The facts will stun you:

• One of the longest surgeries conducted in the region—a 3-day-long surgery
• One of the biggest teams assembled (18 surgeons among others)
• Reconstruction of the jaw with growth potential.

Here, Dr. Moni Abraham Kuriakose shares with us how the team had to fight against severe challenges to save this child suffering from a tumor of the head and neck region.

Read on:

I love children. However, I hate to see them as patients. I took a flight from India to New York to spend time with my old friend, who was undergoing surgery at New York University Medical Center, where we both used to work over two decades ago. During this long flight, an incident that happened nearly 20 years ago flashed through my mind.

It was one of the patients we treated at the newly constituted Head and Neck Institute at Amrita Institute of Medical Sciences (AIMS), Kochi. During the formative years of establishing the Center, I used to take this long flight, commuting between New York and Kochi.

It all started with a chance meeting with Mata Amritanandamayi Devi, Chancellor of Amrita University (Amma), during one of her discourses at Columbia University. I was serving Bellevue Hospital, New York, as Chief of Head and Neck Surgery and my colleague, Richard Cohan, was the radiation oncologist of the service.

Together, we both revived once an illustrious department served by legends like Hayes Martin, who developed radical neck dissection—a fundamental surgical procedure for head and neck cancer surgery over a century ago.

In the summer of 2002, during the discourse at Columbia University, Amma announced that she was planning to start a cancer center in Kochi at the newly established Amrita Institute of Medical Sciences (AIMS) and solicited volunteers. Richard nudged me to explore. Amma introduced us to Ron Gottsagan, the then Administrative Director and Prem Nair, the Medical Director of AIMS.

The One-of-its-Kind Unit 

We pitched the idea of starting a unit, the like of which does not exist anywhere in the world—with complementary medical expertise to manage complex problems of the head and neck region—we called it the "Head and Neck Institute".

We wanted to shift the focus of medical care from the “medical-speciality” approach to the “patient-first approach”. The Prem Nair-Ron Gottsegen duo, which managed the Amrita Institute, was willing to experiment.

We visualized this institute to be managed by different medical specialists like ENT, Plastic, Maxillofacial (relating to the mouth, jaw, face, and neck), surgical oncology (medical specialty that uses surgery to diagnose, treat, and manage cancer) and allied fields as radiation, medical oncology and palliative care (specialized medical care focused on improving the quality of life for individuals with serious illnesses, including cancer, by managing symptoms and side effects of the illness, and its treatments. It aims to relieve suffering by addressing physical, psychological, social, and spiritual aspects of care.

Suddenly, everything appeared to be falling in place as if this idea had a life of its own. Richard resigned from NYU and joined AIMS. Despite being the “doubting Thomas”, I took a year's leave from NYU, spending alternate months between Kochi and New York (I had to wind down my research lab).

The Power of Collaboration  

The concept of a "Head and Neck Institute" was to create a center that could nurture creativity, push the boundaries of what medicine could offer, create an ecosystem where all of us could test the boundaries of our capabilities, but enjoy the work. As the saying goes, "The whole is greater than the sum of its parts". Collectively, we strive to achieve more than what any of the members can achieve individually.

We also started a training program to create a cadre of surgeons who would expand and sustain the ideals. We wanted to create a team from diverse medical specialities aligned to solve complex clinical problems of the head and neck region, agnostic of the medical disciplines they are trained.

Then, it was a manhunt to identify the right people—Subramanya Iyer, a plastic surgeon, whom I met as a fellow trainee in St. Lawrence Hospital, Chepstow, the Welsh Center for Plastic and Maxillofacial Surgery, joined the team. Sherry Peter, a craniofacial surgeon trained in medicine and then dentistry, was already working at AIMS and was brought to the team.

Jerry Paul, a man with a Buddha demeanour, for whom nothing fazes, was assigned as the anaesthetist, and Valsamma and Lilly as nurses in charge of OT and ICU; Kavitha as the administrative assistant of the service.

We were ably supported by Dilip Panikar, a very talented neurosurgeon, and Manoj, a daring cardiovascular surgeon with always a smile on his face, even when blood hits the ceiling. Apart from Richard Cohan and TK Padmanabhan, leading radiation oncology, there was Pavithran, a very knowledgeable medical oncologist, Vijayakumar in surgical oncology and the legendary Rajagopal for pain and palliation.

As the wise person of the cancer service, he ensured that patients' interests are always kept at the heart of all we do. Andrew Fishman, a skull-base surgeon who worked with us in Bellevue Hospital and NYU, later joined the group.

The first trainee, Arun, an ENT surgeon serving as a coordinator of a clinical trial, was recruited from the corridors of AIMS, and then came Vikram, another ENT surgeon who was working in a primary health center near Nagpur.

As a new service with no patronage from any traditional medical speciality, we were scrounging for patients when a seven-year-old (same age as my daughter then) came to our new unit.She was earlier consulted by a world renownedworld-renowned craniofacial surgeon from the United States and deemed to have an inoperable tumor.

The child was suffering from a rare condition called fibromatosis. It is a progressive disorder where abnormal collagen fibers slowly invade normal structures, choke them, and make them dysfunctional. It is a relentless disorder with no effective treatment other than surgery.

During the young age, the child had already undergone two surgeries by the top two surgeons in Mumbai and consulted US surgeon as a last resort.

The child’s condition, then, was that the lesion had recurred in the right jaw and had gone inside the brain. More significantly, it had invaded the carotid artery supplying the brain.

Removing the artery was found to be fatal, hence the tumor inoperable. The disease and the scarring had distorted the growing face.

I quickly reviewed the previous records as well as studied the heaps of scans the child had undergone. Compared to my seven-year-old daughter, naughty, fidgety and always up to something mischievous, this child was drawn to herself, not even making eye contact.

As top doctors in the country and abroad expressed helplessness. Even for me, one look at the massive tumor of the jaw invading the brain, the System 1 reflexive thinking was activated, and I instantly closed the case.

However, at the Head and Neck Institute, we had laid down certain rules—a collective team decision would be followed, not an individual decision. We put up the case in the multidisciplinary tumor board.

As the brain was involved, we requested Dilip Panikar, Chief of Neurosurgery, to attend. He looked at the scans, as a reflex, declared the tumor inoperable. Then I noticed one thing—his eyes were focused on the tumor in the neck rather than in the brain, where he was supposed to focus.

I covered the neck part of the tumor in the scan and repeated the question—is it operable? He paused; the System 2 analytical thinking started functioning. “Yes, it is feasible”, he said.

I focused my attention only in the face and neck and said it was feasible to operate. Then I saw that the whole mood of the tumor board brightened. After all, everyone in the world wants to be successful.

Tumor removal and reconstruction 

Removing the tumor is one thing, but reconstruction of the face and jaw is another major consideration, especially in a seven-year-old child with a growing face.

Dr Iyer, the plastic surgeon, suggested bone from the leg, however, it was less likely to grow. Dr Sherry Peter, who reconstructs jaws in children with impaired growth potential of the jaw, suggested the transfer of the growth centre from the rib. However, in tumor surgery, where all soft tissues along with blood flow are removed, it is unlikely to survive. In tumor surgery, not only the tumor but also the surrounding normal tissue is removed to ensure that the tumor is completely excised.

In cases of trauma, where one needs to repair only the bone, with the soft tissues being intact, the bone graft heals well. For healing, bone grafts take blood supply from adjacent normal tissues. However, in cancer surgery, a bone graft (bone without its blood supply) does not work.

Dr Iyer suggested that he could harvest the rib along with the growth center as well as the surrounding muscles and blood vessels, and reconstruct by microvascular surgery.

One of the trainees, who was up to date with the literature, asked whether it had been done anywhere in the world, in the past.

Dr Iyer, confident in his capabilities, said with his characteristic smile, “Well, this may be the first case in the world, but it is feasible.”

Then attention turned to Jerry Paul, our anesthesiologist, who needed to keep the child under anaesthesia for 2-3 days, the anticipated duration of the operation. Jerry, usually very conservative but extremely supportive, said, “Don’t worry about that part, that’s my responsibility”.

So, the four “feasible” combined and became the solution to a seemingly impossible problem. With a well-thought-out plan, the team started the operation on a Wednesday early morning.

On Day 1: 

Dr Panikar had to free up the carotid artery in the brain from the tumor. The surgery could proceed only if this critical step could be completed. I gave exposure to the artery from the neck, and Dr Panikar patiently freed the artery.

On Day 2:  

With the help of Dr Panikar and the neurosurgery team, the head and neck group removed the tumor from the skull base, neck and jaw, well as the affected brain lining.

On Day 3:  

Dr Iyer and team harvested and reconstructed the jaw with the growth center from the ribs, as well as rebuilt the missing skull through microvascular surgery.

The blood vessels in a 7-year-old child are less than 1-2 mm in size. To reconnect, the surgeons must use very tiny sutures that can be seen only with magnification of up to 20 times under a microscope.

New challenges and indomitable courage 

The child was shifted to the ICU. Dr Iyer’s team may have slept for a few hours when the call came from the ICU that the millimetre-sized blood vessels they had connected to the neck vessels may have been blocked.

In a skull-base surgery, a dead flap— a flap that failed to survive after being transferred from one part of the body to another, meaning the tissue did not receive adequate blood supply—is equal to a dead patient.

The brain floats in a liquid called cerebrospinal fluid. It is contained within a sheet called the dura mater. This also protects against infection from getting inside the brain.

In this child, we had to remove this protective covering and repair it with tissue harvested from elsewhere in the body. This repair will hold only when the supporting tissue used for reconstruction is viable. When the blood flow to the reconstructed tissue is lost, it affects the viability.

If the tissue is not viable, the repair of the dura mater will not hold, and the infection will get inside the brain, which is life-threatening.

The team quickly fixed the problem. Throughout the procedure, the support staff kept the family informed of the child’s progress.

The recovery About 10 days after admission, the child walked out of the hospital free of tumor, and the distorted jaw was reconstructed with a normal-looking face. As the referring surgeon advised, our team “kept an eye” on the child’s progress. We observed a miracle and the transformation of minds slowly unfolding in front of our eyes.

Within one month, the child could get back to school. Once healed, there were no major functional limitations. After the surgery rebuilt the missing skull, she started eating within a week; as well as talking, five days after surgery.

Miracles do happen

The jaw that Dr Iyer reconstructed grew like a normal jaw, creating a symmetrical face. This was the world’s first vascularized growth centre transfer anywhere in the world. (Vascularized means transferring a tissue from one part of the body with its blood supply and then reconnecting this blood vessel to the vessels in the neck.)

Grit and more grit 

The child had some difficulty raising her arms, which required physiotherapy. The scar on the neck, as she grew, became wider and required cosmetic surgery.

The reconstructed jaw did not have teeth. This was later inserted by the AIMS Head and Neck team.

The longest surgery at Amrita  

This child may be the first patient cured of fibromatosis of the skull base. There were several other firsts in that surgery—it was the longest surgery at Amrita Hospital.

Several firsts in the surgery 

• It was the surgery where the largest number of medical team was involved—about 18 surgeons and 8 anaesthesiologists, 20+ nurses, several technicians and many junior doctors and support staff.

All the team members came back to their routine work the next day itself—no break. It was managed as any other surgery, and major , there was no public announcement in the media.

The “Head and Neck Institute” continues to excel..

The “Head and Neck and Plastic Surgery Institute of Amrita continues to excel to greater heights. Dr Iyer’s team has the record of performing the largest number of hand transplants in the world.

Courage is contagious: Spread it

We could also see transformation in the people around us. Dr Jatin Shah, former chief of the Head and Neck service of Memorial Sloan Kettering Cancer Center, once commented that the Amrita Hospital Head and Neck training program is one of the best in the world.

The AIMS trainees now dispersed throughout the country, from Kashmir to Kochi, Gujarat to West Bengal, are transforming the Head and Neck oncology of the country.

Several surgeons from around the globe were trained at Amrita. Many are taking leadership positions, such as the President-elect of the International Association of Oral and Maxillofacial Surgeons.

I keep in touch with patients and their families. A few years back, I caught up with the child and her family in Mumbai. Once a shy introvert child, has now grown into a confident young adult. The occasion was to celebrate her admission to a university in Boston. My daughter, too, got admission to Northwestern University, Chicago.

We are happy that the child not only got cured of an incurable tumor, but is also excelling in life. When I met Richard in New York, I narrated the story of the child.

All this happened because one person dared to say "Yes" and to resign from a comfortable position at New York University, relocate his family, including the pet dog, to a foreign land, to plant a seed for a new idea.

System 2 Analytical Thinking at work  

Renowned psychologist and Nobel Laureate Daniel Kahneman, in his famous book, "Thinking, Fast and Slow", talks of the brain being divided into two agents, called System 1 and System 2, which respectively produce fast and slow thinking. These can also be thought of as intuitive and deliberate thought.

System1 Reflexive Thinking

Often means being quick to act. It is an immediate reaction, though important to overcome dangers, when overwhelmed by challenges, it may freeze thinking.

System 2 Analytical Thinking  

On the other hand, the solution to complex problems needs analytical thinking, coupled with systematic execution. This surgery and the collaboration it brought about highlight the net results of System 2 Analytical Thinking when working together as a team.

Dr Moni Abraham says, “We strive to incorporate the incremental-to-exponential thinking approach of our advisor, Vivek Wadhwa. Here, the concept of ‘the whole is greater than the sum of its parts’ is apt.”

About

Dr. Moni Abraham Kuriakose, formerly Professor and Chairman of the Department of Head and Neck Surgery and Oncology at Amrita Institute of Medical Sciences and Research Center, Kochi, is currently serving as the Medical Director and CEO of Kerala Operations at Karkinos Healthcare, Kochi.

He plans to establish the “Center for Complex Cancer” in Kochi, where no cancer would be regarded as incurable for lack of effort.

If there are no solutions on the globe, we shall strive to create one, keeping the “patient-first approach”. He believes it is not the infrastructure or personnel that matter, it is the approach to solve seemingly impossible problems—collectively and systematically.