Vol 1, Issue 4, December 2007

Wockhardt Hospitals - Mumbai
Bangalore
Kolkata
Hyderabad
Nagpur
Rajkot
Surat

Microlumbar disectomy in the treatment of disc prolapse
Role of Mega Prosthesis in Joint Reconstruction with Traumatic Bone Loss

I n sid e
Case series of effectivity of dual modality therapy in myasthenic crisis
Dentigerous Cyst Removal
Localised giant
pseudopolyposis in ulcerative colitis
News Room

Dear doctor,

T hird time Coronary Artery

Bypass operation We have got an excellent response
for the past three issues of
‘The Specialist’. In this issue, we
have some interesting case studies

T
he increasing number of re-
operative CABG procedures
is primarily due to
progressive atherosclerosis
within the saphenous vein grafts and
native coronary arteries in patients
who have undergone a CABG
procedure at an early age. The
incidence of re-operation after primary
CABG is approximately 3% at 5 years,
11% at 10 years, and greater than 17%
at 12 years1. Campeau and colleagues2
noted that 10 years after the initial
revascularisation 40% of the
saphenous vein grafts were occluded,
whereas 50% of those remaining
exhibited significant stenosis. The
patients undergoing the third or fourth
CABG procedure present unique
challenges. These include the
progression of coronary artery disease,
lack of suitable conduit dense
mediastinal adhesions, and epicardial
scar, which obscures the coronary
anatomy. Refinements in surgical
technique, cardiac anesthesia,
myocardial protection, OPCAB
procedures, and post-operative care
have resulted in an increasing number
of patients undergoing repeated
myocardial revascularisations.
This is a case report of a patient who
has undergone a third CABG
procedure at WOCKHARDT in all our core specialities mainly
HOSPITALS, BANGALORE. Mr. GK
Heart care, Brain & Spine, Bone and
aged 63 yrs had undergone CABG
elsewhere in May 1993 and joint and digestive care. Hope this
November 1993. He had received the clinical knowledge series, would
following grafts, Left mammary artery help you in keeeping abreast of the
to LAD, SVG to obtuse marginal SVG
latest technological advances.
to Diagonal and SVG to PDA. Since 5
to 6 months he had angina on exertion
in spite of increasing the dose of Your feedback and suggestions are
medications. He presented to us with always appreciated.
on going chest pain. When he was
investigated, coronary angiogram Do send your suggestions to
revealed a Native triple vessel disease,
thespecialist@wockhardthospitals.com.
small diffusely diseased LIMA with
sluggish flow, diseased SVG to OM and We thank you for your continuous
blocked SVG to Diagonal and RCA. Left patronage and support.
Ventricular function was normal. He
was a Hypertensive and Diabetic. Warm regards
OPERATIVE TECHNIQUE
Anesthesia and invasive hemodynamic
monitoring techniques are similar to
those employed for any coronary Dr. Llyod Nazareth
revascularisation in high-risk patients. Associate Vice-President
All patients undergoing a redo Wockhardt Hospitals
sternotomy will have transcutaneous
defibrillator pads positioned on the left
lateral chest wall and back before being
draped. A transesophageal echo graphic
probe is placed intra-operatively for
early detection of new myocardial
ischemia, as determined by changes in

The patients
undergoing the third
or fourth CABG
procedure presents
unique challenges.
regional wall motion. Two units of
packed red blood cells are available in
the operating room before the
sternotomy is made. The femoral artery
is prepared before sternotomy. The
forearm prepared to harvest Radial
Artery simultaneously. A repeat median
sternotomy incision was performed. An
oscillating saw used to divide the
sternum, the sternal wires are cut but
left in place while the sternal tables are
cleaved.
After division of the sternum, the heart
and pericardium was freed from the
posterior table of the sternum and chest
wall with sharp dissection and
electrocautery. Entering the pleural
space may expedite mobilisation of the
heart from the sternum. The Right IMA
was harvested as a pedical, meanwhile
the left Radial Artery was harvested.
Adhesions between the heart and
pericardium were sharply divided with
efforts initially directed to mobilising the
right atrium and ascending aorta for
bypass cannulation. To facilitate this
exposure, an initial plane of dissection
is created between the inferior surface
of the heart and the diaphragm. (If
cardiopulmonary bypass is required
then CPB is instituted at this stage.)
Then the left side of the heart is carefully
dissected. 5000 IU of heparin is given
to the patient before starting releasing
the adhesions. With this we have
observed that they tolerate handling
well. Precise dissection is particularly
important at the superior aspect of the
sternum to prevent injury to the phrenic
nerve and IMA pedicle. Once the entire
heart is released the target vessels are
identified and a stagery is formulated.
The RIMA and Radial artery were
disconnected. Using a side biting clamp
applied on to ascending aorta radial
artery was anastamosed to one of the
previous vein graft hood which was
blocked. There was good flow through
this graft. The side biting clamp was
again applied and the RIMA was
anastamosed to the hood of Radial
artery. The flows through the conduits
were good. An octopus IV tissue
stabiliser was used to isolate proximal
part of diagonal artery which was 1.5
mm in size, the radial artery was
anastamosed side to side of diagonal,
the mid portion of LAD just distal to
pervious anastamosis was isolated
which was 1.75 mm, the distal end of
radial artery was anastamosed end to
side of LAD. The OM was isolated
which was 1.5 mm. The RIMA was
anatomosed to side to side of proximal
OM. Lastly, the PDA was isolated which
was 1.5 mm, the distal end of RIMA
was anatomosed to the proximal
portion of PDA end to side. Haemostasis
was attained. The ECG and
haemodynamics were normal. An
epicardial paceing wire was placed over
the inferior wall of LV. Pleural tubes
were placed and sternum was
approximated with No 5 steel wires. He
was ventilated for 12 hours post
operatively and mobilised on the 2nd
post-operative day after tube removal.
He was discharged on 7th post-
operative day.
He has been fully rehabilitated in a
month’s time and is asymptomatic at
present. His stress test is negative for
any inducible myocardial ischemia.
ANGIO PICTURE
COMMENT
Patients undergoing their third CABG
procedure present the surgeon with
multiple operative alternatives and
significant technical challenges.
These include the limited availability
of suitable conduits, hazardous sternal
re-entry, extensive mediastinal scar,
and difficulty in achieving complete
revascularisation of severely diseased
coronary arteries. Nonetheless,
careful patient selection and a precise
surgical technique will yield a
satisfactory early outcome and
gratifying long-term results.
Controversy exists concerning the
management of angiographically
patent but minimally stenotic vein
grafts. Kouchoukos’ group3 studied 16
vein grafts that were removed during
redo CABG, and compared the
angiographic interpretation with the
respective pathologic findings. All
vein grafts exhibited less than 30%
luminal irregularities by re-operative
angiography. However they found
that angiograms underestimated the
degree of atherosclerosis in 13 (81%)
of the vein grafts studied
pathologically. In 9 grafts (56%) with
normal angiographic findings,
moderate or severe atherosclerotic

1
changes were seen on pathologic
examination. They concluded that
vein grafts older than 5 years should
be replaced 3 . This approach is
supported by other authors, who
report the accelerated progression of
atherosclerosis in vein grafts greater
than 5 years old1,2. We favour this
philosophy; however, we
individualise our approach to pre-
existing vein grafts considering both
the angiographic pattern and gross
appearance.
REFERENCES
1. Cosgrove DM, Loop FD, Lytle BW, et al. Predictors
of re-operation after myocardial revascularisation.
J Thorac CardiovascSurg1986; 92:811-21.
2. Campeau L, Enjalbert M, Lesperance J, et al.
Atherosclerosis and late closure of aortocoronary
saphenous vein grafts: sequential angiographic
studies at 2 weeks, 1 year, 5 to 7 years, and at 10 to
12 years after surgery.
3. Circulation 1983; 68 (Suppl 2):1-7. Marshall WG Jr,
Saffitz J, Kouchoukos NT. Management during
reoperation of aortocoronary saphenous vein grafts
with minimal atherosclerosis by angiography. Ann
Thorac surg 1986; 42:163-7.
Courtesy:
Dr. Vivek Jawali, M.S., M.Ch., DNB, FIACS
Chief Cardiovascular and Thoracic Surgeon
Dr. Ganeshakrishnan Iyer, M.S., M.Ch.
Dr. K N Srinivasan, M.S., M.Ch.
Dr. Devananda N S, M.S., M.Ch.
Dr. Murali Manohar V,
M.S., DNB (CVTS), FIACS
Department of Cardiovascular and
Thoracic Surgery.
Wockhardt Hospitals, Bangalore

M icrolumbar disectomy in the treatment

of disc prolapse

L
umbar disc herniation
(prolapse) is one of the major
cause of backache and
sciatica. Though many types
of surgeries have been recommended
and performed, the “Gold standard has
been Microlumbar disectomy” which
is “Minimal Access“ surgical solution
to this benign problem with maximum
benefit. The authors describe their
techniques and advantages of the
procedure. The authors have the
experience over 300 cases being
performed over the last 10yrs and
about 37 of them were performed
over the last 12 months at the
Wockhardt Hospitals Brain and Spine
centre with excellent outcome.
As per MRI three types of disc
herniations can be identified. These may
be contained within the annulus fibrosis
or extruded sub ligamentally (below
PLL) or freely into epidural space.
Fig 1
The following diagram highlights the
INDICATION FOR SURGICAL
utility of operating microscope in
INTERVENTION
giving a magnified, stereoscopic,
1. Significant root compression with coaxially illuminated 3 dimensional
severe radicular pain, with or picture (depth perception) through a
without neurological deficits. narrow access.
2. Back pain with sensory motor Fig 2
radiculopathy
3. Early cauda equina involvement
(bladder and bowel problem)
AIM
Fig 3
To relive the root thecal compression
by the prolapsed disc.
To achieve this minimal acess is
essential so the adjacent neural tissue,
the overlying ligamantum, laminae and
the paraspinal muscles are least
disturbed. This in turn helps in early
recovery, mobilization and speedy
return to normal routine activity.

Fig 4

2
 STEPS OF SURGERY

Fig 5

Fig 8

POST OP CARE
Fig 6
1. Patient ambulated 6-8hrs after
surgery and usually discharged
within 24hrs.
2. Allowed normal activity including
prolonged sitting, bending, weight
lifting for 3 hrs.
3. After 3 weeks put on regular
isometric and isotonic back exercise.

Courtesy:

Fig 7 Dr. K.N Krishna, M.Ch.,

Consultant Neurosurgeon

Dr. Dilip Gopalakrishnan, M.S.,

Spine Surgeon
Wockhardt Hospitals, Bangalore

R ole of Mega Prosthesis in Joint Reconstruction with

Traumatic Bone Loss

HISTORY thigh and knee. She was initially

A 20 year old girl had met with a road
traffic accident in July 2006. She had
sustained compound fracture of Right
Pic 1
treated by debridement and external
fixation. She was presented to us in
September 2006 with external fixator
and wound over thigh (pic1). We
performed repeat debridement and
change of external fixator (pic 2). After
Multiple dressing and debridement, the
wound healed. Then external fixator
was removed (pic 3). But the patient
was not able to walk due to fracture
non-union. Patient was advised Ilizarov
fixation and knee fusion. Patient went
into severe depression and suicidal
tendency. She wanted to walk and also Pic 2

3
Pic 3 Pic 8
have movement at knee joint. After
detailed discussion with the patient
and her parents, it was decided to
peform megaprosthesis, which is
usually done in cases of Bone Cancer.

PROCEDURE Pic 12
Under anaesthesia, right lower was
painted and draped. S shaped incision
was made over anterior aspect of knee Pic 9
avoiding previous scar (pic 4). Lower

Pic 13

Pic 4
end of femur with fracture was
exposed. Lower third of femur was
excised (pic 5,6). Proximal tibia was
cut. Both sides were prepared and

Pic 10 Pic 14

degrees. She has also been

psychologically boosted and happy.

DISCUSSION

Mega prosthesis are implants used in

Pic 5 reconstruction of joints with severe
bone loss due to tumor excision
surgery. The life of this prosthesis is
usually 8-10 years. This is a very rare
situation where in we had to use in
Traumatic Bone Loss.

Pic 11
Pic 6
fixed with mega prosthesis (pic 7,8,9)
(pic 10,11) and the wound was closed Courtesy:
in layers with drain and allowed it to Dr. Sanjay Pai, M.S.
heal. Knee movements started after
wound healing. Dr. Srinivas J V, M.S.

Dr. Vasudev N Prabhu, M.S.

RESULT
Department of Bone & Joint Care
(pic 12,13, 14) At the end of 2 months, Wockhardt Hospitals, Bangalore
patient was able to walk without
Pic 7 support and had knee bending of 80

4
NEUROLOGY &
ase series of effectivity of
CRITICAL CARE
C dual modality therapy in myasthenic crisis
INTRODUCTION
Myasthenia Gravis is an autoimmune
disorder of the neuromuscular junction
characterised by exacerbations and
remissions. Myasthenic crisis is a
serious complication of myasthenia
gravis defined as weakness from
acquired myasthenia gravis, requiring
intubation and ventilation, a situation
corresponding to Grade V of MGFA
classification. It complicates 15 – 20%
of patients in Myasthenia Gravis.
There is limited data on myasthenic
crisis in India. The effectivity of various
modalities of treatment – Plasma
exchange and intravenous
immunoglobulin has not been
sufficiently recorded in order to
determine outcome and disease
stabilisation.
CASE REPORT
Mr. G, a 61 yr old male patient was
presented with late onset Myasthenia
Gravis on oral pyridostigmine and
immunosuppressants. Coronary
Artery Bypass Grafting was done
recently in June 2007, without any
problems. Patient was shifted to the
Intensive Care Unit following a rapid
increase of weakness, and
mechanically ventilated for respiratory
failure. In view of heavy doses of
pyridostigmine used, it was difficult to
The two immune
directed treatment
used for definitive
treatment of
myasthenic crisis are
Plasmapheresis and
intravenous
immunoglobulin.
5
distinguish between a myasthenic
crisis, or cholinergic crisis. Targeting
both approaches, withdrawal of
pyridostigmine (drug holiday) was
implemented and plasmapheresis was
initiated for the myasthenic
component. On neurological
assessment motor weakness
persisted even after completion of all
the cycles with no significant
improvement. Plasma acetylcholine
receptor antibodies were sent which
was elevated at 15.8 mmol/litre,
suggestive of a high antibody load.
Pyridostigmine was then gradually re-
introduced in lower doses.
Due to inadequate neurological
improvement despite
plasmapheresis and restarting of oral
pyridostigmine and steroids, it was
decided to put patient on a sequential
modality of treatment. As a second
measure, Intravenous
immunoglobulin in the dose of
400mg/Kg was administered for 5
days. Tracheostomy was also done for
improved ventilatory toilet and
prolonged ventilatory support. Oral
pyridostigmine was
continued with steroids and
immunosuppressants. Following
intravenous immunoglobulin patient
showed gradual neurological
improvement and was weaned off the
ventilator successfully.
The second case involved an elderly
male patient, a diagnosed case of
Myasthenia Gravis on oral
pyridostigmine and steroids,
presented with similar progressive
weakness, with features of both
myasthenia and cholinergic crisis.
Patient was initially treated with five
cycles of plasmapheresis and
mechanically ventilated. Persistent
weakness was present, preventing
weaning from the ventilator.
As a result, similar to the first
case, sequential intravenous
immunoglobulin was given. The
patient also underwent tracheostomy.
On restarting of oral pyridostigmine
in lower doses and azathioprine (after
control of sepsis), the patient showed
progressive clinical improvement and
was weaned off the ventilator, and the
steroids were tapered off. A follow up
of the acetyl choline receptor
antibodies also showed marked
reduction in level. (22.68 mmol / l – to
18.18 mmol/ litre).
DISCUSSION
Myasthenic crisis frequently occurs
within the first two years after disease
onset. Most often myasthenic crisis
develops in patients with generalised
myasthenia. In more complex cases,
distinguishing between myasthenic
and cholinergic crisis can be difficult,
and patients may show mixed
features of both crises. Early intubation
and mechanical ventilation is the most
important step in the management of
myasthenic crisis, followed by more
definitive measures.
Plasmapheresis and intravenous
immunoglobulin are the two immune
– directed treatment used for definitive
treatment of myasthenic crisis.
Studies comparing plasma exchange
with intravenous immunoglobulin
have demonstrated equal efficacy, but
less adverse effects for intravenous
immunoglobulin. However, the failure
rate of intravenous immunoglobulin
treatment was about 20%. On the
other hand, cholinergic crisis is treated
with withdrawal or reduction of drugs
such as pyridostigmine.
In these two severe and complicated
mixed myasthenic and cholinergic
crises, both problems were targeted.
Drug (pyridostigmine) withdrawal was
done, followed by gradual re-
introduction of the same medication in
a lower dose, and combined with
multimodality sequential therapy for
myasthenia (plasmapheresis and
intravenous immunoglobulin), as one
single modality did not provide the
optimal neurological improvement.
Although current literature states
that plasma exchange is perhaps
slightly superior to intravenous
immunoglobulin in treatment of
myasthenic crisis, we found that the
 neurological benefit of sequential
therapy was much greater than any one
modality. Thus a combined sequential
approach has to be kept in mind, in case
there is a suboptimal treatment
response to any one modality.
CONCLUSION
Patients with myasthenia gravis on
high doses of medications presenting
with severe weakness can have a
complex combination of myasthenic
and cholinergic crisis. In such cases,
D
DENTISTRY
entigerous
Cyst removal
CASE REPORT
A female patient aged 30 years came
to us complaining of transient
numbness in lower left mandible (jaw).
Upon examination of the oral cavity,
there was no visible swelling in the
region of the cyst (located in the lower
left posterior mandible in the region of
second and third molar). No visible
external swelling of the left cheek
either.
Upon evaluation of x-rays, we found a
radioluscency, towards the lower
border of the mandible in the region of
the molars. The third molar (wisdom
tooth) was in a mesio angular impacted
position with the cyst attached to its
crown. The only way to determine if
this was malignant or benign was to
remove the cyst in its entirety and send
for pathological exam. There are no
definite causative factors for this type
of a cyst – this is a Dentigerous cyst
Fig 1: OPG showing cyst
both drug withdrawal for the
cholinergic crisis and sequential
modality of treatment –
plasmapheresis followed by
intravenous immunoglobulin may be
superior than providing any single
modality of treatment.
These challenging cases require
comprehensive multidisciplinary care,
involving Neurology, Critical Care
and Nephrology with adequate
infrastructure to try and provide optimal
outcome to these critically ill patients.
with a differential diagnosis of
Odontogenic Keratocyst.
We would run into the risk of
parasthesia as the nerve was impinged
and has been under trauma for 2 years.
Also during the removal process, it is
inevitable that a few fibres would get
pulled. However this would only be
temporary as the nerve fibres do grow
back. The greater risk we were looking
into was the fracture of the mandible
as the cyst was located in the lower
Fig 2: View of the offending tooth
Fig 3: Cyst with lining intact
Courtesy:
Dr. Chandran Gnanamuthu, M.D, D.M
Dr. Uday Shankar, M.D, D.M
Dr. Sanchayan Roy, D.N.B
Dr. Ravindra Mehta, M.D, F.C.C.P
Dr. R. Sridhar, M.D, D.M.
Department of Brain & Spine
Wockhardt Hospitals, Bangalore
border of the jaw and did not have
sufficient bone structure beneath it
(less than 1 cm). We were equipped
with bone plates in case of a fracture
during the cyst removal.
The surgery was performed under
General Anesthesia in the surgical OT
and took 2 hours to complete. The
entire cyst was removed which
measured about 2.5 x 3 cms in size,
with its lining intact. We did need to
sacrifice the second in addition to the
third molar to ensure the complete
removal. However there was no loss
of sensation (parasthesia) or fracture
of mandible.
Courtesy:
Dr. Sandhya Ramanujam,
B.D.S. (Ind), D.D.S. (USA), C.B.M. (USA),
C.A.D. (USA)
Dental department co-ordinator and Senior
Consultant Implantologist and Cosmetic
dentistry
Dr. Sunil Vasudev, M.D.S
Consultant Oral and Maxillo-Facial Surgeon
Department of Dental care
Wockhardt Hospitals, Bangalore
6
 L
PATHOLOGY ocalised giant pseudopolyposis
L
ocalised giant pseudopolyposis
is a rare complication of ulcerative
colitis. The malignant potential of
dysplasia associated mass
lesions (DALM) complicating ulcerative
colitis is well documented; however not
all the mass lesions are malignant.
We present a case of localised giant
pseudopolyposis, which caused
intraluminal obstruction resulting in
emergency surgery.
CASE HISTORY
A 54-year-old male with three years
history of ulcerative colitis under
medical treatment presented with the
symptoms of loose motions since one
month. On investigation, he had
anemia, leucopenia and
hypoalbunemia. The abdominal CT
scan revealed a large mass at the
splenic flexure bulging into the lumen;
favouring a malignant tumor. At
colonoscopy a large polypoid mass
was observed in the transverse colon
near the splenic flexure, obstructing
the lumen. Mucosal biopsies done
elsewhere, revealed chronic active
ulcerative colitis without dysplasia.
During the course of investigation the
patient developed sub acute intestinal
obstruction, necessitating an
emergency subtotal colectomy.
PATHOLOGY
Gross: The specimen of subtotal
colectomy measured 7cm along the
ileum and 75 cm along the colon. On
opening there were nine lesions in
the ascending and transverse colon
about 12 cm away from the proximal
margin. The largest lesion covered
the entire circumference and was
seen involving 13cm segment of the
intestine. The lesion showed multiple
frond like excrescences floating in
the lumen giving sea-anemone like
appearance. The second largest
lesion was a sessile polyp measuring
7X6cm. The rest of the lesions were
small polyps measuring 0.5cm on
average. The intervening mucosa
was ironed out with loss of
7
in ulcerative colitis
haustrations. Twenty-seven nodes
were dissected.
MICROSCOPY
On microscopic examination, sections
of all mass lesions were more or less
identical. The largest lesion had a
villous configuration with fibro vascular
cores (Fig1). The lining epithelium
resembled normal colonic mucosa.
Signs of activity like micro abscesses
(Fig 2), eosinophilic abscesses,
Fig 1: Lesion with villous configuration and a
central fibrovascular care( H&E, mag XIO)
Fig 2: The lining epithelium resmbles normal
colonic mucosa. Cryptitis & crypt abscesses are
seen. There is no dysplasia or malignancy.
(H&E,magX40)
cryptitis, and ulceration were seen. The
intervening mucosa showed changes
of chronic ulcerative colitis, seen also
at the colonic resection margin. The
lymph nodes showed reactive
changes.
DISCUSSION
Ulcerative colitis is an inflammatory
bowel disease having protracted
course with episodes of exacerbations
and remissions. The mean age of onset
varies from 20 to 30 years and a second
peak at 70 – 80 years. The common
symptoms are diarrhea, loose stools,
rectal bleeding, abdominal pain, fever,
weight loss and anemia. About 10-
15% of the patients present with
severe form of disease with anemia
and hypoalbunemia as was seen in this
case. The protein losing enteropathy
is associated with extensive mucosal
ulceration in severe active
inflammatory disease 1 . The
hypoalbunemia in this case is likely to
be related to this. The late onset of
disease and only three years of
documented disease in this case may
not be accurate in view of the severity
of symptoms, which are complications
of a long standing disease.
Pseudopolyps, DALM, and carcinoma
are the different complications of
ulcerative colitis2,3. The cumulative
incidence of colorectal cancer in
longstanding ulcerative colitis being 3.1
to 43% and approximately increases 1-
2% per year after 10 years of disease3.
The risk of colorectal cancer developing
in a DALM is about 40-50%2,3. Annual
surveillance endoscopy with biopsy is
a must in all cases of long standing
ulcerative colitis.
Pseudopolyps are the most common
local complication accounting for 12.5
to 74%1,2,3,4. Pseudopolyps are seen in
active or quiescent phase of the
disease and there is a direct relation
between severity and extent of
disease and incidence of
pseudopolyposis.
Localised giant pseudopolyposis is a
lesser known complication These may
be found at any site in the colon and in
an occasional case is also reported in
the rectum4. The clinical symptoms
may be dual - those of the disease
(rectal bleed, loose stools) and those
due to intraluminal obstruction
(abdominal mass).
The colonoscopic and radiologic
findings of these giant lesions simulate
a polypoid cancer. Though the
carcinoma arising in ulcerative colitis
is usually a flat and infiltrative
adenocarcinoma, rare cases of
intraluminal polypoid carcinomas are
also known2,5. The other differential
diagnosis includes a villous adenoma,
not a recognised complication of
ulcerative colitis, but has similar
radiologic and endoscopic
appearances. Thus a preoperative
diagnosis of localised giant
pseudopolyposis is difficult on the
basis of radiology and endoscopy2.
Barium enema examination will
delineate the frond like excrescences
and the motility of fronds can be
appreciated on fluoroscopic
examination, which may give a clue to
the benign nature of the lesion.
Pre-operative biopsies of these large
pseudopolyps are always negative for
dysplasia as was seen in the present
case. However in a large lesion,
negative biopsies cannot preclude
sampling errors and only a meticulous
study of the resected specimen will
help to rule out a dysplasia or carcinoma.
On gross examination, the lesions are
usually composed of numerous frond
like excrescences, usually
circumferential and involving some
length of intestine (around 13-15 cm)
as was seen in this case as well 1,2,3,4,5.
News
ROOM
September 30th: The World
Heart Day
Every year World Heart Day is an event
that is celebrated on the last Sunday
of September. Since the inception of
the World Heart Day in the year 2000,
it has become an internationally
recognised event with celebrations
taking place in many countries. Heart
disease is the world’s largest killer,
claiming 17.5 million lives each year.
This paved the way for the creation of
World Heart Day, to create public
awareness of risk factors for heart
diseases and to promote the
preventive measures by increasing
physical activity. This year’s theme
Histologically the lesions are made of
normal or hyperplastic epithelium
covering fibro vascular cores. In the
present case, the signs of activity in
the intervening mucosa and at the
colonic resection margin, suggest an
extensive, widespread and severe
form of the disease. Dysplasia is not
seen in the pseudopolyps and
pseudopolyposis per se is not a
neoplastic transformation.
In the present case, symptoms of
intestinal obstruction necessitated an
unplanned surgical resection. The
outcome of the surgical resection
may be favourable. However,
emergency surgery and
hypoalbunemia were predictors of
adverse outcome in one series as
was also noted in the present case6.
The other local complications of the
disease are perforation with
peritonitis, abscess formation, toxic
mega colon and venous thrombosis.
CONCLUSION
Awareness of the clinical entity of
localised giant pseudopolyposis as a
rare but well documented
complication of Ulcerative colitis can
result in optimising the clinical
management.
was “Healthy Families, Healthy
Communities” with the slogan “Team
Up for Healthy Hearts!”
On the World Heart Day, Wockhardt
set off a movement to increase this
awareness through a huge
community activity like ‘Walkathon’
REFERENCES
1) Bryan RL, Alexander WJ. Letter to the Editor. J
Clin Pathol 1990; 43:346-347
2) Papanikolaou C et al. Colonic Obstruction Due to
Localised Giant Pseudopolyposis Complicating
Ulcerative Colitis. The Internet Journal of Surgery
2006; vol 8: number 2
3) Robert Odze. Diagnostic Problems and Advances
in Inflammatory Bowel Disease. Mod Pathol 2003;
16(4): 343-358
4) Hurlstone DP et al. Large Bowel Obstruction
Secondary to Localized Rectal Giant
Pseudopolyposis Complicating Ulcerative Colitis:
First Reported Case. Endoscopy 2002; 34: 1025
5) Keating JW, Mindell HJ. Localised Giant
Pseudopolyposis in Ulcerative Colitis. Am J
Roetgenol 1976; 126: 1178-1180
6) Almogy G et al. Surgery for Late – Onset Ulcerative
Colitis: Predictors of Short – term Outcome.
Scandanavian Journal of Gastroenterology 2002;
37 (9):1025-1028
Courtesy:
Dr. Kshitija Kulkarni, M.D.
Consultant Pathologist
Dr. Shantha Krishnamurthy, M.D.
Consultant Histopathologist
Wockhardt Hospitals, Bangalore
as walking is the best physical activity
applicable across all age groups. It
was organised at two centres -
Rajajinagar and Bannerghatta road.
Incidentally, Rajajinagar centre has
hosted this activity for the first time
and people of Cunningham area and
Nagarbhavi areas joined at the
8
 Rajajinagar location hospital. At
Bannerghatta road, the event was
flagged off by the CEO Mr. Vishal Bali
and Dr. Lloyd while at Rajajinagar it
was with Mr. Narendra Babu, MLA
and popular Kannada cinestar
Ms. Sudha Rani.
There was an overwhelming
participation from the neighbourhood
residents association, corporates and
other public at both the centres,
touching about 4000 people at
Bannerghatta and close to 3000 at
Rajajinagar.
A free registration was done for a
health check up for the residents
association at the Bannerghatta Road
centre.
Harvard University awards
Dr. Jawali:
Dr. Vivek Jawali, Chief Cardiovascular
Thoracic Surgeon was recently
awarded the prestigious Annual
Lifetime Achievement Award for
Medical Excellence in India by the
Harvard Medical International.
As a part of the Award, Dr. Jawali was
invited along with his wife to visit
Harvard University and address the
faculty there.
During this 5-day visit, Dr. Jawali
interacted and shared experiences
with the senior faculty of the various
institutions of Harvard Medical School
and Harvard University.
Dr. Jawali spoke at the Grand Rounds
of the Massachusetts General Hospital
and the Brigham & Women’s Hospital,
two premier medical institutions of the
world.
9
Dr. Jawali also spent a full day with Dr.
John Mayer, the Director of Cardiac
Surgery at the Boston Children Hospital
and interacted with the senior staff of
pediatric cardiac surgery and pediatric
cardiac anesthesia. The Boston
Children Hospital is the world’s premier
pediatric hospital, associated with the
Harvard Medical School.
He spent a day at the Harvard Medical
School with the Dean and conducted
a 2-hour teaching session with the
students on simulators.
The last day was spent interacting and
networking with the senior members
of the Harvard Medical International.
The highlight of the visit was a dinner
evening with the Nobel Laureate Dr.
Murray, who had performed the first
kidney transplant in 1953 and
pioneered the saga of organ
transplants.
The aim of this visit was to encourage
a deeper networking between the two
institutions – Wockhardt Hospitals and
Harvard Medical International
Launch of Wockhardt Knee Clinic
The Wockhardt knee clinic is the first-
of-its-kind in Karnataka. The emphasis
at this facility is on early diagnosis
and implementation of treatment
programmes to reduce the risk of long
term disability. The clinic provides
patients with an interactive, integrated
opinion of Physiotherapist,
Rheumatologist, Arthroscopist and
Joint replacement surgeon. Just one
sitting diagnoses the problem.
Objectives of Wockhardt Knee Clinic:
1. Focussed multi-disciplinary
holistic approach towards the
treatment of knee problems.
2. Active collaboration in research
towards cutting edge technology
such as cartilage cell transplant
3. Community awareness
programmes to prevent early
degenerative joint disease.
As a part of Wockhardt knee clinic, the
interactive public forum on KNOW
MORE ABOUT YOUR KNEE PAIN by
an eminent panel consisting of
Physiotherapist, Rheumatologist,
Arthroscopist and Joint Replacement
Surgeon was conducted at Wockhardt
Hospitals, Bannerghatta Road,
Bangalore on 28th Oct 2007.
Wockhardt Knee Clinic: One-Stop-
Shop for Knee Pain
Wockhardt Hospitals, Bannerghatta
Road, is launching the Wockhardt Knee
Clinic that will provide patients a
comprehensive, multi-disciplinary
approach to assess and treat knee
problems. Patients can consult four
specialists from different disciplines in
one sitting for just one consultation fee.
The clinic will start end-October and
will be held every Wednesday
between 3 and 4 pm.
Among orthopaedic patients, as much
as 40 per cent constitutes people with
knee problems. Among Indians, knees
are more prone to pain than any other
joints, unlike in the west, where the
most troublesome joints are the hips.
This is due to human structural factors.
But in spite of a huge population that
suffers from knee problems, there are
not many centres in the country that
offer patients comprehensive knee
care. The treatment for knee pain
varies depending on the nature and
stage of the problem. Patients run from
pillar to post looking for the right
answer and often different doctors
offer different opinions, thereby
creating confusion and anxiety in
patients. The panel of doctors at the
Wockhardt Knee Clinic will examine
each case from four different
perspectives and offer patients a
comprehensive diagnosis and
treatment modality.
Knee pain could be the result of a
variety of factors, like osteoarthritis,
rheumatoid arthritis, other arthritic
conditions, sports injuries, postural
problems, muscular sprains and strains
or some other non-specific problem.

The treatment for knee
pain depends on the
nature of the condition
and its stage. If
detected at preliminary
stage then can be
treated with medication
and physiotherapy.
Broadly, these can be classified into
four categories – sprains and muscle
pains, inflammatory diseases like
gouty and rheumatoid arthritis,
meniscal and ligament tears and major
wear and tear (osteoarthritis). The
treatment for knee pain depends on
the nature of the condition and its
stage. Early cases when the condition
is mild may be treated with medication
and physiotherapy. A simple ligament
tear can be corrected with arthroscopy
or minimally invasive minor surgery.
The severe, advanced cases could
require knee replacements. But
depending on the doctor you consult,
you may receive different opinions.
Dr. Sanjay Pai, joint replacement
surgeon, says, “It’s sad to see the
plights of patients. They look for an
answer and each doctor they consult
recommend a different treatment.
Though knee pain is so common, there
is no comprehensive outlook towards
this problem in the city. Wockhardt
Knee Clinic will fill that void.”
Not all knee problems require
replacements and can be treated
arthroscopically. Dr. Gautam Kodikal,
consultant arthroscopy surgeon and
sports medicine, says, “In case of
sports injuries and degenerative
arthritis in the early stages, we can
correct the problem with minimally
invasive arthroscopy. After the
surgery, patients need to consult a
physiotherapist as they require a lot of
rehabilitation. At the Wockhardt Knee
Clinic, patients will get not just a
comprehensive assessment and
treatment of their condition but can
also consult an expert on whatever
follow-up therapy or treatment is
required.” The Knee Clinic will offer
some of the most advanced
techniques in arthroscopy, like mosaic
plasty and cartilage transplant.
Rheumatology is one of major causes
of knee pain but it is often overlooked
by doctors. Says consultant
rheumatologist Dr. Satish Kalanje,
“Doctors pay a lot of attention to the
mechanical reasons that could be
behind knee pain and often miss out
other factors, like a systemic disease.
Diseases like gouty arthritis and
rheumatoid arthritis damage the inner
joint lining and cause pain. But they do
not always manifest in all the joints.
Patients sometimes go in circles and
yet they do not find an answer to the
real reason for their discomfort. We
hope to pick up these cases. If picked
up early, these patients can be
managed with medicines and surgery
can be avoided.”
Physiotherapy is crucial to
orthopaedics but many hospitals offer
it just as an add-on facility and not as
part of an integrated programme. Says
Joseph Pasangha, consultant
physiotherapist, “Patients come to us
after having tried out all other
therapies, like ayurvedic massage,
unani, acupuncture, etc. Conservative
medicine does not offer physiotherapy
as an option. Patients are offered pain
killers that merely mask the pain and
do nothing to treat the condition. The
Wockhardt Knee Clinic will be a one-
stop-shop where we will offer
physiotherapy to treat as well as arrest
a condition.”
A common category of knee pain
patients are post-menopausal women.
They are in a vicious cycle – they gain
weight and suffer from calcium depletion
that causes knee pain, and because of
the pain they cannot exercise and bring
the weight down. With physiotherapy,
the knee muscles are strengthened
without putting any strain on the weak
muscles and cartilages. Thereafter, the
patient is put on a weight reduction
programme and an exercise regimen
which is routinely followed.

Dr. to patient: “Well, Mrs. Jones,

I’m afraid you’re not quite as sick as we’d hoped.”

Patient: How much to have this tooth pulled?

Dentist: $90.00.
Patient: $90.00 for just a few minutes work???
Dentist: I can extract it very slowly if you like.

10
 At the Wockhardt Knee Clinic, the
approach is multi-pronged so that the
patient receives what is best suited for
his or her condition. A patient can walk
in, get all the tests done, meet all the
experts and walk out with a solution
that is long term and permanent.
Launch of Wockhardt Spine Centre
With healthcare in its genes,
Wockhardt Hospitals brings another
breakthrough in advanced care and
technology with its exclusive Spine
Centre at Wockhardt, Bannerghatta
Road. This state-of-the-art centre is an
initiative from Wockhardt Brain and
Spine Centre. Its uniqueness lies in its
multi-disciplinary approach where
neuro and orthopedic surgeons
provide comprehensive care.
The centre was inaugurated by Prof.
R.M Verma , Professor of neurosurgery
at NIMHANS on 25 th November,
2007.The main objective of this centre
is to offer a comprehensive care. The
team of spine centre team comprises
of neurosurgeons, neurologist and
physiotherapist.
The centre is also geared to undertake
the latest advances in surgery that
have been carried out at leading
international spine centres. They
Wockhardt Hospitals,154/9, Bannerghatta Road, Bangalore- 560 076. Tel: 91-80-6621 4444/ 2254 4444. Fax: 91-80-6621 4242/2254 4242
Wockhardt Hospitals, 14, Cunningham Road, Bangalore-560 052. Tel: 91-80-4199 4444/2226 1037. Fax: 91-80-2228 6530
Wockhardt Hospitals, 23, 80 Feet Road, Gurukrupa Layout, Nagarbhavi 2nd Stage, Bangalore – 560 072. Tel: 91-80-2300 4444, Fax: 91-80-2301 4242
Wockhardt Hospitals – ICU & Community Care, 111, West of Chord Road, Opp. Rajajinagar 1st Block, Bangalore – 560 086. Tel: 91-80-2300 4444. Fax: 91-80-2300 4242
E-Mail: 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
Wockhardt, Mumbai, also assists the
surgical facility.
One can choose from Gastric Banding
and Gastric Bypass surgeries post, by
which he/she automatically gets
restricted to eating less, thus absorbing
less food. In Gastric banding a band is
include cervical disc replacement and
placed in the upper stomach to create a
the use of expandable devices for
small stomach pouch, decreasing the
lumbar spine fusion, the latest
capacity of stomach and its capacity to
technique in spine care and minimally
eat. In Gastric bypass surgery, the
invasive cosmetic spine surgery
capacity of the stomach is stapled to
(MICOSS).
create a smaller pocket of stomach and
the intestine is stapled to the smaller
Wockhardt Hospital offers Obesity
management stomach. Laparoscopy and keyhole
surgeries are used for operation, leaving
Obesity occurs over time more calories only tiny scars as they have minimal
are consumed than used. A balance access and assure quick recovery.
between the two has to be maintained.
Morbid weight problems are To educate the public, the Centre will
increasing. Despite diet control and conduct a series of public forums on
exercise regimes; increase in weight Obesity management.The general
has become a health hazard. public are invited to register by calling
up 66214121/66214120.
Wockhardt Hospitals, Bannerghatta
road, from its Centre of Digestive Care
offers exclusive obesity treatments
by a team of expert consultant
physicians, dieticians, endocrinologists,
physiotherapists, anaesthetists, allied
specialists and surgeons. The Centre
of Digestive care, launched in July 2006
performed several operations
successfully.
Head of services Dr. M.G. Bhat, an
experienced surgeon with extensive
experience in complicated
gastrointestinal surgery and Indian Academy of Neurology awards
laparoscopy surgery and Dr. Shabeer Dr Chandran Gnanamuthu
Ahmed, a trained senior doctor in
advanced laparoscopic surgery and Dr Chandran Gnanamuthu, M.D, D.M
colorectal surgery from the UK with a was awarded the Fellowship of Indian
Masters degree in minimal access Academy of Neurology on Oct 4th,
surgery from Scotland work towards 2007 at the Annual Conference of the
giving a healthier and longer life to Indian Academy of Neurology held at
patients. Dr. Raman Goel, an the National Centre for the Performing
experienced obesity surgeon from Arts, Mumbai.