Vol 1, Issue1, Septe be 2011 o , ssue , September 0

Fortis Hospitals Bangalore: Bannerghatta road | Cunningham road | Sheshadripuram | Nagarbhavi | Rajajinagar | Marathahalli clinic
Dear Doctor, Greetings from Fortis Hospitals Bangalore! Your continuous patronage and feedback have always helped us in providing quality healthcare services. In an effort to showcase some of our pioneering work in medical and surgical fields, I am pleased to share the current issue of THE SPECIALIST with you. This issue focuses on cases in Heart Care, Urology, Bone & Joint Care and Digestive Care. For more information on the cases shared, please do feel free to get in touch with us. Your support has been a constant source of motivation that helped us in designing and developing medical programs across our network. All our 5 Hospitals in Bangalore offer a range of services of the highest quality, with the widely acclaimed clinical talent and latest technology that they are equipped with. Both of these are attributes we value, and we constantly strive to add to this talent as also to introduce technologies and techniques that are relevant to the population we serve. We have recently added HIFU (high intensity focused ultrasound), the latest and the most advanced treatment for prostate cancer, at Fortis Bannerghatta Road. This hospital is one of the few in South India, and perhaps the first in Karnataka, to have this technology. We would shortly be launching an IVF programme in Bangalore to cater to the increasing need for that service. I am also glad to inform you that our upcoming Heart Hospital in Mysore (in association with Cauvery Hospital) is nearing completion and we are adding two more large facilities to our existing network in Bangalore City. These initiatives would further strengthen our ability to address the requirements of the region. I look forward to your valuable feedback and suggestions on THE SPECIALIST to make it even more useful and Bannerghatta road 91 80 6621 4444 / 2254 4444/96633 67253 Nagarbhavi 91 80 2301 4444 / 96633 67253 Cunningham road 91 80 4199 4444 / 96633 67253 Rajajinagar 91 80 2300 4444 / 96633 67253 Sheshadripuram 91 80 4020 0000 / 96633 67253 Marathahalli clinic 91 80 6598 2915 / 6532 4444 / 96633 67253 Dilip Jose Zonal Director interesting for the readers. Seasons Greetings & Best Wishes,

Aortic Dissection and Its Management with Frozen Elephant Trunk Procedure Complication of Major Hip Fracture with Head Injury and Its Management Exstrophy-Epispadias Complex and its Management Pancreatic Pseudocyst and its Management Fortis Times

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Times

Aortic Dissection and Its Management with Frozen Elephant Trunk Procedure
Case presentation
A 47-year-old lady presented to a hospital in Zimbabwe with crushing chest pain and was diagnosed to have an aortic dissection (when a tear in the inner wall of the aorta causes blood to ow between the layers of the wall of the vessel, forcing the layers apart, see Fig. 1). Due to the lack of quality healthcare facilities in Zimbabwe, the patient visited Fortis Hospitals after two weeks. Fig. 2: Type A dissection

Management
The patient was planned for a Frozen Elephant trunk procedure. The procedure was performed by team comprising Dr. Mohammed Rehan Sayeed, Senior Consultant Cardiovascular surgeon and Dr. A. Gopi Senior Interventional Cardiologist.

Fig. 1: Aortic dissection

Stage 1 Elephant trunk procedure

Replacement of the ascending aorta and aortic arch replacement with a dacron synthetic graft:
The patient had standard median sternotomy and was placed on cardiopulmonary bypass (heart lung machine). Through deep hypothermic circulatory arrest technique, the body of the patient was cooled to 180 C and the entire blood was drained out. The entire ascending and arch of the aorta was then replaced with a Dacron synthetic graft. (See Fig. 3) The Specialist | 11

Examination findings
The CT angiogram conrmed the dissection ap extended from the base of the right coronary artery to the right femoral artery (Type A dissection, see Fig. 2) and most of the visceral arteries except the left renal artery were being supplied by the true lumen. The descending thoracic aorta was also ballooned out with features of impending rupture. 2 | The Specialist

Pancreatic pseudocyst and Its Management

Aortic Dissection and Its Management with Frozen Elephant trunk procedure

Close follow-up on USG showed total collapse and stents were extracted 6 weeks later (see Fig 2). Post stent extraction USGs over last 4 months did not reveal any recurrence. Patient was asymptomatic. Conclusion: Post cystogastrostomy status stent

extraction done

Discussion
Endoscopic ultrasound offers excellent servicing for draining pseudocysts as it is minimally invasive, avoids vessels in the track. Unlike routine endoscopic drainage pseudocysts which Fig 1: Fundus with cystogastrostomy stent insitu do not indent stomach/duodenum can safely be drained with EUS. Liver abscess subphrenic abscesses and biliomos can also be drained apart from ne needle aspiration cytology (FNAC) of various lesions in GIT as well as organs in close juxtaposition. Fig. 3: Replacement of the ascending aorta and aortic arch The head vessels were reconnected and the circulation was restarted and patient was re-warmed to 360 C. It is known as an elephant trunk procedure because the remaining part of the graft is left hanging in the descending aorta to help in its replacement when the patient comes back for the stage 2 procedure after 3-4 months.

Fig. 4: Endovascular stent

Management
Endoscopic ultrasound (EUS) showed pseudocyst in closed opposition to fundus and body of stomach with few prominent vessels. Options were to perform laparoscopic/open/EUS guided pseudocyst drainage. Pseudocyst was drained by puncturing with a 19 G needle away from collateral and about 800cc uid was drained.

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Stage 2 Frozen Elephant trunk procedure

Replacement of the descending thoracic aorta:
The replacement of the descending thoracic aorta starting from distal to the origin of the subclavian artery to the 10th thoracic vertebral level was done. This was accomplished with a endovascular stent graft (see Fig. 4). The procedure is known as Frozen elephant trunk as it is accomplished in a single sitting and is a hybrid approach to a problem which has high mortality and morbidity (see Fig. 5). Fig. 5: Frozen Elephant trunk procedure subsequent treatment of distal aortic aneurysms. It greatly facilitates and at the same time reduces the risk of multiple-stage aortic replacement.2 It offers several advantages such as saves the proximal graft-to-aorta anastomosis, at the same time avoids dangerous complications at the previous anatomic site. Besides, it also reduces the time of aortic occlusion in simple clamping to that needed for the distal anastomosis.2 This procedure has improved the results of complex replacement of the ascending aorta, aortic arch and distal aorta and has resulted in better survival rates than those of traditional approaches.3 References
1. 2. 3. Lus F, Hagl C, Haverich A, et al. Elephant trunk procedure 27 years after Borst: What remains and what is new? Eur J Cardio-thoracic Surg. 2011;40:1-12. Heinemann MK, Buehner B, Jurmann MJ, et al. Use of elephant trunk technique in aortic surgery. Ann Thorac Surg. 1995;60(1):2-6. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modied elephant trunk procedure. J Card Surg. 1992;7:30112.

Dr. D Srinivasa 91 80 4199 4444

Fig 2: USG abdomen showed that stents were extracted from the patient.

Post operative care

The patient was discharged from the hospital on day 7 after her aorta was xed. A repeat CT angiogram was done to document the position of the stent graft and to conrm that there are no leaks of any kind.

Discussion
The treatment of complex aortic pathology represents a surgical challenge, with high post operative morbidity and mortality rates.1 Elephant trunk is a technique which uses excess intravascular graft length to facilitate subsequent operations to facilitate the

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Dr. Mohammed Rehan Sayeed 91 80 4199 4444/6621 4444

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After three weeks, patient recovered from head injury and was removed from ventilator support, but was complaining of severe pain in hips and developed stiffness. On examination, he was diagnosed to have bilateral sciatic nerve palsy and also the radiological examinations showed evolving myositis ossicans on both the hip joints (see Fig. 3). He was then subjected to low dose radiotherapy and put on indomethacin medication to reduce myositis. At the end of 3 months, the patient was bed ridden, had developed severe xed exion deformity of both hips and knees and there were no signs of sciatic nerve palsy recovery (see Fig. 4).

Complication of Major Hip Fracture with Head Injury and Its Management

Pancreatic Pseudocyst and Its Management

Introduction
A-32-year-old man presented to the hospital with complaints of severe abdominal pain for 3 days in November 2010. Patient was regular ethanol abuser. He had history of severe abdominal pain for which he was admitted for 3 days in a nursing home and treated as Gastritis 1 month before present pain. There was no history of diabetes or hypertension or regular medication intake. He was not receiving any medications for any signicant medical problems. Patient persisted to have pain and contrast enhanced computerized tomography (CECT) abdomen conrmed above ndings. An endoscopic examination did not show any impression/indentation on stomach/ duodenum. Gastro-duodenuoscopy report revealed the following ndings: Cricopharynx is normal. Esophagus showed normal mucosa. GE junction is at 40 cm Fundus showed a cystogastrostomy stent insitu (see Fig 1). Extracted with snares body and antrum of stomach were normal. Duodenum bulb was normal. Dil was normal. The Specialist | 9 Ultrasound abdomen proved a bulky pancreas with signicant peripancreatic inammatory change. On follow up patient developed recurrent pain with fullness of abdomen. An ultrasonography (USG) of abdomen showed a large pseudocyst of pancreas near the head/body and was measuring 11138 cm.

for the management of head injury. His pelvis X-ray showed pertrochanteric fracture right hip and left hip fracture dislocation (see Fig. 1). Once he was stable and on ventilator, he was operated on right hip with dynamic hip screw with trochanteric extension plate. After two days, his left hip fracture dislocation was open reduced and internal xation of acetabulum was performed (see Fig. 2). At the postoperative stage, both the wound injuries healed well. The patients nursing care was very difcult since he had xed exion and abduction deformity in right hip, xed exion deformity in left hip and exion deformity in both knees with sciatic nerve palsy. Left hip excision arthroplasty surgical procedure was planned to give him some left hip mobility, to improve his nursing care and to be able to shift him from bed to wheel chair. After six months, left hip excision arthroplasty Fig. 1: Hip fracture dislocation procedure was performed and some movement was achieved. (see Fig. 5) After excision arthroplasty, although the patient was Fig. 2: Internal xation of acetabulum better in terms of nursing care, but was unhappy with Fig. 4: Fixed exion deformity Fig. 3: Myositis ossicans of both hip joints

thirty-three-year old male sustained a severe head and pelvis injury in a road accident and was admitted in the neurosurgical ICU

Investigations revealed the following:

Total count
Polymorphonuclear cells Lymphocytes Eosinophils Monocytes Haemoglobin Platelet count

13,500
80% 10% 4% 6% 17.8 gm% 2.6 lakh/cumm 6.1 3.1 86 48 800 136 1.05

LFT
Total protein Albumin SGOT SGPT GGT ALP PT/INR

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Exstrophy-Epispadias Complex and its Management

Complication of major hip fracture with head injury and its management

instability associated with excision arthroplasty. The patient then consulted another surgeon who then performed arthrodesis of left hip with DCS implant. But this fusion was done in extension and patient had severe shortening in left lower limb (see Fig. 6).

Fig. 5: Post operative images

exstrophy-epispadias improved.

complex.

The

boy

is

Fig. 7: Right total hip replacement Fig. 8: Anti dislocation liner implanted for hip mobility Fig. 5: Left hip excision arthroplasty osteotomy and constraint liner was performed (Fig. 9). Now the patient wound injuries have healed and he has achieved mobility at both the hips after one year Fig. 6: Arthrodesis of left hip with DCS implant After one year, the patient came back to us for follow-up and further management. Now, the patient was suffering from exion deformity in right hip and extension deformity in left hip. With regular physiotherapy though his knee deformities were reduced and partial recovery of one sciatic nerve was achieved, but yet patient had difculty in standing with one hip in exion and other in extension. Right total hip replacement was performed and cemented stem and cementless shell with anti dislocation liner was implanted for hip mobility (see Figs. 7 & 8). In postoperative period, the patients wound healed well and achieved good right hip movement. After two years, the patient came back and requested for total left hip replacement. He wanted left hip movement and correction of shortening on left lower limb. Left total hip replacement with cementless shell, long cementless stem with subtrochanctric
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currently doing well and his quality of life is also

Fig. 4: Intra Operative Photographs (Clockwise in order)

length to his penis and to help in his attaining puberty at the right time.
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Conclusion
The expert surgeons at Fortis Hospitals gave a new lease of life to 13-year-old boy with

Dr. Mohan Keshavmurthy 91 80 6621 4444/4020 0000

(see Fig. 10). Further, one of his sciatic nerve is improving and currently he is on rehabilitation program.

Fig. 9: Left total hip replacement

Fig. 10: Achieved mobility at both the hips

Dr. J.V Srinivas 91 80 6621 4444

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Exstrophy-Epispadias Complex and its Management

Exstrophy-Epispadias
Complex and its Management

Examination Findings
On examination, he had a meatus at the root of the penis with a constant leakage of urine. An X-ray showed a wide pubic diastasis. A cystogram showed the bladder to be of adequate capacity.

Management
Experts at Fortis Hospitals planed a two staged procedure to correct the defect. The first was to construct the anterior wall of the bladder and reconstruct the continence mechanism. This was done by a procedure called Young Dees Leadbetter technique. In addition, he required a fusion of pubic diastasis by an orthopaedic surgeon.

Exstrophy- Epispadias complex

Procedure 1:
In the 1st procedure a part of his bladder was used to reconstruct the bladder neck to provide the continence mechanism (Young Dees Leadbetter technique) (see Fig. 3)

Case Presentation
A 13-year-old boy born with a variant of exstrophyepispadias complex (see Fig. 1) reported to Fortis Hospitals. Exstrophy-epispadias complex is a condition which comprises of the following birth defects pubic diastasis (where the pubic bones are further apart from each other, see Fig. 2), bladder exstrophy (where the part of the abdominal wall above the bladder is decient), epispadias (a condition where the meatus opening is present anywhere along the dorsal surface of the body of the penis) with an absent continence mechanism (where patient loses the ability to retain urine and is constantly leaking). The condition is rare and it occurs 1 in 30,000 live births. The boy had undergone a surgery at the age of 2 years to correct the condition, however, it failed. Since then 6 | The Specialist he had a constant leakage of urine and was ostracized by neighbors and schoolmates alike. He had to wear diapers to school and his entire family was severely depressed. Fig. 2: Pubic diastasis Fig. 1: Exstrophyepispadias complex

Post Operative Care:

He was discharged after 4 days in the hospital. Four weeks later, his catheter was removed and he was able to hold urine with ease. The next procedure was planned 6 weeks later. Procedure 2 This procedure involved reconstruction of the urethra Cantwell Ransley Repair and the male external genitalia. This involved excision of the urethral stula, releasing adhesions, tissues and suspensory ligament to provide extra length to the penis and a Cantwell Ransley repair (reconstruction of the corpora cavernosa over the urethra over a catheter). See Fig. 4 for intra operative photographs. He was later started on testosterone supplements to aid in growth of the supporting tissue, add

Fig. 3: Young Dees Leadbetter technique

Post Operative Care

He was discharged after 2 days in the hospital and his supra pubic catheter and per urethral catheter were removed on alternate days about a week later. He was able to pass urine well and hold urine easily too (see Fig. 5).

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