Medi Magazine kauvery A quarterly magazine from VOLUME - 16 | ISSUE 02 APRIL 2016 VOLUME

TRICEPS TENDON RUPTURE IN NEONATAL CHRONIC ELBOW DIABETES MELLITUS DISLOCATION

DETECTION OF PRIMARY PERCUTANEOUS RENAL TUMOURS NEPHROLITHOTOMY AND ITS LEGACY

MANAGEMENT OF HIGH CERVICAL KIDNEY CORD DUMBELL FRIENDLY TUMOUR RECIPE

ENDONASAL EXTENDED ENDOSKULL LIFE SAVING OPTION BASE APPROACH IN ACUTE CHOLECYSTITIS

ATRIAL SEPTAL To download this magazine DEFECT (ASD) scan this QR Code with QR scanner APP in your smartphone

This magazine is free circulation for and doctors only, Not for sale. Design and logo of kauvery are property of Kauvery Hospital, To get this magazine copy mail us at: capsule@kauveryhospital. com If you want to know any other details contact us on Editorial Address KAUVERY CAPSULE APRIL 2016 THE TEAM

CAPSULE MAGAZINE Capsule Magazine is published 01 by Kauvery Hospital FROM Copyright 2016 © Kauvery Hospital THE EDITOR’S DESK 02 PATRONS ATRIAL SEPTAL Dr. S. Chandrakumar DEFECT (ASD) Dr. S. Manivannan 03 ADVISORY BOARD Dr. D. Senguttuvan LIFE SAVING OPTION Dr. Aravindan Selvaraj IN ACUTE CHOLECYSTITIS Dr. T. Senthil Kumar EDITOR 05 04 Dr. S. Senthil Kumar TRICEPS TENDON ENDONASAL RUPTURE EXTENDED ENDOSKULL EDITORIAL TEAM BASE APPROACH Dr. S. Velmurugan IN CHRONIC ELBOW Dr. S. Aravinda Kumar DISLOCATION Dr. Iyyappan Ponnuswamy 06 DETECTION OF PRIMARY TECHNICAL TEAM RENAL TUMOURS Dr. Ve. Senthil Vel Murugan Dr. A. Subramanian 08 ADMIN TEAM Mr. A. Madhavan NEONATAL DIABETES Mr. P. Charles MELLITUS Mrs. JPJ. Bindhu 11 10 CO-ORDINATORS PERCUTANEOUS MANAGEMENT Mrs. Percy NEPHROLITHOTOMY Mr. Prakash Ranjith Kumar R. OF HIGH CERVICAL AND ITS LEGACY CORD DUMBELL TUMOUR- MICROSURGICAL EXCISION DESIGN & LAYOUT Mr. Vahid Ali N. 13 KIDNEY FRIENDLY RECEIPE 14 WORLD KIDNEY DAY EDITORIAL OFFICE EVENT PHOTOS Kauvery Hospital VI Floor, Administrative Office, #6, Royal Road, Cantonment, -620001. Call us at (431) 40 77 777 16 E: capsule@kauveryhospital. com W: www. kauveryhospital. com NEW DOCTORS AND QUIZ EDITOR’S DESK 01 APRIL 2016 KAUVERY CAPSULE

FROM THE EDITOR’S DESK DR. S. SENTHIL KUMAR, MS., DNB., (URO) SENIOR CONSULTANT UROLOGIST

Dear Readers, attention, making eye contact, smiling, communi- I welcome you to the —th edition of CAPSULE. cating clearly, understanding and anticipating During the month of Feb - 2016, Kauvery Hospital needs and resolving guest's concern. celebrated its 17th Birthday. The 17th Annual day was celebrated with great enthusiasm by all our Seeking out interactions: A simple example of employees and their Family. The theme was a story of security guard at the park who delight- 'Patient Delight experience', so with relevance to ed a young girl dressed like a princess by asking the patient delight experience I would like to her to sign his Autograph book as if she were a share this article. real princess. It was a simple interaction, but the effect on the girl and her family was powerful. Five Things Organization can learn This security guard is perfect example of an from Disney. employee who actively looks for opportunities to Disney and healthcare are worlds apart in their make a guest feel special. product offering and purpose. While health care is largely a utilitarian service offering (ie, patient Owning the guest: Upon arriving on a Disney need a problem to be resolved,) guest visit Disney property, guests are not passed on to some one park seeking an exciting, carefree experience. else. The important distinction is to remember Despite the obvious differences, success can be that guests are not a burden or an interruption of measured similarly work but rather the entire reason for the Job. The Focus on the guest experience has to become a living, breathing part of an organiza- Accountability: Another important component tion for it to be successful; having it as another in ensuring great service is the establishment of a bullet on a company mission statement will not measurement system that actively collects and produce the desired effect. even solicits feedback from guest and peer cast members, in an unbiased manner. Disney uses Understanding the guest: The foundation for this information to celebrate the great service providing a great experience starts with under- given by cast members via public acknowledge- standing the guest. At Disney park, the cast ment and service awards. members have Risen through the ranks and started on the front lines. This gives cast members I strongly feel that these five things if incorporated an intimate knowledge of the guest because they in any Hospital can provide a delight experience worked face to face with guest on a daily basis. to the patient instead of satisfaction.

Everyone is a performer: The performance is The key take home message is to not presume to not too complicated. Be friendly and attentive, know what the patient wants; find out who the and treat the guest with courtesy and respect patient is and what his/her wants and Needs are, while performing Job functions. This is accom- and how best to meet them. plished through giving the guest undivided KAUVERY CAPSULE APRIL 2016 02 ATRIAL SEPTAL DEFECT

Atrial Septal Defect (ASD)

By Dr. R. Prem Sekar Senior Consultant ATRIAL Interventional Paediatric Cardiologist Kauvery Hospital, SEPTAL DEFECT

Atrial Septal defect Narmadha, a female child, 14 years of shutting off the abnormal, additional (ASD), is a hole in age was apparently without any health blood flow to the lungs. Throughout the partition related problems until 4 weeks ago. All the procedure which lasted 30 minutes, (septum) between of a sudden she experienced Narmadha was awake and bravely took the two upper palpitations and giddiness while in in all the happenings. Soon after the chambers (atria) of school. Her mother who is raising procedure, the tube from her groin was the heart. Over the Narmadha by herself rushed to the removed and she was shifted to be years this hole can school and took her to a nearby with her mother for the night. cause additional doctor, who listened to Narmadha`s blood flow to the heart with a stethescope and found an Narmadha underwent a repeat lungs along with additional abnormal sound in the form echocardiography, ECG and Chest significant of a murmur. An echocardiogram was X-Ray the following day which enlargement of the done revealing that Narmadha had a confirmed perfect placement of the right half of the large hole in her heart (ASD) which has septal occluder with no residual shunt heart. This can result resulted in swelling of the heart and across the atrial septum. She was then in the patient excessive blood flow to the lungs. She discharged home on a low dose aspirin experiencing was referred to the paediatric for a period of 6 months and advice to breathlessness, easy department at Kauvery exercise & play freely. fatiguability, Hospital on 3rd July 2015 for palpitations and management of the same. Device closure of holes in the heart is a occasionally chest revolutionary technique to manage pain. After detailed evaluation Narmadha holes in the heart like ASD, VSD, PDA, was admitted in the pediatric fistulas and other communications. The cardiology ward at Kauvery Hospital on biggest advantage of the procedure is 6th July 2015. On 7th July she was that it is Scar free, hospitalisation is wheeled into the catheterisation limited to 2-3 days, there is no need laboratory. Under local anaesthesia, a for blood transfusions and in older small needle puncture was made in the children can be done without general groin and a small tube called a catheter anesthesia. was introduced into the vein in the Narmadha and her mother were both groin and guided to the heart and very happy having her heart cured for positioned across the hole in the heart. life without a visible scar which is Through this catheter, a septal occluder considered a big taboo in this part of was positioned across the hole the world. completely closing the hole and LIFE SAVING OPTION IN ACUTE CHOLECYSTITIS 03 APRIL 2016 KAUVERY CAPSULE

Life saving option in there is no need to shift these critically ill patients to Acute as this procedure Cholecystitis can be done using bedside of critically USG alone. ill patients Conclusion: PTHC is a life -USG Guided Percutaneous saving procedure in all Transhepatic Cholecystostomy (PTHC) Using Single Puncture critically ill, unfit patients Trocar Technique. who present with acute severe cholecystitis and By aseptic precautions with Interval cholecystectomy associated sepsis. This Dr. V. Senthilvelmurugan adequate local anesthesia, was done after 4-6weeks of procedure helps to relieve Sr. Consultant Radiologist small incision with 11 blade PTHC. All patients their sepsis and optimize was made. Either 8 or 12 F underwent laparascopic them so that a delayed Dr. S. Velmurugan size pigtail catheters were cholecystectomy without laparoscopic Sr. Consultant surgical cholecystectomy can be gastroenterologist used. All patients underwent any conversion to open Kauvery Hospital, Trichy the procedure by single procedure. The presence of performed safely. puncture Trocar technique. PTHC catheter did not make the surgical procedure more The single puncture pigtail difficult, but it actually In our hospital, during the catheter set consists of helped in reducing the past 2 years we have done Pigtail catheter, Needle and inflammation and adhesions 21 PTHC for acute calculus cannula / trocar. Under USG and also in holding the gall cholecystitis for critically ill guidance, pigtail set was bladder up so that there was patients who were not fit for introduced into gall bladder no need for fundal traction. surgery due to various lumen through the liver until The PTHC catheter was reasons in their index the tip was visualised. The removed towards the end of admission. All patients had needle was taken out and cholecystectomy during gall imaging evidence of acute aspiration done using the bladder bed dissection. In all cholecystitis with features of syringe. The position was patients, sub-hepatic drain sepsis. The aim of doing confirmed by aspiration of was kept and this was PTHC was to relieve sepsis pus or infected bile. Then removed after 48hours if and stabilize patient before the cannula was descrewed there was no bile or blood the definitive surgical from the catheter, while the in it. None of the patients procedure. There is no catheter was simultaneously had bile leak (or) bleeding specific contraindication for introduced inside further. and had a smooth this procedure. The catheter was fixed with uneventful recovery. skin stay sutures and Procedure: Procedure connected to continuous Discussion: Using single should be done in an drainage bag. In all cases, puncture Trocar technique is intensive care setting with pus was sent for culture and simple and less traumatising monitoring of vital signs. Pre sensitivity. Initially broad than Seldinger technique. procedural evaluation spectrum antibiotics were Transhepatic route is should include CBC and given and then tailored advantageous than coagulation profile (PT,PTT down according to culture. transperitoneal route in and INR). If the coagulation avoiding slippage of profile is altered it should be Results: All patients catheter and peritoneal corrected before the became better and showed spillage. All cases underwent procedure appropriately. significant clinical PTHC with ultrasonogram To watch the improvement within 24 guidance which is unique procedure’s video Preliminary USG was was hours. At discharge, patients when comparing literature scan this QR Code identified done and shortest were sent home with the where at least few reported through the QR route through liver with PTHC catheter unclamped, cases needed CT scan. It is scanner APP in your minimal trauma. Under for continued drainage. an added advantage that smartphone KAUVERY CAPSULE APRIL 2016 04 ENDONASAL EXTENDED ENDOSKULL BASE APPROACH

Endonasal extended endoskull base approach By Dr. G. Jos Jasper Head of the Department Kauvery Brain & Spine Centre Cantonment, Trichy

Patient Mr. K. Antony On examination, his Peter, a 34 years old male radiological investigations came to our hospital in revealed evidence of anterior July 2013 with complaints interhemispheric space of seizures for the past occupying lesion epidermoid five years and giddiness cyst. Hence he was advised + vomiting along for the for surgical management of past one week. As per the the tumour. After explaining history given by his the details of the procedure relatives, he had to the patient’s wife and his behavioral changes too in relatives he underwent a the recent past as he was surgery. Instead of PRE OPERATIVE totally apathetic with no approaching the tumour interest in either transcranially, he underwent maintaining the surgery through social/domestic endonasal extended relationship. He was also endoskull base approach with not employed and excision of the tumour on 10. showed no interest to go 7. 2013. to any job. After the procedure he showed a remarkable improvement both in his clinical status as well as behavioural activities. Since the surgery the patient has been going regularly to work, and in an active participation in home/social activities.

Although endonasal extended endoskull base approach is a new field, it is a field with a future, as we learn to reapply it in various diseases as we become more experienced. POST OPERATIVE TRICEPS TENDON RUPTURE IN CHRONIC ELBOW DISLOCATION 05 APRIL 2016 KAUVERY CAPSULE

Triceps tendon Clinical presentation: in chronic elbow Forty four year old lady dislocations due to rupture in presented with severe pain restricted movements. chronic in her left elbow more than Hence we recommend unreduced 5 months period with routine pre operative MRI pre-operative movements to identify triceps rupture elbow dislocation ranging from 20-40 deg of pre operatively. By flexion. There was no pain Dr. S. Yogesh free movement. The “three The primary repair of point” bony relationship triceps tendon to Under guidance of was altered. Neurovascular olecranon is difficult in Dr P. R. Ramsamy examination was normal. chronic tears due to the Head of the Department She had undertaken native contracture of the tendon. Orthopedic Surgery Department treatment in the form of Tendon grafts Kauvery Hospital, Tennur, Trichy. splintage and massage. (semitendinosus from X-rays showed unreduced knee) could be planned if Triceps tendon rupture in elbow has posterior dislocation of MRI is done pre been reported worldwide (articles elbow with partially united operatively. In our case, ranging from 1972-2015). However supracondylar fracture of triceps rupture was found triceps tendon rupture in elbow humerus. intra operatively. Hence we along with chronic unreduced managed to create a elbow dislocation has not been Intra operative findings: triceps tendon for insertion reported in the literature. We Elbow joint was with triceps fascia. This present one such case in this article. approached posterioly. The innovative technique could The elbow joint is the 2nd most ulnar nerve was identified be used when triceps commonly dislocated joint in adults and isolated. Joint was tendon rupture is detected following shoulder. The classification found to be dislocated and surprisingly during the intra of acute elbow dislocations is triceps tendon was avulsed operative period. related to direction of forearm from its insertion. The joint bones at time of injury which was debrided and elbow includes posterior, anterior, reduced and fixed with divergent, medial and lateral ulno-humeral pin. Triceps dislocations. The posterior fascia over the distal half dislocation is the most common was dissected and rotated type. Closed reduction has been in reverse to create triceps suggested for unreduced tendon for insertion into dislocations which are less than 3 olecranon. This rotated weeks old and surgical reduction for fascia was attached to the those more than 3 weeks old. olecranon through drill holes. Wound was closed in layers. The pin was removed after 6 weeks and Pathology of a chronic elbow was gradually dislocation: Chronic unreduced mobilized. The post elbow dislocations have myositis of operative movement range brachialis and triceps muscles. They at 4 months was from also have contracture of collateral 30-100 deg of flexion elbow ligaments and triceps muscle. without pain. Ulnar nerve can also get contracted which makes surgical reduction of Discussion and the chronically dislocated elbow conclusion: We rely only joint much more difficult. Joint on X rays for chronic elbow space is filled with fibrous tissue. dislocations and MRI is not Articular cartilage and synovial done routinely. The triceps membrane are gradually destroyed tendon rupture is difficult and replaced by fibrous tissue. to diagnose preoperatively KAUVERY CAPSULE APRIL 2016 06 DETECTION OF PRIMARY RENAL TUMOURS THROUGH PREVENTIVE HEALTH CHECK UPS

Detection of WHO SAID primary renal tumours through MASTER HEALTH CHECK UP preventive health Check ups IS UNNECESSARY?

By Dr. Jeyabharathy Consultant Radiologist, Kauvery Hospital, Chennai

There has been a His ultrasound controversy going on in showed mixed public forums that the echogenic mass lesion master health checkups in the left renal upper do not add to patient pole measuring 5. 6 benefit and cause cms. His subsequent unnecessary financial CT abdomen showed burden to the patient. left renal upper pole mixed density, I would like to share my heterogeneously experiences in the enhancing lesion with detection of primary renal central necrosis tumours in MHC patients measuring about 5.3x in the last 12 months and 3cms. Since there was it is left for the reader to no extracapsular decide on the need to spread, necessary undergo yearly checkup. investigations were done and he was Though we have come taken up for left sided across multiple incidental total nephrectomy . findings of incidental HPE report was low gallstones, renal calculi, grade renal cell ureteric stones and renal carcinoma. He comes failure, the alarm to our hospital for increases when we come regular review and is across incidental doing well. malignancies.

My first patient was a fifty year old gentleman who was normal with no comorbities and wanted a complete health check. DETECTION OF PRIMARY RENAL TUMOURS THROUGH PREVENTIVE HEALTH CHECK UPS 07 APRIL 2016 KAUVERY CAPSULE

our next pateint was a 61 The last patient was a middle year old female who was a aged gentleman who did cardiac patient and wanted not have any symptoms, an abdomen ultrasound as ultrasound showed a large routine check which right renal mass which was revealed a mixed confirmed on CT . In echogenic mass in the left addition CT showed kidney with probable renal perinephric spread of vein thrombosis and tumour. The patient has confirmed on CECT KUB been advised surgery. The patient was lost to Incidental asymptomatic follow up as she preferred renal cell carcinomas are not to do the surgery at uncommon. Renal cell another hospital. carcinoma (RCC) accounts for 3% of all adult malignancies and is steadily increasing at a rate of about 2. 5% per year. Approximately one-third of The third patient was a patients present with fifty old gentleman metastatic disease and who had an earlier hence early detection by ultrasound and was preventive health checkups told he had a probable may be life saving angiomyolipoma in his right kidney which was 4cms in size. His present ultrasound showed 6. 3 cm sized welldefined mixed echogenic lesion in the right renal lower pole CT KUB showed right renal lower pole lesion consistent with Bosniak class 4 cyst with subtle enhancement of internal septa. He was taken up for total radical nephrectomy and the HPE report turned out to be papillary renal cell carcinoma. He came back for his first review and is doing fine. KAUVERY CAPSULE APRIL 2016 08 TWO MONTHS OLD BABY WITH NEONATAL DIABETES MELLITUS

Two months old baby with Neonatal Diabetes Mellitus SUCCESSFUL TREATMENT WITH ORAL SULPHONYLUREA

By Dr. P. Gowri Consultant Diabetologist

Dr. D. Senguttuvan Head of the Department, Department of Kauvery Hospital, Trichy

Neonatal diabetes mellitus Permanent neonatal History: A 52 day old female occurs approximately in 1 diabetes mellitus (PNDM) baby born to out of every 250,000 live diagnosed within the first 6 non-consanguineously married births. It can be either months of life is a rare couple was brought with permanent or transient. disorder likely to be complaints of fever, incessant cry Recent studies indicate that monogenic rather than and decreased feed intake for 2 it is likely to have an autoimmune (1, 2). It is days. Baby had 2 episodes of underlying estimated to affect approxi- convulsions in the previous 2 genetic cause, particularly mately one in 250,000 live days. Birth history revealed Term/ when diagnosed before 6 births (3). Most patients IUGR baby (2kg). Baby was fed months of age. Permanent have heterozygous activat- with breast milk and cow’s milk. neonatal diabetes is most ing mutations in the KCNJ11 1ST dose DPT and oral polio commonly due to and ABCC8 genes encoding drops were given 3 days back. activating mutations in potassium ATP channel either of the genes subunits Kir6. 2 (4) and Examination: Baby was encoding the two subunits SUR1 (5, 6) or heterozygous dehydrated, febrile and was in of the ATP-sensitive mutations in the preproinsu- respiratory distress. Activity was potassium channel in the lin (INS) gene (7). Transfer to poor, peripheries were pale & pancreatic beta cell. In SU therapy has been dusky, and perfusion was poor. most of these patients, it is successful for all patients No abnormality was detected in possible to switch from with KCNJ11 mutation (8). systemic examination. insulin to oral sulfonylurea We here report a case of Investigations revealed elevated therapy leading to neonatal diabetes associat- WBC count, hyperglycemia improved metabolic ed with mutation in the (RBS-517mg %), azotemia, severe control, as well as possible gene KCNJ11 encoding Kir6. metabolic acidosis and urine amelioration of associated 2 and successful replace- acetone was positive. HbA1c was neurodevelopmental ment of insulin with 11. 6%. Insulin autoantibody and disabilities. sulphonylurea. GAD 65 antibody were negative TWO MONTHS OLD BABY WITH NEONATAL DIABETES MELLITUS 09 APRIL 2016 KAUVERY CAPSULE

Management: A diagnosis R201H) was detected. This Follow up: Long term follow associated is Permanent of Neonatal diabetes /Severe confirmed a diagnosis of up is required to assess neonatal diabetes mellitus Diabetic ketoacidosis/Sepsis neonatal diabetes due to a glycemic control and neuro (PNDM). In this phenotype, was made and baby was mutation in the kir 6. 2 developmental improvement. neurological features, started on IV fluids, iv insulin subunit of the K. ATP particularly developmental infusion, antibiotics and channel. Discussion: NDM is a delay and epilepsy are seen ionotropic support. During monogenic form of diabetes in addition to neonatal hospitalization, baby had Since oral sulphonylurea that occurs in the first 6 diabetes. This is known as recurrent episodes of therapy has been successful months of life. NDM can be Developmental delay convulsions and respiratory for all patients with this mistaken for the much more epilepsy and neonatal distress for which she was mutation, the baby was common type 1 diabetes, diabetes (DEND) syndrome. intubated and connected to readmitted for switching over but type 1 diabetes usually Those with a very severe ventilator. CT brain was done from insulin to oral occurs later than the first 6 neurological phenotype that which revealed multiple treatment. Baseline workup months of life. In about half exhibits all the features are infarcts involving bilateral including HbA1c, fasting of those with NDM, the said to have full DEND Posterior cerebral artery c-peptide, height, weight condition is lifelong and is syndrome. A less severe territory. Baby needed and developmental age was called permanent neonatal clinical picture, consisting of treatment with multiple noted. The sulphonylurea diabetes mellitus (PNDM). In neonatal diabetes with anticonvulsants for control of glibenclamide was started at the rest of those with NDM, developmental delay and or seizures. Baby improved with 0. 1mg/kg twice daily along the condition is transient and muscle weakness but not above measures and with s/c insulin. Blood disappears during infancy epilepsy is referred to as discharged with twice daily glucose levels were regularly but can reappear later in life; intermediate (i- DEND) dose of subcutaneous NPH monitored. Baby did not this type of NDM is called syndrome. Our patient falls in insulin and oral have any adverse drug transient neonatal diabetes the severe category. anticonvulsant medications. reactions. OHA dosage was mellitus (TNDM). increased by 0. 2mg/kg/day Our case report suggests Since the onset of diabetes and maintained at There is a spectrum of that oral sulfonylureas can was <6 months, genetic 1mg/kg/day at the end of phenotypes associated with replace subcutaneously mutation analysis of the one week. Insulin was KCNJ 11 mutations. The injected insulin in children KCNJ11, ABCC8 and INS stopped after 1 week of mildest form caused by KCNJ with PND due to Kir6. genes was undertaken. starting OHA. Blood sugars 11 mutation is the Transient 2-activating mutations. All Sample was sent to the were maintaining around neonatal diabetes mellitus neonates with an Molecular Genetics 250mg% and acetone was (TNDM). TNDM usually antibody-negative form of Laboratory of The Peninsula negative. A reduction in the resolves around 18 months diabetes diagnosed before 6 Medical School, Exeter and seizure frequency and of age. A proportion of them months of age should test methodology used was significant improvement in may subsequently relapse undergo genetic mutation sequence analysis of coding milestone development was and are diagnosed with analysis. Treatment with and flanking intronic regions noted after initiation of diabetes in adolescence or sulphonylurea may also limit of the above said genes. sulfonylurea therapy. early adulthood. neurological damage, even Heterozygous missense when it is unable to control mutation of KCNJ 11 gene (p. The second phenotype diabetes.

Gene involved Onset of diabetes Mode of inheritance Treatment

KCNJ11 3 to 6 months Autosomal dominant Treated with insulin in the past but often can be treated with Spontaneous oral sulfonylureas ABCC8 1 to 3 months Autosomal dominant Treated with insulin in the past but often can be treated with Spontaneous oral sulfonylureas

GCK 1 week Autosomal recessive Insulin

IPF1; also known as PDX1 1 week Autosomal recessive Treat to replace endocrine and exocrine pancreas functions

PTF1A At birth Autosomal recessive Treat to replace endocrine and exocrine pancreas functions

FOXP3, IPEX syndrome Sometimes present at birth X-linked Insulin

EIF2AK3, Wolcott-Rallison 3 months Autosomal recessive Insulin and treatment for associated conditions syndrome KAUVERY CAPSULE APRIL 2016 10 MANAGEMENT OF HIGH CERVICAL CORD DUMBELL TUMOUR

MRI Showingthe Anteriorly Placed Lesion With Transforaminal Dumbell Extension

Management of high cervical cord dumbell tumour - Microsurgical excision

By He underwent C1/c2 They are classified as Dr. K. Madhusuthan laminectomy and excision 1. Anterior Consultant Neurosurgeon of extradural and 2. Anterolateral Kauvery Hospital, Tennur, Trichy intradural tumour. He was 3. Poserolateral placed prone and 4. Posterior suboccipital to C4 lamina Introduction: delineated. Initially the Purely anteriorly placed High cervical nerve sheath extradural component lesions may need a tumors(NST) include extending into the muscles transcondylar approach . tumors arising from excised after preserving But because of the c1/c2/c3 nerve roots. They the vertebral artery which dumbell shape, are unique because of was pushed anteriorly. anterolaterally placed their location and Dura opened and the lesions can be operated proximity to vertebral anteriorly placed by the posterior only artery . They constitute intradural component approach. If instability 20% of spinal NST. They excised . WATERTIGHT arises may need postop present with myelopathy dural closure done and spinal stabilisation. In this features or pure neck pain overlaid with fibringlue. case the dumbell tumour alone. Post op, patient had no widened the intervertebral deficit and his pain foramen allowing the Case Summary: decreased and weakness removal of the anteriorly 50 year old male, recently improved. placed lesion with ease. diagnosed with DM and hypothyroidism presented Discussion: Intaop And with h/o neck pain 6 C2 NST pose a surgical Postop Picture months and difficulty in problem because of high After turning head from side to cervical location and its Complete Excision side. He had numbness in relation to vertebral artery. right hand and feet and Anteriorly placed lesions minimal weakness of right are surgical challenges as hand grip. He was undue cord retraction can evaluated outside and result in significant postop diagnosed with C2 neurological deficit. Dural dumbell tumour. Patient rent and wound CSF leak refused surgery initially for can be a significant fear of postop problem in dumbell neurological deficit. tumour. PERCUTANEOUS NEPHROLITHOTOMY AND ITS LEGACY 11 APRIL 2016 KAUVERY CAPSULE

Percutaneous nephrolithotomy and its legacy

By Dr. S. Senthilkumar, Senior Consultant Urologist

Dr. N. Karthickeyan, Consultant Urologist

Kauvery Kidney Center, Tennur, Trichy

Fernstrom and Johansson first removed a renal calculus through a nephrostomy tract in the year 1976. Since then Percutaneous Nephrolithotomy (PCNL) has significantly changed and is continuing to evolve. It is the urologist`s main work horse in the management of renal calculus.

Indications for PCNL: DISCUSSION: 1. Large stone burden > 2 cm PCNL in Special situations and limitations: or 1. 5 cm for lower calyceal PCNL as monotherapy has several advantages in the removal of upper tract stones larger stones. than 2cm, achieving excellent results with minimal morbidity. However, partial or complete staghorn calculi may require multiple punctures or the combination of PCNL and ESWL 2. Staghorn stones. followed by repeat PCNL (sandwich therapy). PCNL should be the preferred technique for patients with struvite stones. When these infected stones are removed completely by PCNL, 3. Stones that are difficult to the patient has a 90% chance of remaining stone free for at least 3 years. Stones larger than disintegrate by ESWL 1. 5cm in the lower pole are best managed by PCNL as a first treatment option, irrespectively (calcium-oxalate monohydrate, of the anatomy of the lower pole. However, PCNL has a higher success rate in the cost of brushite, cystine). higher complication rates. Percutaneous nephrolithotomy is considered the gold standard for managing calyceal diverticula with stones. High rates of stone-clearance (76% to 100%) and 4. Stones refractory to ESWL diverticular obliteration (61% to 100%) have been published in contemporary series. or ureteroscopy.

5. Urinary tract obstructions Stones in Kidneys with anatomic variation: that need simultaneous PCNL in the horseshoe kidney, malrotated and pelvic kidneys and transplanted kidneys has correction (e. g. PUJ been safe and effective, especially when large stones or ureteropelvic junction obstruction obstruction). existed. Renal access is obtained mostly through an upper pole calyx and vascular injury is less likely in these conditions. This is because the whole blood supply enters the kidney 6. Malformations with reduced medial in renal congenital anomalies, and the anterior nature of the transplant kidney in the probability of fragment iliac fossa offers easier access through the anterior abdominal wall for tract dilation. However, passage after ESWL (e. g. a second look procedure is occasionally necessary to render the kidney free of stones. horseshoe or ectopic kidneys, calyceal diverticula. Paediatric Urolithiasis: 7. Obesity Standard PCNL with the use of adult instruments is safe and highly effective treatment for stone disease in infants, preschool or older children. PCNL in children is recommended when Absolute contraindications: ESWL or ureteroscopy have failed, when a large stone burden is treated, and when Uncorrected coagulopathy anatomical abnormalities that may impair urinary drainage and stone clearance exist. Untreated UTI Stone-free rates with a single session of PCNL range from 67% to 100% . KAUVERY CAPSULE APRIL 2016 12 PERCUTANEOUS NEPHROLITHOTOMY AND ITS LEGACY

Upper tract stones in all patients and the renal stones. Two had Obese patients: posterior calyces were the emphysematous Several retrospective most common site of pyelonephritis along with studies indicate that PCNL entry. The overall success renal stones (Figure 2). in obese patients can be rate and the complication They underwent stenting performed with stone-free rates are similar in both initially to control sepsis. rates (as high as 100%), groups. Standard PCNL was done complication rates and For most patients in all of them. All patients hospital stays comparable fluoroscopy or with HSK and stones had to those achieved in an sonography is done to complete stone clearance Figure 1-PCNL in the prone position unselected population. monitor access into the without any complications. renal collecting system. Stones in Solitary Following creation of Last year we have done Kidney: percutaneous renal access, PCNL for ten children Clinical studies in patients tract dilatation is an under 12 years of age. with a solitary kidney have essential step in the Standard PCNL was done also indicated that PCNL performance of using adult instruments. has no clinically significant percutaneous renal One 3 year old boy was adverse effect on renal surgery. With proper tract diagnosed to have right function on a short-term dilatation an appropriate renal calculus (Figure 3) as Figure 2-Horse shoe Kidney or a long-term follow-up. size working sheath can the cause for his recurrent with B/L Renal stones. Note the be placed facilitating abdominal pain and air packets on the right side. Chronic Kidney nephroscopes, working hematuria. He underwent Disease: instruments, nephrostomy percutaneous stone In patients with tubes. Tubeless PCNL removal with uneventful pre-existing renal without nephrostomy recovery. impairment, kidney tubes are done when function in the immediate there is no undue PCNL is the postoperative period did bleeding and major PCS recommended treatment not deteriorate but instead perforation. for staghorn calculus sometimes improve when occupying the entire the renal failure was pelvicalyceal system. Eight Complications during secondary to obstruction patients with staghorn PCNL: or infection. calculus underwent PCNL Figure 3-Right renal calculus Major complications: last year, of which three in a three year old boy Bleeding requiring patients had partial intervention 0. 6-1. 4% Points of PCNL staghorn configuration. Pleural injury 2. 3-3. 1% technique: One of our patient,a 50 Colonic injury 0. 2-0. 8% Percutaneous year old gentleman Septicemia 0. 9%-4. 7% nephrolithotomy is usually underwent multipuncture performed in the prone PCNL for a complete Minor complications: position (Figure 1). This staghorn calculus (Figure Bleeding requiring approach has some 4). The patient was stone transfusions <8% disadvantages, including free (Figure 5 & 6) with Insignificant bleeding patient minimal drop in Fever discomfort,circulatory and haematocrit at the time of Figure 4-Complete left Pain ventilatory difficulties. discharge. staghorn calculus PCNL may be precluded by the presence of PCNL-the road associated pulmonary well-travelled: Conclusion: disorders and/ or obesity. Being the pioneer of PCNL PCNL is a safe and PCNL at the lateral in the Trichy zone, we effective treatment decubitus and supine have done more than modality for large upper position has been seen to 2000 PCNL procedures in urinary tract stones in all be a safe and effective the past 10 years. We age groups. PCNL is the alternative. Regardless of recently had quite a bunch preferred method in the position, the of challenging cases. Six treating stones in pelvicalyceal system was patients with horse shoe abnormally located successfully approached in kidney (HSK) came with Figure 5-Post Left PCNL showing kidneys. complete stone clearance HEALTHY RECIPE 13 APRIL 2016 KAUVERY CAPSULE

Apple-Stuffed Cinnamon Bundle KIDNEY FRIENDLY RECIPE

Ingredients: Cut each stack into 6 squares. 4 apples or 3½ cups (of peeled medium Line the bottom and sides of each muffin cup using one stack diced Granny Smith, Washington Gala, and of squares. Leave an over-hang. Honey Crisp apples mixed) Fill each phyllo lined muffin cup ¼ cup light brown sugar New release from ½ - ¾ full with the apple 2 tbsp. unsalted butter, firm 1/4 cup melted mixture (this will depend on our unsalted butter how big the apples are cut), Kauvery academy. making sure each phyllo lined (for buttering phyllo pastry sheet) muffin cup has equal amounts 1 tsp. cinnamon of apple mixture. To see our video 1/4 tsp nutmeg Scan this Fold excess phyllo dough over QR code 2 tbsp. vanilla extract the apples in each muffin cup 1/4 tsp. corn starch and pinch top closed to create with the bundles. QR scanner App 1/ package (6 sheet) phyllo dough in your Combine in a small bowl: Bake in preheated oven for smartphone 3 tbsp. powered sugar 8-10 minutes or until golden brown. 2 tbsp. cinnamon Garnish with powdered sugar, Preparation: whipped cream and sprig of fresh mint. Pre-heat oven to 350 degrees For those with diabetes, ¼ cup Prepare apple mixture: Agave Nectar can be In large sauté pan on medium high heat, substituted for light brown sauté apples in butter for 6-8 minutes. Stir sugar as a sweetener. in cinnamon, nutmeg, and brown sugar, and cook for an additional 3-4 minutes. In a small cup, mix cornstarch and vanilla Key Nutritional Value: extract until dissolved, stir into apple mixture and cook for additional two Calories - 249 calories minutes on medium high heat. Turn off Trans Fat - 0 grams heat and set aside. Protein - 2 grams Prepare phyllo dough bundles: Cholesterol - 31 milligrams Lightly grease a large six muffin tin pan. Carbohydrate - 29 grams Medical Clowning Starting with the first sheet of phyllo at Kauvery Hospital Potassium - 102 milligrams dough, brush each side with melted butter then dust with the powdered sugar Total Fat - 14 grams and cinnamon mix. Continue until all 6 Phosphorus - 26 milligrams sheets have been buttered and dusted with sugar and cinnamon mix, stacking Saturated Fat - 9 grams one sheet on top of the other as you go. Sodium - 99 milligrams KAUVERY CAPSULE APRIL 2016 14 WORLD KIDNEY DAY EVENTS

Renal update 2016

WORLD KIDNEY DAY was celebrated with an intention to create awareness among the public on KIDNEY HEALTH and ORGAN DONATION. The sequence of events like 1week Special Camp, Signature campaign, Water bottle campaign, launch of Mobile App, Donor Card, Ka Ka Ka Po notion and Radio Jingles made the program a colossal success. The CME on renal update 2016 was a mega hit, more than 150 doctors participated in the event. Every clinician cherished the quality of the gather and the expertise of the speakers. The donor recipient meet was the pin-up among the kidney day Events. Mr. Visu’s emotional touch on organ donation moved the crowd. ORGAN DONOR MEET 15 APRIL 2016 KAUVERY CAPSULE KAUVERY CAPSULE APRIL 2016 16

WE EXTEND A HEARTY WELCOME TO OUR KAUVERY FAMILY

DR. G. JOS JASPER., MBBS., M.CH (NEURO SURGERY)., HEAD OF THE DEPARTMENT, KAUVERY BRAIN & SPINE CENTRE, CANTONMENT, TRICHY

DR.R.UVARAJ DA.,MD(Anaes).,DM(Cardiac Anaes)., CARDIAC ANAESTHESIOLOGIST HEARTCITY

QUESTION Chronic alcoholic patient with recurrent abdominal pain. Now presented with high grade fever, abdominal pain and toxic symptoms. What is the diagnosis?

Answer the Quiz to Emaill: capsule@kauveryhospital. com or DR. PRAVIN GAVASKAR MBBS., MD(PAED), Whatsapp: 98434 12380 CONSULTANT PAEDIATRICIAN and win Surprize Gift CANTONMENT Please send the answers with your full name and mobile number. The correct answers and winner will be disclosed in the next capsule edition.

DR. K. SATHAPPAN MD(ANAES)., FELLOWSHIP IN CARDIAC ANAESTHESIA Answer for the previous Quiz CONSULTANT CARDIAC ANAESTHESIOLOGIST Hemithorax with traumatic diaphragmatic hernia HEARTCITY with rib fractures.

And the winner is Dr. Sivagnanam Trichy

DR. S. BARANIDHARAN MD(ANAES)., INTENSIVIST-ICU SPECIALITIES-CANTONMENT Daily’s complementing Kauvery’s efforts for organ donation Kidney Stone Removal | Kidney Transplant | Prostate Surgery | Dialysis

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