Vol 2, Issue 7, October 2008

TM

TM trade mark of Wockhardt Hospital Limited. Copyright (c) 2007 Wockhardt Hospital Limited. All right reserved.

Wockhardt Hospitals l Mumbai l Bangalore l Kolkata l Hyderabad l Nagpur l Rajkot l Surat

Dor’s Procedure for Left Ventricular Restoration l Unusual Presentation of a Common Neuro Infection
l Surgical Arthroscopy for Discoid Meniscus l Laproscopic Meckel’s Diverticulum using Endostapler l An Unusual Cause of
INSIDE Dyspnoea following Blood Transfusion l Implant Restorations in Dentistry l Neurology Services at Wockhardt Hospitals
l Management of Movement Disorders l News Room

Dear Doctor,
Greetings from Wockhardt Hospitals!
Your continuous support and feedback has encouraged us to take the concept of ‘The Specialist’ across our centers in India. With this, we are
able to share the skills and achievements of Wockhardt clinicians across the medical fraternity. We have earned numerous accolades in our
clinical expertise across specialties in 2008. We became the first hospital in Karnataka to earn the JCI accreditation for quality health care. The
Center for Joint Replacement at Wockhardt Hospitals, Bangalore has performed over 1000 joint replacements since the inception of the
hospital and its services have now been extended to our Nagarbhavi facility. We have performed some ground breaking work such as the first
lumbar disk replacement, removal of brain tumour through the eyebrow, scoliosis surgery performed by a neurosurgeon, joint replacement
surgery on a metal allergic patient using a titanium nitrate implant, open heart surgery on a 900 gm baby and a double switch operation on a 13
year old girl. Advanced procedures such as endoscopic brain and spine surgeries, awake brain tumour surgery, complex interventional
cardiac procedures and cardiac surgeries (in both adults and children), video assisted thoracic surgeries (VATS) are routinely practiced here.
With your trust in us, we continue to surge ahead with such achievements.
An updated Doctors Directory encompassing a complete listing of our specialist doctors and a brief sketch of each of our specialties and
centers is enclosed for your reference which could be a handy guide for interacting with our specialists. Also a compilation of some of the
selected VATS surgeries conducted at our hospital is attached.
We are sure this will further boost your confidence in the quality and service rendered by Wockhardt Hospitals to your patients.
Best wishes

Dr. Lloyd Nazareth

COO – Wockhardt Hospitals

D or’s Procedure for Left Ventricular

Restoration

A 60 year old gentleman

presented to the hospital
with history of progressive
breathlessness now in NHYA III/ IV.
him revealed a triple vessel coronary
artery disease and a left ventricular
injection confirmed the left
ventricular aneurysm.
Although, he required an IABP and

He had a previous history of an 01

anterior wall MI around three years
ago. There was no significant past
history. An echocardiogram
revealed a left ventricular apical
aneurysm with clots and an EF of
30%. A coronary angiogram done on
Surgery was advised and he
underwent a coronary artery bypass
grafting and left ventricular
reconstruction procedure (Dor’s
Procedure). Pre-operative LV angiogram

Post-operative LV angiogram
inotropes his post-operative stay in
the ICU was uneventful in which he
was weaned of the IABP and
inotropes and shifted to the ward on
the 3rd post-operative day and was
discharged from the hospital on the
7th post-operative day.
Discussion
Left ventricular aneurysm is a bulge
or ballooning of the weakened heart
muscle. When the patient has a heart
attack, blood flow to the muscles of
the heart is reduced. Part of the
muscles of the heart die during the
process and healing takes place with
formation of a scar where the heart
muscle dies. Sometimes the scar
tissue becomes thin and bulges out of
the heart muscle causing a left
ventricular aneurysm. Not all
patients with a scar develop a
aneurysm. Up to 25% of people with a
U nusual Presentation of a
Common Neuro Infection
M
rs. Sudha (name
02 changed) presented to us
with history of headache
and binocular diplopia of three
weeks duration. The headache was
predominantly in the region of vertex
aching, continuous and severe in
The Dor’s procedure is one
of the complex procedures
available for management
of such aneurysm
large area of heart muscle death from
a heart attack develop aneurysms.
The aneurysms range from very
small (thumbnail size) to huge
(doubling the size of the heart).
Aneurysms usually form and get
bigger during the first few months
after a heart attack.
The aneurysm causes progressive left
ventricular dysfunction. The scar
tissue is more prone for arrythmias
and over a period of time the normal
left ventricle also shows sign of
dysfunction with chances of
development of mitral insufficiency.
Clots may form in the aneurysm with
increased incidence of dislodgement
of the clots and carried away by the
blood streams to cause strokes and
organ damage.
The Dor’s procedure is one of the
complex procedures available for
management of such aneurysm. The
whole aim of the procedure is to
restore left ventricular geometry,
exclude the infracted septum, resect
the scarred arrytmogenic scarred
intensity. She was treated for pan
sinusitis with little relief. Examination
revealed right 6th nerve palsy with
subtle impairment of sensation in
right ophthalmic branch of
trigeminal nerve; possibility of
Gradenigo’s Syndrome was
ventricular tissue and revascularise
the heart with a bypass surgery.
Overall five-year survival after the
Dor’s operation is 69%. The pre-
operative left ventricular end-systolic
volume index (LVESVI) is a critical
measurement in planning the Dor’s
operation. Patients with symptoms
of heart failure but LVESVI
<60 ml/m2 should not undergo ventri-
cular remodeling, as ventricular size
may become too small.
In contrast, patients with
preoperative LVESVI >100 ml/m2
have a poor long-term outcome from
bypass alone, and the Dor’s
procedure is indicated. These
patients have been shown to have an
increased survival.
Patients with preoperative LVESVI
<80 ml/m2 have, however, a five-year
survival of 79%. This value decreases,
however, to 72% and 67% for patients
with LVESVI between 80–120 ml/m2,
and greater than 120 ml/m 2
respectively.
Dr. Ganeshkrishnan K.T. Iyer
MS, M.Ch
Consultant Cardiothoracic
Surgeon
HEART CARE
considered and she was evaluated
accordingly.
Investigations revealed fasting and
postprandial hyperglycemia with
elevated ESR. MRI of brain revealed
features suggestive of right petrous
apex osteomyelitis and edema
retropharyngeal muscles. ENT
evaluation was normal; but nasal
endoscopy revealed mucopus
dripping from superior meatus on the
right side. Culture of the mucopus
revealed gram positive cocci. He was
treated with intravenous cefriaxone
for 10 days. Fungal etiology was ruled
out with appropriate investigation.
Despite the treatment, headache and
diplopia persisted. LP was done and
CSF analysis revealed 600 cells with
predominantly lymphocytic
pleocytosis, elevated protein and low
sugar. CSF PCR for myco TB was
positive. He was started on ATT.
After the introduction of ATT,
headache intensity showed
remarkable improvement. Over the
next seven days, diplopia
disappeared and euglycemia could
be achieved. Final diagnosis
considered was tuberculous
meningitis with apical petrositis and
diabetes mellitus. This case illustrates
a relatively rare presentation
(Gradenigo’s Syndrome) of a
S urgical Arthroscopy for
Discoid Meniscus
A 17 year old boy presented to
our office with complaints of
a painful limb for the past 6
months and an inability to straighten
out the left leg. Patient and his father
denied any history of trauma. There
was no history of fever, pain or
stiffness in any other joints. The boy
complained that his sporting
activities were restricted and that
quite often he heard clicks from the
left knee.
LP was done and CSF
analysis revealed 600
cells with predominantly
lymphatic pleocytosis,
elevated protein and low
sugar. CSF PCR for myco
TB was positive.
common neuro infection
(tuberculous meningitis). It also
teaches us the value of keeping an
open mind about various
possibilities.
Gradenigo’s Syndrome consists of
three components, otitis media, pain
in the distribution of 1st and 2nd
division of trigeminal nerve and
ipilateral abducent nerve palsy. This
syndrome was named after Giuseppe
Conte Gradenigo, an Italian
otolaryngologist. Chronic
suppurative otitis media is commonly
associated with this syndrome.
However, Gradenigo’s syndrome
can also arise due to any lesion
affecting apex of petrous bone can
cause cranial nerve dysfunction.
Physical examination revealed flexion
deformity of 20 degrees, mild effusion,
range of motion 20-140 with pain in
terminal part of flexion, anterolateral
joint line tenderness, quadriceps
wasting. McMurray’s test was equivocal
and Springer’s test was positive.
On ranging the joint a palpable thud
could be elicited. X-rays were non
contributory. Magnetic Resonance
Imaging (MRI) done, revealed a
Discoid lateral meniscus.
Extradural abscess or
pachymeningitis overlying the
petrous apex without petrositis per se
can also present as this syndrome.
Phlebitis from lateral sinus spreading
along the inferior petrosal sinus can
also produce this. The above case
illustrates that patients still
occasionally present with petrous
apicitis and the clinician needs to be
aware of the conditions presenting
features to prevent possible life
threatening complications.
Dr. C. Udaya Shankar
DM
Consultant Neurologist
Dr. Chandran Gnanamuthu
MD, DM, FIAN, FAAN
Consultant Neurologist
Department of Neurology
BRAIN & SPINE CARE
Dr. Sheelu Srinivas
M.S (ENT), DLO, RCS
(London)
Consultant ENT Surgeon
DEPARTMENT OF ENT
Patient underwent surgical
arthroscopy of the left knee and a
torn discoid meniscus entrapped in
the intercondylar notch was seen. It
was decided to proceed with subtotal
menisectomy (leaving the peripheral
rim) considering the age of the
03
patient. Subtotal menisectomy was
carried as there are high chances of
meniscus regeneration following
subtotal menisectomy. Post-operative
course was uncomplicated although
 patient still had a flexion deformity of
10 degrees.
Patient was placed on protected
weight bearing with use of a night
time knee extension brace. Patient
recovered completely without any
residual deformity.
Discussion
Discoid lateral menisci were first
described in the late 1800s. The
normal configuration of a meniscus is
that of a matured crescent moon,
Fig. 1: MRI Saggital image showing
Discoid Lateral Meniscus
Fig. 3: Arthroscopic appearance of Discoid Meniscus
Fig. 4: Following subtotal Menisectomy
04
whereas that of a discoid meniscus
generally is a thickened, very early
crescent moon. Variations of this Surgical treatment
general shape occur relatively rarely, varies according to
and occasionally, the lunar
the type of lateral
appearance is also found in the
discoid meniscus.
medial meniscus. The discoid shape
results in a membrane barrier that
Arthroscopic
prevents normal contact between the procedures are quite
articular surfaces of the knee and has successful and are
a high incidence of mechanical somewhat more
deformation. technically demanding
Discoid lateral menisci have been
than are routine
reported to occur at the rate of 1.5-3% meniscal tear excisions
because of the
younger age, tighter
Fig. 2: MRI Coronal image showing
Discoid Lateral Meniscus
joints, and less room
available to manipulate
arthroscopic
equipment.
in the general population, whereas
discoid medial menisci have been
reported to occur at the rate of 0.1-0.3%
(Ryu, 1998). The Asian population
has a slightly higher rate of
occurrence; Tokyo's Teishin hospital
reported 16.6% of all knees examined
arthroscopically had a discoid lateral
meniscus (Ikeuchi, 1982).
A discoid lateral meniscus results
from a developmental anomaly
before birth. After birth, no sudden
change occurs in meniscal
development (Clark, 1983). Two
distinct types of discoid lateral
meniscus exist. One is the hyper
mobile, or Wrisberg lateral meniscus,
and the other is a discoid form of an
otherwise normal lateral meniscus.
Both types present unique
pathophysiologic problems.
The Wrisberg type lacks an
attachment to stabilise the posterior
horn to the tibia. It may also be of
normal shape rather than discoid.
The only attachment of the posterior
horn is to the Wrisberg or
meniscofemoral ligament. The
general configuration produces an
unstable or hyper mobile lateral
meniscus.
Surgical treatment varies according to
the type of lateral discoid meniscus.
Arthroscopic procedures are quite
successful and are somewhat more
technically demanding than are
routine meniscal tear excisions
because of the younger age, tighter
joints, and less room available to
manipulate arthroscopic equipment.
Surgical techniques vary, from
sculpting and partial meniscectomy
to complete removal, starting with
removal of the anterior portion for
better arthroscopic visualisation
(Smith, 1999; Ogata, 1997).
L aproscopic Meckel’s Diverticulum
Using Endostapler
M eckel’s diverticulum is a
rare congenital disorder
that was first described
about 400 years ago. Diagnosis is
rarely made pre-operatively as there
may be no symptoms.
The incidence of Meckel’s
diverticulum is rare. A memory aid is
the rule of 2's: 2% (of the population) -
2 feet (from the ileocecal valve) - 2
inches (in length) - 2% are
symptomatic, there are 2 types of
common ectopic tissue (gastric and
pancreatic), the most common age at
clinical presentation is 2, and males
are 2 times as likely to be affected.
Meckel’s diverticulum is located in
the distal ileum, usually within about
60-100 cm of the ileocecal valve. It is
typically 3-5 cm long, runs
antimesenterically and has its own
blood supply. It is a remnant of the
connection from the umbilical cord
to the small intestine present during
embryonic development. The most
Because of the hyper mobility of the
entire meniscus in the Wrisberg (type
III) deformity, sculpting the meniscus
is ineffective, and better results have
been reported with a near-complete
to complete meniscectomy. Using
the Watanabe classification, the
indicated treatment for tears of
discoid meniscus type I (complete),
type II (incomplete), and the central-
holed or ring-shaped version is
removal of the central discoid and
ring portions, including any areas of
tearing, followed by arthroscopic
sculpting of the remaining meniscus
(Monllau, 1998).
common presenting symptom is
painless rectal bleeding, followed by
intestinal obstruction, volvulus and
intussusception. Occasionally,
Meckel's diverticulitis may present
with all the features of acute
appendicitis. Also, severe pain in the
upper abdomen is experienced by
the patient along with bloating of the
stomach region. At times, the
symptoms are so painful such that
they may cause sleepless nights with
extreme pain in the abdominal area.
It can also be present as an indirect
hernia, where it is known as a "Hernia
of Littre". Approximately 98% of
people afflicted with Meckel’s
diverticulum are asymptomatic. If
symptoms do occur, they typically
appear before the age of two.
If there is more time (not an
emergency situation), the best way to
diagnose Meckel's diverticulum is by
Technetium-99m (99mTc)
pertechnetate scan. This scan detects
Dr. Gautam Kodikal
M.S. (Orthopedics)
Consultant Orthopedic Surgeon
Dr Ashish Anand
M.S. (Orthopedics),
DNB, MNAMS
Fellowship - Arthroscopic Surgery
and Sports Medicine (USA)
BONE & JOINT CARE
gastric mucosa; since approximately
50% of symptomatic Meckel’s
diverticula have ectopic gastric
(stomach) cells contained within
them. This is displayed as a spot on
the scan distant from the stomach
itself. Patients with these misplaced
gastric cells may experience peptic
ulcers as a consequence. Patients
presenting with bleeding are to be
investigated by colonoscopy and
screenings for bleeding disorders
should be performed, and
angiography can assist in
determining the location and severity
of bleeding.
Diagnosis with obstruction is big
challenge and CT scan and
ultrasound may not aid in the right
diagnosis. Diagnostic laparoscopy,
however, is the most accurate
05
diagnostic tool. We present a case of
small bowel obstruction due to
Meckel’s diverticulum causing small
bowel obstruction, managed by
laparoscopic surgery.
 Case Report
A 28 year old boy presented to other
medical centre with abdominal pain
and treated as gastroenteritis. Patient
was transferred to our centre for
further management. Physical
examination showed tenderness in
the vicinity of the umbilicus. On
auscultation, high pitched bowel
sounds were heard and a diagnosis of
bowel obstruction was made.
Radiograph of the abdomen was
suggestive of small bowel
obstruction. A CT scan confirmed
dilated small bowel loops and cause
of obstruction was inconclusive.
Diagnostic laparoscopy was carried
out and found to have dilated small
bowel and constricted small bowel
and a band found to be causing this
obstruction which was divided. Later
examination showed this band to be
connected with Meckel’s
diverticulum and laparoscopic
Meckel’s dicetriculectomy was
carried out using endostapler
(Endoscopic Articulating Linear
Cutter, size 45 mm). The diverti-
culum was resected off the ileum and
the specimen was delivered through
the enlarged 12 mm umbilical port
with the use of an endobag. The
Meckle’s diverticulum with band
Diveriticulectomy done by
endostapler
06
A patient with an acute abdomen presents
a situation where the advantages and benefits of
minimal-access surgery can be truly appreciated. Acute
abdomen may be caused by acquired or congenital
conditions, for which minimal-access techniques
provide both the diagnosis and therapy, and a formal
laparotomy can be arrived.
patient was allowed liquids orally on the diagnosis of Meckel’s
the same evening and was discharged diverticulum but despite the
on the second day. availability of modern imaging
techniques, the diagnosis is
Discussion challenging. Laparoscopy is more
useful in this situation.
Meckel’s diverticulum is the most
common form of congenital A patient with an acute abdomen
abnormality of the small intestine, presents a situation where the
resulting from an incomplete advantages and benefits of minimal-
obliteration of the vitelline duct. access surgery can be truly
Although originally described by appreciated. Acute abdomen may be
Fabricius Hildanus in 1598, it is caused by acquired or congenital
named after Johann Friedrich Meckel, conditions, for which minimal-access
who established its embryonical origin techniques provide both the diagnosis
between 1808 and 1820. The tip of the and therapy.
diverticulum is free in 75% of cases,
and in 25% of the cases the tip is Management of Meckel’s
attached to another organ or structure diverticulum in asymptomatic patients
by means of a band like in our case. is controversial. Excision is mandatory
Most patients are asymptomatic, and it for all symptomatic diverticuli. With
is usually an incidental finding when a the advent of gastrointestinal stapling
barium study or laparotomy is devices, excision has become safer,
performed for other abdominal faster and more efficient. Another
conditions. Complications include advantage of stapling is that it closes
bowel obstruction (35%), the bowel lumen as it cuts, thereby
haemorrhage (32%), diverticulitis completely reducing the chance of
(22%), umbilical fistula (10%), contamination.
perforation (5%), other umbilical Laparoscopy has a definite role in
lesions (1%) and intussusception. bowel obstruction, where there is
Meckel’s diverticulitis may mimic dilemma in diagnosis inspite of
appendicitis. modern imaging techniques.
The correct diagnosis is usually Laparoscopy confirms the diagnosis
established at the laparotomy or and most of the surgical pathology
laparoscopy. None of the clinical involving small and large bowel can
be treated in the same sitting in a
features are pathognomonic, and the
specialised centre.
diagnosis is rarely made pre-
operatively. Routine laboratory
studies, such as leukocyte and Dr. Shabeer Ahmed,
erythrocyte counts, serum electro- MS, FRCS (U.K.), MMAS
lytes, blood glucose and urea, serum (Masters in Minimal Access
creatinine and coagulation screen are Surgery)
helpful in the general work-up. These Consultant - General/
Gastrointestinal/
tests will show evidence of acute
Laparoscopic Surgeon
infection. Computed tomography and
DIGESTIVE CARE
ultrasonography have been used for
 A n Unusual Cause of Dyspnoea
Following Blood Transfusion
A 22 year old lady presented
with a history of 6 weeks of
pregnancy with severe
abdominal pain and shock to a
nursing home, where she was
resuscitated for hypovolemic shock.
A TVS (Trans Vaginal Sonogram)
revealed a haemoperitonium and a
left tubal ectopic pregnancy, and an
emergency exploratory laparotomy
was done. This showed a left sided
tubal ectopic with a
haemoperitonium of 1.5 litres. Left
salpingectomy and peritoneal
toileting was done. In the post-
operative period three units of
O-negative blood was transfused.
Shortly after blood transfusion, the
patient had mild abdominal
distension with poor bowel sounds
and became hypoxic. She required
10 units of oxygen per minute to
maintain saturation. A chest x-ray
done at that time showed bilateral
haziness of lung fields (Fig 1). The
Fig. 1: Bilateral diffuse infiltrates
at presentation
rest of the blood parameters were
within normal limits. A provisional
diagnosis of ARDS secondary to
hypovolemic shock and blood
transfusion was made and patient was
shifted to Wockhardt Hospital for
further management.
On admission, the patient was febrile,
tachypnoeic, severely hypoxic but
hemodynamically stable. Chest x-ray
showed bilateral patchy alveolar
opacities consistent with features of
ARDS. Arterial blood gas showed
features consistent with 'acute lung
injury, or ARDS.' Appropriate
supplemental oxygen was provided
and diuretics were also administered.
Antibiotics were also started along
with D.V.T. prophylaxis.
In view of the temporal relationship
of blood transfusion with acute lung
injury, the patient was diagnosed to
have 'Transfusion Related Acute
Lung Injury (TRALI).' The criteria
set forth by the American and
Canadian panels are considered
sufficient to establish the diagnosis.
The basis of diagnosing the patient as
TRALI was based on the following:
Criteria for TRALI
1) No acute lung injury (ALI)
immediately before transfusion
2) New ALI
3) Onset of signs/ symptoms of ALI
during or within 6 hours after the
end of transfusion of one or more
plasma-containing blood
products
4) No temporal relationship to an
alternative risk factor for ALI
With supportive treatment, the
patient improved significantly in the
next forty-eight hours, with rapid
clinical and radiological
improvement (Fig 2), and was shifted
out of medical ICU. Following
recovery patient was discharged
from the hospital in stable condition,
with no sequelae of lung injury.
Fig. 2: Complete resolution
of the infiltrates
Discussion
The incidence of TRALI is not well
established. Ambiguity regarding the
definition of this syndrome, under-
recognition of the syndrome as a
clinical entity by physicians, and
failure to identify milder cases that do
not require therapeutic intervention
each contribute to this problem.
However, using the NHLBI
definition of TRALI, the incidence of
TRALI is estimated to be one case for
every 1000 to 2400 units transfused.
This incidence estimate of 0.04 to 0.1
percent is comparable to other
estimates from previous studies that
used older case definitions.
These cases as underreported are
often misdiagnosed and mistreated
due to their presentation. TRALI is
the leading cause of transfusion-
related mortality in the United States.
There is not much Indian data
available. The estimated mortality
rate for recognised TRALI is 5 to 8
percent. However, most survivors
07
recover completely with appropriate
supportive care and can receive
additional blood products in the
future. Management of the patient
with TRALI is supportive, with the
 expectation that clinical
improvement will occur
spontaneously as lung injury
resolves. Mechanical ventilation is
sometimes required for several days,
and a high concentration of inspired
oxygen and positive end-expiratory
pressure may be required. Milder
cases can be managed with
supplemental oxygen alone. Such
cases often are misdiagnosed and
difficult to treat unless appropriately
approached.
Highlights
1. TRALI can be a serious
complication of a routine
procedure such as blood
transfusion. No transfusion is safe,
DENTISTRY
I mplant Restorations
in Dentistry
Introduction
Gone are the days when missing
teeth had to be replaced by only a
removable partial denture, which in
most cases is uncomfortable and
inconvenient, or by a bridge wherein
healthy tooth structure of
neighbouring teeth are compromised
to be able to act as supporting
structures for the missing tooth
crown.
The latest and highly effective
method of replacing the lost teeth is
by the placement of dental implants.
The dental implant body placed in
08 the jaw replaces the root structure
and this is restored with a crown. The
advantage in this type of restoration is
that the neighboring teeth are not
touched and it is as good as the
natural teeth in functionality. Also it
until the risks are worth the
benefits.
2. This complication can be seen
across all branches of
medicine. Awareness and
early recognition are major
steps towards appropriate
treatment.
3. A l t h o u g h a s e r i o u s
complication, it is a treatable
condition provided diagnosed
early.
4. The gross similarity with
other diseases can often make it
difficult to diagnose as no specific
tests for diagnosis are present.
being a fixed permanent structure,
there is no need for dealing with its
removal and replacement. It also
provides a very natural looking tooth.
Implant bodies are made out of
titanium. They are taken up very well
by the body and least amount of
rejection is seen. This, of course,
being the case when all other factors
are favourable.
The situations when the implant
cases are not conducive to placement
is when the patient has an immuno-
compromised disease, is a bruxer
(grinds/ clenches teeth), has severely
compromised periodontal
conditions. Upkeep of implants is
similar to regular teeth – brush and
floss regularly, avoid any excessive
forceful loads – by way of chewing or
abrasional habits.
Dr. Anu Sridhar
MD
Consultant Obstetrician &
Gynaecologist
WOMAN CARE
Dr. Ravindra M. Mehta
MD, FCCP, American Board
Certified Critical Care
Medicine, Pulmonary
Medicine, Sleep Disorder
Medicine, Internal Medicine
Head of Critical Care,
Consultant Chest Physician and
Interventional Pulmonologist
DEPARTMENT OF
CRITICAL CARE
Case: A case of a lady who had a
root canal treated tooth with a crown
was presented. The tooth eventually
broke and the crown kept coming off.
Upon viewing the x-ray it was seen that
the tooth had fractured along the gum
line and hence did not have adequate
tooth structure to support it.
The treatment planned out was
extraction of the remaining portion of
the tooth and an immediate placement
of the dental implant into the
extraction site. She was then given a
partial denture to wear for the interim
healing period of 4 weeks and
subsequently the tooth was restored
with a crown. The advantage in this
was that her neighbouring teeth were
not touched and she received a
permanent fixed prosthesis which
looks and functions like a natural
tooth.
 Discussion
The placement of the implant
requires a good amount of pre-
surgical planning. We look at dental
orthopantomograms (OPG) to assess
the available bone density and quality
to determine the kind and length of
implant to be used, its proximity to
vital structures, etc. Diagnostic casts
are prepared to assess the clearance
available and any para-normal
functional stresses the implant may
encounter upon functionality.
Next a pre-surgical stent is prepared
to aid in the exact location of the
placement as well as the angulation
of the implant. We then plan out the
healing prosthesis that is placed in
the mouth at the time of surgery
which the patient will go back home
with during the healing period. At
the time of surgery we advocate the
flapless entry in most instances, to
Neurology Services
T he Neurology division at
Wockhardt Hospitals has
been a key and integral part
of the multi-specialty services offered
by this tertiary level care hospital,
ever since its inception in 2006.
The Neurology division now sees an
average of 500 patients every month
in the outpatient clinic (both direct
and cross-referrals) and around 50
inpatient admissions are cared for
every month.
The hospital offers unique strengths
in the management of movement
disorders, stroke, epilepsy, neuro-
muscular diseases, neuro-infections,
demyelinating disorders, etc.
The Critical Care team works closely
with Neurology to provide optimal
care in the management of acute and
critical neurological problems such
as Guillain Barre Syndrome,
Myasthenic crisis, Status epilepticus,
make the surgical site as clean and
bloodless as possible, hence most of
Pre-operative Picture
Post-operative Picture
at Wockhardt Hospitals
Meningo-encephalitis, Coma of
various etiologies, etc.
The hospital has invested in the most
advanced technology in this field so
as to provide a complete and
comprehensive solution to the
patients with neurological disorders –
• 1.5 Telsa MRI supported by
functional imaging and contrast
free angiography
• High speed 64 Slice CT Scan for
volume imaging and
3-dimensional viewing
• Neuronavigation system assisted
operating rooms EEG/ ENMG
• 12 bed Neuro ICU and rehab
• Video assisted endoscopic
techniques
The diagnostic facilities for
move-ment disorders have been
expanded, with the application of
clinical scales, and video
documentation. This allows critical
the times not necessitating sutures.
Again the mode of anesthesia is just
local block or even deep infiltrations
which provide a comfortable level of
painlessness during the procedure.
The post-operative recovery too is
relatively devoid of any discomfort.
Although the patient is put on a
course of antibiotics for a week, and
most often need just a mild analgesic
for a couple of days.
Dr. Sandhya Ramanujam
DDS (USA), BDS (India),
CBM (USA), CDA (USA),
PGDMLE
Consultant - Dental Surgeon
Implantology and Aesthetic
Dentistry,
DEPARTMENT OF
DENTISTRY
evaluation of patients for more
advanced therapies such as deep
brain stimulation which is likely to be
made available shortly. The
diagnostic services would be further
extended for epilepsy, especially
long-term EEG monitoring. A small
group of patients have been worked
up for possible vagal nerve
stimulation for long-term
management of intractable epilepsy.
Also interventional neuro-radiology
and endovascular neurosurgery,
along with neuro-rehabilitation, to
complement an advanced stroke
programme are planned.
At Wockhardt Hospitals there are
two seats every year for Fellowship 09
Training in Neurology, under the
Rajiv Gandhi University for Health
Sciences. The course is for
18 months, starting in January
2009. For more information, please
call: 080 6621 4028 or email us at
kusuma.harinarayan@wockhardt
hospitals.com
 Management of
Movement
Disorders
M ovement is mediated
through the pyramidal
system, the basal ganglia
and the cerebellum in the brain.
These are discrete parts of the brain
which perform specific but different
functions, which are wired to each
other for the performance of normal
movement.
The movement disorders are a
diverse group of pathologic
dysfunctions in the nervous system,
giving rise to any of these: an
abnormal movement, a paucity of
movement, an abnormality of muscle
tone or a disturbance in postural
reflex.
The common movement disorders
are Tremors, Chorea, Parkinson's
disease, Dystonia and Writer's
cramp.
Investigation
The patient gives a detailed history of
what has been occurring in terms of
the symptoms. The investigation is
followed by a neurological physical
examination. Scales are used
(basically written proformas) to assess
the severity and type of movement
disorder. Various movement
sequences are recorded on video as a
baseline before any treatment, to later
compare the patient's performance in
specific functions.
This is followed by basic bloods tests,
a CT/ MRI brain scan and EEG or
10
The Department of Neurology at Wockhardt Hospitals
Dr. Chandran Gnanamuthu
MD, DM, FIAN, FAAN
Consultant Neurologist
EMG along with some specific tests
that may be needed, depending on
the diagnostic possibilities that the
physician is thinking of.
Treatment
1) Medications: Medications that
either stimulate or inhibit the specific
receptors for central nervous system
chemicals (neurotransmitters) are the
mainstay of management of
movement disorders.
2) Botulinum toxin injection: This
toxin is injected into muscles to
partially paralyse them, and thereby
control the abnormal movement.
Several sites are injected in one
sitting, and several such sessions may
be required at 4 week intervals.
3) Stereotactic surgery: After
detailed visualisation using CT/ MRI
and mapping the brain, ablation
(destruction) of certain parts of the
brain nuclei and/ or its circuits will
generally give relief from the
abnormal movement.
4) Deep brain stimulation: The
position of the basal ganglia nuclei
are identified using CT/ MRI brain
scans. Electrodes are placed onto
specific brain nuclei and electrical
signals are sent from a generator
placed under the skin, in the chest.
The patient has the option of
controlling the current from the
generator, for symptom relief.
Dr. C. Udaya Shankar
DM
Consultant Neurologist
Specific Medical Concerns
The first task of the physician is to
arrive at a diagnosis, or a highly
probable diagnosis, using various
lines of investigation.
The best line of treatment: Each
patient would need to be tried on a
specific combination of drugs which
may vary from 1 to 3 months, to
assess the best outcome with drug
management. Following this minor
adjustment in drug dosages may be
required once every three months.
Likely outcomes: It is usually
expected that the abnormal
movement decreases to a remarkable
extent. If the problem had been one
of rigidity and paucity of movement,
then movements should be more
easily performed. A small sub-set of
patients are not likely to improve on
medications, for which deep brain
stimulation or Stereotactic surgery
should be considered to give optimal
relief.
Movement disorders are generally
progressive degenerative disorders,
which means that the pathological
course cannot be greatly altered,
though significant improvement in
function can be provided.
However, the goal of management is
to provide optimal relief and restore
normal functionality, with the least
side effects and thereby significantly
improve quality of life for the
patient.
Dr. Vijay Chockan
PhD (Neuro Sciences)
Specialist in Movement Disorder
Consultant Neurophysiologist
 News Room
Wockhardt Hospitals
achieves JCI accreditation
First in the region to get the
coveted gold seal of quality
healthcare
Wockhardt
Hospitals,
Bangalore has
become the first
super specialty
hospital in
Karnataka to
achieve accreditation from Joint
Commission International (JCI),
USA. JCI is the gold standard in
global healthcare quality standards
and the global leader in healthcare
accreditation having accredited 140
hospitals in 27 countries. Wockhardt
Hospitals, Bangalore now joins an
exclusive group of super specialty
hospitals worldwide, which have
passed JCI’s stringent healthcare
quality standards.
Live Surgery—
Video Assisted Thoracic
Surgery (VATS)
A team ofexperienced cardiothoracic
surgeons supported by advanced
laparoscopic surgeons at Wockhardt
Hospitals, Bangalore conducted a
live video assisted thoracic surgery.
This was attended by the leading
chest physicians, pulmonologists and
cardiologists of Karnataka.
Dr. Vivek Jawali, Chief
Cardiothoracic surgeon, along with
Dr. Shabeer Ahmed, GI and Minimal
Access Surgeon at Wockhardt
Hospitals conducted this live surgery
on two patients suffering from
tumour in the chest, and
hyperhydrosis (excessive sweating of
the hands, face, arm pits and feet).
Girl undergoes series
of surgeries to put arteries
in right place
A 13-year-old girl from Coorg went
through a series of surgeries to
correct the wrong positioning of
ventricles and arteries in her heart.
Congenital cardiac defects of this
nature, called congenitally corrected
transposition of the great arteries,
affects not more than one per cent of
children born with heart problems.
She also had situs inversus, which
means all her organs are positioned
on the opposite side, including the
heart.
In the latest and the most
complicated surgery conducted by
Dr. N.S. Devananda, Consultant
Cardio Vascular Surgeon, this
second child of a farmer couple
underwent the double switch
operation after left ventricular
‘retraining’ at Wockhardt Hospitals.
That has set right the anomalies in the
circulation in her body.
Wockhardt brings cheer to
the life of Goan children
with heart defect
In the past one year, there has been
significant rise in the awareness about
congenital heart diseases among the
general public in Goa. This trend
started after Wockhardt Hospitals,
Bangalore, launched its health
education drive last year targeting
healthcare professionals and the
general public in Goa.
Wockhardt Hospitals’ special focus
on Goa has helped identify and treat
children born with congenital heart
defects. For a Goan, the best of
cardiothoracic surgery from
Wockhardt Hospitals has come
within reach because of the
government’s proactive healthcare
scheme, MEDICLAIM.
Heart Valve; Why Replace?
When You Can Repair
In a press
conference
h e l d i n
Bangalore,
Dr. Ganesh
Krishnan Iyer
states that
repairing rather than replacing a
patient's mitral valve yields
significant benefits including shorter
hospital stays, lower patient risk,
improved durability, and lower
complications and death rates. Heart
valve dysfunctions such as stenosis
and regurgitation of the aortic, mitral, 11
and tricuspid valves may require
repair or replacement of the diseased
valve.
Major technical and technological
advances in the treatment of valvular

heart disease have fueled global
trends toward minimisation of
morbidity through more natural and
less traumatic approaches to surgery.
Long-term results have demonstrated
significant benefits for patients
undergoing valve repair when
compared to patients having valve
replacement. Since the need for long-
term anticoagulation is avoided,
these benefits primarily mean
increased freedom from valve-
related complications such as
thromboembolism and major
bleeding episodes, and death.
World Heart Day awareness
campaign
On the occasion of the world heart
day (September 28, 2008),
Wockhardt Hospitals, Nagarbhavi,
Rajajinagar, Cunnigham and
Bannerghatta Road flagged-off an
awareness campaign “listen to your
heart”. The campaign was launched
by Mr Narendra Babu, MLA of
Rajajinagar by taking a pledge to give
30 minutes of his time every day to
take care of his heart. The theme of
this world heart day being “Know
12
Cunningham Road.
Tel: 91-80-4199 4444/ 2226 1037
Email: care@wockhardthospitals.com Visit us: www.wockhardthospitals.net
We look forward to hearing from you. Send in your views and
suggestions to thespecialist@wockhardthospitals.com
News Room
your risk”, the objective of the
campaign was to educate people
about their heart risk, by providing
tips for a healthy heart, know
symptoms, calculate risk analysis and
understand basic emergency steps
during heart emergency. Such
initiatives of community centers like
Wockhardt Hospitals, Rajajinagar
and Nagarbhavi had a mass appeal
impacting many localites and senior
citizens in and around Rajajinagar
and Nagarbhavi. Further,
propagating the theme, Wockhardt
Hospitals have gone ahead sending
posters, booklets, emails and sms to
corporates and public across
Karnataka.
Five surgeries in four years
Pediatric Heart Surgeons at
Wockhardt Hospitals led by Dr.
Devananda N. S., Cardiovascular
Surgeon at Wockhardt Hospitals,
Bangalore added another feather to
their cap by successfully operating a
little girl three times in four years to
rectify her congenital heart problem.
Akanksha, who underwent all three
surgeries successfully, was born with
a rare and highly complex heart
problem. She had a single pumping
chamber (ventricle) with complete
obstruction to the blood flow in the
main blood vessel of the body (aortic
interruption). On 21st December
2004, Akanksha, who was around
one month old then underwent her
first open heart surgery. The
obstructed tube was cleared of
obstruction and the blood flow to the
Bannerghatta Road. Rajajinagar.
Tel: 91-80-6621 4444/ 2254 4444 Tel: 91-80-2300 4444
lungs was restricted by banding the
pulmonary artery. Dr. Devananda
and his team performed the second
open heart surgery on her on 1st April
2006. The restrictive hole was
widened, the blood vessel from the
heart to the lung was disconnected
from the heart - a Glenn Shunt was
performed. On 31st July 2008 she
underwent the final open heart
surgery wherein repair of the
aneurysm of the ventricle and a
Fontan operation were successfully
done. She recovered well after the
third surgery and was discharged
from hospital in August 2008.
Launch of CJR at
Nagarbhavi
Printers: EXCEL GRAPHICS, Nov 2005
World renowned orthopedic
surgeon Dr. Andrew Cobb, with Dr.
Sanjay Pai and team comprising of
Dr. Vasudev Prabhu, Dr. J V
Srinivas, Dr Ashish Anand
performed a live demonstration of
Hip Replacement surgery at
Wockhardt Hospitals, Nagarbhavi.
Dr. Cobb designed the first Hip
Implant years ago for De Puy
Company. This was the tate-of-the-art
Center’s first initiative for Joint
Replacement. It offers
comprehensive service and provides
diagnosis, management and
rehabilitation under one roof at an
affordable cost. The Center for Joint
Replacement at Wockhardt
Hospitals, Bone & Joint care has
successfully conducted over 1000
joint replacement surgeries from the
time of its inception.
Nagarbhavi
Tel: 91-80-2301 4444