Four patients have successfully undergone surgery for the repair of Type A aortic dissection at Amrita Institute of Medical Sciences within a span of just 10 days, after they were referred post-haste from hospitals all over Kerala, including Palakkad, Perinthalmanna and Kochi, to save their lives.
An aortic dissection is a tear in the inner lining of the aorta (the largest artery in the human body which arises from the heart and from which all other blood vessels arise). The tear in the aorta wall occurs just above the aortic valve which separates the heart from the aorta. Blood enters inner layers of the wall of aorta through the tear, and passes downwards, sometimes all the way to the legs. Death occurs due to the rupture of the aortic wall because of pressure of the blood, or extension of the tear backwards to the aortic valve, causing a leak. Sometimes, the tear can extend to vessels supplying blood to the brain, triggering a brain stroke.
‘Type A’ Aortic dissection is a life-threatening medical emergency – without cardiac surgery, patient mortality is almost 100% within a few days. The condition is not very common and many patients die even before reaching the hospital. Very few hospitals in Kerala, or even in India, have the capability to conduct such surgery, and four such surgeries in a span of ten days is almost unheard of. One of the reasons for such success is that Amrita Hospital has established a dedicated Centre for Aortic Diseases and Marfan Syndrome - to cater to patients with all kinds of aortic diseases.
Said Dr. Kirun Gopal, Associate Professor, Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences, Kochi: “Type A Aortic dissection has a high mortality if not treated surgically, with half the patients dying within 48 hours of the tear occurring in the aorta. It is a rare disease with incidence of around 3.5 persons per 100,000 population. Due to this, diagnosis is usually delayed at hospitals that do not commonly see such cases. They treat the condition as a heart attack or problems arising due to acidity or gas. The most common symptom of Type A Aortic dissection is severe chest pain, which the patients typically describe as the worst-ever pain they have ever experienced in their life. Diagnosis is by echocardiogram or, more definitively, with CT scan of the chest.”
Added Dr. Praveen Varma, Professor and Head, Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences, Kochi: “The only effective treatment for type A aortic dissection is surgery. However, it is a major operation which involves replacing the aortic valve, the aortic root and the ascending aorta and re-implanting the coronary arteries into the graft. The surgery is done using a technique called total circulatory arrest. This involves cooling the patient to 18 degrees and shutting off the circulation completely for a short period, including the heart bypass machine, so that the aorta can be repaired. The operative mortality is higher compared to standard cardiac surgery, varying from 17-26%.The patients need to be operated as soon as they arrive at the hospital, as mortality increases with each passing hour. At Amrita Hospital, we have experience of patients having a cardiac arrest in the casualty or even while being shifted to the operating theatres.”
He added: “The surgery for Type A aortic dissection typically takes around six hours. Last year, we at Amrita Hospital conducted five cases of acute aortic dissection with no mortality at all. These past 10 days, however, we have done four cases successfully. This is a big achievement as this surgery is not done in most cardiac surgery centres due to the higher risk of patient dying. It is a ten hour surgery that costs about Rs 4 to 5 lakhs.”
The four patients which successfully underwent surgery for repair of Type A aortic dissection include Jayanthi, a 43-year-old housewife from Wayanad, and Subramaniom Potty, a 59-year-old retired temple Santhi from Kochi. Both these patients were operated by the surgical team one after the other without a break. The other two patients include John S, a 55-year-old ex-army man, and Krishnaveni, a 59-year-old retired teacher.
Amrita Hospital Kochi felicitated organ donation champion Mr. Pramod Mahajan on January 07, 2019 through a flag-off ceremony for the next phase of his National bike tour to promote awareness on organ donation.
67 year old, Mr. Pramod Mahajan hails from a farming community in Pune. In the year 2000, he donated one of his kidneys to an army jawan and saved his life. Since then he has been an active champion for organ donation. On Oct 21, 2018, he started on a National bike tour from Pune, Maharashtra aimed at raising awareness to promote organ donation. He has covered a remarkable distance of 8000 kms in 80 days on his bike and has met with several medical and community leaders across the length and breadth of the country in order to spread his message. The last leg of his trip was flagged off by the organ transplant team of doctors at Amrita Hospital on January 07, 2019.
The flag-off ceremony was done by Dr. (Col). Vishal Marwaha, Principal, Amrita School of Medicine in the presence of Dr. Sanjeev K. Singh, Medical Superintendent, Amrita Hospital, Dr. Subramania Iyer, Chairman and Professor, Plastic Surgery and Head & Neck Surgery, Amrita Hospital, Dr. Mohit Sharma, Professor, Plastic Surgery, Amrita Hospital, Dr. S. Sudhindran, Professor, Gastrointestinal Surgery, Amrita Hospital, Mr. Prasad V.G., Transplant Coordinator, Amrita Hospital and Mr. Manu the 1st hand transplant recipient. In his message Mr. Pramod Mahajan said: “After touring around the country, I know that Kerala is leading the country in all aspects but unfortunately not in the organ donation scene. My prayer before starting today is that Kerala should lead the country in this area also in the coming years.”
On November 27th, 2018, a team of reconstructive surgeons from Amrita Institute of Medical Sciences, Kochi, was honored by the National Organ and Tissue Transplant Organization (NOTTO) at the 9thIndian Organ Donation Day held at New Delhi, for their path-breaking achievement of conducting a ‘Hand Transplant’.
Dr. Subramania Iyer, Chairman and Professor, Plastic Surgery and Head & Neck Surgery, Amrita Institute of Medical Sciences, received the award on behalf of the team from Shri Ashwini Kumar Choubey, Hon. Minister of State, MoHFW and Smt. Anupriya Patel, Hon. Minister of State, MoHFW in the presence of Preeti Sudan, Secretary (Health), Dr. R.K. Vats, Addl. Secretary, Dr. C. Vijaya Baskar, Minister of Health, Government of Tamil Nadu and Dr. S. Venkatesh, Director General of Health Services.
For the last ten years, Majeed, a 45-year-old father of four school-going children from Kerala’s Palakkad district, was forced to live a secluded life, hiding his face from the world. The reason: the man had cancer affecting the left side of his lower jaw that resulted in a jaw tumour so large, it is rarely found in medical literature. Thankfully, Majeed’s life changed for the better a few days ago when a team of 12 surgeons at Kochi’s Amrita Institute of Medical Sciences (Amrita Hospital) removed the humongous deformity – weighing a whopping five kilos and measuring 20 x 15 x 10 cm – in a surgery that lasted 12 hours.
The tumour started growing on Majeed’s lower jaw in 2008 and protruded out to the left. The dense collection of bone and fibrous tissue led to a grotesque appearance of his face and enormous difficulty in swallowing and speaking, in addition to the social stigma. From being a social activist loved by all for his willingness to people, he became a recluse and stayed confined to his house. He and his family became dependent on the benevolence of others even for basic needs of life, as he could not go to work and people began making fun of his appearance.
Majeed was treated at a reputed cancer centre in Kerala where a part of his jaw was removed. However, there was a recurrence of the disease two years later and he had to undergo yet another surgery. He did well for a few years, but developed the disease on the other side of the jaw three years ago. Since the disease was extensive and reconstruction difficult, he was suggested palliative chemotherapy. Despite continuing with chemotherapy for several cycles, the swelling on his face continued to enlarge, making his life unbearable. That is when Majeed heard of a similar surgery done at Amrita Hospital, and decide to visit Kochi for treatment.
Said Dr. Subramania Iyer, Chairman and Professor, Plastic Surgery and Head & Neck Surgery, Amrita Institute of Medical Sciences, Kochi, who led the team of surgeons: “Majeed underwent a PET CT scan to determine the extent of the spread of the disease. Since it was found confined only to the jaw, we had extensive discussions with our tumour board and considered curative treatment for the patient. Majeed and his family decided to go for surgery despite being advised that the results may not be very good in the long term regarding disease control or having a good cosmetic and functional outcome. This is one of the largest ever reported lower jaw tumours of its kind. The huge mass was leading to grave complications. If the condition had persisted, Majeed would have found it impossible to use his mouth.”
The removal of the tumour as well as reconstruction of the lower jaw was a great challenge. Surgeons had to carry out the procedure without endangering Majeed’s life. It involved detaching the tumour from the skull bone and keeping the reconstructed jaw in place. The tumour’s removal was complicated due to its huge size and the involvement of the entire lower jaw. The amount of blood loss was a cause of worry, but this was controlled by temporarily blocking blood vessels to that part of the face.
Said Dr. Subramania Iyer: “The tumour including the entire remaining lower jaw was removed. Reconstruction had to be meticulously planned. Micro-surgical transfer of Majeed’s leg bone was carried out to construct a new lower jaw. The patient regained the function of normal eating and talking within a span of three weeks after surgery. The surgeons reconstructed his lips and he was discharged. Majeed’s tumour has been removed fully and he has been started on chemotherapy for the next two months to prevent it from coming back.”
After the successful surgery, patient Majeed said: “Because of this huge deformity on my face, my whole life had collapsed. I began staying indoors as people would be repulsed by my appearance and make fun of me. It is a huge relief to get the tumour off my face – it is almost like a second birth. If the tumour would not have been removed, my life would have been in danger as the cancer could have spread to other areas including my lungs. My tumour has been removed completely. I am truly grateful to the doctors of Amrita Hospital for enabling me to lead a normal life.”
India is currently suffering from a multi faceted burden of disease — the unfinished agenda of infectious diseases; the challenge of non communicable diseases (NCDs), linked with lifestyle changes; and the emergence of new pathogens causing epidemics and pandemics. NCDs and injuries together have overtaken infectious and childhood diseases in terms of disease burden in every state of the country, posing a new challenge to public health.
NCDs today account for 61.8% of all deaths in India, followed by communicable diseases (27.5%) and injuries (10.7%). While infectious and associated diseases made up majority of disease burden in most of the Indian states in 1990, this was less than half in all states in 2016. The health system of India is largely geared to address only acute disease as of now, and there is a need to change this tendency to include the rising pattern of non-communicable diseases.
This was said by experts in public health assembled at the two-day International Public Health Conference held at the Amrita Institute of Medical Sciences during November 02 -03, 2018. The event has brought together dozens of experts from the government, NGOs, global health bodies and the corporate world to discuss the challenges facing public health in India, including universal health coverage, cancer, cardiovascular disorders, dengue, snake bites, oral health, diabetes, and mental health.
Said Dr Vijaykumar, Chief of Public Health and Community Medicine, Amrita Hospital “India’s public health situation is problematic, with underfunded and overcrowded hospitals and inadequate rural coverage. This is despite increasing demand due to the growing incidence of age and lifestyle-related chronic diseases. The Indian healthcare sector today witnesses 50% spending on inpatient beds only for lifestyle diseases. In addition, the country has 65 million diabetes patients, among the highest in the world. This has resulted in the rapid development of super-specialty hospitals to combat lifestyle diseases. The rapid growth of the private health sector has come at a time when India’s public spending on health at 0.9% of GDP is ahead of only five other countries in the world – Burundi, Myanmar, Pakistan, Sudan and Cambodia. Only 33% of Indian healthcare expenditure in 2012 came from government sources. Of the remaining private spending, as much as 86% was out-of-pocket. Over 40% of all patients admitted in Indian hospitals have to borrow money or sell assets to cover their medical expenses, and 25% of all farmer patients are driven below the poverty line by catastrophic healthcare costs.”
Talking about the most pressing diseases impacting public health in India he added: “While the biggest killer of Indians in 1990 was diarrheal disease followed by ischemic heart disease, today this order has got reversed. Lung diseases have also grown rapidly among the Indian population. Chronic obstructive pulmonary disease (a group of lung conditions that cause breathing difficulties) has climbed the charts to become the second deadliest killer of Indians today, up from number 5 in 1990. Diarrheal diseases, cerebrovascular disease, lower respiratory infections and tuberculosis, in that order, remain the other four leading causes of death of Indians today. While the per person disease burden dropped in the country by 36% from 1990 to 2016, major inequalities remain among the states, with the burden varying almost two-fold between them. Child and maternal under-nutrition is still the single largest risk factor in India, responsible for 15% of the total disease burden in 2016.”
The experts recounted the enormous challenges in improving the overall public health in India. Dr Prem Nair, Medical Director, Amrita Hospital opines: “India is presently in a state of transition – economically, demographically, and epidemiologically – in terms of health. Apart from the high disease burden, other challenges in improving public health include low government expenditure on health, the shortage of human capital in the healthcare industry, lack of private-public partnership, absence of an organized health system, inefficient public health workforce, non-usage of modern technology by public health system, and lack of access to marginalized populations.
The experts also deliberated upon the ways to meeting these challenges. Said Dr Ashwathy, NCD expert, “Investing more in health as well as disease prevention and health promotion should be the topmost priority. The government expenditure on health should increase to at least 2.5% of GDP by 2025. The existing government healthcare infrastructure needs strengthening to improve the process of service delivery. The emerging epidemic of non-communicable diseases needs to be addressed. India has one of the lowest densities of health workforce in the world, including physicians (7 per 10,000 population) and nurses (17.1 per 10,000 population), as against the global average of 13.9 and 28.6, respectively.”
The experts said that while Ayushman Bharat Yojana is a big step in public health and a harbinger of change, the road to universal health coverage will not easy in a country like India. It depends on how fast and how well can the government evolve this scheme with the changing and emerging healthcare needs of Indians.
Said Dr Vijayakumar: “Ayushman Bharat signals a shift of focus of the government from particular diseases and reproductive and child health to comprehensive primary healthcare. There is heavy involvement of the private sector in this scheme. Yet, several issues remain. The program is being launched without much preparation and there is lack of focus on reform of the broader healthcare system. Package rates under Ayushman Bharat for various procedures and interventions are deemed too low by private hospitals. It caters to only inpatient expenditure, while outpatients and medicines are not included in the program. Without effective and comprehensive primary healthcare, pouring money into hospitalization at the secondary and tertiary level will only lead to an increase in overall health expenditure.”