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Abstracts of Papers Presented at the 118th Research Meeting of The Medical Research Centre of Bombay Hospital (Convenor Dr. HL Dhar)

1. Anaesthetic Management of A Patient with Triple Vessel Disease. Poor left Ventricular Function, Diabetes Mellitus, and Morbid Obesity for Biventricular Pacing with ICD Placement

Gauri Sankhe, Pradnya Kulkarni, DK Baheti

We report this case to highlight the difficulties encountered in conducting anaesthesia for a high risk patient in cardiac catheterization laboratory. Opioid induction is commonly used technique in patients with poor left ventricular function. Opioid induction has demonstrated smooth induction, maintenance. A 46 yr old male with BMI as a V posted for biventricular pacing with ICD. Patient was a case of hypertension, diabetes mellitus. Patient had past history of brainstem stroke in 1998. He was treated for the same and completely recovered. Patient was on antihypertensives, insulin, antiarrhythmics and hypolipidaemic drugs. Patient was refractory to antiarrhythmics and diagnosed to have repeated episodes of ill sustained ventricular tachycardia. He had repeated episodes of pulmonary oedema which needed hospitalization. After preanaesthetic evaluation the patient was taken on table. Angiography was done under local anaesthesia. Immediately patient developed pulmonary oedema. General anaesthesia with controlled ventilation was administered in view of treatment of pulmonary oedema and completion of procedure. Induction was done with opioid and low dosage hypnotic. Maintenance was on TIVA. Ventricular tachycardia and ventricular fibrillations were induced to test ICD. Intra and postoperative period was uneventful. Patient was electively ventilated in the postoperative period for 12 hours. Patient was discharged from ICU after 72 hours and one month follow up showed improved left ventricular function.

2. Pilonidal sinus excision and primary closure

MM Begani, Naresh Row

To show the possibility of local block for pilonidal sinus excision and closure.

With proper cases selection and practice, field block anaesthesia can be used for excision and primary closure of pilonidal sinus. 150 cases of primary and recurrent pilonidal sinus cases operated over a period of 6 years. Use of field block with a combination of 2% lignocaine HCl and 0.5% bupinavacain with IV sedation was done in all cases. Dye sonogram was performed on table with complete excision of all the tracts, followed by primary closure done in two layers.

2 patients had recurrence, where dehiscence of wound and non-healing required repeat surgery. The rest of the patient did not have any untoward complication and retured to normal activity within 48 hours. Excision and primary closure of pilonidal sinus can be safely performed under local field block in trained hands.

3. Congenital Muscular Torticollis - Endoscopic Surgical Correction by Trans-axillary Approach

D Vartak, SR Tambwekar, K Khadalia, VS Tambwekar, R Ginwalla

Congenital muscular torticollis (CMT) results from fibrosis and subsequent shortening of one sternocleidomastoid (SCM) muscle. The exact pathology leading to the contracture is not known. However it may be secondary to trauma or ischaemia which may result in pseudo tumour colli (in the junction of the middle and distal third of the muscle). The primary insult could be birth trauma or an abnormal in-utero head-position or the cause may even be myodysplasia of genetic origin.

Muscular torticollis can cause severe limitations of neck position and, over time, may result in significant craniofacial deformation.

Surgical intervention is done to release, lengthen or excising a segment of the sternocleidomastoid muscle leaving visible scars in the neck which draw attention to the otherwise not-so-significant SCM asymmetry. Two cases have been done by this method.

4. Median Sternotomy Dehiscence : A Multi-Faceted Approach to a Complex Problem

RF Ginwalla, SR Tambwekar, K Khadalia, VS Tambwekar, DN Vartak

The standard approach used to expose the heart, great vessels and mediastinum is via the median sternotomy. With the advances in cardiothoracic surgery in recent years, this incision has become commonplace, as have its concomitant complications, such as wound dehiscence.

All patients who were referred to us had gaping chest wounds with chronic sinuses. Almost all the patients were diabetic, and presented form 1-8 months post-CABG. All diabetics were put on Insulin.

Multiple therapeutic modalities were initiated to help clean up the heavily infected granulation tissue...

We have found that Median Sternotomy Dehiscence is an extremely morbid complication for the patient, who is usually depressed, and physically and financially depleted. A multi-disciplinary step-by-step approach is required, and the patient frequently needs counseling regularly, as a patient, slow-and-steady pre-and-post operative management is what works best.

5. A large lipoma of the thigh operated under LA : Case Report

Niranjan Agarwal, MM Begani

To report a case of large lipoma of the thigh operated under local anaesthesia in a case considered unfit for any other form of anaesthesia. 70 years old male patient presented with a large swelling in the back of his left thigh. Extending from the gluteal fold up to the popliteal fossa. Half encircling the thigh, about 19 x 17 cm since 2 years causing difficulty in walking and sitting. Patient was a known hypertensive with poor cardiac function, fitness for surgery was given only for local anaesthesia. Careful and selective utilization of local anaesthesia can be safely used for cases where general or regional anaesthesia is contraindicated.

6. General surgeries under local anaesthesia

MM Begani, Niranjan Agarwal, Naresh Row

To present retrospective analysis of the increasing spectrum of general surgical cases which can be performed under local anaesthesia. The advent of better anaesthetic agents, it has been possible to perform a large number of cases under local/regional anaesthesia. Many minor and major cases can be easily performed, thus reducing the side effects and risks involved with other types of anaesthesia. Especially if the patient is not fit for any other type of anaesthesia, this method of administering block is very helpful. Over the past 20 years, we have performed more than 15,000 cases. We have evaluated statistics of the past 3 years, which we will be presenting to you. With proper training and experience, a surgeon can perform a large number of cases under local blocks.

 

1. 3-D Conformal Radiation Therapy

SK Bhargava, SS Dagaonkar, Geetika Bisht

With rapid development in computer technology, there are tremendous development in radiation therapy technology for dose delivery and minimizing dose to normal tissues.

To achieve goal of Radiation Therapy - "to cure cancer locally without excessive side effects or toxicity, is to deliver precisely the entire irradiation dose to the target volume and none to the uninvolved normal structures", this new 3-D Conformal Radiation Therapy developed. This 3-D CRT resulted into [1]. Better local tumour control, [2] Reduced Toxicity, [3] Improved survival, [4] overall good quality of Life.

Development of 3-D CRT is attributed to [1]. High Power Computers, [2]. Graphic work stations, [3] wide use of CT Scanners, [4]. Array of tools, [5] Networking . 3-D CRT has got some limitations e.g. It is expensive and needs proper and judicious selection of patients.

We will be discussing these in detail with case planning presentation.

2. Role of Conventional Techniques in Modern Day Radiology

Siddharth Jadhav, DB Modi, Sandip Punamiya, V Salgia

Since the advent of sonography and cross-sectional imaging, conventional radiology has taken a back seat both in the clinical setting and sadly even among radiologists in training. Through the few examples we wish to emphasize the importance of conventional radiology.

The modalities in the armoury of conventional radiology are

Plain radiography, different Urological procedures, Barium and contrast studies, Hysterosalpingography, Sialography etc.

Newer modalities like USG, doppler, CT, MRI and nuclear medicine have added newer dimensions to the field of imaging. Availability and cost are still major obstacles in a country like India. A fair number of cases can be successfully diagnosed by conventional techniques alone. In the rest, they help in triaging of patients for further imaging. In conclusion, even though there are limitations to conventional techniques, they are the most appropriate initial choice of imaging in a fair number of cases even today.

3. CT-Spect Fusion Imaging in The Evaluation of Bone Graft Viability

Siddharth Jadhav, Atul Marwah

Bone graft viability is an important issue in patients who have undergone vascularised bone grafting. Routinely 3-Phase planar bone scintigraphy is performed in evaluation of vascularised bone grafts. SPECT (Single Photon Emission Computed Tomography) bone scan is generally used in patients with maxillo-facial vascularised bone grafts due to better spatial resolution. Anteromedially placed superficial fibular graft showed preserved uptake. There was a photon deficient area in the region of impailed fibular graft with no evidence of uptake in it.

CT-SPECT fusion imaging is one of the latest diagnostic imaging modality.

It can play an important role in the evaluation of bone graft viability as it provides accurate anatomic and physiological details in cases with complex graft anatomy.

We present a case where CT-SPECT fusion imaging has been used to evaluate complex graft anatomy.

4. Calculation of Glenoid Version in Obstetric Brachial Plexus Palsy - A Study of 8 Cases

Anisha Sawkar, Inder Talwar, Sunila Jaggi, Mukund Thatte

In the period between December 2003 and July 2004, 8 cases of obstetric brachial plexus palsy with shoulder deformity were analyzed by CT imaging at the Bombay Hospital Institute of Medical Sciences.

Patients presented with limited abduction and external rotation of the shoulder. The angle of glenoid version and the extent of glenohumeral deformity were calculated based on a method described by Freidman et al. The normal angle of glenoid version is between 0 and 8 degrees and normally 35-50% of the humeral head should be anterior to a line drawn connecting the vertebral border of the scapula and the centre of the glenoid cavity. Keeping these normal values in mind, the extent of glenohumeral deformity was graded from I to VII, in ascending order of severity.

The results of this study were beneficial to the operating surgeon to plan the appropriate surgical modality tailored to the case. The surgical options were a tendon transfer surgery, humeral derotation osteotomy and Open reduction and capsulorrhaphy, depending on the grade of glenohumeral deformity.

To conclude, this study proved a useful guideline to the operating surgeon to decide the most suitable treatment option in cases of obstetric brachial plexus palsy presenting with shoulder deformity.