MANA AROGYAM: Vascular Surgery

MANA AROGYAM: Vascular Surgery

Vascular Surgery

Surgical correction of vascular defects is safe and effective for many patients in whom less invasive procedures are not adequate. The common conditions that need surgical interventions are Aneurysms & Varicose Veins. The other less common vascular diseases which need surgical intervention are;

Arteriosclerosis obliterans

Aortoiliac occlusive disease

Superficial femoral occlusive disease

Tibial artery disease

Deep venous thrombosis

The centre offers surgical revascularization procedures that provide excellent outcomes for many patients at risk for loss of limb or seriously impaired quality of life.

Step 1
Under image guidance. the doctor passes a very small balloon through a thin tube (catheter) into the blood vessel to the site of the blockage

Step 2
The Cryoplasty balloon is filled with liquid nitrous oxide. which turns into a gas. The balloon expands and cools the plaque as it opens up the blockage.

Step 3
Once the blood vessel is opened the gas is released and the balloon is deflated and removed.

Interventional Radiology

Interventional radiology (IR) procedures are an advance in medicine that often replaces open surgical procedures. They are generally easier for the patient because they involve no large incisions, less risk, less pain and shorter recovery times.

Advanced training of Interventional Radiologists with imaging guidance, can diagnose and treat a large number of ailments. Interventional radiologists perform a vast variety of procedures.



Screening is useful in certain high-risk groups. This includes patients with Diabetes, High blood pressure, Smoking, High blood cholesterol, & with Family history of atherosclerotic problems and circulatory problems. Several simple screening tests, which are non-invasive and painless, can detect the problems early. These include:

Carotid Scan
Carotid Scan consists of a carotid duplex ultrasound scan and a blood pressure check for severe hypertension. It can detect the most frequent causes of stroke - significant internal carotid artery stenosis.

Aortic Scan
Aortic Scan an ultrasound scan of the aorta. The scan can tell how big the aneurysm is and when it needs treatment.

PAD Scan
PAD Scan is a doppler exam for PAD can quickly determine if there is any impairment in the circulation to the limbs. The exam can identify blockages in the leg arteries and tell how severe the blockage is and whether treatment is needed.

Laboratory Tests
Certain laboratory tests include Bleeding time (BT), Clotting Time (CT) & Prothrombin Time (PTT).

SMILE DESIGNING

Most people are surprised to know that modern dentistry and techniques can help to reshape their teeth, smile and entire appearance and help them lead a more confident and joyful life.

Designing a smile requires an expert doctor with years of experience and the creativity and skills to deliver good results. Smile designing includes coming to the dentist with a vision of what you want the smile to be like . the dentist then performs a series of exams on your teeth like evaluating the bite, the colour of the rest of the teeth, the shape etc and will take digital pictures of what they currently look like. Then by using designing softwareand incorporating the patient's desires, they are able to create an " after" image to show the patient what they could look like after the treatment has been completed. The patient can then either accept the changes or in turn suggest some more specifics and once the final look has been agreed upon, the treatment is commenced and the end result is achieved as close to the 'mock-up' as possible. This way , the patient is able to get a fairly good idea of what they could look like prior to going in for any major reconstructive work.

We also do full mouth reconstruction /rehabilitation which involve

* Severely Flourosed teeth which are malformed and discoloured
* Severe Bruxism cases where teeth have been ground down leading to sensitivity or exposure of the nerves - here the bite is re-established and sensitivity eliminated by use of crowns and occlusal guards to discontinue the habit
* In deep bite cases wherein the bite can be opened orthodontically or via strategically placed crowns
* Tetracycline staining , Diastemas, Malformed teeth, Crowding of teeth etc can all be corrected with Crowns, veneers and Laminates.

In today's world of improved technology, confidence and aesthetics can be largely improved upon by utilizing the techniques available from expert hands...we at Wockhardt strive hard on providing our patients that option..

CASE STUDY: Full Mouth Rehabilitation with Dental Implants and Smile Designing with Ceramic Crown done.
Patient reported with missing teeth and unaesthetic smile with attritioned teeth
Patient never felt like smiling because of the unaesthetic appearance and display of metallic crowns done previously

Smile designing trial is given after insertion of implant with acrylic crowns. Trial is the exact replica of how the smile will look like with ceramic crowns. Trial is necessary to take the patients approval that he is comfortable and happy with the final smile design.

HOW PARKINSON'S DISEASE OCCUR ?

Parkinson's disease is a slowly progressive neurodegenerative disease caused when a small group of brain cells that control body movements die. This disease was first described by James Parkinson in 1817. The disease occurs in about 1% of the people over the age of 65 years. The peak onset of the disease is in the sixth decade of the life. However young onset Parkinson's disease is not uncommon. Though we do not have a clear statistics for Indian population, we are aware that it is more common in Parsi community. According to one estimate it affects more than one million people in United States.


Symptoms


The four major symptoms of Parkinson's disease are:

* Rigidity - stiffness when the arm, leg, or neck are moved
* Resting tremor - tremor most prominent at rest, when sitting quietly
* Bradykinesia - slowness in initiating movement which may contribute to decreased facial expression, change in speech pattern, shuffling gait, smaller-lettered handwriting, trouble with fine finger movements
* Loss of postural reflexes - poor balance and coordination

Not every one with Parkinson's disease experiences the same symptoms. The speed at which symptoms appear in each individual also differs. Hence few people have an accelerated progress of the disease where as some people remains static and slowly progressive in their disease. The disease is never symmetrical on both the sides. It usually affects one side of the body first followed by the involvement of the other side of the body at the later stage.

About 60% of the people with Parkinson's disease experience resting tremor. Symptoms often begin with occasional trembling of one hand that gradually becomes constant. The tremor can progress to the other hand, to the legs and occasionally to the face. However in some patients first manifestation of the disease is bradykinesia i.e. slowness of body activities.

There are many other diseases that can present with parkinsonian symptoms. However they are different in their progress, response to treatment and outcome, than Parkinson's disease. This includes diseases like multi-system atrophy, progressive supranuclear palsy (PSP), cortico-basal ganglionic degeneration (CBGD), etc.

Although tremors would seem to be the biggest problem with the people suffering from Parkinson's disease, the most frustrating symptoms are the symptoms associated with slow movements and gait disturbances. As a result, people with this disease often have trouble dressing, handling utensils, eating, and with personal hygiene. They may also experience difficulty in rising from chair, turning in bed, or getting in and out of car. Without treatment, pronounced disability occurs in about 9 years. However current symptomatic medication may control progression and patients continue to do well longer.

There are no laboratory tests or radiological investigations to diagnose Parkinson's disease. The diagnosis of the disease still remains a clinical judgment. The Parkinson's disease disabilities can be assessed by Unified Parkinson's disease rating score (UPDRS), Schwab and England activities of daily living score and Hoehn and Yahr scoring.

What causes Parkinson's Disease?

Although no distinct cause has been determined, Parkinson's disease is due to gradual loss of cells in an area deep within the brain called substantia nigra, which normally produces a chemical called dopamine. Once produced, dopamine travels to other portions of the brain. One portion called the striatum is the coordination center for various brain circuits. As there is insufficient dopamine in the striatum, the chemical imbalance leads to the symptoms of Parkinson's disease. Later in the disease, cells in other portion of the brain and nervous system also degenerate.

No one knows why this dopamine producing cells die. Scientists are exploring several theories including chemical reactions within the body, exposure to toxic substances and certain genetic factors. A new gene in certain families suffering from Parkinson's disease known as Parkin gene has been identified to be the positive factor for Parkinson's disease. However this has been found to be positive in a small group of patients with young onset of Parkinson's disease. The research is still going on to find out the real cause for Parkinson's disease in large patient population.

Treatment, Medication and Surgery

Symptomatic treatment for Parkinson's disease is usually successful, especially in the early years, although it does not stop its progress to cure the disease. Experts believe that a comprehensive approach to treatment is most effective. This approach includes early diagnosis, exercise, good nutrition and medication that reduces the symptoms. Many people find that an important part of the care is the health, comfort, and information they get in participating the Parkinson's disease support group. These groups discuss such problems of daily living and are among the first to learn about research results and new treatments.

Medication can provide dramatic relief from the symptoms of Parkinson's disease. Neurologists prescribe treatment separately to each patient as disease of each patient is different from other. It may take time and patience to correctly titrate suitable medicine for every individual. The most effective medical treatment for parkinsonian symptoms has been a drug called Levodopa. This drug therapy replenishes the dopamine in the brain and hence is effective in reversing the symptoms of Parkinson's disease. Other drugs that mimic the effect of dopamine called dopamine agonist are also available. They may be prescribed alone in the early disease phase or in combination with Levodopa for later stages to reduce the side effect of Levodopa. Various group of dopamine agonist are available. Continuous research is going on to identify newer and more effective drugs to treat Parkinson's disease. Those who are interested in participating trial of new drugs can ask neurologists for information.

Surgery Pallidotomy, Thalamotomy and Deep Brain Stimulation are the commonly performed surgeries for Parkinson's disease.The surgery is usually offered when medicines fail to give adequate relief from the symptoms. Surgical treatment has been relatively safe and their results are long lasting.

FAQ'S

When should one think about surgery?

Surgery is helpful for relieving tremors, drug induced side effect leading to involuntary movements called dyskinesia, frequent on-off fluctuations, prolonged off periods, pain, dystonia (curling of fingers and toes), postural imbalance, severe rigidity, hallucinations, etc. In short any patient:

Who is not satisfied with his/her level of control of Parkinson's disease. Exhibits Parkinson's disease symptoms causing a decline in the quality of life Has had an adequate and reasonable trial of medications is a candidate for surgery.


Is there any age limit for Parkinson's disease surgery?

Though there are no specific age restrictions for this surgery, it can be said that the patient who is "young" enough to think about surgery can be offered surgery. Common age group of patients undergoing this surgery is between 40 to 75 years. The average age of our patient is around 53 years.


Does any intercurrent disease restrict surgical option?

Diseases like diabetes, hypertension or cardiac problems are not a contraindication for surgery. However active infection or blood clotting disorders are contraindications for surgery.

What is Thalamotomy?

Thalamotomy is an operation by which the tremor generating cells located within the thalamic nuclei of brain are selectively destroyed to control tremors.

What is Pallidotomy?

Pallidotomy is an operation in which an area in the brain called Globus pallidus internus is selectively destroyed to control symptoms of advanced Parkinson's disease like dyskinesias, dystonia, rigidity etc


What is Deep Brain Stimulation Surgery for Parkinson's Disease?

Deep brain stimulation (DBS) involves implantation of electrode deep within the brain. In recent times, Subthalamic Nucleus stimulation has emerged as the favoured site for DBS. This electrode is permanently left in place and connected to a small implantable pulse generator (IPG) (Fig. 3). This remotely programmed pacemaker emits minute pulses of energy through the electrode to block the abnormal activity in the brain that cause the symptoms of Parkinson's disease. Precise targeting improves effectiveness and reduces complications. Additional advantages are that these newer techniques do not require purposeful destruction of the brain. In addition, the stimulation is adjustable and can be tailored to the individual patient. Subthalamic DBS is the most effective in terms of the range of symptoms that respond and the ability of patients to reduce medications. It is better for gait and balance problems than most any other form of treatment.


What is a typical Parkinson's disease surgery like?

Parkinson's disease surgeries are done without general anaesthesia, with patient fully awake. It involves fixation of stereotactic frame to the patient's head under local anesthesia (Fig. 4). This frame is used to locate the brain targets with the help of CT and MRI scans. The coordinates (reference points) that are obtained from this scans are then transferred to the theater computers and final read outs are obtained. These points are then set on the stereotactic arc system and a fine electrode is introduced into the brain, through a small hole drilled into the skull. Electric current is passed through the electrode to check its position in relation to the vital structures surrounding the target area. Neurologist present in the operation theater constantly assesses the clinical improvement in the symptoms
like tremor and rigidity vis a vis side effects. Once it is confirmed that the electrode is in the right place, either destruction of small group of cells is done or a permanent electrode is implanted.


How long does the surgery take?

The actual operation takes approximately three to four hours, but the entire procedure including the CT and MRI scan takes five to six hours.

If the patient is awake, does it not cause any discomfort or pain?

No, the entire procedure is completely painless and without any discomfort. However, we do have an anesthetist and physiotherapist to look after the patient during surgery.


When does the patient realize the benefit of surgery?

The improvement is seen immediately on the operation table. The tremors disappear with similar improvement in stiffness, bradykinesia and pain.

What are the risks of surgery?

The surgery is very safe. There is negligible risk of weakness or visual disturbance. In our series (which is the largest no. of surgeries for Parkinson's disease performed in India) we have less than 2% risk of serious complications.


Who performs this procedure?

The procedure should be performed only at a center that has made the investment and commitment in obtaining state-of-the-art equipment and forming a multi-disciplinary, experienced team consisting of neurosurgeons, neurologists, and neurophysiologists. Wockhardt Brain & Spine Care at Mumbai, India, is one such place where there are dedicated Functional Neurosurgery and Movement Disorder departments having the necessary expertise to perform such complex surgeries.

What are the advantages of surgery?

The advantages of surgery are related to the improvement in disabilities that the patient suffers from Parkinson's disease. The activities of daily living improve, patient can resume his/her work and patients who are severely dependent on others become independent. It improves most of the symptoms of Parkinson's disease patient. Younger patients can even go back to work.

LIVER DESEASES

The liver is the largest and one of the most complex organs in the body. It is essential for survival. From ancient times the liver was considered an organ of fate. The Egyptians considered the liver to be the seat of the life force. It is located on the right side of the abdomen. It is respected by the surgeons for its inherent myths as well as because it is one of the most vascular organs in the abdomen.
Liver: is an essential organ for survival

The functions of the liver are numerous and complex :

* It produces bile, which aids in the digestion and absorption of fats and certain vitamins
* It is a large factory playing a key role in the metabolism of carbohydrates, fats, proteins which are consumed in the diet and acts as a storehouse for these substances.
* It is a major check post for micro - organisms as well as for various toxins absorbed from the intestines.
* It helps filter many chemical substances and waste products from the blood. Most medicines are cleaned from the bloodstream by the liver. The liver also metabolizes alcohol.
* It produces various protein molecules that are responsible for clotting of blood.

WHAT MAKES LIVER UNIQUE ?

RESERVE :
The liver functions continue to be normal even if 70% of the liver is damaged or removed. This explains why cancer patients survive after large potions of cancerous liver is removed. Similarly more than half of the normal liver can be removed for living donor liver transplant.

REGENERATION :
It's the only organ in the body which can regenerate itself after large portions of it is removed surgically. It usually takes 4-6 weeks for the liver to regenerate to 90% of its original volume.

Cirrhosis of liver :
In cirrhosis of the liver, scar tissue replaces normal, healthy tissue blocking the flow of blood through the organ and preventing it from working. Cirrhosis is the eighth leading cause of death by disease, killing about 25000 people each year. Also the cost of cirrhosis in terms of human suffering, hospital costs, and lost productivity is high. It is estimated that 10-15 lakh Rs are spent on each patient with cirrhosis on medicines and other hospital treatments, from the time of detection of disease to death of the patient. The average survival time of the patient with cirrhosis after liver failure sets in is 2 years.

Causes of Liver cirrhosis :

Alcoholic Liver Disease :
Alcoholic liver disease in early stages is preventable and the progress of disease can be halted by stopping alcohol.
Viral hepatitis :
Hepatitis may be caused by many viruses, each with a different presentation and prognosis. Hepatitis B is caused by the infectious Hepatitis B virus (HBV). The hepatitis B virus is primarily found in the blood of infected individuals. Transmission of HBV takes place via blood transfusion, percutaneous introduction (i.e. needlestick injury). Sexual transmission is also possible though inefficeint. Children of mothers with active HBV are also at risk of acquiring HBV. Hepatitis - B vaccine is the essential preventive measure. Hepatitis C virus infection causes low grade damage to the liver that over several decades can lead to cirrhosis. HCV is a major cause of acute hepatitis and chronic liver disease, including cirrhosis and liver cancer. HCV is spread primarily by direct contact with human blood. The major causes of HCV infection worldwide are use of unscreened blood transfusions, and re-use of needles and syringes that have not been adequately sterilized. No vaccine is currently available to prevent hepatitis C and treatment for chronic hepatitis C is available but expensive. The chance of cure with medicines is between 30%-80%, depending on the viral subtype.

Drugs, toxins and metabolic diseases :
Drug- induced hepatitis is rare and is caused by toxic exposure to certain medications, vitamins, herbal remedies, or food supplements. Usually, the toxicity occurs after taking the causative agent for several months.

Symptoms of Liver diseases :
In the early stages, the patients with cirrhosis suffer from non-specific complaints like Exhaustion, Fatigue, Loss of appetite, Nausea, Weakness, Weight loss and Itching. The disease may progress and the patient may develop complications like swelling over feet (Edema) or swelling of abdomen (Ascites), higher tendency for bruising and bleeding, yellowing of the skin and eyes (jaundice), altered mentation, neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleep habits (Encephalopathy) due to Toxins in the blood or brain. Portal hypertension may develop leading to varices and they can rupture leading to vomiting of blood or bleeding through the rectum. Kidney failure may also develop in late stages. Diabetes may develop when the cirrhosis advances. Cirrhosis of liver is an irreversible disease.

Predict the Onset Of Glaucoma

GLAUCOMA is an irreversible disease affecting the optic nerve and is usually caused by increased fluid pressure inside the eye. Glaucoma can be difficult to detect and diagnose. Measurement of eye pressure, examination of the optic nerve, and visual field testing, in particular, are simple, painless tests that help to determine if a patient has glaucoma. Recently, a new tool has become available to eye care specialists to help predict the development of glaucoma in patients with high eye pressure (ocular hypertension).

Researchers in the U.S. have developed a "glaucoma risk calculator" that estimates the five-year risk of a patient with ocular hypertension progressing to glaucoma.

The risk calculator was developed based on a comparison of data collected from patients with ocular hypertension and compared with the data obtained independently in the national multi-centre Ocular Hypertension Treatment Study (OHTS).

Predictive model

This recent study validated key patient risk factors that predict the progression from ocular hypertension to glaucoma — risk factors such as older age, high intraocular pressure, thin central cornea, larger vertical cup-to-disc ratio, and higher visual field pattern standard deviation index.

The risk calculator provides the eye specialist with a single number that estimates the risk for developing glaucoma within the next five years of an individual patient.

To simplify the predictive model for clinical use an easy-to-use slide rule-type device known as the STAR (Scoring Tool for Assessing Risk) has now become available.

Use of a risk calculator may improve allocation of healthcare resources and provides information that helps an eye care specialist manage a patient with ocular hypertension. As an example, it may be recommended that a patient who is at low risk for developing glaucoma be withdrawn from treatment and examined at less frequent intervals. In contrast, treatment might be recommended to another patient who is at high risk for developing glaucoma.

Help patients

Use of a risk calculator provides information that can help patients understand their condition, but is not meant to replace the experience and clinical judgment of an eye specialist. As new data become available, it is likely that new and improved risk calculators will emerge. These calculators may incorporate new risk factors or eliminate others to improve their predictive abilities.

It is recommended that everyone at risk should have regular comprehensive eye examination and not just a refraction or glass power check up. This is particularly important for those at highest risk, such as those with ocular hypertension or a family member with glaucoma.

Looking into the stomach

Endoscopy is a procedure where a flexible instrument is passed through mouth or anus (known as upper endoscopy and colonoscopy respectively), to examine the internal lining of the gastrointestinal tract.

In Upper GI endoscopy the oesophagus, stomach and initial part of small intestine (duodenum) are examined while in colonoscopy the entire large intestine and also a part of most distal small intestine (Ileum) is examined. This procedure is done under conscious sedation and is usually an office procedure.
Changing role

As endoscopy evolved, its role and emphasis has changed from being a diagnostic tool to a therapeutic mean. One of the earliest applications of therapeutic endoscopy was in controlling bleeding from various sources in the GI tract.

Peptic ulcer is the commonest cause of gastrointestinal bleeding and surgery was the standard therapy for this condition till about two decades ago. But the success of endoscopic treatment has marginalised the role of surgery to one of rescue therapy.

An endoscopist has various means in his armamentarium to control bleeding, starting from injection to application of clips and to direct coagulation of bleeding vessels. There are many means to effectively and quickly stop bleeding.

The biggest advantage is that endoscopy requires much less time and no general anaesthesia in critically sick patients. Endoscopic banding and glue injection has proven to be very effective in control of bleeding in patients with cirrhosis of liver. These patients are very high risk for any kind of surgical procedures.

Endoscopic dilatation is a procedure where a narrowing in the GI tract can be opened up by the help of certain accessories. The commonest cause is ingestion of corrosive agents. In addition to simple dilatation, stents, which are like spring coils made of metal, can be placed in the GI tract. This restores the patency of the GI tract and avoids surgery. These patients are usually moribund patients with terminal malignancy and stenting provides adequate palliation. Patients who are unable to take food due to cancers of oesophagus and stomach can start food intake very rapidly after this procedure.

Foreign bodies accidentally ingested by children can be easily retrieved by endoscopy. Polyps are commonly found benign tumours of GI tract that can cause bleeding or even are a precursor of malignancy. These can be removed by cutting through cautery and thus obviating surgery.

Heart burn is one of the most common GI symptoms, which require a long term medical therapy in many patients. Suturing of the junction of the food pipe and stomach is now done endoscopically to prevent acid reflux in patients with heartburn. This is undertaken in patients not responding to drugs and when the only option is surgery.

Endoscopic retrograde cholangio-pancreatography (ERCP) is a procedure where one can enter bile duct and pancreatic duct at the site where these ducts open in the gastrointestinal lumen. The most common applications are to remove stone in the bile duct and pancreatic duct.

Also any obstruction in these ducts can be by-passed by placing stents. All these procedures so far required fairly complicated surgical procedures. Now endoscopy has reduced the hospital stay and costs to a great extent.

Efforts are on to do surgeries of internal organs like gall bladder and uterus through a small hole made into the stomach. This would even make the button-holes of laparoscopic surgery a thing of the past.
Great strides

Apart from the strides in therapeutic endoscopy great strides have been made in imaging characteristics of endoscopes. Narrow band imaging and optical coherence tomography are now available and in near future will play a vital role in early diagnosis of malignancy.

Endoscopic ultrasound (EUS) is fusion of endoscope with ultrasound probe. This allows much better imaging of walls of internal organ and their adjacent organs. This adds tremendously to the diagnostic capabilities and in addition is very useful as therapeutic tool.

Thus endoscopy has come a long way in the last two or three decades. The advances are likely to make it more useful and the role of endoscopist is likely to expand in providing non-surgical treatment of various condition of the gastrointestinal tract.