Lilavati Times - Issue -8 (22-12-15)-final-2

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LILAVATI HOSPITAL
MEDICAL TIMES
FEBRUARY 2016
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LILAVATI HOSPITAL
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Contents
Overview: Lilavati Hospital & Research Centre
Lilavati Kirtilal Mehta Medical Trust
EDITORIAL TEAM
Dr. Ajit Menon
Dr. Bharat Shah
Dr. Chandralekha Tampi
Dr. Kiran Coelho
Dr. Prasad Wagle
Dr. Sanjeev Mehta
Dr. Swati Kanakia
CO-ORDINATOR
Mr. Kundan Singh
All the correspondence should be addressed:
To,
The Editor
Lilavati Hospital Medical Times,
Lilavati Hospital & Research Centre,
A-791, Bandra Reclamation, Bandra (W),
Mumbai - 400 050,
Fax: 91-22-2640 7655
Website: www.lilavatihospital.com
Email: medicaltimes@lilavatihospital.com
Overview: Lilavati Hospital and Research Centre ........... 1
Lilavati Hospital Today .......................................................
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Renovated ICCU ......................................................... 3
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PET Scan ..................................................................... 4
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Coronary GRAFT Patency Flowmeter ....................... 4
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New Facility ............................................................... 4
Lilavati Hospital and Research Centre is run and managed by Public
Charitable Trust - Lilavati Kirtilal Mehta Medical Trust, which was formed
in 1978. The Trust was settled by late Shri Kirtilal Manilal Mehta. The Trust
is engaged in innumerable charitable endeavors across India.
Late Shri Kirtilal Mehta
Review Article: ...................................................................
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Psychology .................................................................. 5
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How I treat: Pediatric Hematology ............................. 6
Case Reports .......................................................................
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Anaesthesiology........................................................... 9
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Cardiovascular and Thoracic Surgery ....................... 18
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Chest Medicine ......................................................... 20
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Nuclear Medicine ...................................................... 23
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Orthopaedic ............................................................... 25
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Urology...................................................................... 30
The Lilavati Kirtilal Mehta Medical Trust is being
managed and administered by:
Interim Board
Late Smt. Lilavati K. Mehta
Chairman
Justice (Retd.) J. N. Patel
and
Trustees
Smt. Charu K. Mehta
Smt. Rekha H. Sheth
Straight from the heart ................................................... 32
Educational Activities ..................................................... 33
Lilavati Hospital & Research Centre
SEWA ............................................................................. 34
Lilavati Hospital & Research Centre is a premier multi specialty tertiary care hospital located in
the heart of Mumbai, close to the domestic and the international airport. It encompasses modern health care
facilities and state of art technology dedicatedly supported by a committed staff. Lilavati Hospital has
focused its operation on providing quality care with a human touch which truly reflects the essence of its
motto, “More than Health Care, Human Care”. Being a centre of medical excellence where technology
meets international norms and standards, the hospital has got what it takes to be the pioneering quality
healthcare institute and hence is one of the most sought after and patient friendly hospital.
Feathers in Cap ............................................................... 35
Fun Time ......................................................................... 36
Services available ........................................................... 37
Doctors associated with Lilavati Hospital ..................... 38
Important numbers.......................................................... 42
The views expressed in the Medical Times are not of Lilavati Hospital or the editor or publisher. No part of the Medical Times can be reproduced
in any form including printing or electronic without the written permission of the editor or publisher. The information provided on medicines,
materials, investigations, procedures, therapies and anything medical is the sole responsibility of the author of the article and the hospital shall not
be responsible for any such information.
Mission: To provide affordable healthcare of international standard with human care.
Motto: More than Healthcare, Human Care.
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Lilavati Hospital Today
Renovated ICCU
Highlights
316 bedded
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hospital including 79 Intensive care beds.
12 state-of-the-art
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Full fledged
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More
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well equipped operation theatres.
Dental & Dermo cosmetology clinic.
than 300 consultants and manpower of nearly 1,800.
Hospital
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attends to 300 In-patients and 1,500 Out-patients daily.
Modern
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Cathlabs having specialized SICU & ICCU with highly trained cardiac care medical staff.
Lilavati
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Kirtilal Mehta Medical trust is an approved research organization by Ministry of Science &
Technology having all modern facilities necessary for conducting research.
Highlights
Total
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Lilavati Kirtilal Mehta Medical Trust Research Centre
The Lilavati Kirtilal Mehta Medical Trust Research Centre is a Scientific and Industrial Research
Organization approved by Ministry of Science and Technology (Govt. of India). The Research Centre
under guidelines of Dept. of Science & Technology works in close collaboration in evaluating and
developing technologies for better health care to the sick people. The research centre has undertaken
multidisciplinary researches in the fields of Cardiology, Radiology, Cerebrovascular Diseases (Stroke),
Ophthalmology, Chest Medicine, Nuclear Medicine, Pathology, Oncology, Orthopedics etc, to cite a few.
One of the important aim of the Research Centre is to establish Community based epidemiological
researches in Cerebrovascular disease in stroke. As a policy, Drug and Device Trials are not undertaken
at the Research Centre.
number of ICCU beds is 19.
Portable
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digital X-ray with on spot visual display improves and expedites decision making about
patient care.
C MAC
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Advanced ABG
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The Central
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Positive
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Each
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machine with point of care testing for Electrolytes, Glucose and Lactate.
pendent in each cubicle provides better interface between patient and ventilator/ monitor.
& Negative Isolation rooms. 1 Isolation Bed with C - Arm Compatibility.
Cubicle has Dialysis facility.
The
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design of ICCU incorporates various infection control practices minimizing risk of hospital
acquired infections.
Provides
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accessibility to OT complex and Cath labs.
Separate
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counselling room for relatives thus improves communication and confidence.
Bright
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2
Flexible intubating laryngoscope for difficult endotracheal Intubation.
lightning system is installed creating better atmosphere for doctors & patients.
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Review Article: Psychology
PET Scan
Dr. Varkha Chulani, Clinical Psychologist & Psychotherapist
Lilavati Hospital & Research Centre is now equipped with Siemens Biograph mCT 20 PET scanner.
A man who moralizes is usually a hypocrite - Oscar Wilde.
Key Features
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Higher
sensitivity LSO (Lutetium crystals) based system built on a scalable platform. The system
utilizes the smallest 4 x 4mm LSO crystals offering better sensitivity, higher count rate statistics
and high resolution images.
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Access
to virtually all large patients with its 78cm large bore, 80kW X-ray generator, 227kg bed
limit and unique magnetic deflection table movement design.
The
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system provides superb visualization particularly of small tumors with an industry-leading
95 mm 3 volumetric resolution.
A specialized
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high-definition imaging feature which virtually freezes respiratory motion enabling
full HD lesion detection and accurate standard uptake value (SUV) quantification.
Utilizes
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time-of-flight detection technology for improved image quality at lower injected dose and
with 2mm PET spatial resolutions across the field of view.
Coronary GRAFT Patency Flowmeter
Lilavati Hospital is recently equipped with Coronary GRAFT Patency Flowmeter which is first of its
kind in India. This imaging system is used in Cardiac surgery to assess GRAFT flow / perfusion in
coronary bypass surgery. It enables the surgeon to locate intramyocardial coronaries which are not
seen on surface of the heart. Cardiac surgeon can now assess the percentage of coronary block /
stenosis by epicardial Doppler probe to decide about the graftability of coronary vessel. Epiaortic
ultrasound helps to avoid brain stroke from atherosclerotic plaques in ascending aorta and
measurement of graft flow intraoperatively.
In the past few weeks there has been uproar about statements made by celebrities about the deteriorating
situation in our country. An expression that every person in a democracy has a right to express. And if
you objectively assess has a lot of truth to it too. But as you are aware it led people to react in manners
that were atrocious. From questioning the celebrities’ patriotism for the country to taking digs at their
personal life the tirades smacked of irrationality and the inability to reason. I would go as far as saying that
it exposed people’s poor thinking skills besides their failure to judge sensibly. Every argument was a
fallacy and in the court of law would have fallen flat on its face! So to all of you reading this go brush up
your reasoning skills just in case you too had some strange ‘illogical’ arguments about what was said and
were attempting to defend your country from harm!
Intolerance is a psychologically interesting phenomenon because it is symptomatic of insecurity and fear.
Zealots who would if they could persecute you into conforming to their way of thinking might claim to
be trying to save your soul despite yourself but they are really doing it because they feel threatened. So
what got people to actually react in the manner that they did? Even the so-called ‘intellectuals’, the supposed
‘well-wishers’ of the nation the purported ‘well-read’? It was their belief that these celebrities ought to live
as they think they should! By the imposition of beliefs and practices that they thought was ‘right’! The
reactors were fearful. They believed that unless a tight grip is kept on human thoughts and instincts the
earth will break open and demons will rise. And more so because the people who said what they did were
influencers people in positions of power. Many were worried that this proverbially could lead to an
ideational revolution. Like the Taliban of Afghanistan who force women to wear veils to stay at home and
to give up education and work because they are afraid of women’s freedom; people in our culture - that has
never encouraged questioning as a way of life - feel nervous that their ‘supremacy’ will be under risk
specially when those who have clout begin to air their views. We revere silence. We love hiding truths.
Brushing realities under the carpet gives us comfort. We are a nation in denial!
All these functional imaging and blood flow measurements allows Cardiac surgeons to optimize surgical
outcome in Heart surgery and prevent avoidable complications more accurately.
But why only talk of a culture that feels threatened. Let’s come closer home. Families that try to protect
‘traditions’ because they are alarmed by youth’s insouciance do not comprehend the adage of live and let live.
So, they compel their youth to only marry whom they choose. To get into family businesses which have no
allure for their progeny. Persist with archaic rituals that have no significance except the formal procedure that
continues since no one has the courage to step away even though they may see no value in what passes forth.
New Facility
Helen Keller said, “the highest result of education is tolerance”. Anyone can put forth a point of view but no
one can force another to accept it. It is the burden of our unquestioned convictions makes us intolerant. As
Nietzsche said, “convictions are more dangerous enemies of truths than lies”. We can only be coerced
through argument through honest reasoning. What underlies tolerance is the recognition that there is plenty
of room in the world for alternatives to co-exist and that if one is offended by what others say or do it is
because one has let it get under one’s skin. We tolerate others best when we know how to tolerate
ourselves; learning how to do so is the aim of a civilized life.
All days round the clock OPD Pathology and Radiology investigations without any Emergency charges.
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Ah! It would mean most of us in this country would qualify as hypocrites simply by that definition. Look
around and see. We are being imposed upon - how to live, eat, speak, errr… not speak, behave, decide our
sexual preferences, the list is endless. And that too by people who if they looked at themselves in the mirror
may end up cracking it!
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How I Treat :Pediatric Hematology
Dr. Swati Kanakia, MD, DCH, PhD
Cervical Lymphadenitis is the enlargement and inflammation of the cervical lymph nodes accompanied
by tenderness whereas cervical lymphadenopathy refers simply to enlarged lymph node/s of the neck.
These two terms are often used interchangeably. Patients with enlarged lymph nodes are commonly seen
in clinical practice. Healthy adults and children frequently have lymph nodes that are palpable especially
children between 4 to 8 years of age.
What is the size of nodes to decide that they are abnormal? That depends upon the site of the node.1
Site of lymph node
Size
Cervical
1.0 cm
Inguinal
1.5 cm
Epitrochlear
0.5 cm
Supraclavicular.
0.2 cm
bites and exposure to animals must be sought. Family history of tuberculosis and TB contact can help
to identify the cause. Infections of the scalp and lice are a common cause of posterior cervical
lymphadenitis. What is frequently overlooked are medications causing lymphadenopathy. They include
allopurinol, anti-hypertensives, anticonvulsants, anti-malarials, antibiotics like cephalosporins, and
sulfonamides.3 Immunizations can also cause lymphadenitis. They are live attenuated BCG, MMR, DPT,
OPV and typhoid.
Matted lymph nodes are considered to be tuberculous, waxing and waning nodes which are “shotty”
suggest Hodgkins disease, nodes which decrease in size in response to an infection are likely to be due to
auto immune lymphoproliferative syndrome or ALPS. Tender nodes are suggestive of infection whereas
firm hard painless nodes are commonly seen in cancers e.g. leukemia lymphoma, neuroblastoma of the
cervical nodes or metastatic cancers.
Pre auricular LN
Drain - eyelid,
conjunctiva,
temporal region,
pinna
Sub mental LN
Drain - lower lip,
floor of the mouth,
tip of the tongue,
skin of cheek
Sub occipital LN
Drain - scalp, head
There are various causes of cervical lymphadenopathy ranging from a nonspecific upper respiratory
tract infection to a malignancy and deciding which lymph nodes require further investigations is a
challenge for the attending physician.
Sub mandibular LN
Drain - tongue,
submaxillary
gland, lips, mouth
Acute, Subacute or Chronic Lymphadenopathy
Anterior cervical LN
Drain - larynx,
tongue, oropharynx,
anterior neck
Based on the duration of lymphadenopathy it can be classified as acute, sub-acute and chronic. Acute
lymphadenopathy is less than two weeks in duration. Subacute lymphadenopathy lasts 2-6 weeks. Whereas
chronic lymphadenopathy is typically > 6 weeks duration.
Anatomy and Physiology
Lymph nodes are areas of concentrated lymphocytes and macrophages along the lymphatic veins. They
are of varying sizes. Particulate matter in the lymph is filtered by the reticular and lymphoid tissue as
it passes through lymph nodes. Material that is not filtered off within one lymph node passes on to
the next one and so on. Thus by the time the lymph reaches the blood it has usually been cleaned of
all impurities. In some instances where phagocytosis is incomplete the node may enlarge.2
Post auricular LN
Drain - external
auditory meatus,
pinna, scalp
Posterior cervical LN
Drain - scalp, neck,
upper thoracic skin,
arms, pectorais
Supra clavicular LN
Drain - mediastinum, lungs, esophagus
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History and Clinical Presentation
Clinical presentation depends on the cause of the lymphadenitis or lymphadenopathy.
Children typically present with fever, malaise, anorexia and myalgias. There may be pain or tenderness of
node along with sore throat or upper respiratory tract infection. Patients present to the doctor with ear pain.
Frequently the lymphadenopathy is due to cavities and associated toothache is seen. A history of insect
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Indications for Excision Biopsy5
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Abscess formation.
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A significant increase in size over 2 weeks on treatment.
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A significant lymph node not responding to antibiotic therapy in 4-6 weeks.
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No resolution in 8 weeks.
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Lymph nodes which rapidly increased in size.
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Hard or matted in the posterior triangle of the neck or the supraclavicular region.
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Hard nodes fixed to surrounding structures.
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Where there was difficulty in clinical diagnosis, particularly in those few cases where a fine
needle aspiration is equivocal.
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Development of new signs and symptoms e.g. weight loss, PUO, night sweats.
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Case Report: Anaesthesiology
Red flags for malignant lymphadenopathy
Duration
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- Lymphadenopathy lasting more than 1 month.
Site - supraclavicular lymph nodes, nodes in the posterior triangle.
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Non matted / discreet.
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Consistency - hard and fixed to surrounding tissue.
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Working Together - Team approach in The Management of
Complex Paediatric Surgical Conditions
Dr. Sucheta Gaiwal, MBBS DNB, FCPS Anaesthesia , PGD - Medico legal systems,
Dr. Rajesh Nathani, MBBS MS (Gen Surg) Mch (Ped Surg), Dr. Deepak Chabra, MS (Bom),
DNB MRCS (Edin, UK) surgical oncologist, clinical fellow HPB (Nagoya, Japan),
Dr. Nitin Dange, MS MCh Neurosurgery
Well felt sharp borders suggest malignant nodes.
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Waxing waning.
Introduction
Accompanying clinical symptoms-fever, weight loss, night sweats, itching, accompanying
hepato splenomegaly.
A not so routine preoperative X-ray chest in a child.....
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Localized more likely to be malignant rather than generalized which is more likely to be due to an
infection / autoimmune disease.
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Conclusion
Lymphadenopathy is a result of a vast array of disease processes. The mnemonic “MIAMI” gives
the major classes. Malignancies, Infections, Autoimmune disorders, Miscellaneous Iatrogenic.
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Lymphadenopathy has a readily diagnosable infectious cause in most patients.
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Less obvious causes can be diagnosed after considering the patient's age, the duration of the
lymphadenopathy, localizing or constitutional signs and symptoms.
The problem of unexplained lymphadenopathy can be sorted out after a trial of antibiotics and a
three- to four-week observation period.
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Excision biopsy of the most accessible and enlarged lymph node is preferred over FNAC.
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References
1. Nelson Essentials of Pediatrics, 6th edition Pg 378.
2. Toxicol Pathol. 2006;34(5):409-24.
3. Semin Oncol. 1993 Dec;20(6):570-82.
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That’s how a 3 years old child was presented to us with a huge mediastinal mass. Airway management
in patients with mediastinal mass with or without the evidence of airway obstruction poses unique
challenge to the anesthesiologists throughout the peri operative period. These large mediastinal tumours
with apparently normal airways preoperatively may develop an obstructed airway after induction of
general anaesthesia (GA).1 Sometimes, a life threatening airway compression can occur even after an
uneventful endotracheal intubation and performing an emergency tracheostomy to relieve obstruction
may prove futile as the obstruction may be distal to the tube (lower airway obstruction).2 In the presence of
severe symptoms of cardiorespiratory compression such as, positional dyspnoea, orthopnoea, stridor,
syncope, and superior venacava syndrome (SVCS) administration of GA may be fatal.3,4,5 The profound
hypoxia may also be due to compression of great vessels in the presence of patent airway. Therefore
vigilance must be maintained throughout the perioperative period.
Selection of type of endotracheal tube for one lung ventilation in paediatric patients is difficult as choice is
very limited. Post-operative period is prone to complications like airway collapse, herniation, pulmonary
torsion, major haemorrhage and atelectasis. A multidisciplinary approach involving Anaesthesiologist,
Paediatric surgeon, Thoracic surgeon, Neurosurgeon and Paediatric intensivist leads to a favourable
outcome.
Ganglioneuroma is rare and benign tumour of autonomic nerves arising from neural crest which are
undifferentiated cells of sympathetic nervous system. We are reporting a case of large posterior mediastinal
ganglioneuroma in a 3 years old female child after taking informed consent from her parents.
Keywords
Difficult airway, one lung ventilation, posterior mediastinal mass.
4. Clin Pediatr (Phila). 2006 Jul;45(6):544-9.
Case Report
5. Curr Opin Otolaryngol Head Neck Surg. 2013 Dec;21(6):567-70.
A 3 years old 12 kg child sustained left forearm fracture. During preoperative assessment chest radiograph
(Fig 1) revealed large mediastinal mass and was referred to our institute for further evaluation. On enquiry,
parents gave history of multiple episodes of syncope with cyanosis on exertion and recurrent cough and
cold. No history of sensorimotor impairment. On auscultation air entry was decreased on right side except
in upper zone. Other systemic examination and haematological investigations were within normal limits.
Computed tomography (Fig 2) showed 11x11x10 cm lobulated homogenous mass in right posterior
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mediastinum and mild right pleural effusion. Magnetic resonance imaging revealed the mass extending in
spinal canal from right neural foramina T4-9. Tracheal and esophageal anterolateral displacement was
evident. A team of surgeons comprising a Paediatric surgeon, Oncosurgeon and Neuro surgeon planned
excision of mass in left lateral position with right extended postero-lateral thoracotomy.
Anaesthesia plan
General anaesthesia one lung ventilation with left endobroncheal intubation. We avoided epidural due to
extension of tumour in spinal canal.
Using 22G intravenous (IV) line in situ child was premedicated with Fentanyl 25 mcg and Midazolam
600 mcg. Standard monitors were attached. Paediatric airway cart and 3.7 mm fiberoptic bronchoscope
kept ready. Child was preoxygenated with 100% oxygen. Anaesthesia was induced with IV Propofol and
Sevoflurane.
Fig.2. CT scan cross sectional view
After confirmation of mask ventilation Atracurium was given. The child was intubated with Kimberly
Clark tube 4.5 mm till cuff was just beyond cords. Tube was fixed after noting marking at right angle of
mouth - 15 cm. ETCO2 graph confirmed proper placement of endotracheal tube. Anaesthesia maintained
with O2 - Air (FiO2 0.5) + Sevoflurane + intermittent atracurium boluses. Right radial artery was
cannulated using 22G arteriofix cannula for blood pressure monitoring. Right internal jugular vein was
cannulated with 5 Fr triple lumen catheter under ultrasound guidance. Single lung ventilation was achieved
by advancing endotracheal tube (ETT) in left bronchus under fiberoptic guidance, making sure that upper
lobe bronchial opening was patent. Tube was fixed at 17 cm at right angle of mouth and isolated left lung
ventilation was confirmed by auscultation. We used pressure controlled mode, respiratory rate 22 per
minute and positive end expiratory pressure 6 cm of H2O. Intraoperative blood pressure was maintained
between 50th - 90th percentile (91-104 mmHg systolic and 52-66 mmHg diastolic) for 3 years age.
Actual surgery
Frozen: matuaring ganglioneuroma
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Incision: Large thoracic, costal margin cut as it was felt necessary to completely define the tumor but
was not necessary to enter abdomen.
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Fig.1. X-ray chest of the child
Fig.3. The operated specimen
Surgical Challenges
Preoperative biopsy was not possible.
If ganglioneuroma-complete surgical excision.
If ganglionueroblastoma or neuroblastoma preop chemotherapy and then operate
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Huge tumor occupying two-thirds of the chest
in close proximity to vital mediastinal structures
with extension below the diaphragm in close
proximity to IVC-likely to be difficult to
remove, blood loss
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Extension across the inter-vertebral foramina and
complete removal of intra-spinal extension
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Plan
Do a limited thoracotomy, send for frozen
and decide management after the report.
Involve Oncosurgeon (Dr. Deepak
Chhabra) to aid in difficult dissection
Adequate amount of blood kept ready
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Involve Neurosurgeon (Dr. Nitin Dange)
to tackle this challenge
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Tumor completely excised (stuck to thoracic wall), including intra-vertebral extensions. (Fig.3)
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Total blood loss 250 ml.
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Intra operatively during dissection there were frequent variations in BP due to compression of aorta.
Surgeons were requested to release any compression caused. Intraoperative arterial blood gas showed
minimal hypercapnea (pCO2 52) with pH 7.32. Once tumour was debulked and shaved off leaving
posterolateral attachment the ETT was withdrawn by 2 cm to achieve two lung ventilation. Neuro surgeon
completed excision of the trans-foraminal extension. Duration of one lung ventilation was 4 hours,
involving intermittent suctioning of left lung through ETT and recruitment manoeuvre to maintain
SpO2>94%. Intra operatively analgesia was maintained with IV morphine, total 3 mg, IV paracetamol
250 mg. Fluid losses and 250 ml blood loss intra-operatively was replaced by 330 ml crystalloids, 230 ml
colloids and 160 ml packed red blood cell. Total urine output was 150 ml for total surgical period of
8 hours. Infiltration of 0.25% Bupivacaine was given during closure and diclofenac suppository 12.5 mg
per rectally for post-operative analgesia.
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Post operative ABG was within normal limits. Patient was electively ventilated in paediatric intensive
care unit (PICU). Child was extubated after 34 hours and shifted to ward on day 3. Right intercostal drain
was removed on post-operative day 6.
Long Term Follow Up (3 months)
Acknowledgments
We are deeply indebted to the Paediatric surgery and Anaesthesia departments, especially the residents
and associate specialists. We also appreciate the help provided by the PICU team, our pediatric nurses,
the OT staff.
Well clinically and radiologically. All investigations sent postop are normal.
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References
Plan
Keep under long term surveillance (clinical and radiological) with follow up every 6 months for
assessing recurrence.
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MRI Chest after a year to ensure no residual tumor.
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Discussion and conclusion
Mediastinal masses are known to be a nightmare for Anaesthesiologists. Neurogenic tumours are the
most common posterior mediastinal masses in paediatric population. Incidence of paraganglioma in
children is rare and spinal involvement is not known. Risk of cardiorespiratory failure is greater with
large mediastinal masses as they can cause compression of heart, lungs, large vessels and spinal cord.
History of our child was suggestive of cardio-respiratory compromise. We didn’t do pulmonary function
testing as child was too small to perform the test. Patients who have airway compromise flow volume
loops on spirometry have found poor correlation with degree of airway obstruction. Lalwani et al
described airway obstruction in immediate post-operative period in their patient with large posterior
mediastinal mass developing stridor and respiratory distress after extubation. Bechard et al reported
incidence of intraoperative cardiorespiratory complications 3.8% and postoperative respiratory
complications 10.5%. Therefore to be cautious we shifted our patient electively on ventilator to PICU.
Children are more prone to anaesthesia related deaths in such cases because cartilaginous structure of
the airway is more compressible in children. Providing one lung ventilation has unique challenges in
paediatric patients. Isolation of lung with double lumen Marraro’s tube is only for infants. These tubes
are uncuffed resulting in leak and inflation of opposite lung. The smallest available Univent tube is for
child above 6 years. Smallest ETT through which balloon tipped bronchial blocker can be passed is
5.0 mm. Our patient being 3 years of age we had no option but to do selective endobroncheal intubation.
We used Kimberly Clark size 4.5 mm microcuff ETT as the distance between the tip of tube to distal cuff
is short helping in maintaining patency of upper lobe bronchus. These tubes have a short cuff with a
smooth, thin membrane which allows lower inflation pressure to seal trachea. We could reduce duration of
one lung ventilation after debulking of tumour by simply withdrawing the tube. Post-operative period is
prone to complication like airway collapse, herniation, pulmonary torsion, major haemorrhage and
atelectasis. In our patient the final good result was the result of good planning and the involvement of
multiple specialists.
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1. Bray RJ, Fernandes FJ. Mediastinal tumors causing airway obstruction in anaesthetized children.
Anaesthesia 1982; 32: 571-575.
2. Todres ID, Reppert SM, Walker PF, Grillo HC. Management of critical airway obstruction in a child
with a mediastinum tumor. Anesthesiology 1976; 45: 100-102.
3. Hall KD, Friedman M. Extracorporeal oxygenation for induction of anaesthesia in a patient with an
intrathoracic tumor. Anesthesiology 1975; 42: 493-495.
4. Levin H, Rursztein S, Heifetz M. Cardiac arrest in a child with an anterior mediastinal mass. Anesth
Analg 1985; 64: 1129-1130.
5. Tonneson AS, Davis FG. Superior vena cava and bronchial obstruction during anesthesia.
Anesthesiology 1976; 45: 91-92.
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Case Report: Anaesthesiology
Bilateral Transversus Abdominus Plane Catheters with Continuous Infusion:
A Safe and Effective Postoperative Regional Analgesic Technique for Lower
Abdominal Surgery.
Dr. Vaibhavi Baxi, D.A. F.C.P.S DNB, Dr. Niral P. Bhankhariya, M.D. Anaesthesiology
Abstract: Transversus Abdominis Plane (TAP) block is a regional analgesic technique to provide
analgesia following surgeries with incisions on lower abdominal wall. Use of TAP catheters with
continuous infusion of local anaesthetic holds considerable promise as it is simple, effective and safe. We
report a case of lower abdominal surgery in which surgically placed bilateral TAP catheters proved
efficacious with decreased overall consumption of systemic opioids.
Keywords
Tranversus Abdominis Plane Block, regional anaesthetic technique, ropivacaine.
Introduction
Different modalities like the thoracic epidural and intravenous patient controlled analgesia (PCA) with
opioids have been used for postoperative pain relief after abdominal surgeries. A single shot Transversus
Abdominis Plane block (TAP block) with local anaesthetic has also been used in addition to opioids for
postoperative pain relief. By insertion of a catheter in the same plane (TAP) and continuous or intermittent
boluses of local anaesthetic, prolonged analgesia can be achieved. This also helps in reducing the overall
consumption of opioids. We report a case of anterior resection where we achieved satisfactory post
operative analgesia using bilateral TAP block with continuous infusion of local anaesthetic.
Case Report
A 43 years old male patient, weighing 55kg, known hypertensive and diabetic for ten years was diagnosed
to have carcinoma of rectum since 1 year and was scheduled for anterior resection. Patient had history of
frequent convulsions since childhood along with intellectual disability. He also had mild thoracolumbar
scoliosis. He was on anticonvulsants, antihypertensives and oral hypoglycemic agent with poor control
of blood sugars. Patient had received six chemotherapy cycles in the past one year. He had undergone
diversion colostomy for intestinal obstruction about two weeks back. His preoperative blood
investigations, ECG, chest X ray and 2-two dimensional echocardiography were all within normal limits.
Patient was premedicated with tab. pantocid 40mg along with his regular antihypertensive and
anticonvulsant drugs with a few sips of water orally in the morning of surgery. In view of his intellectual
disability and severe anxiety of separation from family members it was decided to sedate him just outside
the recovery room followed by general anaesthesia in the operation theatre. Epidural anaesthesia was
avoided for the same reason. Continuous infusion of local anaesthetic through bilateral TAP catheters
and PCA morphine was planned for postoperative analgesia.
14
On the morning of surgery transdermal patch of mixture of local anaesthetics (prilocaine+lignocaine) was
applied on the dorsum of both of his hands and intravenous access was achieved. Patient was sedated with
i.v. midazolam 1.5mg in presence of family members followed by general anesthesia with controlled
ventilation in the operation theatre. Surgery lasted for about three hours during which 300 micrograms of
fentanyl was used for intraoperative analgesia. The surgery proceeded uneventfully. Before the closure of
abdominal wall we requested the surgical assistant to introduce 16g epidural catheter between the internal
oblique and tranversus abdominis muscles one on each side. In addition to the pre-existing three distal
openings in each epidural catheter five more openings with 25g needle were made to allow even spread of
the drug in the plane between the muscles. Catheters were then tunneled out through the abdominal wall
using the touhy’s needle and fixed at 15 cm mark on the skin. At the end of surgery TAP catheter was
checked for resistance to flow of drug after confirming negative aspiration for blood. We injected 10 ml of
0.2% of ropivacaine through the catheters on each side. Patient was extubated and was shifted to recovery
area. Elastomeric pump for continuous infusion of 0.2% ropivacaine was started at the rate of 5ml/hour on
each side in the recovery room. We also started iv PCA morphine as planned preoperatively. After half an
hour observation in recovery area, patient was shifted to the intensive care unit for overnight observation.
Post op day 1 patient was comfortable with VAS score 3 out of 10 and only 2-3mg morphine was used over
24 hrs. TAP infusion was continued post operatively for two days and PCA morphine for three days.
Discussion
The transversus abdominis plane (TAP) block was first described by Rafi and then later by McDonnell
et al as a mode of providing analgesia following lower abdominal procedures.1, 2 Following this initial
report, the TAP block has been used to provide analgesia to the anterior abdominal wall following
several different abdominal surgical procedures including appendectomy, cholecystectomy, cesarean
section and most laparoscopic incisions.
Pain after the abdominal surgery is mainly transmitted by the afferent nerve supply of the anterior
abdominal wall. McDonnell et al3 described the postoperative pain management of the 16 patients by single
shot TAP block that had undergone large bowel resection. They concluded that the group of 16 patients
who received TAP block in addition to the standard care had reduced cumulative postoperative morphine
consumption at 4h, 6h and at 24h. Postoperative pain scores were reduced at all time points assessed after
TAP block both at rest and on movement .In our case patient’s VAS score was 3 and morphine consumption
on first postoperative day was 3 mg with continuous 0.2% ropivacaine infusion at 5ml /hr.
E. C. Hessian et al4 conducted a prospective observational study to evaluate peak and mean plasma
concentrations of ropivacaine during a continuous 72 h TAP ropivacaine infusion .Twenty patients who
underwent intra-abdominal cavity surgery with mid-line laparotomy incision were enrolled. At the
completion of surgery, ultrasound-guided subcostal or posterior TAP blocks with catheter for continuous
infusion were introduced. Dosing regimen for TAP blocks was loading dose of ropivacaine 150 mg (20 ml
ropivacaine 3.75 mg/ml each side) for body weight <70kg and ropivacaine 200 mg (20ml ropivacaine
5 mg/ml each side) for body weight >70 kg. Infusion dose of ropivacaine (2 mg/ml) 0.1 ml/kg/h each side.
15
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Maximum dose was 7 ml/hr each side. Peripheral venous blood samples (7 ml) were taken at 0, 2, 6, 12, 24,
48, and 72 h after TAP block. The range of total plasma ropivacaine concentrations was 0.98-3.41 mg/ litre
for posterior infusions and 0.96-3.48 mg litre for subcostal infusions. Our patient received bolus dose of
10ml of 0.2% of ropivacaine (20mg) on each side in operation theater. In recovery area we started bilateral
TAP infusion of 0.2% of ropivacaine at the rate of 5ml/hr (i.e. 0.1ml/kg/h)on each side. Although there are
data evaluating plasma concentrations of local anaesthetics after TAP block there is not enough published
literature describing levels resulting from TAP block followed by continuous infusion.
Tap block and catheter placement can be done using sonographic guidance following the closure of
abdominal wall. However in our patient we placed the catheters while the abdominal wall was still
unsutured by dissecting the plane between the transverses abdominis and internal oblique surgically.
Making multiple punctures in the catheter ensured spread of drug all along the plane which we visually
confirmed after tunnelling the catheters by injecting saline through them before closing the abdominal
wall.
Literature describes two types of TAP blocks: posterior and subcostal. In the posterior approach the
ultrasound transducer is moved more posteriorly aiming to view the point where the transversus abdominis
muscle begins to tail off. It is beneficial for (T10-L1 dermatome) lower abdominal surgeries. While the
subcostal TAP block involves deposition of local anaesthetic in the neurofascial plane between rectus
abdominis and transverses abdominis muscles. It is beneficial for (T6-T10 dermatome) upper abdominal
surgeries.5
References
1. Rafi AN. Abdominal field block: A new approach via the lumbar triangle. Anaesthesia 2001; 56:
1024-6.
2. O’Donnell BD, McDonnell JG, McShane AJ. The transversus abdominis plane (TAP) block in open
retropubic prostatectomy. Reg Anesth Pain Med 2006; 31: 91-5
3. John G. McDonnell, Brian O’Donnell,Gerard Curley. The Analgesic Efficacy of Transversus
Abdominis Plane Block After Abdominal Surgery: A Prospective Randomized Controlled Trial.
Anesth Analg 2007;104:193-7
4. E. C. Hessian, B. E. Evans, J. A. Woods et al. Plasma ropivacaine concentrations during bilateral
transversus abdominis plane infusions. British Journal of Anaesthesia 111 (3): 488-95 (2013).
5. Niraj G., A. Kelkar, R Powell. Ultrasound guided subcoatal transversus abdominis plane block.
International journal of ultrasound and applied technologies in perioperative care. January-April
2010;1(1):9-12.
TAP blocks are adjunctive techniques for analgesia. They do not adequately provide anaesthesia for
surgery as it provides no visceral anaesthesia or analgesia. These are fascial plane techniques and rely on
the deposition of large volumes of local anaesthetic to anaesthetise multiple small abdominal wall nerves.
Maximum local anaesthetic doses must be calculated to avoid the effects of systemic toxicity especially
when using continuous infusions.
Conclusion
With the above case report we conclude that TAP catheter
with continuous infusion provides a safe alternative to
epidural as a regional analgesic technique. It provides
satisfactory postoperative analgesia in lower abdominal
surgeries in addition to decreasing the consumption of
opioids.
16
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LILAVATI HOSPITAL
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Case Report: Cardiovascular and Thoracic Surgery
Morrow’s procedure with Mitral Valve Replacement in a case of
Hypertrophic Obstructive Cardiomyopathy (HOCM): A rare procedure
Dr. Abhishek Shah, DNB Medicine, DNB Cardio,
Dr. Charan Reddy KV, MD DNB Medicine, DNB Cardio,
Dr. Pavan Kumar, MS, MCh Consultant Cardiac Surgeon,
Dr. Suresh Vijan, MD, FRCP(UK), FACC, FESC, FSCAI, FEISI,
Dr. Leena Pawar, MD Consultant Anaesthesiologist
A 45 year old male, Non-Diabetic, Non-Hypertensive presented to Lilavati Hospital on 14th October’
2015 with chief complains of Breathlessness on exertion since 5-6 months and giddiness off and on.
Patient was apparently asymptomatic before 5-6months when he gradually developed breathlessness
on exertion initially on walking for 500-600mts and on climbing two flight of stairs and gradually
progressed to develop breathlessness on minimal exertion over the past couple of days and associated
with giddiness in the form of vertiginous sensation. There was no history of chest pain, paroxysmal
nocturnal dyspnoea, orthopnoea, palpitations or pedal odema.
On general examination patient was conscious, co-operative & well-oriented. Pulse was 90/min,
regular, normal in force & volume, no radio-radial or radio-femoral delay with normal condition of vessel
wall. BP- 110/70 mmHg in right arm in supine position. There was no pallor / cynosis / clubbing / icterus /
pedal odema or lymphadenopathy.
On cardiovascular system examination the apical impulse was shifted outwards & downwards and
hyperdynamic in nature. S1 soft, S2- not heard and a high-pitched, blowing Pansystolic murmur, grade
IV, heard best at the apex, in left lateral position with the diaphragm of the stethoscope, radiating to
the axilla and back and associated with a thrill was present.
Investigations
ECG showed Left Axis Deviaiton with Left Bundle Branch Block with Left ventricular Hypertrophy
and strain pattern.
l
Xray chest suggestive of Cardiomegaly with straightening of the left border of the heart (s/o left
atrial hypertrophy).
l
Echocardiography: A hallmark for diagnosis: showed left ventricular hypertrophy, systolic anterior
motion of mitral valve, LVOT gradient of 90mmHg, left atrial enlargement (62 mm), asymmetrical
septal hypertrophy (1.98 cm), grade IV mitral regurgitation and diastolic dysfunction.
l
The patient underwent Morrow’s Procedure (Left Ventricular Sub-aortic Septal Muscle Excision through
Aorta) with Mitral Valve Replacement (27# St Jude Mechanical Bileaflet Prosthasis) on 16th Oct’ 2015.
Intra-op TEE suggested reduction of LV-Aorta gradient to 4 mmHg and Sub-aortic Septal thickness
reduction from 2.9 to 1.2 cm.
Post procedure the patient’s symptoms relieved, 7th day post-op echo showed a the left ventricular
outflow tract gradient decreased to 4 mmHg and well functioning Mitral Prosthetic Valve with a 50% LV
ejection fraction. The patient recovered well and discharged and currently on regular follow up.
Review of Literature
Hypertrophic cardiomyopathy (HCM) is a primary disease of the myocardium (the muscle of the heart)
in which a portion of the myocardium is hypertrophied (thickened) without any obvious cause creating
functional impairment of the cardiac muscle. HCM is a common inherited cardiac disorders (1:500). It is a
No.1 cause of sudden cardiac death in young people including young athletes. The annual mortality is
estimated at 1-2 %. Familial hypertrophic cardiomyopathy is inherited as an autosomal dominant trait and
is attributed to mutations in one of a number of genes that encode for one of the sarcomere proteins most
commonly being the ß myosin heavy chain gene on chromosome 14.
The pathophysiology of HCM involves 4 interrelated processes: Left Ventricular outflow obstruction,
Diastolic Dysfunction, Myocardial Ischemia and Mitral Regurgitation. Risk Stratification and Screening
involves patients who have a family history of sudden cardiac death, young patients who have had several
episodes of syncope (fainting), patients who experience an abnormal blood pressure response with
exercise, patients who have a history of arrhythmia with a fast heart rate and patients with severe
symptoms and poor heart function.
Signs & Symptoms include sudden cardiac death, shortness of breath-especially on exertion, orthopnea
and paroxysmal nocturnal dyspnea, chest pain-especially during exercise, fainting-especially during
or just after exercise or exertion, sensation of rapid, fluttering or pounding heartbeats (palpitations), a
Double Apical Impulse and a characteristic medium pitch crescendo-decrescendo systolic murmur
along the lower left sternal border and apex and radiates to suprasternal notch which increases on
Valsalva Maneuver & standing and decreases on squatting & hand grip.
The diagnostic modality for HCM is Echocardiography which shows Systolic Anterior Motion of Mitral
Valve, LV Hypertrophy, Left Atrial Engargement (Volume & Diameter) and Asymmetric Septal
Hypertrophy.
Treatment Modalities include Left Ventricular Myomectomy and Mitral Valve Replacement, Catheter
Septal Ablation, Pacemaker Implantation, Implantable Cardioverter Defibrillator and Cardiac
transplantation.
Cardiac Catheterization: revealed hypertrophied left ventricle with markedly reduced left ventricular
cavity size, a grade IV mitral regurgitation and a massive left atrium. A significant post-ectopic rise
in the left ventricular outflow gradient of 80mmHg was documented.
l
Thus a diagnosis of Hypertrophic Obstructive Cardiomyopathy with Grade IV Mitral Regurgitation was
made.
18
Cardiac Cath
Mitral Valve
Replacement
Operative
Septal Excision
Pre-op 3D
thichenned septum
Pre-op Sigmoid
shaped Septum
19
LILAVATI HOSPITAL
MEDICAL TIMES
Case Report: Chest Medicine
Pulmonary Tuberculosis and Nocardiosis Co-infection
Dr. Neethu Sukumaran, DNB resident, Dr. Sandeep Tilve, DNB FCCP,
Dr. Rushika shah, DNB FCCP, Dr. Jalil D Parkar, MD FCCP
Introduction
Pulmonary Nocardiosis is a severe but less frequent infection caused by gram positive aerobic organisms of
Nocardia species. In humans, pulmonary infections are predominantly caused by Nocardia Asteroids
(85%). In India Nocardiosis often mimics Tuberculosis presentation which causes lot of misdiagnosis
and delay in treatment initiation.
Treatment
The patient was on mechanical ventilator. He was given IV antibiotics (Meropenem / Linezolid /
fluconazole). Based on the reports shifted to IV Imipenem and septran (Sulphmethoxasole + Trimethoprim)
and anti tubercular treatment was also added (HREZ) and Linezolid continued. After two weeks of IV
antibiotics there was clinical and radiological improvement, patient was extubated and the drain was
removed. Patient was sent home on oral medicines AKT and Septran DS for a duration of 3 months.
In follow up visit after 1 month patient was clinically better and Chest Xray showed improvement and was
advised to continue AKT and Septran for 6 months and regular follow up.
Discussion
Case Report
A 51 year old male smoker presented with cough for 2 months and acute breathlessness of 1 day
following fall. There was no history of haemoptysis or fever at the time of presentation. No history of
weight loss or loss of appetite. He had history suggestive of poorly controlled Bronchial asthma since
past 20 years requiring frequent steroid intake for the same.
He was investigated outside with chest Xray which showed left hydropneumothorax for which an ICD
was inserted and was referred to us.
On examination his pulse was 118 per minute, RR- 24 per minute, BP-110/80 mmhg Spo2-90% on room
air febrile (100.4) with left ICD in situ. Chest examination revealed reduced breath sounds on left side
with crackles bilaterally.
Investigations
His blood investigations showed Hb-9g%, TLC- 9600/cmm, CRP- 564, PCT-8. All other parameters
like liver function and renal functions were normal. HRCT chest with contrast showed left lower lobe
consolidation with cavitation and BPF. Left multiloculated hydropneumothorax and multiple cavitatory
lesions scattered over both lungs.
Pleural fluid examination done was exudative, hemorrhagic with high LDH and neutrophillic
predominance. Pleural fluid AFB and Gram stain and Fungus was sterile. Cytology showed inflammatory
changes. ADA was normal. An Infection (? Kochs, ?fungal) and Malignancy was suspected.
HIV Elisa was negative. Patient was put on invasive mechanical ventilation in view of respiratory failure.
Bronchoscopy was done showed inflamed tracheobronchial tree and BAL was negative for AFB and there
was no growth in gram and fungal stain and cytology showed no malignant cells.
Considering multiple loculations thoracoscopic decortications was done. It showed multiple septations
and pyothorax. Tissue biopsy was positive for MTB complex on gene Xpert with intermediate resistance
to Rifampicin. It also showed Nocardia species, however species identification was not done.
Histopathology showed acute on chronic inflammation.
20
Pulmonary Nocardiosis is caused by an aerobic gram positive organisms of genus Nocardia. It may present
as sub acute or chronic form with manifestations as localized or diffuse pneumonia, inflammatory
endobronchial masses which may be accompanied by cavitations, abscess formation, empyema, pleural
effusion.1 In disseminated nocardiosis at least 70% have pulmonary involvement. It commonly occurs
with debilitating conditions like as in immunocompromised (lympho-reticular malignancy, seropositives,
renal transplants, long term steroid users), chronic lung disease, alcoholism etc.2,3
Most infections are acquired due to contaminated soil. Person to person transmission is rare. Occasionally
seen as skin contaminants. The clinical manifestations of pulmonary nocardiosis are non specific with
symptoms of days to weeks.4 Remissions and exacerbations over a period of several weeks are frequent.4
It mimics pulmonary tuberculosis in both clinical and radiological characteristics.5 Co-infection with
tuberculosis are also reported.
Disseminted disease occurs in half of pulmonary nocardiosis. CNS is most common site, other being skin,
sub cutaneous tissue, kidney, bone and muscles.
They are slow growers, mild acid fast with modified (1% sulphuric acid) technique and grown on
Sabouraud’s dextrose agar. Therefore when suspecting instructions are to be given to the microbiologist
regarding the same.
The treatment of choice includes sulphonamides (Sulphmethoxazole + Trimethoprim). Depending on
the clinical presentation, sites involved and degree of involvement adjuvant surgical treatment may be
necessary.
Patients with severe disease (disseminated / pulmonary cavitations with effusions) require addition of 2
or more drugs. Combination of Amikacin + Beta lactams along with Septran can be given. A 3 drug regimen
- Septran + Amikacin and either Carbapenem (Imipenem / cilatatin) is also advised. Linezolid has also
strong in vitro activity against most species. Other agents includes Minocycline, Clindamycin and
Cephalosporins.
In severe cases intravenous antibiotics should be given for at least 2 weeks. Oral medications to be
continued for upto 6 weeks in less severe cases and 6 months to a year in severe cases.
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LILAVATI HOSPITAL
MEDICAL TIMES
Case Report: Nuclear Medicine
Conclusion
Beware of oculo-stenotic reflex - gate keeper function of Nuclear Medicine
In this case the patient was immunocompromised due to his long term steroid use and poorly controlled
asthma. He was diagnosed with pulmonary tuberculosis and nocardia co-infection. Therefore in
immunocomprmised patients with pulmonary tuberculosis not responding to anti tubercular treatment,
nocardiosis should also be kept in mind and investigated accordingly. Treatment for nocardia should be
prolonged for at least 6 months as exacerbations are also frequent in these cases.
Dr. R. D. Lele, MBBS, MRCP (Edin), FRCP (London), Hon. D. Litt,
Dr. Karuna Luthra, MBBS, DNB, Dr. Pallavi Patil, MBBS, DNB Nuclear Medicine,
Dr. Raksha Irny, MBBS, DNB, Dr. Anil Sharma, MBBS, MD in Medicine
Case
Chest xray at the time of admission:
left loculated effusion
Chest Xray after 1 month follow up:
HRCT Chest: left hydropneumothorax
with cavitatory lesions
References
1. GaudeGS et al. Clinical profile ofpulmonary nocardiosis. Indian J Chest Dis Allied Sci 1994; 41:155.
2. Lerner PI. Nocardia species. In: Mandell GI, Douglas RG, Bennett JE, eds Principles & Practice of
Infectious Diseases. 3rd Edn. New York, Churchill Livingstone 1990; 1926.
3. Rodrigues JL, Barrio JL, Pitchenik AI et al. Pulmonary nocardiosis in acquired immunodeficiency
syndrome: Diagnosis with bronchoalveolar lavage and treatment With non-sulphur containing drugs,
Chest, 1986,90(6), 912.
4. Gregory A, Filice, D.A. Actinomycosis and Nocardiosis.In Fishman's Pulmonary Diseases and
Disorders; 3rd ed; Vol 2: Mcgraw Hill; 2257.
5. Lerner PI. Nocardiosis. Clin Infect Dis. 1996;22: 891.
22
Mr. M. G, male, aged 73 with hypertension and angina underwent coronary angiography at Lilavati
Hospital & Research Centre on 25th October 2013. The angiography shows extensive stenosis in all the
branches of left coronary artery (Fig. 1).
The patient’s son being a member of the staff at Lilavati Hospital & Research Centre brought him to
Nuclear Medicine Dept. for exercise radionuclide Myocardial Perfusion and Functional Imaging test
which was done on 31st October 2013 (Fig. 2). Post stress and resting images showed normal perfusion in
all myocardial segments. Gated images showed good wall motion and thickening in all segments with
global LVEF 75%. This was an example of extensive collateral circulation via the normal right coronary
artery. ECG showed horizontal ST depression in leads II, III, aVF at peak exercise representing
microvascular dysfunction akin to Syndrome X which is amenable to aggressive medical management. He
received medications for microvascular dysfunction. A repeat radionuclide stress MPFI was done on 9th
June 2015 which again showed normal tracer uptake in all the cardiac segments, normal wall motion and
thickening with LVEF 68% (lower than that in 2013). His aggressive medical management (Calcium
channel blockers, nitrates, beta blockers and statins) continues and he leads a normal life.
According to Braunwald (2011), 40% of CABG and angioplasties are done unnecessarily because of the
reliance on anatomical information alone. Syndrome X is a good example of angina due to microvascular
dysfunction in the presence of normal epicardial vessels. It is especially common in women.
As a policy of quality assurance in patient care our hospital has proposed a package deal - combining
coronary angiography (conventional as well as CT angiography) with MPFI being carried out on the
same or next day.
With the installation of the new PET scan facility at our hospital a new dimension is added to cardiac
imaging.
FDG PET provides metabolic images of the heart. Normal heart preferentially takes up fatty acids.
Ischaemic or hibernating myocardium expresses GLUT-1 transporters which take up glucose (Fig. 3).
FDG PET helps to determine which patients will benefit by angioplasty (Fig. 4A and 4B) FDG positive
images represent ischemic viable myocardium while FDG negative images show dead myocardium
(no benefit by angioplasty).
23
LILAVATI HOSPITAL
MEDICAL TIMES
Case Report: Orthopaedic
A Won Battle against Spine Tumour: Solitary Plasmacytoma of Dorsal Spine
Dr. Ram Chaddha, M.S. (Orth.), Dr. Amit Kohli, MBBS, D'ORTHO,
Dr. Saurav Narayan Nanda, Final Year Resident, Orthopaedics & Trauma,
Dr. Sanjay Tripathi, Final Year Resident, Orthopaedics & Trauma,
Dr. Munjal S Shah, Final Year Resident, Orthopaedics &Trauma,
Dr. Rakesh Khiani, Final Year Resident, Orthopaedics &Trauma
Abstract
Solitary plasmacytoma of bone are rare presentation and only few cases are reported in scientific literature.
We report a case of Solitary plasmacytoma of bone treated at our tertiary care hospital Mumbai.
Introduction
Fig. 1- Severe stenosis seen in
the left coronary system seen on
angiography
Fig. 2- normal perfusion seen in
all myocardial segments on nuclear
Myocardial perfusion scan
Fig. 3- normal coronary angiogram
& stress FDG PET showing extensive
ischemic myocardium.
Fig. 4- Upper row: 13N-NH3 PET
myocardial perfusion image.
Lower row: 18F-FDG PET
myocardial metabolic image.
Fig. 4: - (A) - Normal perfusion and normal metabolism.
(B) - Poor perfusion but preserved metabolism; perfusion metabolic mismatch represents hibernating
myocardium.
(C) - Absent perfusion and absent glucose uptake; perfusion metabolic match represent scarred
myocardium.
Patients with ischemic (A) and hibernating (B) benefit from revascularization whereas patients with
scarred myocardium (C) will not benefit from revascularization.
References
1. Mehta PK, Bairey Merz CN. Treatment of angina in subjects with evidence of myocardial ischemia and
no obstructive coronary artery disease. In: Bonow RO, ed. Braunwald's Heart Disease. 9th ed.
Philadelphia, PA: Elsevier; 2011.
24
Solitary plasmacytoma of bone is a rare hematologic malignancy with radiologic evidence of a solitary
lesion in the absence of significant bone marrow plasma cell infiltration (5%- 10%). It leads to absent
(or low) serum and urine levels of monoclonal protein[1].
Solitary plasmacytoma is the most common form of plasmacytoma and accounts for 3-5% of all plasma
cell malignancies most commonly found in the spine without evidence of multiple myeloma elsewhere[2]
and has better prognosis.
Most commonly affects the axial skeleton (25%-60%) and has a predilection for the thoracic spine[2].
The median age is 55 years [3], male to-female ratio is 2:1[4]. Incidence rate rises exponentially by advancing
age however it is less common at older ages in comparison with multiple myeloma (MM)[5]. The mean
survival of patients with skeletal solitary plasmocytoma is 75% at 5-year follow-up. Half of solitary
plasmacytomas turn into multiple myeloma 2 to 10 years from diagnosis (average 3.5 years)
Diagnosis is made by multiple investigations. Histological demonstration of plasma-cell tumor done by
bone biopsy.
To rule out systemic tumor involvement, a bone marrow aspirate must be performed in both sternal and
iliac locations.
Routine investigation ie WBC count and differential count, ESR serum calcium, alkaline phosphatase
isoenzymes, creatinine, protein electrophoresis and urinalysis with Bence-Jones protein inspection.
CT scan of the chest, abdomen and pelvis for primary or secondary tumor location .
An MRI for degree of tumoral compromise of the vertebra, vertebral canal occupancy and spinal cord
compression by neoplastic tissue.
A CT scan for degree of architectural compromise presence of any bone fragments occupying the spinal
canal .
PET scan in staging patients with presumed solitary plasmacytoma.
Monoclonality and / or an aberrant plasma cell phenotype should be demonstrated with useful markers
being CD19, CD56, CD27, CD117 and cyclin D1.
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LILAVATI HOSPITAL
MEDICAL TIMES
Treatment include radiotherapy, surgery, radiotherapy combined with surgery, +/- chemotherapy and
vertebroplasty or kyphoplasty for local control of the disease, fixation of spine for spinal stability,
correction of deformity to decrease pain and improve or prevent neurological deterioration.
Case
A 54 years male presented with gait imbalance with the history of back pain for past 3 months worse in
morning and after prolonged sitting. There was bilateral lower limb weakness and imbalance while
walking for past 10 days and patient needed support during ambulation. He had been managed
conservatively prior to admission.
On examination there was broad based shuffling gait, tenderness over mid dorsal and dorsolumbar
junction, B/L lower limb motor power grade 3 to 3+, sensory hypo aesthesia below D7 vertebral level. B/l
knee and ankle jerks brisk and plantar reflexes were up going. Straight leg raise test, Thomas test, range
of motion of the hips, upper limb reflexes were normal and distal pulsation were palpable.
Fig. 4: MRI (STIR sequence) of D6
vertebra axial view showing significant
cord compression by the tumour mass.
Fig. 5: CTScan of dorsal spine lat view
showing course calcification with
trabecular pattern of D6 vertebral body.
Fig. 6: CT Scan of dorsal spine AXIAL
view showing course calcification with
trabecular pattern of D6 vertebral body.
Fig. 7:post embolisation x-ray of dorsal
spine lateral view showing polyvinyl
alcohol patch at D6 vertebra level.
Fig. 8:intra-operative picture
showing posterior decompression of
D6 vertebra with stabilisation.
Fig. 9:immediate post op x-ray of dorsal
spine AP/lat view showing stabilisation
and fixation with pedicle screw.
The patient was admitted with a provisional diagnosis of infection / primary neoplasm / secondary
metastasis for further management.
Routine blood investigation were normal. Serum protein electrophoresis showed no M band.
Dorsal spine X-rays showed slight irregularity of D6 vertebra (superior end) (Fig-1).
MRI revealed diffuse marrow signal alteration involving D6 vertebral body with a large mass in the
Rt>Lt pre vertebral region as well as in the anterior epidural space causing significant cord compression
(Fig-2,3,4) . The lesion most likely looked like neoplastic lesion.
CT scan was performed and the report of dorsal spine revealed homogenous right paraspinal soft tissue
lesion with course calcification at D6 level associated with corse trabecular pattern D6 vertebral body
suggestive of hemangioma & plasmacytoma (Fig-5,6).
Fig. 1: X-ray of dorsal spine - ap/lat
showing diffuse soft tissue swelling around
D6vertebra.
26
Fig. 2: MRI (STIR sequence) lateral view
of dorsal spine showing hypodense area
of D6 vertebral body causing cord
compression.
Fig. 3: MRI (STIR sequence) AP view of
dorsal spine showing hypodense region
involving D6 vertebra and
adjacent soft tissue.
Fig. 10: 3 month post op x-ray of dorsal
spine AP/lat view showing stabilisation
and fixation with pedicle screw.
Fig. 11: histopathological picture
showing sheet of plasma cells exhibiting
eccentrically placed dense nuclei with
few binucleated plasma cells.
27
LILAVATI HOSPITAL
MEDICAL TIMES
The patient was posted for surgery. Posterior thoracic decompression at D6 level with stabilisation at
D4,D5,D7,D8 level using pedicle screws was achieved (Fig-9,10) and surgical biopsy was send.
Histopathological examination report of paraffin sections revealed soft tissue bits showing diffuse
infiltration by sheets of plasma cells exhibiting eccentrically placed dense nuclei with few binucleated
plasma cells (Fig- 12).
The immune-histochemical study shows CD138 positive and CD20 negative with kappa light chain
restriction by plasma cells and bony sections demonstrated plasmacytoma.
Reference
1. Jyothirmayi R, Gangadharan VP, Nair MK. Radiotherapy in the treatment of solitary plasmocytoma.
Br J Radiol 1997;70:511-16.
2. Major NM, Helms CA, Richardson WJ. The “mini brain”: plasmocytoma in a vertebral body on MR
imaging. AJR Am J Roentgenol 2000;175:261-63.
3. M. A. Dimopoulos, L. A. Moulopoulos, A. Maniatis, and R. Alexanian, “Solitary plasmacytoma of
bone and asymptomatic multiple myeloma,” Blood, vol. 96, no. 6, pp. 2037-2044, 2000.
Post operatively patient was able to ambulate without support with the brace. To exclude multiple
myeloma, biopsies from multiple sites, detail bone survey, serum protein electrophoresis, urinary protein
electrophoresis and urinary bense jones protein were performed and were negative.
4. E. Wiltshaw, “The natural history of extramedullary plasmacytoma and its relation to solitary myeloma
of bone and myelomatosis,” Medicine, vol. 55, no. 3, pp. 217–238, 1976.
A final diagnosis of solitary plasmacytoma was thus made. The patient has been receiving 10 doses of
radiotherapy to 40 Gy and is free from pain, 3 months post-op .
5. R. H. Liebross, C. S. Ha, J. D. Cox, D. Weber, K. Delasalle, and R. Alexanian, “Clinical course of
solitary extramedullary plasmacytoma,” Radiotherapy and Oncology, vol. 52, no. 3, pp. 245-249,
1999.
Conclusion
As per recommendation plasmacytoma should be treated by radical radiotherapy encompassing the
primary tumour with a margin of at least 2 cm. Upto 5cm a radiotherapy dose of 40 Gy in 20 fractions
and >5cm, upto 50 Gy in 25 fractions is recommended.
Patients are re-evaluated with the measurements of M-protein and CBC for progression and development
of Multiple Myeloma and should be repeated at 6-week intervals for the first 6 months and then
with prolongation of clinic visits. If a new bone pain takes place additional workup like appropriate
imaging will be needed.
Systemic myeloma progression being the main problem for the prognosis of the disease. The diagnosis
and staging of plasmacytoma need an evaluation with more specific histological, phenotypic and
radiographic methods in order to exclude occult Multiple myeloma and other plasma cell neoplasm.
Close cooperative work done by a team of a hematologist, radiotherapist and surgeon will ensure the best
results after the treatment.
28
29
LILAVATI HOSPITAL
MEDICAL TIMES
Case Report: Urology
Squamous cell carcinoma of the Prostate
Dr. Sharad Shah, MS, M.ch Urology, Dr. Manu Gupta, MS, DNB, 3rd year resident,
Dr. Deepak Kumar, MS, DNB, 3rd year resident, Dr. Pawan Rahangdale, MS, DNB,
2nd year resident, Dr. Vedant Lakhe, MS, DNB, 2nd year resident,
Dr. Irfan Khan, MS, DNB, 1st year resident, Dr. Chirag Gupta, MS, DNB, 1st year resident
Introduction
Prostatic malignancy is the commonest malignancy affecting men. Most of the prostatic tumors are
adenocarcinoma while squamous cell carcinoma is a rarity (less than 1%). Pure squamous cell carcinoma
behave different than adenocarcinoma. They are aggressive tumors with poor survival and are less
amenable to various treatment modalities. We present a unique case of primary squamous cell carcinoma
(PSCC) of the prostate.
Case Report
A 61 year old male presented with obstructive lower urinary tract symptoms of two
year duration. He had previously undergone visual internal urethrotomy for
urethral stricture disease. During a recent CABG surgery, a SPC was inserted
due to inability to place a urethral foley catheter. Later, evaluation by a RGU
showed a blind ending urethra.
A decision to do urethroscopy and a cystoscopy
through SPC and railroading if possible was
taken. Urethroscopy showed blind ending urethra till
proximal bulb. And cystoscopy showed a
large mass protruding from internal meatus into
bladder.
Per rectal examination confirmed a hard nodular prostate. A biopsy was done
transrectally and sent for histopathological examination.
MRI showed a large midline pelvic mass of around 8.2 x 9.2 cm involving prostate,
seminal vesical and prostatic, membranous and proximal penile urethra and
infiltrating into bulb and corpora cavernosa. Posteriorly the mass was abutting the
rectum however there was no involvement of the rectum. There were no bony or
lymph nodal metastasis. PSA was 0.8 ng/ml.
Histopathology report showed a poorly differentiated squamous cell carcinoma composed of islands of
malignant polygonal cells with moderately pleomorphic hyperchromatic nuclei. Keratinization was seen
in multiple places.
In view of poor cardiac and medical status and over all poor prognosis, patient and family chose not to
pursue further active treatment.
30
Discussion
Primary squamous cell carcinoma of the prostate is a rare and aggressive malignancy found in less than 1%
of men suffering from prostatic malignancy. The origin of squamous cell carcinoma is thought to be of
prostatic urethral urothelium or from the transitional epithelium of periurethral ducts or the basal cells of
prostatic acini. Some investigators concluded that squamous cell carcinoma develops due to adverse
stimuli affecting columnar cells causing them to lose their ability to produce PSA and prostatic acid
phosphatase (PAP) although retaining the ability to produce keratin.
Clinically PSCC is distinctly different from prostatic adenocarcinoma. The presenting symptoms are
often similar to advanced adenocarcinoma. Patients with PSCC ranged in age from 42 to 85 years
with presenting symptoms including LUTS, acute urinary retention, urinary tract infection, hematuria
and bony pain secondary to metastases. Around 50% of patients were found to have metastases to varying
locations including bone, lungs, liver and lymph nodes with survival ranging from 0 to 60 months with
an average survival of 11.9 months.
In terms of clinical markers the squamous variant typically does not result in elevated levels of PAP or
PSA. In addition, bone metastases are found to have an osteolytic rather than the osteoblastic appearance
seen in adenocarcinoma.
Because PSCC remains a rare occurrence no specific treatment modality has been widely accepted.
Surgical treatment and multimodal approaches are most commonly used with varying degrees of success.
Recently chemo-radiation therapy with cisplatin and 5-fluorouracil (5-FU), followed by a full course of
radiation therapy using a linear accelerator (19 MV photons) showed 60 month survival in a patient.
Similarly others treated a patient with radical cystoprostatectomy followed by adjuvant chemotherapy
using the methotrexate (MTX), peplomycin (PEP) and CDDP regimen with a 60-month survival rate.
Surgical treatment reported by Little and associates resulted in a 40-month and 25-month survival in two
cases. Patients one with organ-confined disease and one with lymph node involvement underwent
aggressive surgical treatment including radical cystoprostatectomy and bilateral pelvic lymphadenectomy.
The patient with organ-confined disease underwent an additional total urethrectomy and ileal conduit
urinary diversion whereas the patient with metastatic disease had a Kock pouch urinary diversion.
Experience using radiation therapy for the treatment of PSCC is limited.
Primary squamous cell carcinoma of the prostate continues to be an infrequent and aggressive malignancy
with no definitive management recommendations available.
References
1. Fernando Munoz, Pierfrancesco Franco, Patrizia Ciammella, Mario Clerico, Mauro Giudici, Squamous cell
carcinoma of the prostate: long-term survival after combined chemo-radiation. Radiat Oncol. 2007; 2: 15.
Published online 2007. 04.03.
2. Yang Wang, Yihua Wang, Yi Ma, Bin Zhu. Primary squamous cell carcinoma of the prostate, Quant Imaging
Med Surg 2012;2(4). DOI: 10.3978/j.issn.2223-4292.2012.11.05.
3. Bracarda S, de Cobelli O, Greco C, Prayer-Galetti T, Valdagni R, Gatta G, de Braud F, Bartsch G. Cancer of the
prostate. Crit Rev Oncol / Hematol. 2005;56:379-396. doi: 10.1016/j.critrevonc.2005.03.010.
4. Okada E, Kamizaki H. Primary squamous cell carcinoma of the prostate.
Int J Urol. 2000;7:347-350.
31
LILAVATI HOSPITAL
MEDICAL TIMES
Straight from the heart
At Lilavati Hospital every patient has the perfect
atmosphere to help gain the road to recovery.
Educational activities
Our hospital doctors share their intellectual capital and expertise with others through CMEs using
means like workshops, seminars, conferences, live telecast of procedures and surgeries, which they
are performing. Our hospital is accredited by Maharashtra Medical Council for conducting CMEs.
Sr. no.
ICU department has excellent service, knowledge of
nurses is above expectations. In ICU even doctors make
you feel at home & it is truly Human care
Topic
Organized month
1
Hernia Updates
September
2
Pediatric Urology
October
3
Pain Management
November
4
Pediatric Hematology
December
Prompt service and the confidence of doctors in treating the
patient in such a critical situation is commendable.
Hats off to the entire team of Lilavati !!
Appreciate the well qualified and experienced doctors
being down to earth and the cheerful service by the
nursing staff
Such a long stay but your absolutely brilliant nurses
and attendants of the 11th floor A wing feel like a
family now. Thank you so much my ANGEL’s !!
Pain Management
The Hospital really & truly lives up to its motto of
complete Human care & not just Health Care. The
extraordinary attentiveness by the Sr Surgeon, Consultants,
Doctors & nursing staff was exceptionally good
Doctors are qualified & focused, nurses are well
informed & dedicated to their work, positive
environment prevails everywhere here.
Hernia Updates
Pediatric Urology
32
33
LILAVATI HOSPITAL
MEDICAL TIMES
SEWA
Feathers In Cap
The social service wing of the hospital-SEWA - serves to the health requirements of the needy
people. This department seeks to bridge the gap between the needy patients and the fast evolving
medical technology. Various social activities such as free OPD, services to senior citizen, sending
mobile vans to Adivasi areas for organizing free health checkup camps are undertaken as an on-going
process. The Roshni Eye bank managed by Lilavati Hospital is a well-equipped comprehensive centre
for cornea removal, supplying, processing, storing, and corneal transplantation. We have taken up
new initiative of “Swastha Bachpan” which comprises of free health checkups for underprivileged
children.
Efforts and hard work put in by team Lilavati Hospital has resulted in various awards and accolades:
All India Critical Care Hospital Ranking Survey 2016 conducted by Optimal Media Solutions - a division
of Times Internet Limited (A Times Group Company) in association with i3 Research Consultants,
New Delhi ranked Lilavati Hospital and Research Centre No. 1 in Mumbai and Western Region for
Paediatrics and Gynecology & Obstetrics .
l
Our hospital received “India’s Most Trusted Brand Award-2015 in Best Hospital Category” by
India’s Most Trusted Brand Award Council.
l
THE WEEK-NIELSEN survey for rating the best hospitals in the country has yet again adjudged
Lilavati Hospital amongst the best hospital ranking 8th in the country. Eleven other specialties of our
hospital are also ranked amongst the Top 15.
l
BENEFICIARIES
Year
Free OPD
SEWA Mobile Clinic
2013-2014
14301
30232
2014-2015
14371
21207
Ranked No.
8
Ranked No.
OTHER SPECIALITIES
34
Free OPD
Sewa Roshni Eye Bank
Sewa Nana Nani
Mobile Medical Clinic
Gynaecology
Diabetic Care
Opthalmology
Gastroenterology
Research Facilities
Neurology
Cardiology
Pulmonology
Orthopaedics
Oncology
Paediatrics
-
Ranked 3rd in India
Ranked 7th in India
Ranked 7th in India
Ranked 9th in India
Ranked 9th in India
Ranked 10th in India
Ranked 10th in India
Ranked 10th in India
Ranked 11th in India
Ranked 11th in India
Ranked 14th in India
35
LILAVATI HOSPITAL
MEDICAL TIMES
FUN TIME
Services Available
Identify the Diseases
MEDICAL
Anesthesiology
Audiology and Speech Therapy
Cardiology
Chest Medicine
Chronic Pain Management
Dental
Dermo Cosmetology
Diabetology & Endocrinology
Gastroenterology
Haematology
Hair Transplant
Head and Migraine Clinic
Internal Medicine
Infectious Diseases
Medical Oncology
Nephrology
Neurology
Psychiatry / Psychology / Neuropsychology
Physiotherapy
Pediatrics
Rheumatology
Sleep Medicine
1.
+
PER
2.
+
RIA =
3.
+
+
4.
+
+
5.
+
=
+
NIA =
+
=
=
Kindly email us your answers on
medicaltimes@lilavatihospital.com
Congratulations
Winners of September issue quiz
Dr. Shefali Pandey
Dr. Dayanand Ghorpade
Dr. Ketan K Mehta
36
SURGICAL
Bariatric Surgery
Cardiothoracic Surgery
Colorectal Surgery
ENT and Head & Neck Surgery
Gastro Intestinal Surgery
General Surgery
Gynecology, Obstetrics & IVF
Minimal Invasive Surgery (Laproscopic Surgery)
Neuro Surgery
Onco Surgery
Ophthalmology
Orthopedics, Sports Medicine
Pediatric Surgery
Plastic & Reconstruction Surgery
Spine Surgery
Transplant: Corneal & Kidney
Urology, Andrology
Vascular Surgery
CRITICAL CARE
Intensive Care Unit (ICU)
Intensive Cardiac Unit (ICCU)
Neo-Natal Intensive Care Unit (NICU)
Paediatric Intensive Care Unit (PICU)
Paralysis & Stroke Unit
Surgical Intensive Care Unit (SICU)
DIAGNOSTICS
Imaging Services
BMD
CT
Interventional Radiology
MRI
Mammography
Nuclear Medicine
OPG
PET Scan
Sonography
X-ray
LABORATORY SERVICES
Blood Bank
Histopathology
Microbiology
Pathology
24 HRS SERVICES
Ambulance
Emergency
Pharmacy
Roshni Eye Bank
37
LILAVATI HOSPITAL
MEDICAL TIMES
Doctors Associated with Lilavati Hospital
Andrologist
Dr. Shah Rupin S.
Anaesthesiologist
Dr. Barot Hemangini
Dr. Baxi Vaibhavi
Dr. Budhakar Shashank
Dr. Gandhi Nisha
Dr. Gaiwal Sucheta
Dr. Gawankar Prakash
Dr. Joshi Kunal
Dr. Kharwadkar Madhuri
Dr. Kulkarni Satish K.
Dr. Mahajan Anjula
Dr. Mascarenhas Oswald
Dr. Khatri Bhimsen
Dr. Shah Falguni
Audiology & Speech Therapists
Dr. Bhan Satyan
Dr. Gorawara Pooja
Dr. Parulkar Bakul
Dr. Patadia Rajesh
Cardiovascular & Thoracic Surgeons
Dr. Bhattacharya S.
Dr. Honnekeri Sandeep T.
Dr. Jaiswal O. H.
Dr. Joshi Suresh
Dr. Kaushal Pandey
Dr. Kumar Pavan
Dr. Mehra Arun P.
Dr. Nand Kumar
Dr. Rachmale G. N.
Dr. Ravishankar V.
Dr. Shetty Mohan
Cardiologists
Dr. Ballani Prakash H.
Dr. Bang Vijay
Dr. Dargad Ramesh R.
Dr. Gokhale Nitin S.
Dr. Hemant Kumar
Dr. Jhala Darshan
Dr. Kothari Snehal N.
Dr. Lokhandwala Yash
Dr. Mehan Vivek
Dr. Merchant S. A.
Dr. Menon Ajit R.
Dr. Mehta Haresh G.
Dr. Nabar Ashish
Dr. Pillai M G
Dr. Pinto Robin
Dr. Punjabi Ashok H.
Dr. Samuel K. Mathew
38
Dr. Sanzgiri P. S.
Dr. Shah Chetan
Dr. Sharma Anil K.
Dr. Suratkal Vidya
Dr. Vijan Suresh
Dr. Vyas Pradeep R.
Dr. Vora Amit
Dr. Vaishnav Sudhir
Dr. Vajifdar Bhavesh
Chest Medicine
Dr. Chhajed Prashant
Dr. Mehta Sanjeev K.
Dr. Prabhudesai P. P.
Dr. Parkar Jalil D.
Dr. Rang Suresh V.
Colorectal Surgery
Dr. Chulani H. L.
Cosmetic Surgery
Dr. Doshi Milan
Dentistry / Dental Surgeons
Dr. Bhavsar Jaydeep P.
Dr. Deshpande Dilip
Dr. Gala Dhimant
Dr. Joshi P. D.
Dr. Khatavkar Arun
Dr. Kamdar Rajesh J.
Dr. Nayak Arun
Dr. Parulkar Darshan
Dr. Sanghvi Sameer
Department of Imaging
Dr. Bajaj Anita
Dr. Deshmukh Manoj
Dr. Ingule Amol
Dr. Kulkarni Makrand
Dr. Mehta Mona
Dr. Sobti Shyam K.
Dermatologists
Dr. Goyal Nilesh
Dr. Mehta Nimesh
Dr. Oberai Chetan
Dr. Parasramani S. G.
Diabetologists
Dr. Joshi Shashank R.
Dr. Panikar Vijay
ENT Surgeons
Dr. D’souza Chris E.
Dr. Pusalkar A.
Dr. Parasram Kamal S.
Gastro Surgeons
Dr. Bharucha Manoj
Dr. Kulkarni D. R.
Dr. Mehta Hitesh
Dr. Shah Ankur
Dr. Varty Paresh
Dr. Wagle Prasad K.
Dr. Zaveri Jayesh P.
Gastroenterologists
Dr. Barve Jayant S.
Dr. Gupta Ravi
Dr. Kanakia Raju R.
Dr. Khanna Sanjeev
Dr. Phadke Aniruddha Y.
Dr. Parikh Samir S.
Dr. Shah Saumil K.
Gastroenterology and Hepatology
Dr. Shah Jayashri
General Surgeons
Dr. Dhumane Parag
Dr. Garud T. V.
Dr. Mehta Narendra
Dr. Shastri Satyanand B.
Dr. Shetty Sadanand V.
Gynaecologist
Dr. Agarwal Rekha
Dr. Coelho Kiran S.
Dr. Dhanu Vilas R.
Dr. Goyal Swarna
Dr. Nanavati Murari S.
Dr. Pai Rishma D.
Dr. Palshetkar Nandita
Dr. Pai Hrishikesh
Dr. Shah Cherry C.
Haematology
Dr. Agarwal M. B.
Dr. Bhave Abhay
Headache & Migraine
Dr. Ravishankar K.
Healthcheckup Consultant
Dr. Desai Sandeep
Infectious Diseases Consultant
Dr. Nagvekar Vasant C.
Intensivist
Dr. Ansari Abdul
Dr. Shrinivasan R.
Dr. Vas Conrad Rui
Interventional Radiology
Dr. Limaye Uday S.
Dr. Sheth Rahul
Dr. Warawdekar Girish
Joint Replacement Surgeon
Dr. Maniar Rajesh N.
Nephrologists
Dr. Chaudhari Anup
Dr. Mehta Hemant J.
Dr. Shah Arun
Dr. Suratkal L. H.
Dr. Upadhyaya Kirti L.
Neurologists
Dr. Chauhan Vinay
Dr. D’souza Cheryl
Dr. Sirsat Ashok M.
Dr. Vyas Ajay
Neuropsychologist
Dr. Panjwani Siddika
Neuro Surgeons
Dr. Dange Nitin
Dr. Goel Atul
Dr. Ramani P. S.
Nuclear Medicine
Dr. Krishna B. A.
Dr. Luthra Karuna
Oncologists
Dr. R. Gopal
Dr. Smruti B. K.
Oncosurgeons
Dr. Chabra Deepak
Dr. Deshpande Ramakant K.
Dr. Jagannath P.
Dr. Parikh Deepak
Dr. Sharma Sanjay
Dr. Shah Rajiv C.
Ophthalmology
Dr. Agrawal Vinay
Dr. D’souza Ryan
Dr. Mehta Salil
Dr. Mehta Himanshu
Dr. Nadkarni Shivram
Dr. Nagvekar Sandip S.
Dr. Parikh Rajul
Dr. Shah Manish
Dr. Shah Sushmita
Dr. Shah Gaurav
Dr. Vaidya Ashish R.
Orthopaedic Surgeons
Dr. Agrawal Vinod
Dr. Archik Shreedhar
Dr. Chaddha Ram
Dr. D’silva Domnic F.
Dr. Desai Sanjay S.
Dr. Deshmukh Niranjan
Dr. Garude Sanjay
Dr. Joshi Anant
Dr. Kohli Amit
Dr. Mukhi Shyam R.
Dr. Nadkarni Dilip
Dr. Padgaonkar Milind
Dr. Panjwani Jawahar S.
Dr. Thakkar C. J.
Dr. Vatchha Sharookh P.
Dr. Warrier Sudhir
Physicians / Internal Medicine
Dr. Ballani A. G.
Dr. Bandukwala S. M.
Dr. Dalvi Sunil G.
Dr. Gidwani Vinod N.
Dr. Jadwani J. P.
Dr. Medhekar Tushar P.
Dr. Medhekar Amey T.
Dr. Nair C. C.
Dr. Shimpi Shrikant
Pathologists
Dr. Chavan Nitin
Dr. Dhunjibhoy Ketayun R.
Dr. George Asha Mary
Dr. Mehta Kashvi
Dr. Rangwalla Fatema
Dr. Saraswat Shubhangi
Dr. Tampi Chandralekha
Psychiatrist
Dr. Deshmukh D. K.
Dr. Shah Bharat R.
Dr. Vahia Vihang N.
Paediatric Surgeons
Dr. Karmarkar Santosh J.
Dr. Nathani Rajesh
Dr. Redkar Rajeev G.
Paediatricians
Dr. Ali Uma
Dr. Avasthi Bhupendra
Dr. Chittal Ravindra
Dr. Gupta Priyam
Dr. Lokeshwar M. R.
Dr. Sharma Shobha
Dr. Ugra Deepak
Paediatric Cardiology
Dr. Changlani Deepak K.
Paediatric Haematology / Oncology
Dr. Kanakia Swati R.
Paediatric Neurosurgery
Dr. Andar Uday
Paediatric Neurology
Dr. Kulkarni Shilpa
Dr. Shah Krishnakumar N.
Plastic Surgeons
Dr. Kumta Samir
Dr. Purohit Shrirang
Psychologist
Dr. Chulani Varkha
Physician / Rheumatologist
Dr. Gill Niharika
Dr. Sangha Milan
Physiotherapist
Dr. Garude Heena
Spine Surgeons
Dr. Bhojraj Shekhar
Dr. Nene Abhay
Urologists
Dr. Pathak Hemant R.
Dr. Raina Shailesh
Dr. Raja Dilip
Dr. Sanghvi Nayan
Dr. Shah Sharad R.
Dr. Utture Anand
Dr. Vaze Ajit M.
Urological Laparoscopic Surgeon
Dr. Ramani Anup
Vascular Surgeons
Dr. Patel Pankaj
Dr. Pai Paresh
Paediatric Opthalmology
Dr. Doshi Ashish
Pain Management
Dr. Baheti Dwarkadas
Dr. Jain Jitendra
39
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