motion 20-140 with pain in terminal part of flexion, anterolateral joint line tenderness, quadriceps
wasting. McMurray’s test was equivocal
and Springer’s test was positive. On ranging the joint a palpable thud could be elicited. X-rays were non contributory. Magnetic Resonance Imaging (MRI) done, revealed a Discoid lateral meniscus.
Pa t i en t unde rwen t su rg i ca l arthroscopy of the left knee and a torn discoid meniscus entrapped in the intercondylar notch was seen. It was decided to proceed with subtotal menisectomy (leaving the peripheral rim) considering the age of the patient. Subtotal menisectomy was carried as there are high chances of meniscus regeneration following subtotal menisectomy. Post-operative course was uncomplicated although
urgical Arthroscopy for Discoid MeniscusS
nusual Presentation of a Common Neuro InfectionU
Dr. Ganeshkrishnan K.T. Iyer
MS, M.Ch
Consultant Cardiothoracic
Surgeon
HEART CARE
Dr. C. Udaya Shankar
DM
Consultant Neurologist
Dr. Chandran Gnanamuthu
MD, DM, FIAN, FAAN
Consultant Neurologist
Department of Neurology
BRAIN & SPINE CARE
Dr. Sheelu Srinivas
M.S (ENT), DLO, RCS
(London)
Consultant ENT Surgeon
DEPARTMENT OF ENT
02 03
The Dor’s procedure is one of the complex procedures available for management
of such aneurysm
LP was done and CSF analysis revealed 600
cells with predominantly lymphatic pleocytosis,
elevated protein and low sugar. CSF PCR for myco
TB was positive.
patient still had a flexion deformity of 10 degrees.
Patient was placed on protected weight bearing with use of a night time knee extension brace. Patient recovered completely without any residual deformity.
Discoid lateral menisci were first described in the late 1800s. The normal configuration of a meniscus is that of a matured crescent moon,
Discussion
whereas that of a discoid meniscus generally is a thickened, very early crescent moon. Variations of this general shape occur relatively rarely, and occasional ly , the lunar appearance is also found in the medial meniscus. The discoid shape results in a membrane barrier that prevents normal contact between the articular surfaces of the knee and has a high incidence of mechanical deformation.
Discoid lateral menisci have been reported to occur at the rate of 1.5-3%
in the general population, whereas discoid medial menisci have been reported to occur at the rate of 0.1-0.3% (Ryu, 1998). The Asian population has a slightly higher rate of occurrence; Tokyo's Teishin hospital reported 16.6% of all knees examined arthroscopically had a discoid lateral meniscus (Ikeuchi, 1982).
A discoid lateral meniscus results from a developmental anomaly before birth. After birth, no sudden change occur s in men i sca l development (Clark, 1983). Two distinct types of discoid lateral meniscus exist. One is the hyper mobile, or Wrisberg lateral meniscus, and the other is a discoid form of an otherwise normal lateral meniscus. Bo th t ypes p re sen t un ique pathophysiologic problems.
The Wrisberg type lacks an attachment to stabilise the posterior horn to the tibia. It may also be of normal shape rather than discoid. The only attachment of the posterior horn is to the Wrisberg or meniscofemoral ligament. The general configuration produces an unstable or hyper mobile lateral meniscus.
Meckel’s diverticulum is a rare congenital disorder that was first described
about 400 years ago. Diagnosis is rarely made pre-operatively as there may be no symptoms.
The inc idence o f Meckel ’ s diverticulum is rare. A memory aid is the rule of 2's: 2% (of the population) - 2 feet (from the ileocecal valve) - 2 inches (in length) - 2% are symptomatic, there are 2 types of common ectopic tissue (gastric and pancreatic), the most common age at clinical presentation is 2, and males are 2 times as likely to be affected.
Meckel’s diverticulum is located in the distal ileum, usually within about 60-100 cm of the ileocecal valve. It is typically 3-5 cm long, runs antimesenterically and has its own blood supply. It is a remnant of the connection from the umbilical cord to the small intestine present during embryonic development. The most
common presenting symptom is painless rectal bleeding, followed by intestinal obstruction, volvulus and intussusception. Occasionally, Meckel's diverticulitis may present with all the features of acute appendicitis. Also, severe pain in the upper abdomen is experienced by the patient along with bloating of the stomach region. At times, the symptoms are so painful such that they may cause sleepless nights with extreme pain in the abdominal area.
It can also be present as an indirect hernia, where it is known as a "Hernia of Littre". Approximately 98% of
people afflicted with Meckel’s diverticulum are asymptomatic. If symptoms do occur, they typically appear before the age of two.
If there is more time (not an emergency situation), the best way to diagnose Meckel's diverticulum is by T e c h n e t i u m - 9 9 m ( 9 9 m T c ) pertechnetate scan. This scan detects
gastric mucosa; since approximately
50% of symptomatic Meckel’s diverticula have ectopic gastric (stomach) cells contained within them. This is displayed as a spot on the scan distant from the stomach itself. Patients with these misplaced gastric cells may experience peptic ulcers as a consequence. Patients presenting with bleeding are to be investigated by colonoscopy and screenings for bleeding disorders shou ld be pe r fo rmed , and a n g i o g r a p h y c a n a s s i s t i n determining the location and severity of bleeding.
Diagnosis with obstruction is big challenge and CT scan and ultrasound may not aid in the right diagnosis. Diagnostic laparoscopy, however, is the most accurate diagnostic tool. We present a case of small bowel obstruction due to
Meckel’s diverticulum causing small bowel obstruction, managed by laparoscopic surgery.
Fig. 1: MRI Saggital image showing
Discoid Lateral Meniscus
Fig. 2: MRI Coronal image showing
Discoid Lateral Meniscus
Fig. 3: Arthroscopic appearance of Discoid Meniscus
Fig. 4: Following subtotal Menisectomy
Dr. Gautam Kodikal
M.S. (Orthopedics)
Consultant Orthopedic Surgeon
Dr Ashish Anand
M.S. (Orthopedics),
DNB, MNAMS
Fellowship - Arthroscopic Surgery
and Sports Medicine (USA)
BONE & JOINT CARE
aproscopic Meckel s Diverticulum Using Endostapler
’L
04 05
Surgical treatment varies according to
the type of lateral discoid meniscus.
Arthroscopic procedures are quite
successful and are somewhat more
technically demanding than are
routine meniscal tear excisions
because of the younger age, tighter
joints, and less room available to
manipulate arthroscopic equipment.
Surgical techniques vary, from
sculpting and partial meniscectomy
to complete removal, starting with
removal of the anterior portion for
better arthroscopic visualisation
(Smith, 1999; Ogata, 1997).
Because of the hyper mobility of the entire meniscus in the Wrisberg (type III) deformity, sculpting the meniscus is ineffective, and better results have been reported with a near-complete to complete meniscectomy. Using the Watanabe classification, the indicated treatment for tears of discoid meniscus type I (complete), type II (incomplete), and the central-holed or ring-shaped version is removal of the central discoid and ring portions, including any areas of tearing, followed by arthroscopic sculpting of the remaining meniscus (Monllau, 1998).
Surgical treatment varies according to the type of lateral discoid meniscus.
Arthroscopic procedures are quite successful and are somewhat more
technically demanding than are routine
meniscal tear excisions because of the
younger age, tighter joints, and less room
available to manipulate arthroscopic equipment.
patient still had a flexion deformity of 10 degrees.
Patient was placed on protected weight bearing with use of a night time knee extension brace. Patient recovered completely without any residual deformity.
Discoid lateral menisci were first described in the late 1800s. The normal configuration of a meniscus is that of a matured crescent moon,
Discussion
whereas that of a discoid meniscus generally is a thickened, very early crescent moon. Variations of this general shape occur relatively rarely, and occasional ly , the lunar appearance is also found in the medial meniscus. The discoid shape results in a membrane barrier that prevents normal contact between the articular surfaces of the knee and has a high incidence of mechanical deformation.
Discoid lateral menisci have been reported to occur at the rate of 1.5-3%
in the general population, whereas discoid medial menisci have been reported to occur at the rate of 0.1-0.3% (Ryu, 1998). The Asian population has a slightly higher rate of occurrence; Tokyo's Teishin hospital reported 16.6% of all knees examined arthroscopically had a discoid lateral meniscus (Ikeuchi, 1982).
A discoid lateral meniscus results from a developmental anomaly before birth. After birth, no sudden change occur s in men i sca l development (Clark, 1983). Two distinct types of discoid lateral meniscus exist. One is the hyper mobile, or Wrisberg lateral meniscus, and the other is a discoid form of an otherwise normal lateral meniscus. Bo th t ypes p re sen t un ique pathophysiologic problems.
The Wrisberg type lacks an attachment to stabilise the posterior horn to the tibia. It may also be of normal shape rather than discoid. The only attachment of the posterior horn is to the Wrisberg or meniscofemoral ligament. The general configuration produces an unstable or hyper mobile lateral meniscus.
Meckel’s diverticulum is a rare congenital disorder that was first described
about 400 years ago. Diagnosis is rarely made pre-operatively as there may be no symptoms.
The inc idence o f Meckel ’ s diverticulum is rare. A memory aid is the rule of 2's: 2% (of the population) - 2 feet (from the ileocecal valve) - 2 inches (in length) - 2% are symptomatic, there are 2 types of common ectopic tissue (gastric and pancreatic), the most common age at clinical presentation is 2, and males are 2 times as likely to be affected.
Meckel’s diverticulum is located in the distal ileum, usually within about 60-100 cm of the ileocecal valve. It is typically 3-5 cm long, runs antimesenterically and has its own blood supply. It is a remnant of the connection from the umbilical cord to the small intestine present during embryonic development. The most
common presenting symptom is painless rectal bleeding, followed by intestinal obstruction, volvulus and intussusception. Occasionally, Meckel's diverticulitis may present with all the features of acute appendicitis. Also, severe pain in the upper abdomen is experienced by the patient along with bloating of the stomach region. At times, the symptoms are so painful such that they may cause sleepless nights with extreme pain in the abdominal area.
It can also be present as an indirect hernia, where it is known as a "Hernia of Littre". Approximately 98% of
people afflicted with Meckel’s diverticulum are asymptomatic. If symptoms do occur, they typically appear before the age of two.
If there is more time (not an emergency situation), the best way to diagnose Meckel's diverticulum is by T e c h n e t i u m - 9 9 m ( 9 9 m T c ) pertechnetate scan. This scan detects
gastric mucosa; since approximately
50% of symptomatic Meckel’s diverticula have ectopic gastric (stomach) cells contained within them. This is displayed as a spot on the scan distant from the stomach itself. Patients with these misplaced gastric cells may experience peptic ulcers as a consequence. Patients presenting with bleeding are to be investigated by colonoscopy and screenings for bleeding disorders shou ld be pe r fo rmed , and a n g i o g r a p h y c a n a s s i s t i n determining the location and severity of bleeding.
Diagnosis with obstruction is big challenge and CT scan and ultrasound may not aid in the right diagnosis. Diagnostic laparoscopy, however, is the most accurate diagnostic tool. We present a case of small bowel obstruction due to
Meckel’s diverticulum causing small bowel obstruction, managed by laparoscopic surgery.
Fig. 1: MRI Saggital image showing
Discoid Lateral Meniscus
Fig. 2: MRI Coronal image showing
Discoid Lateral Meniscus
Fig. 3: Arthroscopic appearance of Discoid Meniscus
Fig. 4: Following subtotal Menisectomy
Dr. Gautam Kodikal
M.S. (Orthopedics)
Consultant Orthopedic Surgeon
Dr Ashish Anand
M.S. (Orthopedics),
DNB, MNAMS
Fellowship - Arthroscopic Surgery
and Sports Medicine (USA)
BONE & JOINT CARE
aproscopic Meckel s Diverticulum Using Endostapler
’L
04 05
Surgical treatment varies according to
the type of lateral discoid meniscus.
Arthroscopic procedures are quite
successful and are somewhat more
technically demanding than are
routine meniscal tear excisions
because of the younger age, tighter
joints, and less room available to
manipulate arthroscopic equipment.
Surgical techniques vary, from
sculpting and partial meniscectomy
to complete removal, starting with
removal of the anterior portion for
better arthroscopic visualisation
(Smith, 1999; Ogata, 1997).
Because of the hyper mobility of the entire meniscus in the Wrisberg (type III) deformity, sculpting the meniscus is ineffective, and better results have been reported with a near-complete to complete meniscectomy. Using the Watanabe classification, the indicated treatment for tears of discoid meniscus type I (complete), type II (incomplete), and the central-holed or ring-shaped version is removal of the central discoid and ring portions, including any areas of tearing, followed by arthroscopic sculpting of the remaining meniscus (Monllau, 1998).
Surgical treatment varies according to the type of lateral discoid meniscus.
Arthroscopic procedures are quite successful and are somewhat more
technically demanding than are routine
meniscal tear excisions because of the
younger age, tighter joints, and less room
available to manipulate arthroscopic equipment.
patient was allowed liquids orally on the same evening and was discharged on the second day.
Meckel’s diverticulum is the most common form of congenital abnormality of the small intestine, resulting from an incomplete obliteration of the vitelline duct. Although originally described by Fabricius Hildanus in 1598, it is named after Johann Friedrich Meckel, who established its embryonical origin between 1808 and 1820. The tip of the diverticulum is free in 75% of cases, and in 25% of the cases the tip is attached to another organ or structure by means of a band like in our case. Most patients are asymptomatic, and it is usually an incidental finding when a barium study or laparotomy is performed for other abdominal conditions. Complications include b o w e l o b s t r u c t i o n ( 3 5 % ) , haemorrhage (32%), diverticulitis (22%), umbilical fistula (10%), perforation (5%), other umbilical lesions (1%) and intussusception.
Meckel’s diverticulitis may mimic appendicitis.
The correct diagnosis is usually
established at the laparotomy or
laparoscopy. None of the clinical
features are pathognomonic, and the
diagnosis is rarely made pre-
operatively. Routine laboratory
studies, such as leukocyte and
erythrocyte counts, serum electro-
lytes, blood glucose and urea, serum
creatinine and coagulation screen are
helpful in the general work-up. These
tests will show evidence of acute
infection. Computed tomography and
ultrasonography have been used for
Discussion
t h e d i agno s i s o f Mecke l ’ s
diverticulum but despite the
availability of modern imaging
techniques, the diagnosis is
challenging. Laparoscopy is more
useful in this situation.
A patient with an acute abdomen presents a situation where the advantages and benefits of minimal-access surgery can be truly appreciated. Acute abdomen may be caused by acquired or congenital conditions, for which minimal-access techniques provide both the diagnosis and therapy.
M a n a g e m e n t o f M e c k e l ’ s diverticulum in asymptomatic patients is controversial. Excision is mandatory for all symptomatic diverticuli. With the advent of gastrointestinal stapling devices, excision has become safer, faster and more efficient. Another advantage of stapling is that it closes the bowel lumen as it cuts, thereby completely reducing the chance of contamination.
Laparoscopy has a definite role in bowel obstruction, where there is dilemma in diagnosis inspite of modern imaging techniques. Laparoscopy confirms the diagnosis and most of the surgical pathology involving small and large bowel can be treated in the same sitting in a specialised centre.
Case Report
A 28 year old boy presented to other medical centre with abdominal pain and treated as gastroenteritis. Patient was transferred to our centre for further management. Physical examination showed tenderness in the vicinity of the umbilicus. On auscultation, high pitched bowel sounds were heard and a diagnosis of bowel obstruction was made. Radiograph of the abdomen was s ugge s t i v e o f sma l l bowe l obstruction. A CT scan confirmed dilated small bowel loops and cause of obstruction was inconclusive.
Diagnostic laparoscopy was carried out and found to have dilated small bowel and constricted small bowel and a band found to be causing this obstruction which was divided. Later examination showed this band to be
c o n n e c t e d w i t h M e c k e l ’ s diverticulum and laparoscopic
Meckel’s dicetriculectomy was carried out using endostapler (Endoscopic Articulating Linear Cutter, size 45 mm). The diverti-culum was resected off the ileum and the specimen was delivered through the enlarged 12 mm umbilical port with the use of an endobag. The
Meckle’s diverticulum with band
Diveriticulectomy done by endostapler
Dr. Shabeer Ahmed,
MS, FRCS (U.K.), MMAS
(Masters in Minimal Access
Surgery)
Consultant - General/
Gastrointestinal/
Laparoscopic Surgeon
DIGESTIVE CARE
n Unusual Cause of Dyspnoea Following Blood TransfusionA
A 22 year old lady presented with a history of 6 weeks of pregnancy with severe
abdominal pain and shock to a nursing home, where she was resuscitated for hypovolemic shock. A TVS (Trans Vaginal Sonogram) revealed a haemoperitonium and a left tubal ectopic pregnancy, and an emergency exploratory laparotomy was done. This showed a left sided t u b a l e c t o p i c w i t h a haemoperitonium of 1.5 litres. Left salpingectomy and peritoneal toileting was done. In the post-operative period three units of O-negative blood was transfused. Shortly after blood transfusion, the patient had mild abdominal distension with poor bowel sounds and became hypoxic. She required 10 units of oxygen per minute to maintain saturation. A chest x-ray done at that time showed bilateral haziness of lung fields (Fig 1). The
rest of the blood parameters were within normal limits. A provisional diagnosis of ARDS secondary to hypovolemic shock and blood transfusion was made and patient was shifted to Wockhardt Hospital for further management.
On admission, the patient was febrile, tachypnoeic, severely hypoxic but
hemodynamically stable. Chest x-ray showed bilateral patchy alveolar opacities consistent with features of ARDS. Arterial blood gas showed features consistent with 'acute lung injury, or ARDS.' Appropriate supplemental oxygen was provided and diuretics were also administered. Antibiotics were also started along with D.V.T. prophylaxis.
In view of the temporal relationship of blood transfusion with acute lung injury, the patient was diagnosed to have 'Transfusion Related Acute Lung Injury (TRALI).' The criteria set forth by the American and Canadian panels are considered sufficient to establish the diagnosis.
The basis of diagnosing the patient as TRALI was based on the following:
Criteria for TRALI
1) No acute lung injury (ALI) immediately before transfusion
2) New ALI
3) Onset of signs/ symptoms of ALI during or within 6 hours after the end of transfusion of one or more p l a sma - con ta in ing b lood products
4) No temporal relationship to an alternative risk factor for ALI
With supportive treatment, the patient improved significantly in the next forty-eight hours, with rapid c l i n i c a l a n d r a d i o l o g i c a l improvement (Fig 2), and was shifted out of medical ICU. Following recovery patient was discharged from the hospital in stable condition, with no sequelae of lung injury.
Discussion
The incidence of TRALI is not well established. Ambiguity regarding the definition of this syndrome, under-recognition of the syndrome as a clinical entity by physicians, and failure to identify milder cases that do not require therapeutic intervention each contribute to this problem. However, us ing the NHLBI definition of TRALI, the incidence of TRALI is estimated to be one case for every 1000 to 2400 units transfused. This incidence estimate of 0.04 to 0.1 percent is comparable to other estimates from previous studies that used older case definitions.
These cases as underreported are often misdiagnosed and mistreated due to their presentation. TRALI is the leading cause of transfusion-related mortality in the United States. There is not much Indian data available. The estimated mortality rate for recognised TRALI is 5 to 8 percent. However, most survivors recover completely with appropriate supportive care and can receive additional blood products in the future. Management of the patient with TRALI is supportive, with the
06 07
A patient with an acute abdomen presents a situation where the advantages and benefits of
minimal-access surgery can be truly appreciated. Acute abdomen may be caused by acquired or congenital conditions, for which minimal-access techniques
provide both the diagnosis and therapy, and a formal laparotomy can be arrived.
Fig. 1: Bilateral diffuse infiltrates at presentation
Fig. 2: Complete resolution
of the infiltrates
patient was allowed liquids orally on the same evening and was discharged on the second day.
Meckel’s diverticulum is the most common form of congenital abnormality of the small intestine, resulting from an incomplete obliteration of the vitelline duct. Although originally described by Fabricius Hildanus in 1598, it is named after Johann Friedrich Meckel, who established its embryonical origin between 1808 and 1820. The tip of the diverticulum is free in 75% of cases, and in 25% of the cases the tip is attached to another organ or structure by means of a band like in our case. Most patients are asymptomatic, and it is usually an incidental finding when a barium study or laparotomy is performed for other abdominal conditions. Complications include b o w e l o b s t r u c t i o n ( 3 5 % ) , haemorrhage (32%), diverticulitis (22%), umbilical fistula (10%), perforation (5%), other umbilical lesions (1%) and intussusception.
Meckel’s diverticulitis may mimic appendicitis.
The correct diagnosis is usually
established at the laparotomy or
laparoscopy. None of the clinical
features are pathognomonic, and the
diagnosis is rarely made pre-
operatively. Routine laboratory
studies, such as leukocyte and
erythrocyte counts, serum electro-
lytes, blood glucose and urea, serum
creatinine and coagulation screen are
helpful in the general work-up. These
tests will show evidence of acute
infection. Computed tomography and
ultrasonography have been used for
Discussion
t h e d i agno s i s o f Mecke l ’ s
diverticulum but despite the
availability of modern imaging
techniques, the diagnosis is
challenging. Laparoscopy is more
useful in this situation.
A patient with an acute abdomen presents a situation where the advantages and benefits of minimal-access surgery can be truly appreciated. Acute abdomen may be caused by acquired or congenital conditions, for which minimal-access techniques provide both the diagnosis and therapy.
M a n a g e m e n t o f M e c k e l ’ s diverticulum in asymptomatic patients is controversial. Excision is mandatory for all symptomatic diverticuli. With the advent of gastrointestinal stapling devices, excision has become safer, faster and more efficient. Another advantage of stapling is that it closes the bowel lumen as it cuts, thereby completely reducing the chance of contamination.
Laparoscopy has a definite role in bowel obstruction, where there is dilemma in diagnosis inspite of modern imaging techniques. Laparoscopy confirms the diagnosis and most of the surgical pathology involving small and large bowel can be treated in the same sitting in a specialised centre.
Case Report
A 28 year old boy presented to other medical centre with abdominal pain and treated as gastroenteritis. Patient was transferred to our centre for further management. Physical examination showed tenderness in the vicinity of the umbilicus. On auscultation, high pitched bowel sounds were heard and a diagnosis of bowel obstruction was made. Radiograph of the abdomen was s ugge s t i v e o f sma l l bowe l obstruction. A CT scan confirmed dilated small bowel loops and cause of obstruction was inconclusive.
Diagnostic laparoscopy was carried out and found to have dilated small bowel and constricted small bowel and a band found to be causing this obstruction which was divided. Later examination showed this band to be
c o n n e c t e d w i t h M e c k e l ’ s diverticulum and laparoscopic
Meckel’s dicetriculectomy was carried out using endostapler (Endoscopic Articulating Linear Cutter, size 45 mm). The diverti-culum was resected off the ileum and the specimen was delivered through the enlarged 12 mm umbilical port with the use of an endobag. The
Meckle’s diverticulum with band
Diveriticulectomy done by endostapler
Dr. Shabeer Ahmed,
MS, FRCS (U.K.), MMAS
(Masters in Minimal Access
Surgery)
Consultant - General/
Gastrointestinal/
Laparoscopic Surgeon
DIGESTIVE CARE
n Unusual Cause of Dyspnoea Following Blood TransfusionA
A 22 year old lady presented with a history of 6 weeks of pregnancy with severe
abdominal pain and shock to a nursing home, where she was resuscitated for hypovolemic shock. A TVS (Trans Vaginal Sonogram) revealed a haemoperitonium and a left tubal ectopic pregnancy, and an emergency exploratory laparotomy was done. This showed a left sided t u b a l e c t o p i c w i t h a haemoperitonium of 1.5 litres. Left salpingectomy and peritoneal toileting was done. In the post-operative period three units of O-negative blood was transfused. Shortly after blood transfusion, the patient had mild abdominal distension with poor bowel sounds and became hypoxic. She required 10 units of oxygen per minute to maintain saturation. A chest x-ray done at that time showed bilateral haziness of lung fields (Fig 1). The
rest of the blood parameters were within normal limits. A provisional diagnosis of ARDS secondary to hypovolemic shock and blood transfusion was made and patient was shifted to Wockhardt Hospital for further management.
On admission, the patient was febrile, tachypnoeic, severely hypoxic but
hemodynamically stable. Chest x-ray showed bilateral patchy alveolar opacities consistent with features of ARDS. Arterial blood gas showed features consistent with 'acute lung injury, or ARDS.' Appropriate supplemental oxygen was provided and diuretics were also administered. Antibiotics were also started along with D.V.T. prophylaxis.
In view of the temporal relationship of blood transfusion with acute lung injury, the patient was diagnosed to have 'Transfusion Related Acute Lung Injury (TRALI).' The criteria set forth by the American and Canadian panels are considered sufficient to establish the diagnosis.
The basis of diagnosing the patient as TRALI was based on the following:
Criteria for TRALI
1) No acute lung injury (ALI) immediately before transfusion
2) New ALI
3) Onset of signs/ symptoms of ALI during or within 6 hours after the end of transfusion of one or more p l a sma - con ta in ing b lood products
4) No temporal relationship to an alternative risk factor for ALI
With supportive treatment, the patient improved significantly in the next forty-eight hours, with rapid c l i n i c a l a n d r a d i o l o g i c a l improvement (Fig 2), and was shifted out of medical ICU. Following recovery patient was discharged from the hospital in stable condition, with no sequelae of lung injury.
Discussion
The incidence of TRALI is not well established. Ambiguity regarding the definition of this syndrome, under-recognition of the syndrome as a clinical entity by physicians, and failure to identify milder cases that do not require therapeutic intervention each contribute to this problem. However, us ing the NHLBI definition of TRALI, the incidence of TRALI is estimated to be one case for every 1000 to 2400 units transfused. This incidence estimate of 0.04 to 0.1 percent is comparable to other estimates from previous studies that used older case definitions.
These cases as underreported are often misdiagnosed and mistreated due to their presentation. TRALI is the leading cause of transfusion-related mortality in the United States. There is not much Indian data available. The estimated mortality rate for recognised TRALI is 5 to 8 percent. However, most survivors recover completely with appropriate supportive care and can receive additional blood products in the future. Management of the patient with TRALI is supportive, with the
06 07
A patient with an acute abdomen presents a situation where the advantages and benefits of
minimal-access surgery can be truly appreciated. Acute abdomen may be caused by acquired or congenital conditions, for which minimal-access techniques
provide both the diagnosis and therapy, and a formal laparotomy can be arrived.
Fig. 1: Bilateral diffuse infiltrates at presentation
Fig. 2: Complete resolution
of the infiltrates
Neurology Services at Wockhardt Hospitals
he Neurology division at Wockhardt Hospitals has been a key and integral part T
of the multi-specialty services offered by this tertiary level care hospital, ever since its inception in 2006. The Neurology division now sees an average of 500 patients every month in the outpatient clinic (both direct and cross-referrals) and around 50 inpatient admissions are cared for every month.
The hospital offers unique strengths in the management of movement disorders, stroke, epilepsy, neuro-muscular diseases, neuro-infections, demyelinating disorders, etc.
The Critical Care team works closely with Neurology to provide optimal care in the management of acute and critical neurological problems such as Guillain Barre Syndrome, Myasthenic crisis, Status epilepticus,
Meningo-encephalitis, Coma of various etiologies, etc.
The hospital has invested in the most advanced technology in this field so as to provide a complete and comprehensive solution to the patients with neurological disorders – • 1.5 Telsa MRI supported by
functional imaging and contrast free angiography
• High speed 64 Slice CT Scan for v o l u m e i m a g i n g a n d 3-dimensional viewing
• Neuronavigation system assisted operating rooms EEG/ ENMG
• 12 bed Neuro ICU and rehab• Video assisted endoscopic
techniques
The diagnostic facil i t ies for move-ment disorders have been expanded, with the application of c l i n i c a l s c a l e s , a nd v i d eo documentation. This allows critical
evaluation of patients for more advanced therapies such as deep brain stimulation which is likely to be made available shortly. The diagnostic services would be further extended for epilepsy, especially long-term EEG monitoring. A small group of patients have been worked up for possible vagal nerve s t i m u l a t i o n f o r l o n g - t e r m management of intractable epilepsy. Also interventional neuro-radiology and endovascular neurosurgery, along with neuro-rehabilitation, to complement an advanced stroke programme are planned.
At Wockhardt Hospitals there are
two seats every year for Fellowship
Training in Neurology, under the
Rajiv Gandhi University for Health
Sciences. The course is for
18 months, starting in January
2009. For more information, please
call: 080 6621 4028 or email us at
kusuma.harinarayan@wockhardt
hospitals.com
08 09
Dr. Sandhya Ramanujam
DDS (USA), BDS (India),
CBM (USA), CDA (USA),
PGDMLE
Consultant - Dental Surgeon
Implantology and Aesthetic
Dentistry,
DEPARTMENT OF
DENTISTRY
DENTISTRYmplant RestorationsI in Dentistry
Introduction
Gone are the days when missing teeth had to be replaced by only a removable partial denture, which in most cases is uncomfortable and inconvenient, or by a bridge wherein hea l t hy t oo th s t r u c tu r e o f neighbouring teeth are compromised to be able to act as supporting structures for the missing tooth crown.
The latest and highly effective
method of replacing the lost teeth is
by the placement of dental implants.
The dental implant body placed in
the jaw replaces the root structure
and this is restored with a crown. The
advantage in this type of restoration is
that the neighboring teeth are not
touched and it is as good as the
natural teeth in functionality. Also it
being a fixed permanent structure,
there is no need for dealing with its
removal and replacement. It also
provides a very natural looking tooth.
Implant bodies are made out of titanium. They are taken up very well by the body and least amount of rejection is seen. This, of course, being the case when all other factors are favourable.
The situations when the implant
cases are not conducive to placement
is when the patient has an immuno-
compromised disease, is a bruxer
(grinds/ clenches teeth), has severely
c o m p r o m i s e d p e r i o d o n t a l
conditions. Upkeep of implants is
similar to regular teeth – brush and
floss regularly, avoid any excessive
forceful loads – by way of chewing or
abrasional habits.
Case: A case of a lady who had a root canal treated tooth with a crown was presented. The tooth eventually broke and the crown kept coming off. Upon viewing the x-ray it was seen that the tooth had fractured along the gum line and hence did not have adequate tooth structure to support it.
The treatment planned out was extraction of the remaining portion of the tooth and an immediate placement of the dental implant into the extraction site. She was then given a partial denture to wear for the interim healing period of 4 weeks and subsequently the tooth was restored with a crown. The advantage in this was that her neighbouring teeth were not touched and she received a permanent fixed prosthesis which looks and functions like a natural tooth.
e x p e c t a t i o n t h a t c l i n i c a l i m p r o v e m e n t w i l l o c c u r spontaneously as lung injury resolves. Mechanical ventilation is sometimes required for several days, and a high concentration of inspired oxygen and positive end-expiratory pressure may be required. Milder cases can be managed with supplemental oxygen alone. Such cases often are misdiagnosed and difficult to treat unless appropriately approached.
Highlights
1. can be a serious
complication of a routine
procedure such as blood
transfusion. No transfusion is safe,
TRALI
until the risks are worth the
benefits.
2.
are major s teps towards appropriate treatment.
3.
, it is a treatable
condition provided diagnosed early.
4.
can often make it
difficult to diagnose as no specific tests for diagnosis are present.
This complication can be seen
across al l branches of
medicine. Awareness and
early recognition
A l t h o u g h a s e r i o u s
complication
The gross similarity with
other diseases
Dr. Anu Sridhar
MD
Consultant Obstetrician &
Gynaecologist
WOMAN CARE
Dr. Ravindra M. Mehta
MD, FCCP, American Board
Certified Critical Care
Medicine, Pulmonary
Medicine, Sleep Disorder
Medicine, Internal Medicine
Head of Critical Care,
Consultant Chest Physician and
Interventional Pulmonologist
DEPARTMENT OF
CRITICAL CARE
Discussion
The placement of the implant requires a good amount of pre-surgical planning. We look at dental orthopantomograms (OPG) to assess the available bone density and quality to determine the kind and length of implant to be used, its proximity to vital structures, etc. Diagnostic casts are prepared to assess the clearance available and any para-normal functional stresses the implant may encounter upon functionality.
Next a pre-surgical stent is prepared to aid in the exact location of the placement as well as the angulation of the implant. We then plan out the healing prosthesis that is placed in the mouth at the time of surgery which the patient will go back home with during the healing period. At the time of surgery we advocate the flapless entry in most instances, to
the times not necessitating sutures. Again the mode of anesthesia is just local block or even deep infiltrations which provide a comfortable level of painlessness during the procedure. The post-operative recovery too is relatively devoid of any discomfort. Although the patient is put on a course of antibiotics for a week, and most often need just a mild analgesic for a couple of days.
Pre-operative Picture
Post-operative Picture
make the surgical site as clean and bloodless as possible, hence most of
Neurology Services at Wockhardt Hospitals
he Neurology division at Wockhardt Hospitals has been a key and integral part T
of the multi-specialty services offered by this tertiary level care hospital, ever since its inception in 2006. The Neurology division now sees an average of 500 patients every month in the outpatient clinic (both direct and cross-referrals) and around 50 inpatient admissions are cared for every month.
The hospital offers unique strengths in the management of movement disorders, stroke, epilepsy, neuro-muscular diseases, neuro-infections, demyelinating disorders, etc.
The Critical Care team works closely with Neurology to provide optimal care in the management of acute and critical neurological problems such as Guillain Barre Syndrome, Myasthenic crisis, Status epilepticus,
Meningo-encephalitis, Coma of various etiologies, etc.
The hospital has invested in the most advanced technology in this field so as to provide a complete and comprehensive solution to the patients with neurological disorders – • 1.5 Telsa MRI supported by
functional imaging and contrast free angiography
• High speed 64 Slice CT Scan for v o l u m e i m a g i n g a n d 3-dimensional viewing
• Neuronavigation system assisted operating rooms EEG/ ENMG
• 12 bed Neuro ICU and rehab• Video assisted endoscopic
techniques
The diagnostic facil i t ies for move-ment disorders have been expanded, with the application of c l i n i c a l s c a l e s , a nd v i d eo documentation. This allows critical
evaluation of patients for more advanced therapies such as deep brain stimulation which is likely to be made available shortly. The diagnostic services would be further extended for epilepsy, especially long-term EEG monitoring. A small group of patients have been worked up for possible vagal nerve s t i m u l a t i o n f o r l o n g - t e r m management of intractable epilepsy. Also interventional neuro-radiology and endovascular neurosurgery, along with neuro-rehabilitation, to complement an advanced stroke programme are planned.
At Wockhardt Hospitals there are
two seats every year for Fellowship
Training in Neurology, under the
Rajiv Gandhi University for Health
Sciences. The course is for
18 months, starting in January
2009. For more information, please
call: 080 6621 4028 or email us at
kusuma.harinarayan@wockhardt
hospitals.com
08 09
Dr. Sandhya Ramanujam
DDS (USA), BDS (India),
CBM (USA), CDA (USA),
PGDMLE
Consultant - Dental Surgeon
Implantology and Aesthetic
Dentistry,
DEPARTMENT OF
DENTISTRY
DENTISTRYmplant RestorationsI in Dentistry
Introduction
Gone are the days when missing teeth had to be replaced by only a removable partial denture, which in most cases is uncomfortable and inconvenient, or by a bridge wherein hea l t hy t oo th s t r u c tu r e o f neighbouring teeth are compromised to be able to act as supporting structures for the missing tooth crown.
The latest and highly effective
method of replacing the lost teeth is
by the placement of dental implants.
The dental implant body placed in
the jaw replaces the root structure
and this is restored with a crown. The
advantage in this type of restoration is
that the neighboring teeth are not
touched and it is as good as the
natural teeth in functionality. Also it
being a fixed permanent structure,
there is no need for dealing with its
removal and replacement. It also
provides a very natural looking tooth.
Implant bodies are made out of titanium. They are taken up very well by the body and least amount of rejection is seen. This, of course, being the case when all other factors are favourable.
The situations when the implant
cases are not conducive to placement
is when the patient has an immuno-
compromised disease, is a bruxer
(grinds/ clenches teeth), has severely
c o m p r o m i s e d p e r i o d o n t a l
conditions. Upkeep of implants is
similar to regular teeth – brush and
floss regularly, avoid any excessive
forceful loads – by way of chewing or
abrasional habits.
Case: A case of a lady who had a root canal treated tooth with a crown was presented. The tooth eventually broke and the crown kept coming off. Upon viewing the x-ray it was seen that the tooth had fractured along the gum line and hence did not have adequate tooth structure to support it.
The treatment planned out was extraction of the remaining portion of the tooth and an immediate placement of the dental implant into the extraction site. She was then given a partial denture to wear for the interim healing period of 4 weeks and subsequently the tooth was restored with a crown. The advantage in this was that her neighbouring teeth were not touched and she received a permanent fixed prosthesis which looks and functions like a natural tooth.
e x p e c t a t i o n t h a t c l i n i c a l i m p r o v e m e n t w i l l o c c u r spontaneously as lung injury resolves. Mechanical ventilation is sometimes required for several days, and a high concentration of inspired oxygen and positive end-expiratory pressure may be required. Milder cases can be managed with supplemental oxygen alone. Such cases often are misdiagnosed and difficult to treat unless appropriately approached.
Highlights
1. can be a serious
complication of a routine
procedure such as blood
transfusion. No transfusion is safe,
TRALI
until the risks are worth the
benefits.
2.
are major s teps towards appropriate treatment.
3.
, it is a treatable
condition provided diagnosed early.
4.
can often make it
difficult to diagnose as no specific tests for diagnosis are present.
This complication can be seen
across al l branches of
medicine. Awareness and
early recognition
A l t h o u g h a s e r i o u s
complication
The gross similarity with
other diseases
Dr. Anu Sridhar
MD
Consultant Obstetrician &
Gynaecologist
WOMAN CARE
Dr. Ravindra M. Mehta
MD, FCCP, American Board
Certified Critical Care
Medicine, Pulmonary
Medicine, Sleep Disorder
Medicine, Internal Medicine
Head of Critical Care,
Consultant Chest Physician and
Interventional Pulmonologist
DEPARTMENT OF
CRITICAL CARE
Discussion
The placement of the implant requires a good amount of pre-surgical planning. We look at dental orthopantomograms (OPG) to assess the available bone density and quality to determine the kind and length of implant to be used, its proximity to vital structures, etc. Diagnostic casts are prepared to assess the clearance available and any para-normal functional stresses the implant may encounter upon functionality.
Next a pre-surgical stent is prepared to aid in the exact location of the placement as well as the angulation of the implant. We then plan out the healing prosthesis that is placed in the mouth at the time of surgery which the patient will go back home with during the healing period. At the time of surgery we advocate the flapless entry in most instances, to
the times not necessitating sutures. Again the mode of anesthesia is just local block or even deep infiltrations which provide a comfortable level of painlessness during the procedure. The post-operative recovery too is relatively devoid of any discomfort. Although the patient is put on a course of antibiotics for a week, and most often need just a mild analgesic for a couple of days.
Pre-operative Picture
Post-operative Picture
make the surgical site as clean and bloodless as possible, hence most of
11
News Room
Wockhardt Hospitals
achieves JCI accreditation
Live Surgery—
Video Assisted Thoracic
Surgery (VATS)
First in the region to get the
coveted gold seal of quality
healthcare
W o c k h a r d t H o s p i t a l s , Bangalore has become the first super specialty h o s p i t a l i n Ka rna t aka t o achieve accreditation from Joint Commission International (JCI), USA. JCI is the gold standard in global healthcare quality standards and the global leader in healthcare accreditation having accredited 140 hospitals in 27 countries. Wockhardt Hospitals, Bangalore now joins an exclusive group of super specialty hospitals worldwide, which have
passed JCI’s stringent healthcare quality standards.
A team ofexperienced cardiothoracic
surgeons supported by advanced
laparoscopic surgeons at Wockhardt
Hospitals, Bangalore conducted a
live video assisted thoracic surgery.
This was attended by the leading
chest physicians, pulmonologists and
cardiologists of Karnataka.
D r . V i v e k J a w a l i , C h i e f Cardiothoracic surgeon, along with Dr. Shabeer Ahmed, GI and Minimal
Access Surgeon at Wockhardt Hospitals conducted this live surgery on two patients suffering from t umour i n t h e che s t , and hyperhydrosis (excessive sweating of the hands, face, arm pits and feet).
A 13-year-old girl from Coorg went through a series of surgeries to correct the wrong positioning of ventricles and arteries in her heart. Congenital cardiac defects of this nature, called congenitally corrected transposition of the great arteries, affects not more than one per cent of children born with heart problems. She also had situs inversus, which means all her organs are positioned
on the opposite side, including the heart.
In the latest and the most complicated surgery conducted by Dr. N.S. Devananda, Consultant Cardio Vascular Surgeon, this second child of a farmer couple underwent the double switch operation after left ventricular ‘retraining’ at Wockhardt Hospitals. That has set right the anomalies in the circulation in her body.
In the past one year, there has been
Girl undergoes series
of surgeries to put arteries
in right place
Wockhardt brings cheer to
the life of Goan children
with heart defect
significant rise in the awareness about congenital heart diseases among the general public in Goa. This trend started after Wockhardt Hospitals, Bangalore, launched its health education drive last year targeting healthcare professionals and the general public in Goa.
Wockhardt Hospitals’ special focus on Goa has helped identify and treat children born with congenital heart defects. For a Goan, the best of cardiothoracic surgery f rom Wockhardt Hospitals has come within reach because of the
government’s proactive healthcare scheme, MEDICLAIM.
In a press con f e rence h e l d i n Banga l o r e , Dr. Ganesh Krishnan Iyer s t a t e s tha t repairing rather than replacing a patient 's mitral valve yields significant benefits including shorter hospital stays, lower patient risk, improved durability, and lower complications and death rates. Heart valve dysfunctions such as stenosis and regurgitation of the aortic, mitral, and tricuspid valves may require repair or replacement of the diseased valve.
Major technical and technological advances in the treatment of valvular
Heart Valve; Why Replace?
When You Can Repair
10
Movement Disorders
Management of
ovement is mediated through the pyramidal Msystem, the basal ganglia
and the cerebellum in the brain. These are discrete parts of the brain which perform specific but different functions, which are wired to each other for the performance of normal movement.
The movement disorders are a diverse group of pathologic dysfunctions in the nervous system, giving rise to any of these: an abnormal movement, a paucity of movement, an abnormality of muscle tone or a disturbance in postural reflex.
The common movement disorders are Tremors, Chorea, Parkinson's disease, Dystonia and Writer's cramp.
The patient gives a detailed history of what has been occurring in terms of the symptoms. The investigation is followed by a neurological physical examination. Scales are used (basically written proformas) to assess the severity and type of movement disorder. Various movement sequences are recorded on video as a baseline before any treatment, to later compare the patient's performance in specific functions.
This is followed by basic bloods tests, a CT/ MRI brain scan and EEG or
Investigation
Specific Medical Concerns
The first task of the physician is to arrive at a diagnosis, or a highly probable diagnosis, using various lines of investigation.
The best line of treatment: Each patient would need to be tried on a specific combination of drugs which may vary from 1 to 3 months, to assess the best outcome with drug management. Following this minor adjustment in drug dosages may be required once every three months.
Likely outcomes: It is usually expected that the abnormal movement decreases to a remarkable extent. If the problem had been one of rigidity and paucity of movement, then movements should be more easily performed. A small sub-set of patients are not likely to improve on medications, for which deep brain stimulation or Stereotactic surgery should be considered to give optimal relief.
Movement disorders are generally progressive degenerative disorders, which means that the pathological course cannot be greatly altered, though significant improvement in f unc t i on can be p rov ided . However, the goal of management is to provide optimal relief and restore normal functionality, with the least side effects and thereby significantly improve quality of life for the patient.
EMG along with some specific tests that may be needed, depending on the diagnostic possibilities that the physician is thinking of.
1) Medications: Medications that
either stimulate or inhibit the specific
receptors for central nervous system
chemicals (neurotransmitters) are the
mainstay of management of
movement disorders.
2) Botulinum toxin injection: This
toxin is injected into muscles to
partially paralyse them, and thereby
control the abnormal movement.
Several sites are injected in one
sitting, and several such sessions may
be required at 4 week intervals.
3) Stereotactic surgery: After detailed visualisation using CT/ MRI and mapping the brain, ablation (destruction) of certain parts of the brain nuclei and/ or its circuits will generally give relief from the abnormal movement.
4) Deep brain stimulation: The position of the basal ganglia nuclei are identified using CT/ MRI brain scans. Electrodes are placed onto specific brain nuclei and electrical signals are sent from a generator placed under the skin, in the chest. The patient has the option of controlling the current from the generator, for symptom relief.
Treatment
The Department of Neurology at Wockhardt Hospitals
Dr. Chandran Gnanamuthu Dr. C. Udaya Shankar Dr. Vijay Chockan
MD, DM, FIAN, FAAN DM PhD (Neuro Sciences)
Specialist in Movement Disorder
Consultant Neurologist Consultant Neurologist Consultant Neurophysiologist
11
News Room
Wockhardt Hospitals
achieves JCI accreditation
Live Surgery—
Video Assisted Thoracic
Surgery (VATS)
First in the region to get the
coveted gold seal of quality
healthcare
W o c k h a r d t H o s p i t a l s , Bangalore has become the first super specialty h o s p i t a l i n Ka rna t aka t o achieve accreditation from Joint Commission International (JCI), USA. JCI is the gold standard in global healthcare quality standards and the global leader in healthcare accreditation having accredited 140 hospitals in 27 countries. Wockhardt Hospitals, Bangalore now joins an exclusive group of super specialty hospitals worldwide, which have
passed JCI’s stringent healthcare quality standards.
A team ofexperienced cardiothoracic
surgeons supported by advanced
laparoscopic surgeons at Wockhardt
Hospitals, Bangalore conducted a
live video assisted thoracic surgery.
This was attended by the leading
chest physicians, pulmonologists and
cardiologists of Karnataka.
D r . V i v e k J a w a l i , C h i e f Cardiothoracic surgeon, along with Dr. Shabeer Ahmed, GI and Minimal
Access Surgeon at Wockhardt Hospitals conducted this live surgery on two patients suffering from t umour i n t h e che s t , and hyperhydrosis (excessive sweating of the hands, face, arm pits and feet).
A 13-year-old girl from Coorg went through a series of surgeries to correct the wrong positioning of ventricles and arteries in her heart. Congenital cardiac defects of this nature, called congenitally corrected transposition of the great arteries, affects not more than one per cent of children born with heart problems. She also had situs inversus, which means all her organs are positioned
on the opposite side, including the heart.
In the latest and the most complicated surgery conducted by Dr. N.S. Devananda, Consultant Cardio Vascular Surgeon, this second child of a farmer couple underwent the double switch operation after left ventricular ‘retraining’ at Wockhardt Hospitals. That has set right the anomalies in the circulation in her body.
In the past one year, there has been
Girl undergoes series
of surgeries to put arteries
in right place
Wockhardt brings cheer to
the life of Goan children
with heart defect
significant rise in the awareness about congenital heart diseases among the general public in Goa. This trend started after Wockhardt Hospitals, Bangalore, launched its health education drive last year targeting healthcare professionals and the general public in Goa.
Wockhardt Hospitals’ special focus on Goa has helped identify and treat children born with congenital heart defects. For a Goan, the best of cardiothoracic surgery f rom Wockhardt Hospitals has come within reach because of the
government’s proactive healthcare scheme, MEDICLAIM.
In a press con f e rence h e l d i n Banga l o r e , Dr. Ganesh Krishnan Iyer s t a t e s tha t repairing rather than replacing a patient 's mitral valve yields significant benefits including shorter hospital stays, lower patient risk, improved durability, and lower complications and death rates. Heart valve dysfunctions such as stenosis and regurgitation of the aortic, mitral, and tricuspid valves may require repair or replacement of the diseased valve.
Major technical and technological advances in the treatment of valvular
Heart Valve; Why Replace?
When You Can Repair
10
Movement Disorders
Management of
ovement is mediated through the pyramidal Msystem, the basal ganglia
and the cerebellum in the brain. These are discrete parts of the brain which perform specific but different functions, which are wired to each other for the performance of normal movement.
The movement disorders are a diverse group of pathologic dysfunctions in the nervous system, giving rise to any of these: an abnormal movement, a paucity of movement, an abnormality of muscle tone or a disturbance in postural reflex.
The common movement disorders are Tremors, Chorea, Parkinson's disease, Dystonia and Writer's cramp.
The patient gives a detailed history of what has been occurring in terms of the symptoms. The investigation is followed by a neurological physical examination. Scales are used (basically written proformas) to assess the severity and type of movement disorder. Various movement sequences are recorded on video as a baseline before any treatment, to later compare the patient's performance in specific functions.
This is followed by basic bloods tests, a CT/ MRI brain scan and EEG or
Investigation
Specific Medical Concerns
The first task of the physician is to arrive at a diagnosis, or a highly probable diagnosis, using various lines of investigation.
The best line of treatment: Each patient would need to be tried on a specific combination of drugs which may vary from 1 to 3 months, to assess the best outcome with drug management. Following this minor adjustment in drug dosages may be required once every three months.
Likely outcomes: It is usually expected that the abnormal movement decreases to a remarkable extent. If the problem had been one of rigidity and paucity of movement, then movements should be more easily performed. A small sub-set of patients are not likely to improve on medications, for which deep brain stimulation or Stereotactic surgery should be considered to give optimal relief.
Movement disorders are generally progressive degenerative disorders, which means that the pathological course cannot be greatly altered, though significant improvement in f unc t i on can be p rov ided . However, the goal of management is to provide optimal relief and restore normal functionality, with the least side effects and thereby significantly improve quality of life for the patient.
EMG along with some specific tests that may be needed, depending on the diagnostic possibilities that the physician is thinking of.
1) Medications: Medications that
either stimulate or inhibit the specific
receptors for central nervous system
chemicals (neurotransmitters) are the
mainstay of management of
movement disorders.
2) Botulinum toxin injection: This
toxin is injected into muscles to
partially paralyse them, and thereby
control the abnormal movement.
Several sites are injected in one
sitting, and several such sessions may
be required at 4 week intervals.
3) Stereotactic surgery: After detailed visualisation using CT/ MRI and mapping the brain, ablation (destruction) of certain parts of the brain nuclei and/ or its circuits will generally give relief from the abnormal movement.
4) Deep brain stimulation: The position of the basal ganglia nuclei are identified using CT/ MRI brain scans. Electrodes are placed onto specific brain nuclei and electrical signals are sent from a generator placed under the skin, in the chest. The patient has the option of controlling the current from the generator, for symptom relief.
Treatment
The Department of Neurology at Wockhardt Hospitals
Dr. Chandran Gnanamuthu Dr. C. Udaya Shankar Dr. Vijay Chockan
MD, DM, FIAN, FAAN DM PhD (Neuro Sciences)
Specialist in Movement Disorder
Consultant Neurologist Consultant Neurologist Consultant Neurophysiologist
12
News Room
Cunningham Road.Tel: 91-80-4199 4444/ 2226 1037
We look forward to hearing from you. Send in your views and suggestions to [email protected]
Bannerghatta Road.Tel: 91-80-6621 4444/ 2254 4444
Rajajinagar.Tel: 91-80-2300 4444
NagarbhaviTel: 91-80-2301 4444
Email: [email protected] Visit us: www.wockhardthospitals.net
heart disease have fueled global trends toward minimisation of morbidity through more natural and less traumatic approaches to surgery.
Long-term results have demonstrated significant benefits for patients undergoing valve repair when compared to patients having valve replacement. Since the need for long-term anticoagulation is avoided, these benefits primarily mean increased freedom from valve-related complications such as thromboembolism and major bleeding episodes, and death.
On the occasion of the world heart day (Sep tember 28 , 2008 ) , Wockhardt Hospitals, Nagarbhavi, Rajajinagar, Cunnigham and Bannerghatta Road flagged-off an awareness campaign “listen to your heart”. The campaign was launched by Mr Narendra Babu, MLA of Rajajinagar by taking a pledge to give 30 minutes of his time every day to take care of his heart. The theme of this world heart day being “Know
World Heart Day awareness
campaign
lungs was restricted by banding the pulmonary artery. Dr. Devananda and his team performed the second
st open heart surgery on her on 1 April 2006. The restrictive hole was widened, the blood vessel from the heart to the lung was disconnected from the heart - a Glenn Shunt was
stperformed. On 31 July 2008 she underwent the final open heart surgery wherein repair of the aneurysm of the ventricle and a Fontan operation were successfully done. She recovered well after the third surgery and was discharged from hospital in August 2008.
World renowned orthopedic surgeon Dr. Andrew Cobb, with Dr. Sanjay Pai and team comprising of Dr. Vasudev Prabhu, Dr. J V Sr in ivas , Dr Ashish Anand performed a live demonstration of Hip Replacement surgery at Wockhardt Hospitals, Nagarbhavi. Dr. Cobb designed the first Hip Implant years ago for De Puy Company. This was the tate-of-the-art Center’s first initiative for Joint R e p l a c e m e n t . I t o f f e r s comprehensive service and provides d iagnos i s , management and rehabilitation under one roof at an affordable cost. The Center for Joint Rep lacement a t Wockhard t Hospitals, Bone & Joint care has successfully conducted over 1000 joint replacement surgeries from the time of its inception.
Launch of CJR at
Nagarbhavi
your risk”, the objective of the campaign was to educate people about their heart risk, by providing tips for a healthy heart, know symptoms, calculate risk analysis and understand basic emergency steps during heart emergency. Such initiatives of community centers like Wockhardt Hospitals, Rajajinagar and Nagarbhavi had a mass appeal impacting many localites and senior citizens in and around Rajajinagar a n d N a g a r b h a v i . F u r t h e r , propagating the theme, Wockhardt Hospitals have gone ahead sending posters, booklets, emails and sms to corporates and public across Karnataka.
Pediatric Heart Surgeons at Wockhardt Hospitals led by Dr. Devananda N. S., Cardiovascular Surgeon at Wockhardt Hospitals, Bangalore added another feather to their cap by successfully operating a little girl three times in four years to rectify her congenital heart problem. Akanksha, who underwent all three surgeries successfully, was born with a rare and highly complex heart problem. She had a single pumping chamber (ventricle) with complete obstruction to the blood flow in the main blood vessel of the body (aortic interruption). On 21st December 2004, Akanksha, who was around one month old then underwent her first open heart surgery. The obstructed tube was cleared of obstruction and the blood flow to the
Five surgeries in four years
Prin
ters
: E
XC
EL G
RA
PH
ICS
, N
ov 2
00
5
