Dr Kaushal Pandey, cardiovascular/thoracic surgeon at Fortis Hospital

Man with heart on the wrong side undergoes rare surgery

Doctors at Fortis say 67-year-old is only the 27th person in the world to undergo a bypass with his condition

When Mulund resident Ramesh Gopinath Goswami felt some pain in his chest last month, he went to get a routine test done, and left doctors at Fortis Hospital baffled by what they saw. His angiography reports showed multiple blockages in his three coronary arteries, but doctors struggled to identify what they were seeing.

 “We realised that the arteries that are normally on the left side were on his right, and vice versa,” said Dr Kaushal Pandey, cardiovascular/thoracic surgeon at Fortis. “The human heart is normally felt on the left side of the body, but in this case, we could feel it on the right side.”

Goswami, a 67-year-old Dharmacharya, suffers from a condition called dextrocardia- a congenital condition where the heart reversed.

“We decided we had to perform a bypass surgery, even though it was complicated,” said Dr Pandey. “Before conducting the surgery, however, we performed some other tests and were surprised when we realised that it wasn’t just his heart, but his entire body was a laterally inverted image of the normal human form (called sinus inversus). His appendix and liver were on the left side instead of the right and his spleen was on the right side instead of his left.”

Doctors said that incidences of dextrocardia with situs inversus occur only in 1 of around 30,000 cases. In such cases, there are high chances that the diagnosis can go wrong, if the doctor hasn’t identified the condition. Doctors said that since the heart is normally felt on the left side, ECG results can easily be wrong.

THE SURGERY

Even though the angiography report showed that coronary arteries were blocked, when doctors began the procedure, they were admittedly a little confused by what they saw. “Identifying major arteries are very important, but when you’re so used to seeing them a certain way, it can get very confusing,” said Dr Pandey. “I was standing on the right side of the operating table - where I normally stand - but had to shift to the other side to begin to identify the arteries correctly.

However, the surgery went off very smoothly after that.”

“I kept thinking that one little mistake can prove fatal,” added Dr Pandey.

Beena Daru, Goswami’s daughter said, “My father eats only sattvik food, and has never been diagnosed with a serious disease before in his life. We didn’t expect that he would have multiple blockages,” she said. “But we are very thankful that everything is alright.”

Goswami is recuperating after the surgery and will be discharged soon.

LATERALLY INVERTED BODIES

» Sinus Inversus, also known as oppositus, is a congenital condition where the major visceral organs are reversed or mirrored from their normal positions.

» It occurs in approximately 1 in 10,000 people, while dextrocardia with sunis inversus occurs in 1 in around 30,000 cases.

» In the absence of congenital heart defects, people can lead normal healthy lives, without complications related to their medical condition.

» Many notable people, including Canadian actress Catherine O'Hara, are known to suffer from the condition.

Dr Rakesh Rai, a liver transplant surgeon at Fortis Hospital, Mulund,

Liver on the edge

You barely get to know when things go wrong with your liver, warn doctors. Here’s what you need to know to keep your ‘aide de digestion’ safe

Our heart needs a lot of care we are told, but what of the body’s largest solid organ that lies below it? Union minister for science and technology Vilasrao Deshmukh is being treated at a Chennai hospital for multiple liver conditions — it’s time to pay heed to our own.
The multi-tasking organ performs several functions: it metabolises fats and carbohydrates, eliminates toxins, synthesises protein and secretes bile to aid digestion. All of these are vital to our well being. Yet, says Dr Rakesh Rai, a liver transplant surgeon at Fortis Hospital, Mulund, it’s tough to know when things aren’t right with the liver.

LATE DETECTION IS COMMON

Rai says liver diseases have subtle symptoms that a patient almost always misses. “Typical symptoms are generic — fatigue, weakness, anaemia, fluid collection in the legs and tummy, and drowsiness. The only way to detect a liver disease is when you chance upon it during a health check up. That’s why they are rarely diagnosed in time.”
   But the price we pay for late detection is high. Major liver complications include cirrhosis, acute hepatitis A, B, C and E, chronic hepatitis B and C, liver tumour and cancer. In India, more than 2 lakh people die of liver diseases every year, according to data published by the World Health Organisation, in April 2011.

ALCOHOL ISN’T SOLE CAUSE

Dr Sanjay Nagral, consultant liver surgeon at Jaslok Hospital, Peddar Road, says, “In cirrhosis, which is the final phase of chronic liver disease, functionality declines and the liver becomes pockmarked and shrunken. Usually, cirrhosis is diagnosed at a late stage. It is a progressive disease that has to be monitored once in six months to rule out formation of tumours. Many patients resort to alternative medication, which only worsens the situation.”
   Cirrhosis, contrary to popular belief, isn’t just a result of alcohol abuse, but can also be caused by hepatitis B, C and D or due to a fatty liver. Non alcoholicfatty liver disease (NAFLD) is linked to obesity, unhealthy food habits, a sedentary lifestyle and diabetes. So, one way to avoid cirrhosis, even if you don’t drink, is to make sure you lead a healthier lifestyle.
   “The solution is similar to the one for preventing heart disease. Eat healthy, exercise and shun junk food,” says Nagral. Doctors also recommend cirrhosis patients to go off salt since excess of it leads to water retention.

WHAT ABOUT HEPATITIS?

The sharp rise in hepatitis B and C cases is mostly because of incorrect hospital practice, such as the casual use of unsterilised hospital equipment, including injection needles, feels Nagral. “As a nation, we are hooked on to injections. We believe it’s a cure for every ailment. As a result, a lot of hepatitis infections get easy access to our bodies. Also, practice safe sex since hepatitis B and C are transferred through body fluids,” he cautions.

BINGE DRINKING HARMS LIVER, TOO

“Drinking from an early age is now common and nobody believes in moderation. We have had bizarre cases of 16-year-old boys with alcohol-related cirrhosis. The youth need to be told to quit or cut down, because once cirrhosis sets in, there is no treatment left other than a liver transplant,” says Rai.
   Alcohol targets the liver (causing cirrhosis) and the pancreas (causing pancreatitis), but it rarely targets both at once. Both conditions, if not treated in time, are fatal.

WHEN TRANSPLANT IS NECESSARY

Doctors first advise patients to cut down on alcohol — better late than never works with a little luck on your side. The good news is that the liver has the terrific ability to regenerate and restore its functions. “Of the 200 patients we evaluated for liver transplant last year, about 10 cirrhosis patients who were on the waiting list for surgery quit alcohol. Six months later, they didn’t need a transplant, as their livers had regenerated,” says Nagral.
   Liver transplant is an expensive option, and meant for those who haven’t responded to cutting back on alcohol and medication. Nonavailability of donors is also a problem that faces patients, as redtapeism is for those who wish to donate. Nagral says, “At Rs 12 to Rs 14 lakh, a liver transplant is not as unaffordable as it used to be. However, the wait for the donor may be long.”

Dr Girish Nair, Neurologist at Fortis hospital

City doctors teach patients the art of swallowing

A simple bodily function that most of us pay no attention to — swallowing — has become a prime focus of doctors at Fortis hospital while helping patients recuperate.

Dysphagia or difficulty in swallowing is a common disorder that affects patients with severe head injuries or brain stroke. This results in greater health care costs and other complications like dehydration, malnutrition and pneumonia.

While swallowing therapy is given equal importance during a patient’s treatment abroad, it is steadily picking up in India.

Dr Girish Nair, neurologist at Fortis hospital said, “We take swallowing for granted but for patients who find this difficult, it is a big problem that extends their stay in the hospital. Our main aim is to reduce the pain of an extended stay in the hospital and to make patients independent, at least while eating.”

Fortis’ neurology and ENT department formed a special team on an experimental basis a year ago and has helped 100 patients so far. The team consists of a neurologist, an ENT doctor, a radiologist, a dietician and nursing staff.

“We have to teach these patients the art of swallowing that they forget because of their illness. Our therapy includes measures like tongue training and chin tuck exercises,” said Dr Sanjay Bhatia, ENT surgeon at Fortis. He added that along with the nurses, even the patient’s relatives are trained so that therapy is given to the patient constantly.

Around 27% to 50% of stroke patients face difficulties swallowing. “We generally keep the patient on a rice tube which is traumatic and discomforting to the patient as he has to change the tube every seven days. Alternately, we use a percutaneous gastrostomy tube which is not visible to others and inserted surgically that last 6-8 months.” While these procedures do help in aiding nutrition, there is still a high risk of infection and issues of aspiration.

Dr Nair cited a recent success case when he said, “A woman had suffered a massive brain stroke and her entire left side was paralysed. She couldn’t speak and had problems swallowing. Within a week of our therapy, she was able to eat herself and we discharged her.”

Dr Girish Nair, Neurologist, Fortis Hospital

He learnt to swallow all over again

A road accident left Mahesh Khatre unable to swallow. Here's how he learnt to, all over again

Mahesh Khatre, a 53-year-old bank employee was a victim of a hit-and-run accident in June. He sustained a brain haemorrhage for which he was operated. But, Khatre lost his ability to swallow, an action that a healthy adult performs 600 times a day. His condition was called oropharyngeal dysphagia. Those struck by it are unable to chew, swallow, or transfer food to the oesophagus, the food pipe.

The deceptively simple act of swallowing is one of the most complicated tasks performed by the central nervous system. It requires precise co-ordination between the brain and 50 pairs of muscles and nerves in the neck so as to allow the food to reach the stomach, and not to, say, the lungs, every time you eat.

Here's Khatre's story about how he learnt to swallow again. It's something I didn't know, but learnt — the slightest miscoordination in the act of swallowing can turn life-threatening — you could asphyxiate on your saliva, or the fluids could go down your wind pipe. Like breathing, swallowing too, is an involuntary action and is controlled by the brain. But, in case of brain injuries or neurological conditions such as Parkinson's and Alzheimer's, the crucial nerve links between the brain and the neck are severed. Patients then have to depend on feeding tubes to stay alive.

I have had a lot of time to think about swallowing.

The accident
Early in June, a biker hit me and sped away when I was crossing a road in Mulund. I fell down and hurt the right side of my head. Although I got up immediately, I felt dizzy, and decided to check into a hospital. The doctors found that I had sustained a brain haemorrhage and operated on me immediately. I remained unconscious for two weeks, and was put on a ventilator. When I regained consciousness, my throat was dry and I realised that I was unable to swallow anything, including my saliva. You could say, I forgot how to.

I was suffering from oropharyngeal dysphagia, and my doctors said that I must learn how to swallow again.

My brain went into a hyper catabolic state because of stress. I began burning 2,000-2,400 calories every day despite doing nothing but lie on the hospital bed. Though I was fed supplements, my nutritional intake couldn't keep up. I lost 15 kilos in two months.

Any number of things could have happened — malnutrition, severe dehydration, aspiration pneumonia (inflammation of the lungs that comes from breathing unfiltered air). I needed to teach myself how to swallow, and fast. ENT surgeon Dr Sanjay Bhatia stepped in.

Smart brain, smart me
Our brain is capable of reassigning functions of damaged areas to healthy regions, if taught to do so. Dr Bhatia taught me five important swallowing strategies. Suck-swallow technique: Sucking is one of the first reflex actions humans learn, and that's how I had to start, too. I was advised to suck on a lollipop twice a day. A vertical back tongue motion pushed the saliva to the back of my mouth, and helped trigger my taste buds.

Tongue click: I would fold my tongue and produce a clicking sound. Then I'd stick it out and keep it hanging for five seconds, after which I would roll it back to touch the roof of my mouth with the tip.
Cheek exercise: I would fill my mouth with air and pass it from one cheek to the other. It strengthened the tongue and the cheek muscles and taught me to keep my lips shut. Chin tuck: I would tuck my chin to my chest to constrict the airway and elevate the larynx manually. This taught my brain to take control over the neck muscles.
Toothbrush gag: Putting a toothbrush at the back of the tongue initiates the gag reflex which pushes the larynx upwards and blocks the airway. I practised it to exercise the open and close movement of the wind pipe.

Within a month, I was able to eat semi-solid foods like mashed potatoes and yoghurt. Now, after spending 10 weeks in the hospital, I am able to eat solid food.

Munch on this
Neurologist Dr Girish Nair of Fortis Hospital says swallowing centres are located in different regions of the brain, including the medulla oblongata, the cerebral cortex (responsible for memory, language and consciousness), and the cranial nerve nuclei located in the brain stem.There are three phases of swallowing:

Oral: Food is chewed and mixed with saliva. The tongue pushes the food into the pharynx, the passage that connects the mouth to the oesophagus, or food pipe, located below the larynx (see figure 1).
Pharyngeal: As soon as the food enters the pharyngeal passage, nerves signal the brain to trigger a swallowing reflex. The neck muscles elevate the larynx and seal the windpipe. The food passes through the pharynx into the esophagus (see figure 2).
Oesophageal: Till food enters the oesophagus, breathing is suspended. Once the food is in the oesophagus, nerves signal the brain to lower the larynx and open the air passage. The food moves to the stomach and the process is repeated.

Dr Prakash Vaidya, pediatrician, Fortis Hospital

7 YEAR- OLD SURVIVES RARE SKIN DISEASE

Thane boy fights a 40-day battle to survive PLEVA, a rare skin disease SEVEN year- old Thane boy suffering from a rare skin disease named Pityriasis lichenoides et varioliformis acuta (PLEVA) survived a 40-day battle to stay alive. While cases of PLEVA are rarely detected, the case of Tarun Awasthi (name changed on request), who was infected with an even rare type of PLEVA called Mucha-Habermann disease, shocked the doctors at Fortis Hospital in Mulund. Tarun, a Class three student, was discharged earlier in August. Speaking to SMD, Tarun’s mother Sakshi (name changed on request), said, “Initially, when Tarun complained about the boils on his chest, we suspected mosquito bites. The local doctor diagonised it as an allergy and prescribed antibiotics.” Gradually, the allergy spread to his stomach and back and his body started developing a rash. The doctor prescribed other medication,” said Sakshi. “On June 17, Tarun had a temperature of 104 degrees. We rushed him to another doctor who conducted a skin biopsy test and referred us to Fortis Hospital,” added Sakshi. At Fortis, Tarun was kept in the general ward for 10 days. His temperature remained at 105 degrees during these 10 days. Shortly, his rashes started bleeding and his condition worsened even further. He was then shifted to the ICU on June 30. “ Tarun’s skin started peeling off and it also gave out a foul odour. Doctors told us that he had a high rate of infection,” said Sakshi. A team of seven specialists doctors from Fortis worked on Tarun’s case. Tarun was kept unexposed to the environment. His complete body dressing was changed twice a day. Dr Prakash Vaidya, pediatrician, Fortis, said, “It was a team effort that saved Tarun’s life after a struggle of 40 days. When he initially arrived, he had a very high fever and severe ulceration of skin called PLEVA which is a rare case in our country. The cause for PLEVA is still unknown to the medical world.” Tarun is back home and is responding well to the treatment. His body has almost recovered from the infection. What is PLEVA? > In Pityriasis lichenoides et varioliformis acuta (PLEVA), the skin starts debriding (peeling), which exposes the body to several types of microorganisms and virus. > It reduces the immunity level of the body, too. > If not detected in time, the disease could prove fatal > The doctors claim that curing a patient infected with PLEVA, is a challenge as the fluid injected in the body for the cure reduces the immunity level of the patient. The doctors have to simultaneously increase the patient’s immunity level