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Cochin Clinical Society Meeting January 2022

Jan 20 | 2:00 PM

The Cochin Clinical Society brings to you case discussions from various specialties of medicine presented by the doctors of Lisie Hospital, Ernakulam. Dr. Anwar K - If it is not left take the right Dr. Antony George - The man with a five chambered heart Dr. Hasim Ahmed - A bridge across two lumens Dr. Neenu P - And all that was needed was a good WASH Dr. Sandeep Suresh - An intriguing triad of epistaxis, exopthalmos and lymphadenopathy

[Music] good evening to all of you let me in the outset thank the question clinical society for giving the hospital the opportunity to do the third i i presume it is a third online question clinical society meeting which started recently i am so happy to uh to host uh the ccs meeting on behalf of the lizzie hospital and i welcome all the uh hosts of the clinical society um on behalf of the libya hospital especially to dr vasanthanaya a warm welcome um and also dr uh ramesh shanai as well as dr subramanyam and also i welcome our director father paul keredin uh who would be delivering the word of thanks and let me welcome dr matthew philippe who doesn't need any introduction at all he's the head of the department of uh gastroenterology of philisti hospital and he has kindly consented to chair the session and with his vast experience and exposure in the medical field i am sure he will be able to coordinate the program in a befitting manner i also welcome all the speakers who has really taken so much of pain and effort to prepare slides collect informations and uh for joining this lissie clinic in clinical society meeting um and once again let me welcome all of you and i invite dr matthew phillip to take over the session and start with the the talks thank you josh for your kind words and for the kind invitation to share the session and thanks to the office marriage of chinese society for giving this opportunity to moderate this uh online wonderful clinical session and as usual we have five wonderful cases and jaws would be knowing there are so many cases where putin put across for presentation society but with the difficulty we could select around five cases which are all quite interesting cases and it's all thought-provoking cases new interactions new procedures and we have five interesting cases and the first one is by dr anwar and he's from the department of cardiology and he is presenting if it is not left take the right so dr anwar you start your journey don't take left or right straight okay respected chair senior members teachers my dear friends and colleagues very good evening to all i am dr anwar from department of cardiology i am a dmv trainee i am here to present before you an interesting case of a 77 year old male 1 he said no he's a non case of systemic hypertension and is on anti-high pregnancy he presented with six month history of generalized edema abdominal distension and scrotal swelling initially he was evaluated in the department of general medicine they did all the routine investigations to roll out the causes for anasaka that is generalized edema the routine investigations like blood routine examination uh esr urine routine examination serum electrolytes renal function test total protein albumin uh then thyroid profile urine 24-hour protein etcetera all within normal leaves so they went ahead with usc abdomen which was normal and the liver kidneys plain all were normal except for the gross societies so they did a acidic fluid tapping and study which showed high sag ascites there was no evidence of any malignancy or tuberculosis and they did a ct abdomen also which showed norm which was normal except for the dilated infervenica and hepatic veins and also there was gross acidities so actually they will roll out all the causes for ana sarkar the causes can be renal causes like renal failure nephrotic syndrome etc then hepatic causes like chronic liver disease cirrhosis then some sometimes drugs can cause anasaka and allergic reactions then hypothyroidism uh cardiac causes can also be there they did usc abdomen which showed liver kidney extra driver within normal limits and normal echo texture a lefty rft were within normal limits and there was no history of any drug intake except the except for the antihypertensive there was no history of any uh exposures or allergic reaction his thyroid profile was within normal limits and seeing the dilated hepatic veins and inferior vena cava they referred the patient for cardiac evaluation they send a cardiac consolation we saw the patient and took over to our side for further evaluation so again we started from the history he gave the history of progressive generalized edema for past six months initially it was only pdl edema which was pitting type of edema later on progress to abdominal distension and for the past two weeks he is having orthopedia also but there was no history of any paroxysmal nocturnal dyspnea no history of any chest pain syncope palpitation no history suggests you of any hepatic or renal dysfunction no history of any drug intake other than anti-hypertensives no history of any exposures or allergic reactions one example on examination he was disney febrile and he was obese with a bmi of 30 and the there was elevated jugular venous pressure of 10 centimeter above the root of neck with normal waveforms and there is a bilateral beating type of pedal edema also abdomen was distended his blood pressure was 150 bar 80 millimeters of mercury in sitting position right upper arm and pulse rate was 90 per minute which was regular normal rhythm and normal character and precodium was symmetric with normal apex speed there was rv type of epigastric pulsation palpable there was no left parasternal hume or palpable p2 first and second heart sounds were normal there was no third or fourth heart sounds there was no there were no murmurs or additional sounds right hypochondria must enter to summarize the clinical findings he had generalized edema elevated jugular venous pressure rv type of epigastric transition and right hypochondria was tender without any history of peroxism and optimal dystrophy all these are suggestive of an right side right heart pathology with systemic venous congestion now now what are the causes for systemic venous congestion the most common causes for a systemic venus congestion are congestive heart failure then myocardial diseases like restrictive cardiomyopathy constrictive pericarditis dilated cardiomyopathy arithmeogenic right ventricular cardiomyopathy then vascular causes like chronic thromboembolic pulmonary hypertension with the right ventricular dysfunction then valvular causes like tricuspid regurgitation tricuspid stenosis etc then ischemic causes like right ventricular myocardial infarction this was his ecg which was essentially normal uh normal sinus rhythm with frequent supraventricular ectopics and there was loss of r wave in the b to lead and there is a q wave in lead 3 only that can be normal also x-ray showed [Music] cardiomegaly with right ventricular type of apex there was no features of any pulmonary venous congestion and this was the echo can you please play the videos yes yes okay uh in the first first clip you can see the uh left ventricle which was uh uh of good ventricular good systolic function there is gross left ventricular hypertrophy is there right ventricle and right atrium are dilated but there is no definite regional wall motion abnormality next slide please okay please display the video okay rest multi-mode mild tricuspid regurgitation also next slide okay and you can see a moderate ph also in the doppler so echo findings are concentric left ventricular hypertrophy normal left this left system is normal uh no regional wall motion abnormality right atrium and right ventricles were dilated and there is also moderate ph so uh these are the differential diagnosis after seeing the investigations echo echo and x-ray ecg there is definite rv pathology can be rv dysfunction uh restricted cardiomyopathy constricting pericarditis then there is possibility of chronic thromboembolic pulmonary hypertension so uh we went ahead with the ct thoraxicity a pulmonary angiogram which showed no evidence of any filling defect suggestion of ct eps that is chronic probability permanent hypertension the pericardium was normal normal thickness there was no evidence of any calcification of pericardium so we ruled out uh the constrictive possibilities of constrictive pericarditis and ctph and we did a gas study also to assess the pressures of the heart chambers the right atrium the mean pressure was 28 millimeters of mercury right ventricle it was a systolic pressure of 52 and diastolic pressure of 29 pulmonary artery showed ah 62 bar 80 millimeters of mercury with mean pressure of 35 millimeters of mercury left ventricle it was 180 bar 28 and in iota it was 190 bar 110 millimeters of macro so what is the interpretation of cascity here uh the right atrial and right ventricular mean pressures are elevated and the left ventricular end diastolic pressure is also elevated so patient is in congestive heart failure and a lv endoscopic pressure is approximately equal to rv industrial pressure and all these are suggestive of a restrictive physiology but one there was one old finding that is mean pulmonary artery pressure is not that much elevated it is only 35 millimeters of mercury and patient is having only mild ph that is against the diagnosis of against the possibility of restrictive cardiomyopathy so what next as the part as a part of custody we did a coronary angiogram also so which showed display the video oh yes your time is getting assisted okay uh here you can see the uh critical stenosis of a left circumflex and near total occlusion of the proximal right coronary artery so we came to the conclusion that next slide please we came to the conclusion of possibility of ischemia-induced rv dysfunction and the diagnosis was chronic isolated ischemic rv dysfunction with systemic venous congestion and uh he was he improved with the standard therapy and advised to undergo pci2 right coronary artery and left circumference artery my take-home message is uh systematic uh history taking and clinical examination are still important and ischemic heart disease can also present with anasaka don't be lv centric always because uh most of the cardio is nowadays while dealing with coronary artery disease they are concerned about the left side of the heart only but ah ischemic heart disease can also present like isolated rv uh pathologies are we failure our harvest function okay thank you thank you thank you anwar and it's a very interesting uh issue and it's a very seldom thought also and very well worked up as a housekeeping announcement those who want to ask questions he can put questions in the comment box and that that we will discuss on the comment box and tell me ask that question because i cannot see very well here so i think you know here the interesting point is that it's actually a high sagas i think you know and we are you know as gastronors we are also very much interested in high psychosis and we have come across cases where we diagnosed constitutive recoverages and right out right ventricular emf and all those things and sent back to the cardiologist i think it's quite interesting and whenever a scientist comes i think you know studying that fluid and looking for sag that is very very important and that will give us an idea where what type of uh ascites you are handling with whatever disease you are having and in this patient final diagnosis what do you think is it's because of ischemic heart disease affecting the right ventricle am i right yes sir chronic ischemia causing rv dysfunction so it's a chronic issue it's not like he never had suppose this patient we know that we have come across patients with a right representation like cardio failure and hypotension analysis and this patient he has no uh i mean um symptoms no he has no anger and is it described this these type of entities are described yes sir any questions on the comment box jos um actually we were also unpleasantly surprised many times when um when we open uh for a cabg the left ventricle is pumping well and the rb is really uh you know looking quite bad and a lot of a lot of patients we have operated who you know i mean easy patient was in sinus with them but a lot of patients we see with rv dysfunction they go into atrial fibrillation also early enough and early itself and once the ischemia is corrected uh they do well and over a period of time the rv improves but when i looked at the angiogram this guy has got a significant led disease as well uh whether it's it's which i misinterpreted or not it looks like it's a triple vessel disease a long drop is very symptoms good i'll be no regional motion abnormalities only rb dysfunction i think it you know we have to keep a high index of suspicion and it is very interesting case and uh how is the patient now he is symptomatically better than we we advised for angioplasty and he will come next month okay any other questions uh those can you see any questions on the comment box um yes uh i don't know how to open the uh no no there is so you can just click on the comments uh uh option right from the box and i think subramaniam server asked how come it wasn't manifesting on the ecg oh yes if it is chronic ischemia causing there is only dilatation of the dilatation there is no regional motion abnormality there is only direction and rv dysfunction only that is also chronic so you don't expect any ecg changes as such no yes is that right yes okay thank you amber and it is if there are no other questions i think we should go for the next case thanks amber a lot uh for this interest and the thought working case rather i would say that the patient has come with anasaka and finally without a left heart failure isolated right heart failure or something like that without any permanent hype there are so many issues of this i think it's a very landing just got to give us a lot of leading points [Music] for each presentation and because of the technical issues the first we have to allow a little bit more time okay so good evening everyone yes sir good evening everyone respected teachers and my dear colleagues my uh presentation is a bridge across two lumens i myself dropped hearthstone representing this institute of gastroenterology so the patient profile is a 65 year old female who is a diabetic hypertensive with the history of cva she presented to us with a history of fatigue early satiety and post-triangle vomiting of three months duration and the vomiting contained undigested food and was coffee colored and it was coffee color she had significant weight loss which was not quantified and in this three months she has literally become better so in clinical examination hemodynamically she was stable her general examination she was catholic and she had power and cystic examination showed an epigastric mass and she was she had a cog score of three investigation wise she had a anemone of 8.7 she had hypoproteinemia with severe hypernemia and she had dissolved ecg chest x-ray and upcoming x-ray race the video please we did a upper gs copy for this patient and when we went in we could see that there was cases of food and as we went down from body to the andrew you can see that there is some infiltration in the pyloro and complex you can see that you are not able to get across to d1 due to the narrowing next slide [Music] yes so we did a ct abdomen and there was a circumferential proliferative mass involving the pilot region causing stasis and dilatation of the stomach so you can see that there is a mass the arrow shows there is a pyloric neoplasm and you can see that the stomach is distinct with the contrast and there was perigastric extension lymphoma metastasis and mental deposits so here we have a disseminated customer stomach with gastric outward obstruction in an elderly female with multiple commodities with their neck box score of three so what are the options that we have so basically basically we have only palliative options so there's in surgical and non-surgical so the non-surgical options are oneness and aso digital tube we put across a tube we put a tube across the obstruction but the problem is there can be accidental removal there can be two blocks there will be nasal rotation and the main thing is the patient cannot take orally and there will be poor quality of life next is the self-expanding metal stent sems and the thing is the stem displacement they can be stent displacement which is described even up to 30 to 40 percent there will be tumor in growth or overgrowth producing the blockade of stem they can be footballers infection and rarely perforation when we deploy the stem but the good point is the patient can take hormone coming to the surgical uh methods you have the gastrointestinal ostomy here the problem is in a cactic sick patient who is with multiple commodities duration of anesthesia will be a problem and there will be significant post surgical mobility but the good point is the patient can take oral fields next is the feeding jagenostomy which is again a surgical procedure here also the revolution of anesthesia may not be tolerated by some patients there will be tube dislocations there will be two blocks and the main thing is the patient cannot take order so here we have age patient with common objects with an echo score of three that is pro performance status with the disseminated cosmos term of the gastric outlet obstruction so the palliative options were given surgical versus non-surgical the only demand that she made was she did not want any surgery and she wanted to eat orally so are there any new options for this female and yes we do have it that is an endoscopic ultrasound guided gastrogenous so here the eusgj it is a fully endoscopic creation of the gastrointestinal bypass which is a new kid on the block this process this procedure basically involves locating the jejunum into sonographically from the stomach and we place a dedicated by flanged lumen opposing metals that is lamps in short across a newly created fistless cut it is done only in few centers in the world and we do it so the technical success is 85 to 90 percent and the clinical success is 75 to 90 percent and the complications include abnormal pain peritonitis peptide is predominantly when we do it sometimes the phalanx the phalange of the skin might get slipped so that can produce retinitis and bleeding so the pros of this procedure is less anesthesia time we usually get it done in 15 to 20 minutes relatively safe and sick patients not amenable for surgery no incision is there so there's no question of poor wound healing because majority of the patients have severe hypoproteinemia and there is no risk of post-op incisional pain preventing ambulation and deep breathing and the greatest thing is they can be started on feeds the following day so the prerequisites for this procedure is the tumor should be limited to the android it should not come up to the body or go distally beyond vj flexion and the ct should show no obstruction distill the proximal system fluoroscopy should be there ear strained and experienced endoscope should be there necessary accessories including the lamps delivery system and trained endoscopic stuff so the challenges the main challenge in this is basically obtaining a stable distended judgmental loop adjacent to the stomach various methods are used and we have created our own novel technique here we have used a twelve french nais tube and we have modified and fitted with two balloons which can be inflated and there are four ports through two ports for inflating the balloons on one cord for putting the guide wire and another port for flushing in water so that jesus can be distended and we'll see how this works so coming to the procedure to get an idea if you look at the stage picture one first we put it across a catheter across the structure and pass a guidewire and over the guide wire we pass the balloon then we distend the both the balloons so you can see that the judgment becomes uh stable and it becomes close to the stomach then we inflate the judgment with water water mixed with methylene group why methylene group we will see shortly so once this jejunum is distended we identify this part under the using the eus and once this part is identified we use the lamps delivery system we put a hole in we put in the stem and thus aluminum is created play the video so here we saw that you know we are not able to go across so what we do is we put in a catheter across and put in a guide wire because this can be seen under fluoroscopy you can see that we are passing a guide wire across the structure or the growth into the jejunum and over the guide wire we put in the balloon this is the balloon and that we put in you can see that in fluoroscopy and the balloon can be easily passed over the guide wire into the jejunum once it reaches the judgment what we do is we inflate both the balloons around 20 cc of water mixed with mexican glue is injected and you can see that the balloon is getting inflated and we get a stable glue so once this is done what we do is we inject we have pass water into the judging loop thereby distancing it and we visualize it using eos and you can see that the loop is getting disturbed ideally a three to four centimeter this tension should be there and once this loop is identified this is just we are measuring so that you know we make sure and once the loop is identified we walk in with the lam's delivery system and this you can see it under fluoroscopy we are putting a hole across into the original room and we deploy the distal phalanx once the digital phalange is deployed we pull it towards the stomach so that the wall of the stomach as well as the genome comes close by and then we deploy the proxima proximal phalange in the stomach so once the proximal phalange is opened the blue water comes so once we see blue water we know that we are yes we are where we have gone where we want it next we put in a cre balloon we dilate the stem up to 12 to 15 mm and once the dilatation is done you can see it under fluoroscopy we can see you can see the dilatation once it is dilated you can see that yes a new lumen is ready we have bridged it slides yes so this is the top picture shows a post of intra intra procedure you can see that the lumen with the stent connecting both the lumens and the picture to the left you can see that the next day we did a contrast study and you can see the contrast going from the stomach across the stent into the genome and this is a ct image which shows the stent connecting these two lumens so post-procedure period we start on we usually start to increase the next day itself equals the semi-solids and the patient gets discharged the following day so the take-home message is eus gasteous guided gastroenterology is a novel endoscopic therapy for patients with gastric outward obstruction it is safe in sick patients not amenable for surgery and it is as efficacious as their surgical counterpart thank you thank you for this interesting technique as well as devices inventing our own devices for use procedures i think that is very interesting and this type of tubes are not freely available and it's still evolving so it is made custom made and is quite good and totally useful and um [Music] hashim the main concern when it comes like this now and operate in when you do a surgical gastric bypass the low the size of the dj is quite good so when you do these type of procedures like do you think that the size of the uh dj is yes size is enough because the size is almost two centimeters two centimeters yes 20 mm the diameter of these tests so that is more enough for the food to pass sorry i am not able to hear hello [Music] [Music] or a draining tube you can drain the situs and then do the procedure so aside this is not a counter indication and it's only a relative contraction assessment of the patient the question is you know do the patients see a stomach with metastatic disease they don't live very long so their main thing is they just we still remember patients saying i just want to eat through my mouth so nutritionally the yes they may not improve that yes there will be some improvement but not much nutritionally they will impress it is a catabolic state the survival but the disease will take its course yes [Music] is that this is done basically for malignant diseases well well there are some case reports where they have done it but it is not uh this is generally not recommended but now yes not recommended yeah they have even yeah yes and there is another question is what are the complications that can occur in this cell so the complications can be one uh one is during the deployment of the stent sometimes the distal phalanx if you don't if you don't make sure that it is within the it just lumen for that the drizzle luna has to be dilated at least three centimeters extended at least three centimeters or else what can happen is the salines may get deployed outside so that can produce uh pertinitis or bleeding the next is bleeding sometimes he can produce severe abdominal pain also i think the most important complication is that technique related no it's actually my yes technically yes another thing is if yes if we don't distant the system properly there will be rapid runoff of the water to the column and accidentally we might do a gastropolis to be rather than a gastroenterologist and dr supervisor is asked whether this can be lost endoscopically later no sir most of the patients may not make it till then because we do it for metastatic disease well this is actually what is asked for is for benign process now in benign courses what we did yes we can we can probably try it with the always go over the clip you can just remove that you can just just remove it yes just remove it yes yes that is true but if it bursts we can always use an overscore that is over the clip to over the scope click to close one more question during the procedure yes perforation is one of the risks many that i see the thing is it's a relatively new technique so there are many institutions a few institutions which are doing it and their sample size is actually less than 50. so if you look at it the complication rate is anywhere between 1 to 10 and yes they ever had one or two cases where the perfection has happened luckily for us we have done 13 and uh i think the most important thing is now you have to have a good technique and yes we should have a good uh endoscopist that plays a major role and i i think this accessory you know the tube which you are made is quite good and yes so thanks a lot actually which is available that the problem is that cube is very flimsy that is one second thing is you need an over tube to pass it but this uh this njtu which you have made it is very uh it's slightly uh uh mostly so it's very easy to pass stiff so it's very easy to pass across actually no sir not sir it's not available this invention was made for the next case there are some more questions we will address it later and now thanks hashim for this interesting problem invention everything uh innovations whatever it is so i think we should move to the next place by dr anthony george he is from the department of cardiovascular he is going to present a case with a man having five chambered hearts dr anthony please good evening all uh let's go into my presentation it's about a 48 year old gentleman who did not have any cardiac comorbidities who presented by himself to the hospital with complaints of breathlessness of a recent onset on evaluation he was found to have few waves in the ecg and echo evaluation showed the presence of a severe biventricular dysfunction and an aneurysmal cavity on the basal inferior wart now this a neurosmall cavity was of size around nine into eight centimeters and contain the layered plot of size around sixth now for the normal left ventricle has a size of less than six mil centimeters on further angiographic evaluation he was also found to have triple vessel coronary artery disease uh the types of left ventricular aneurysms it can be a true aneurysm or a pseudo aneurysm both are as a result of a myocardial infarction and result in a dyskinetic portion of the left ventricle that is as the left ventricle contracts the neurosmall cavity expands and vice versa now to compare and contrast between true aneurysms and pseudo-aneurysms pseudo aneurysms are always found in the led territory of the heart has relatively wider neck and is lined by myocardium whereas a pseudo aneurysm has a narrower neck it's located poster basically and is lined by a clot which means there is no structural support for the left ventricle and it is always at a risk of expansion and potentially fatal rupture thus a pseudo aneurysm always calls for a surgical approach towards repair now with this gentleman the surgery was complicated because of the presence of a significant biventricular dysfunction and the requirement to go on cardiopulmonary bypass and do a neurosmall surgery which involves a surgical instruction on the left ventricle which results in further left ventricular dysfunction and in increases the left ventricular irritability as you can see the intraoperative finding can see the aneurysmal cavity which pushes the right ventricle above and to the left resulting in a uh resulting in replacing the major chunk of the media scanner uh i have a couple of echo images could you play uh the clip 5a please yes so they'll be played together simultaneously okay fair enough uh so the one on the left it shows the aneurysmal cavity with the contained plot in relation to the mitral valve this is an on first view of the mitral valve so it's located postero basically you have in a neurosmall cavity with a layered plot inside and on the slide on the right side could you make that play please also it's playing can you not see it i'll start it again okay can you see the video i can't see it moving but basically i want to demonstrate the fact that the neural sag sac has a larger depth than diameter so it's probably a pseudo aneurysm i just wanted to focus on the relative dimension of the aneurysmal neck and the dimension of the sac thank you can i go back to the slideshow please the next slide please so you can swipe to the next slide yeah sorry that thanks uh these images are used to demonstrate the size of the lv plot inside and its relative position compared to the left ventricle now this patient underwent a neurosmectomy with coronary artery bypass grafting he uh required a total iot cross clamp time that's the ischemic time to the heart of 102 minutes and a cardio foundry bypass time of 212 minutes 200 grams of clot was removed from the sac the neurosmall cavity was opened and a ptfe patch was placed followed by trapping over the repair and as i told subsequent graph to be ladd dm1 and om now in any patient who requires support of an extracorporeal circulation during grafting the period of weaning is of crucial importance weaning is nothing but changing over the patient from a full circulatory support to a spontaneous cardiac activity now the important points are to make sure that the heart is generating adequate blood flows and adequate pressures to maintain tissue perfusion and this requires optimization of both systemic and permeable circulations and requires a teamwork and close clear communication between the surgeon anesthesiologist and the perfusionist now it also involves supporting the heart to improve its contractility and cardiac output and it can involve pharmacological as well as mechanical supports which i'll be talking on later now going back to the physiology of weaning and improvement of tissue oxygenations as dr anwar rightly told it's also important to focus on the right ventricle as the left ventricle in order to improve the right ventricular output and left cholesterol in cardiac output and to improve the tissue perfusion and tissue oxygenation staying on physiology for another slide remember that oxygen delivery depends on the cardiac output the hemoglobin level oxygen saturation or hemoglobin saturation and oxygen partial pressures and the cardiac output in turn depends on the preload after load contractility and heart rate thus to optimize the tissue oxygen delivery you have to constantly and constantly assess and titrate or drugs to improve the cardiac output and tissue delivery now remember that we do this pharmacological support with use of multiple agents which can be broadly classified as inotropes inodylators vasopressors vasodilators and we know dilators now also remember that these are drugs with differing actions of on multiple receptors and the actions on multiple receptors change as the dosages increase or decrease by a fraction of few micrograms per kg per minute so a very fine tuning and very fine titration of these agents along with surgical manuals need to be ensured to optimize tissue oxygen delivery and ensure a successful weaning from cardiac family bypass now apart from the pharmacolog apart from the routine pharmacological supports we might also require agents such as inhale nitric oxide and also optimization of cardiac output and oxygen delivery by using blood and blood products now our patient our patient came off bypass but he displayed a very significant right ventricular dysfunction you could go back into the slideshow thank you now this was not unexpected because he already had a poor right ventricular and as i told we subsequently added the insult by use of a cardiopulmonary bypass and a left hand reclass surgery so measures had to be employed to improve the right ventricular cardiac output and this was to improve the contractility using enotropes adjust the intrathoracic pressure by fine tuning of the ventilation as in changing the positive and exploratory pressures tidal volumes inspiratory expiratory time and expiratory ratios optimizing the preload maintaining a coronary perfusion pressure by increasing vasopressors as against to enotropes and by causing pulmonary vasodilation our first stage was to add and increase the dose of dobutamine which is a relatively good eno dilator that is increases the contractility and causes vasodilation thus reducing the afterload but we also had to use inhaled nitric oxide now why is inhaled nitric oxide important it causes selective primary acidity and because it is metabolized in the boundary circulation you don't have much of systemic side effects now what we had to watch for was the present was the formation of nitrogen dioxide because in lower doses nitrogen dioxide increases the airway reactivity whereas at a higher doses it can itself result in boundary edema and reduce myocardial function another thing to watch for was the presence of methemoglobinemia which reduces the tissue availability of oxygen and thus results in tissue hypoxia as i told of endpoint was tissue oxygen consumption and controlling methamoglobinemia was also important now we also had to use a mechanical support in the form of an ibp ibp is nothing but a balloon placed inside the iota which inflates during systole sorry in place during diastole and deflates during systole thus improving the diastolic coronary blood flow and increasing the forward cardiac output now we used all this he recovered the myocardial function over a period of time the inotropic supports could be tapered off in two days it was off the ventilator in two days the iabp support was drawn out after four days the patient was shifted to the warden on the fifth day and could be discharged from the hospital on 10 days and he's under a regular follow-up now i'm sure many of you are familiar with this clip from the second skill thank you thank you anthony for this excellent work of excellent diagnosis thank you management and the last side slide tells everything and uh yeah i i appreciate and thank all the team members involved in this it's a wonderful uh wonderful time and i would like to know for i mean i say common uh lay down i just want to know how do you differentiate a pseudo aneurysm and a true annulation of the heart because we know that this is a death defying entity when you get a pseudonym from your heart it is actually very serious thing and if you don't diagnose early if you don't manage early they may rupture and they may die so it's a very serious situation but uh considering yourself through aneurysms you know it can be managed medically also so how do you differentiate between these two yes uh i go by the slide that i presented a true aneurysm it would be the location of the aneurysm a posterior basal region is the most common location for a pseudo aneurysm and uh the that ratio between the next size and the sax size though it's not a foolproof criteria it can be taken up as a indicator of whether it is a relatively larger neck and a smaller body so that the neck two body size ratios around one is to one whereas a pseudo aneurysm has a neck to body size ratio of half so the neck is relatively smaller compared to the body but as again the i don't think there are any food telling that this is yes it's in fact a pseudonym other than doing a pathological study later and finding out true what could be the cause in this patient what would be the cause in this patient uh she would have had a prior mi now why why i focused on the defined death part is also because of this history he probably had he stayed asymptomatic he had a free wall doctor which started so he he had a mi he had a freeward rupture he presented himself with minimal symptoms he underwent a very complex procedure and then he came out alive so that's why i was focusing on that beating the death part or beating the death in a game of chess yes i think i think the last slide tells it all and i think there's no and george you want to say something on this the case which he presented was one of the biggest uh pseudo-aneurysms which we ever operated even judah never seems versa is not that common it was so striking as if you remember the picture which we showed at the beginning the entire neurosum was bigger than the total heart itself and so surprising to see how this man survived all this while you know along with other countries also involved technically it's not very challenging but again once you remove an aneurysm the heart is relocated already the heart is not functioning well especially the neurosum neck is so close to the mitral valve attachment where a little bit of variation or change in the suturing technique can probably precipitate a severe mitral regurgitation which probably could be also fatal so um you know it was overall clinically as well as surgically as well as management i think the statistic will have the highest challenge that's the reason why dr anthony's person in the case rather than a surgeon post-operative care is very important and i think it is something which is a teamwork which really led to a successful culmination of the treatment i think i think it's uh very hard to know that the anesthetist is presenting and the surgeons allowed the anesthetist to present it that's also it's a good gesture showing that how much hard work they are doing behind the curtain and it's very interesting and thanks a lot i think you know there are a lot of focuses for anthony in the comment box but there is no hard asset questions there and one more thing is as a subramanyas has recurrence rights of such pseudonyms what's the recurrence rate i am not really sure also i am not sure about the recurrence rate sorry recurrence is not that common uh provided you know the edges of the aneurysmectomy is quite strong and we could do a suturing but we had one patient who had a recurrence of the aneurysm about five years later probably he had a very small leak from one of the suture lines which kind of culminated in an aneurysm but generally other currents may not really need any attention it can be conservatively managed thanks a lot i think we need to move we are getting late and thanks andy thank you and moving to the next case that is by dr ninopi who is a dmv trained in the department of anesthesia and she is going to tell us and all that needed was a good wash and the citizens are known to wash their hands after the case but no this is actually they are going to wash the patient so let us have that dr nino good evening to all my teachers and colleagues uh so i'm starting with my presentation and all that was needed was a good watch coming to the case scenario a 37 year old female presented to the pulmonology opd with history of breathlessness and cough with expectation which was mucoid since two days and history of one episode of fever which was shown after receiving the second dose of co-hacks there was no other presenting symptoms and she had no texts at home she gives a history of similar symptoms recurrently for the past five years for which she had consulted multiple physicians and she was treated by them as copd bronchial asthma and lower respiratory fat infection she also gives history of intake of systemic steroids for long term on examination her bp and heart rate was normal saturation was 95 in romaine she was stacking with a respiratory rate of 25 she had more fascists and bmi was 25. uh examination of respiratory system revealed fine instantly repetitions in the left infrared capillar and infra axillary areas investigation that followed included a coveted pronat which was negative her uh hemoglobin and serum ig levels was normal there was mild elevation in the total count and crp a 2d echo and pfd was done which was normal sputum was sent for culture gram steel and microscopy which was also negative and other routine blood investigations were also normal and uh the patient abg showed pao2 of 85 and she was maintaining a saturation of 97 with two liters of oxygen and her chest x-ray pa view showed non-homogeneous opacities in the left mid zone and lower zone so this is the chest x-ray pa view showing the non-homogeneous opacities in the left midzone and norbuster and treatment was initiated for the patient with bronchodilators steroids and antibiotics and minimal oxygen support uh the investigation is then followed by a ct products uh that for uh that showed crazy paving pattern with ground glass opacities and septal thickening predominantly in the left lung so the ct shows the crazy paving pattern at the level of tracheal bifurcation in the left lung so this is also a safety image showing the ground glass opacities with crazy paving predominantly in the left lower lobe so uh with this clinical laboratory and radiological investigations we could narrow down our probable diagnosis to uh pneumonia especially pneumonias pneumonia interstitial pneumonitis pulmonary alveolar proteinosis acute respiratory distress syndrome bronchoelevel or carcinoma a video bronchoscopy was then done by the pulmonologist under local anesthesia and sedation bronchial lavish and transplant lung biopsy from the left lower lower sticker the bongo alberon lavish was milky in nature cereal alligators showed yellowish milky fluid the bronchial lavish was then sent for culture which included aerobic fungal culture fungal stains and mycobacterium tuberculosis panel which were all negative and the bronchial wash bronchial wash and cytology and the past stain was negative the biopsy finding was suggestive of resolving pneumonia so uh the patient she showed clinical and radiological improvement after the bronchial average and she was discharged but was this the end a happy ending no it was not she presented a one uh presented one month later with history of breathlessness and cough with mucoid expectation since four days uh there was no other significant history uh on examination her bp and heart rate was normal saturation was 93 in romer and she was stacked with a respiratory rate of 30 and her blood investigations were normal and in one examination uh the respite of the respiratory system there were fine inspiratory crackles audible in the left for axillary and infrastructure areas as before and hs63 was also repeated and it also showed non-homogeneous opacities in the left midsole and lower zone and she was admitted and the treatment was initiated with crocodile later steroids and oxygen supplementation as she had shown miley women with the symptoms of the same before initially she was marrying a saturation of more than 95 percentage with minimal oxygen support but progressively the oxygen oxygen requirement was increasing and serial abcs were done which showed progressive hypoxemia so this abc shows the patient's po2 of 46 in rome so this could put us in a grave dilemma because on one side there was high index of clinical and radiological suspicion for pulmonary alveolar proteinosis and also the patient improved after diagnostic bronchial or lavish in the previous admission on the other side the histopathology and cytology was negative and above there was a patient who progressively was re-saturating and showing no improvement in her clinical condition uh so a multi-disciplinary approach was taken and discussions were held by pulmonologist anaesthesiologist patient and her relatives and with their consent we decided to proceed with the whole lung language so before the whole lung lavish epidural bronchoscopy was done by the pulmonology team under local anesthesia and sedation and wrangle washer scent for cytology and culture so uh the preferred mode of anesthesia was general anesthesia with uh intubation with the double lumen tube and after reoxidation and giving iv injection agents muscle relaxant the patient was intubated with the left side of double human tube can you please play the video first video so this video shows the integration so basically the double lumen tube has two lumens uh bronchial lumen and tracheal lumen and the the left sided uh the bronchial lumen will be inside the left endo ender bronchial area and the tracheal lumen will be just above the trachea just above the carena and uh after intubation the broccolin tracheal cuffs were inflated and we isolated the lungs and double leg mechanical ventilation was initiated and then the patient was uh positioned to lateral like with this position uh with left lung on the non-dependent position i would like to explain more about that so this is the position of the patient with the non-dependent uh with the left lung on the non-dependent position and then after confirming the position of the double lumen 2 the the single lung ventilation was initiated and uh the um bronchial tube that is the lung to be lavished um that is the bronchial uh like the wrong tube will be lying in the left lung so this tube will be connected to the um the tubings which carries the warm normal saline and uh lavish will be initiated and the other lumen will be connected to the ventilator so uh after adequate oxidation was confirmed uh with single ventilation the lung lavage was initiated with the patient in reverse standalone work and lateral ligamentous position and after the lung was full the fluid was then stopped and the patient was made supine and then the percussion of the lung was done for about five minutes and then the drain tube was connected in the same lip and the patient is made lateral liquidus and trendline work position and the fluid was drained by gravity into a container so when this flow decreases the outflow of tube will be clamped the patient will be again placed in reverse network position inflow tube will be connected and one normal saline will be passed to the lungs and the process will be repeated so the um uh initially the milky white effluent uh becomes less of opaque progressively and that is when then the double lung ventilation was received and the patient was positioned supine so in our procedure uh we used about nine liters of a normal select and uh approximately the same amount of fluid was drained and uh the procedure took for approximately about eight hours can you please play the second video so this shows the gravity dependent drainage of the bronchioles fluid okay uh after that uh the patient uh the double human tube was changed into uh uh changed into the single lumen tube and then uh she was ventilated overnight and exhibited the next morning and the patient was comfortable in roommate and she was maintaining normal saturation the bronchial brain lavish fluid which we uh sent the procedure for repeat cytology was positive for the diagnosis of pulmonary alveolar proteinosis that is it was past positive and diastasis so uh what is pulmonary alveolar proteinosis it is a rare uh disease where there is impaired surfactant metabolism and there is accumulation of alveoli of proteinaceous material which is rich in surfactant protein and its component it is of three types autoimmune congenital or secondary and the standard treatment of uh which is whole and lavish that is the removal of the proteinaceous material the uh i would like to mention about the autoimmune type it is the most common and it is mostly seen in the adults and here the basis produces gmcs of auto antibody which impairs the function of the gmcsf and thus its uh the ability of the gmcsf to stimulate the alveolar macrophages will be inhibited so the macrophages won't be able to remove the surfactant so the treatment options for uh pulmonary envelop totenosis includes whole language as mentioned before then exogenous gmcsf supplemental therapy metrics map and plasma process for the removal of the antibody and the ultimate treatment is lung transplantation and the treatment protocol uh involves the concinital cases observation oxygen therapy whole and leverage and lung transplantation for the secondary secondary type it is the treatment of underlying condition and for the autoimmune type the treatment depends upon the clinical presentation for mild cases which is asymptomatic or with a with a pulmonary uh with a po2 of more than 65 then uh observation is needed and if the patient progresses further then um he or she can be taken for a whole long leverage or gmcsf and novel therapies but if the patient presents uh with uh if the patient is symptomatic and uh there is a pao2 of less than 65 and the pulmonary alveolar arterial oxygen gradient is more than 40 then a lung language is necessary and then the patient can be put under follow-up and if the patient uh again progresses with the disease then she can be tried with the lung lavish or gmcs of a normal therapy so the main anesthetic challenge uh involved here was that we have to wash the lungs and also oxygen can be supplied only by the same root and we have to tackle the most common complication in operatively that occurs that is hypoxia so post procedure the patient showed significant radiological and clinical resolution and she was discharged without any medications on the next postoperative day the procedure would need to be repeated the next time the symptoms appear obvious usually after around six months uh to one year which was informed to the patient so the year 2021 have been the years of obsessive hand washing and for a change we decided to wash the lungs so and i would like to acknowledge and appreciate the efforts in excellent management of the patient condition by anesthesia team under doctor arjun and dr harry krishna and pulmonology team under doctor paramedicine and dr thomas green sir i would also like to extend uh the my heartfelt gratitude for all the anastasia technicians or tico and recovery staff and physiotherapy team thank you thank you nino um i think we have not have much time for discussion but are there two questions uh relation between this and uh covet 19 because you know you told that this after the covert vaccination and did the patient have covered is it a code related disease what what do you think the patient had uh we had done echo with runat which was negative so you don't think it is anything to do with code no and also she had a recurrent uh episodes like this since the past five years so thank you so much nino and uh thanks the anesthesia team and partner team for this excellent case and wonderful management uh though it was quite tedious but it was really rewarding so i think you know we'll thanks and you know we'll go for the last case uh that is by dr sandeep suresh and he is the surgical nonviolence and he is going to present an intriguing triad of epistaxis exothalamus and lymphadenopathy dr sandeep your time is 10 minutes and we start now uh well my topic is uh an intriguing triad of epistaxis proptosis and lymphatic uh case summary this was a 49 year old gentleman who came to us with a presentation of nasal block insulator nasal block and epistaxis of eight one and a half years duration uh this patient had presented to the ent opt to her dr reena uh initially around six months back with similar complaints was advised surgery biopsy and surgery but he did not turn up for uh for some reason and then he came back to our opd almost six months later on examination there was a tumor completely occluding the right nasal cavity which bled to touch uh the right eye was proposed however the vision was normal there was a five into four centimeter heart fixed swelling in the right side of the neck however there were no water or sensory deficits we had done an imaging workup for him which included an mri hiddenik and ct pns with nick the imaging as you can see here on the left hand side of the screen it shows a tumor involving the right nasal cavity heterogeneously enhancing hypotenuse lesion involving the anterior and posterior ethmoid sinuses as can be seen in the arrow on the picture on the left hand side and it was extending all the way posteriorly to the nasopharynx as can be seen in the picture on the right hand side of your screen the uh yeah the tumor was also in going intracranially superiorly uh with destruction of the uh fovea ethmoidalis and uh and there was erosion of the lamina paparazzi uh uh and the tumor was extending to the right orbit as can be seen in the arrow on the right right right picture uh the imaging of the neck actually showed enlarged lymph nodes uh involving the levels 2 5 and 1b now and scientology examination was done from the right level 2 lymph node which showed metastasis from round cell new the biopsy of the nasal tumor was done uh and it showed around cell neoplasm uh rhoblastoma um as in of our work we had we went for a pet ensure that the lymph nodes were actually from the cynonysal tumor so the pet scan showed no distant metastasis and the lymph nodes showed fdg ability similar to that of the tumor we had taken up this case for a multi-disciplinary tumor about discussion with the diagnosis of olfactory neuroblastoma involving the right synonymous cavity staging a modified kaddish d with intracranial and intraorbital extension and ipsilateral cervical lymph node metastasis um the team including dr reena reent h.o.d senior neurosurgeon dr prithvi medical oncologist dr yaya shankar and myself we went ahead with a plan of surgery for the for the complete accession of the tumor with the right modified radical neck dissection followed by an adjuvant post-operative rt as part of the part of our treatment plan we had decided to embolize the tumor pre-operatively our approaches our surgical approaches included addressing the tumor and in three different levels which included an extended transnasal endoscopic approach for the cyanonasal tumor the plan was actually to go intracranially through the trans-nasal route and if possible deliver the intracranial part of the tumor trans nasally however we also had the back-up plan of a right frontal craniotomy for the intracranial component and to address the neck following that so we did a preoperative tumor embolization uh dr dele for our interventional radiologist can you please play the video so here on the left hand side of your screen you can see there is an abnormal tumor blush which is see seen in the pre-embolization video uh which is because of feeder vessels from the right external carotid artery on the right side after successful embolization you can see that abnormal tube of blush is uh mis is absent so after a successful embolization with pva uh we took up the patient for uh surgery after 24 hours per operatively uh transnational picture showed a firm mass in spite of the impulization it was still profusely bleeding probably because of the supply from the internal carotid artery branches superiorly it was eroding the [ __ ] from plate and going trans intracranially and laterally into the orbit as well so coming to the surgery so we went ahead with the trans-nasal endoscopic tumor excision as you can see here this is the tumor occluding the right nasal cavity the tumor is carefully being dissected all around the tumor getting separated from the right lateral nasal wall as you can see here the tumor was basically attached to the olfactory area and occluding the frontal sinuses the sphenoid sinuses as well a tumor was involving the anterior and posterior sinuses which was which were carefully meticulously dissected out by dr reena here we can see after the tumor dissection after clearing the lateral wall of the tumor we could actually expose the right laminar paparasia the light right uh lamina paparazzi was uh removed and the periorbita was excised and the tumor which was medial to the right medial rectus was actually removed trans nasally so the basically the intraorbital component was removed trans nasally however we were unable to remove the intracranial component because and hence we went back to our original plan to go transcranially dr prithvi and his neurosurgery team went ahead with the right frontal craniotomy the intra cranial portion involving the dura was excised the anterior cranial fossa defect was repaired uh with facial later fat and the sealed glue we went to the neck dissection multiple nodes uh multiple columns involving the right level as you can see in the picture on the left it was carefully and meticulously dissected from the underlying structures and finally after a 36 hour long surgery the patient was taken to the post-op recovery he was under the neurosurgery care for almost four days in the neurosurgical icu there was no neurological deficits or csf leak in this case however we had kept the lumbar drain for nearly two days he had fever spikes for which we had sent for a culture culture and the antibiotics were changed according to the culture report he was shifted to the room by post-op day 5 an active physical rehabilitation initiated the patient was discharged on post-operative day 16 he was ambulated his vision was normal he was able to take overly this was a post-operative ct which was done on post of day three here you can see on the picture on the left hand side uh the the sagittal section shows a complete removal of the tumor mass you can see superiorly you can see that defect in the skull base the axial section also shows good tumor clearance we came to the coming to the histopathology report we had the histopathology report of an olfactory neuroblastoma hyams grade 3 with lymphatic embodi there were 42 lymph nodes harvested of which 26 showed metastases with extranodal extension the immunohistochemistry was also suggested of olfactory neuroblastoma with s100 and synoptophysene positivity with this diagnosis of uh kaddish uh i mean of a high grade uh olfactory neuroblastoma we had to subject him to an adjuvant post-operative radiotherapy um dr joe's fault from rajiv hospital um he he was the consultant and uh he the patient was given 60 grays in 30 fractions to the post-op bed and the right neck uh the radiotherapy was started on post-operative day 42 here the challenge was actually to preserve the vision of the right type and at the end of it now when we look back at things uh now he's almost one month post-op president is doing well his vision is normal and there is no neurological deficits the origin of the olfaction the treatment options including us include a single modification for low grade and small muscles and a multi multimodality treatment which includes surgery radiotherapy and chemo for advanced high grade tumors uh the prognosis uh the tumor has got a relatively better prognosis uh following surgery with post-operative rp as compared to surgery alone and a better local regional control uh with surgery followed by post-operative this was a multi-disciplinary approach that we had and the success goes to the entire team uh the take-home points from this presentation are the olfactory neuroblastoma is a tumor which presents with intracranial which can present with inter crane intraorbital involvement but however uh with such an extensive tumor invo with involvement of the lymph nodes without distant metastasis is a rare presentation uh interesting early detection treatment is the key in providing best treatment outcomes what is this in is required to keep the patient on a successful follower thank you thank you sandeep for this industry and it's actually a herculean task of doing an excellent surgery and this shows the importance of having a multi-disciplinary team in managing such type of cases and well done an excellent result and i think you know i really appreciate and thank you and i think there are a lot of comments i could see that appreciating the team for this wonderful surgery there were comments on ihc but it's unsaid already and also there is a suggestion there is a comment on uh pre-operative pre-operative playstation which is also going to be commented to be an excellent technique of reducing the and i think now we come to the end of this and uh i thank all the presenters who have done extremely well dr from cardiology department presenting an excellent case of a rare case of chronic ischemia presenting us congratulate dr amber and the cardiology cardiology team for excellent vocab for the case another case by dr hashim from department of astrology and it is a new technique and it's a relatively accessory is being deviced locally and the same hospital is an excellent i congratulate dr pragasakri and his team for his excellent presentation and work of cases dr andy george did an extremely nice case of pseudo needles of the heart and very difficult surgery cardiology cardiothoracic team by dr jos chaka priyapuram and the anesthesia cardiac anesthesia team ex well done dr nino you have done an extremely industry present extremely interesting case the washing of lands anesthesia team pulmonary team requires a big approach for this wonderful case dr sandeep again it was an interesting case i really appreciate and therefore taken by the team so this shows that the excellent quality of work being done in the uh lizzie hospital there are extremely nice cases and difficult cases and new technologies everything is wonderful so i think you know before going to father karen for giving out of thanks i think i request dr vasantha to make a few comments as the coordinator as the chief person of our coaching clinical society dr vasantha after that doctor josh takawa thank you very much for the presentations and i look forward to the next case next meeting we see where you have more just in case the person thanks okay thank you very much i hope you can hear me yes i can't see you okay okay uh i am so pleased to be part of peace [Music] uh ccs i know it's a society where everyone is given a chance to present the academic growth of the health field i am so happy that uh see ccs is doing a great job uh thank you for choosing lisey hospital for the presentation at the third ccs meeting and it was a honor and privilege for us for our doctors to do uh it with very much seriousness and joyfully they have done their work i am addressing almost the main doctors of the town and the whole world i am also placing the challenge to all of you let us all work together in spite of the hospitals and institutions we come together to find the best solutions for treatments for the people we have very skilled doctors we are most modern state of our devices and very supportive actually a great teamwork multi-department coordination and that's what make our hospital standing out taking this kind of cases and give the treatment to the people as we all say necessity is the master of invention and the world places in front of us lot of necessities and challenges and finally we will have to be very innovative in our field we have the brain we have the innovative and inventive mind we have facilities so we'll be able to do even unimaginable procedures if we come together to work i am thanking all the main uh office parents and uh the leaders of ccs and i'm specially thanking dr jos peripuram we call him jp and uh for our beloved doctors who are heading two major departments in our hospital i'm so happy that they are heading it and we are so blessed with them and their skills in our hospital and uh thank you very much dr vasanthanya she is also a well-known renowned doctor who is guiding uh the society and i am proud of our dr anwar hasim anthony george nino and sandeep they're all youngsters i am just thinking of what are the potentials our doctors have they can come up with any possible challenges and they will be able to face it and they can come up with the solutions which is which are very innovative and i am proud of them and i thank them on behalf of our hospital and ccs uh we give we give them a big round of applause to all of them and also i just want to announce to you this is a poet time and pandemic time we are working together i know you are working too much and you are all tired but you all been there in our program uh when the time permits certainly i wish to hold this offline in our hospital css ccs programs and this will be a great eye opening for all the doctors around and i thank everybody once again thank you father for the kind words and dr josh you have asked me to tell about the best case uh what i found is all the cases are so wonderful it's still difficult you know suppose you have got five children all are excellent then how can you choose which is the best i congratulate everybody here all the cases are so wonderful and it's very difficult to differentiate which is which stands out of uh among this so i cannot just choose anything thank you so much

BEING ATTENDED BY

Dr. Murtuza Zozwala & 409 others

SPEAKERS

dr. Anvar K

Dr. Anvar K

Consultant Cardiologist, Lisie Hospital, Kerala

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dr. Hasim Ahamed

Dr. Hasim Ahamed

Consultant Gastroentrologist, Lisie Hospital, Kerala

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dr. Antony George

Dr. Antony George

Consultant Cardiac Anaesthesiologist, Lisie Hospital, Kerala

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dr. Neenu P

Dr. Neenu P

DNB Trainee in Anaesthesia

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dr. Sandeep Suresh

Dr. Sandeep Suresh

Consultant Head & Neck Surgeon, Lisie Hospital, Kerala

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. Anvar K

Dr. Anvar K

Consultant Cardiologist, Lisie Hospital, Kera...

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dr. Hasim Ahamed

Dr. Hasim Ahamed

Consultant Gastroentrologist, Lisie Hospital,...

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dr. Antony George

Dr. Antony George

Consultant Cardiac Anaesthesiologist, Lisie H...

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dr. Neenu P

Dr. Neenu P

DNB Trainee in Anaesthesia

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dr. Sandeep Suresh

Dr. Sandeep Suresh

Consultant Head & Neck Surgeon, Lisie Hospit...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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