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Doppler Guided Hemorrhoid Artery Ligation (DGHAL)
- Most advanced treatment of piles
Summary
This is a new technique for treating hemorrhoids. It has proven to be a safe and effective alternative to operative hemorrhoidectomy. It is an office procedure and postoperative pain is usually minimal to mild. Normal activities and work can usually be resumed within 48 hours. Nevertheless, this is a new procedure and all considerations regarding a new procedure apply here.
In 1995, a Japanese surgeon, Kazumasa Morinaga, conceived of a novel way to treat hemorrhoids. He identified the hemorrhoidal arteries by means of a Doppler (ultrasound) technique. He designed a special instrument, which contained a Doppler transducer and a window, which permitted the surgeon to identify and ligate the hemorrhoidal arteries by placing a suture (stitch) around them. This is a simple maneuver, which produced prompt resolution of most of the hemorrhoidal symptoms of bleeding and protrusion. When we first became aware of the paper we were impressed with the concept of ligating the hemorrhoidal arteries, as a therapy for hemorrhoids, and that this had never been tried. We were skeptical as to how effective this would be in eliminating hemorrhoidal symptoms. By now several thousand patients, mostly in Japan, Australia and Southeast Asia have been treated with this technique.
The results continue to be impressive. In one study of 1,415 patients, the treatment was successful in 93.2% and unsuccessful in 6.8% in a follow-up of 5-24 months.
Technique
Across the world variations in techniques for Doppler Guided Hemorrhoid Artery Ligation are evolving. At this time, we prefer giving the patient intravenous anesthesia using Propofol (Diprivan) administered by a board certified anesthesiologist. We then introduce rectal local anesthesia by a series of injections about the anus and rectum. Because of the intravenous anesthesia, this step is painless. No preparation is necessary. The specially designed proctoscope is then inserted into the rectum. The hemorrhoidal arteries are identified and suture ligated. It is interesting to note that traditionally it had been felt that most patients had 3 hemorrhoidal arteries. The new Doppler technique indicates that people have up to six such vessels. An effort is made during surgery to eliminate all of those vessels.
The patient can go home and resume his/her usual activities after the sedation wears off. There is often a feeling of a desire to defecate after the procedure, which can last for 12-24 hours. Most patients are back to work within 24-48 hours. There is usually little or no bleeding in the immediate postoperative period. There is a rare risk of late bleeding 1-3 weeks after the procedure. The use of aspirin predisposes to that complication and you are advised to avoid aspirin for 5-7 days prior to and 3 weeks after the procedure.
Indications
What is the optimum place for this procedure? We initially offered this new procedure to patients who required an operative hemorrhoidectomy and in whom for various reasons this could not be performed. We were delighted with the results. We are gradually expanding the indications for Doppler Guided Hemorrhoid Artery Ligation. Earlier, many patients were treated with rubber band ligation, as that had been the only alternative to an operative hemorrhoidectomy. Many of these patients would be expected to do better with Doppler Guided Hemorrhoid Artery Ligation. This technique has been successfully employed in patients who have hemorrhoidal symptoms of bleeding, recurrent acute attacks of piles, or protrusion. Pure external hemorrhoids would not be expected to respond to hemorrhoid artery ligation and still would require an operative technique.
In putting Doppler Guided Hemorrhoid Artery Ligation in proper perspective, it is not as simple as hemorrhoid rubber band ligation or injection sclerotherapy, but a lot simpler than an operative hemorrhoidectomy where classically the haemorrhoids are cut and removed.. This technique is particularly applicable to patients who already have problems with continence or who are considered to be at risk for post hemorrhoidectomy incontinence as well patients who prefer an alternative to a possibly painful postoperative period of up to 2 weeks. Doppler Guided Hemorrhoid Artery Ligation can readily be performed as an office procedure. No hospitalization is required. There is far less postoperative pain then an operative hemorrhoidectomy with more rapid return to normal activities and work. Over 90% of patients are back at work within 48 hours.
Contraindications
The main contraindication to this procedure is the required use of anticoagulants. Both Coumadin and aspirin predispose to late bleeding and this would be a relative contraindication to hemorrhoid artery ligation.
Complications
Reported complications from this procedure were quite infrequent. Approximately 1/2% of patients developed delayed hemorrhage, infection or perianal thrombosis. Approximately 1% developed anal fissures. There were no cases of urinary retention and no cases of incontinence.
By:
Dr. Jugindra S, MS
Medical Superintendent & Consultant General and Laparoscopic Surgeon
Shija Hospitals and Research Institute
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‘Smile Train Shija Cleft project – Ukhrul Mission’ and ‘Shija mission for Vision’
Somdal Camp, 22nd April 2010
On 21st of April 2010, a team from SHRI left Imphal for Ukhrul at around 12:00 noon for a detection camp (Cataract, Cleft lip & palate) at Somdal, a village 55kms away from Ukhrul District Headquarter of Manipur.
It was a cloudy Wednesday, the team comprising of 2 consultants (Dr. Sachindra L and Dr. Ramananda H), 2 Ophthalmic Assistants (Homendrajit L and Nandakumar L), 2 SHRI marketing personnel (Harris Chongtham and Ajoy Kumar T) and a driver left SHRI for Ukhrul main town, 83kms east of Imphal.
After spending the night in Ukhrul main town, the team headed towards Somdal the next day at around 7:00 am in the morning. After passing through a treacherous, non-existent and difficult ‘muddy’ road (very skillfully maneuvered by the driver), the team reached Somdal at around 9:30 am in the same morning. The already bad condition of the road was further worsened and compounded by the incessant rain.
The camp kicked off as soon as the team reached Somdal. Already there was a huge crowd waiting at the Public Health Centre (PHC), Somdal. Some were already stationed at the PHC from the previous day itself who came just for the camp. These people are from the neighboring villages who had to start their journey much before the camp started because there are still no transport facilities and proper roads to reach the camp site. Some even had to walk 30 Kms by foot just to reach the camp site.
Around 250 patients turned up for the camp and were all screened for cataract and cleft lip/palate. Among these patients, 38 were found to have cataract and 3 cleft lips/palate patients were found and recorded. These detected patients are to be brought to SHRI in two batches to be operated and treated. Transportation and treatment (surgery and other associated treatments) is to be provided free of cost for all the detected patients. This is the first time a camp like this has ever been organized in the history of Somdal, a place which depends on its PHC till date for the health care of the entire village and neighboring villages as well. The camp was organized in collaboration with the State Blindness Control Society, District Program Manager (DPM) Ukhrul, District Administration of Ukhrul and SHRI under the on-going health campaigns of SHRI namely, ‘Smile Train Shija Cleft project – Ukhrul Mission’ and ‘Shija mission for Vision’. With the grace of God, things went according to plan albeit bad weather, road conditions and other things and thus, the camp was a great success. SHRI has been engaging itself for the past 4 years in such activities providing world class health-care facilities even to patients residing at some of the most remote places on Earth mainly emphasizing on reaching out to people stationed at far-flung areas who do not have access to adequate medical facilities and also to those who cannot afford to avail proper medical treatment due to economic constraints. Now, SHRI is poised to take on more such social responsibilities in the immediate future with plans to reach out to every nook and corner of Manipur and render its services.
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Shija Hospitals made a new Guinness World Records   
Before After Compiled by Tony Meetei Little Satyajit was born with a ‘ record ’. He does not ‘ hold ’ it any more though. But those who took it away from him - and saved his life - a year ago have now found their place in the Guinness Book of World Records.
Yes. Dr Palin Khundongbam , the Managing Director and the man heading the hospital in Imphal, and his team made a new Guinness World Records by removing the ‘ gigantic neck tumor ’ that Satyajit was born with. The tumour weighed 1.2 Kgs or 40 per cent of his total body-weight of 3.0 Kgs. The operation was carried out on March 17, 2003, when he was just 12-day-old.
The previous record in this category was made by surgeons who had removed a neck-tumour that weighed 10 percent of the patient’s total body-weight. Laura Hughes of Guinness World Records Limited recently wrote to Dr Khundongbam, confirming that he had indeed set a new record.
Ranjitkumar of Ningomthong, a mushroom-trader, was frightened, when an ultrasonography at the Regional Institute of Medical Sciences (RIMS) in Manipur’s capital Imphal, revealed that the baby, his wife Bilashini was carrying had a big mass of flesh attached to its neck. The doctors, however, could make a safe delivery through caessaraen section on March 5, 2003.
But the baby boy had a huge swelling at the right side of his neck. The swelling prevented head-movement because of its weight. It was irregular in shape, tensed with engorged blood vessels and necrosed at its distant most part, easily bleeding to touch. The trachea was shifted to the opposite side. After examination, Dr Khundongbam told them that if the tumour was not removed immediately, the baby’s life would be in danger. On the other hand, he explained to them, an operation to remove the tumour would also be very risky.
The child’s parents wanted to take a chance and opted for operation. It took 35 minutes to remove the swelling. The docs of the hospital tried their best to minimize the blood-loss. The child was monitored intensively for a day and then shifted to the general ward. Breast-feeding was started on the third day after operation. The stitches were removed on the eighth day.
The biopsy revealed that the tumour was a benign cystic hygroma. “ This is a rare birth deformity, formed by lymphatic vessels, commonly seen over the neck, axilla and groin and sometimes causes difficulty in birth. But the lesion in this case was extremely large and never seen before,” said the doctor.
That it was no mean feat to remove such a big swelling from a 12-day-old patient was known to Dr Khundongbam. However, he did not know that it could qualify for a record. But, some months later, he came to know from a TV programme that a such an operation by a doctor in a western country had been declared as a Guinness World Record, but the weight of the tumour in that case had been only 10 per cent of the patient’s total body-weight.
It was only then that Dr Khundongbam realized that what they did could indeed be recognized as a world-record, since the tumour in their case weighed 40 per cent of the patient’s body-weight. he wrote to the Guinness World Records Limited and sent all evidences, photos and video-clippings. And, early this month, the Guinness World Records Limited sent him a letter confirming that they have set a new world-record.
Satyajit was fine for several months after the operation. But, unfortunately, another tumour has appeared near his ear. It has been diagnosed as a malignant germ cell tumour and he is now undergoing radiotherapy. However, as Dr Khundongbam said, his present tumour is no way related with the one he was born with and the causes of their occurrence are also different.Thanks to Shija Hospitals a record has been set and more importantly a human life saved
Courtesy:
Link: http://www.manipurpage.com/?src=Awards_and_Records.Shija_Hospitals_made_a_new_Guinness_World_Records&uTool=yes
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Importance of House keeping in Health care Industry Introduction: The role of housekeeping in hospitals is to create a peaceful, infection – free and pleasant atmosphere required for the speedy recovery of the patients. It should also create a homely atmosphere for the patients.
Housekeeping refers to the general cleaning of hospitals and clinics, including the floors, walls, and certain types of equipment, tables and other surfaces.
Why should we pay attention to housekeeping at work?
Effective housekeeping can eliminate some workplace hazards and help get a job done safely and properly. Poor housekeeping can frequently contribute to accidents by hiding hazards that cause injuries. If the sight of paper, debris, clutter and spills is accepted as normal, then other more serious health and safety hazards may be taken for granted.
Housekeeping is not just cleanliness. It includes keeping work areas neat and orderly; maintaining halls and floors free of slip and trip hazards; and removing of waste materials (e.g., paper, cardboard) and other fire hazards from work areas. It also requires paying attention to important details such as the layout of the whole workplace, aisle marking, the adequacy of storage facilities, and maintenance. Good housekeeping is also a basic part of accident and fire prevention.
Effective housekeeping is an ongoing operation: it is not a hit-and-miss cleanup done occasionally.
Periodic "panic" cleanups are costly and ineffective in reducing accidents.
• tripping over loose objects on floors, stairs and platforms
• being hit by falling objects
• slipping on greasy, wet or dirty surfaces
• striking against projecting, poorly stacked items or misplaced material
• cutting, puncturing, or tearing the skin of hands or other parts of the body on projecting nails, wire or steel strapping To avoid these hazards, a workplace must "maintain" order throughout a workday. Although this effort requires a great deal of management and planning, the benefits are many.
What are some benefits of good housekeeping practices?
Effective housekeeping results in:
• reduced handling to ease the flow of materials
• fewer tripping and slipping accidents in clutter-free and spill-free work areas
• decreased fire hazards
• lower worker exposures to hazardous substances
• better control of tools and materials
• more efficient equipment cleanup and maintenance
• better hygienic conditions leading to improved health
• more effective use of space
• reduced property damage by improving preventive maintenance
• less janitorial work
• improved morale
Staff training is an essential part of any good housekeeping program. Staff need to know how to work safely with the products they use. They also need to know how to protect other workers such as by posting signs (e.g., "Wet - Slippery Floor") and reporting any unusual conditions.
Housekeeping order is "maintained" not "achieved." This means removing the inevitable messes that occur from time to time and not waiting until the end of the shift to reorganize and clean up. Integrating housekeeping into jobs can help ensure this is done.
A good housekeeping program identifies and assigns responsibilities for the following:
• clean up during the shift
• day-to-day cleanup
• waste disposal
• removal of unused materials
• inspection to ensure cleanup is complete
Do not forget out-of-the-way places such as shelves, basements, sheds, and boiler rooms that would otherwise be overlooked. The orderly arrangement of operations, tools, equipment and supplies is an important part of a good housekeeping program.
The final addition to any housekeeping program is inspection. It is the only way to check for deficiencies in the program so that changes can be made. The documents on workplace inspection checklists provide a general guide and examples of checklists for inspecting offices and manufacturing facilities
Reasons for the uneconomic running of Housekeeping department
1. Wastage of labour – too many staff
- outdated jobs;
- outdated equipment;
- little mechanical equipment;
- outdated materials;
- outdated designs;
- stock not being used (money lying idle);
- lack of supervision;
- lack of planning;
2. Wastage of materials – extravagant use of cleaning agents;
- insufficient cleaning of articles;
- insufficient care of articles;
- incorrect methods of cleaning;
- extravagant use of heat, light and water.
Arju O.
Executive-House keeping
Shija Hospitals and Research Institute,Langol
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Glaucoma
Overview
Glaucoma is a disease caused by increased intraocular pressure (IOP) resulting either from a malformation or malfunction of the eye’s drainage structures. Left untreated, an elevated IOP causes irreversible damage the optic nerve and retinal fibres resulting in a progressive and permanent loss of vision. However, early detection and treatment can slow, or even halt the progression of the disease.
The eye constantly produces aqueous, the clear fluid that fills the anterior chamber (the space between the cornea and iris). The aqueous filters out of the anterior chamber through a complex drainage system. The delicate balance between the production and drainage of aqueous determines the eye’s intraocular pressure (IOP). Most people’s IOPs fall between 8 and 21.
Common types of glaucoma
Open Angle
Open angle (primary open angle) is the most common type of glaucoma. With this type, even though the anterior structures of the eye appear normal, aqueous fluid builds within the anterior chamber, causing the IOP to become elevated. Eye drops are generally prescribed to lower the eye pressure. In some cases, surgery is performed if the IOP cannot be adequately controlled with medical therapy.
Acute Angle Closure
Only about 10% of the population with glaucoma has this type. Acute angle closure occurs because of an abnormality of the structures in the front of the eye. In most of these cases, the space between the iris and cornea is more narrow than normal, leaving a smaller channel for the aqueous to pass through. If the flow of aqueous becomes completely blocked, the IOP rises sharply, causing a sudden angle closure attack.
While patients with open angle glaucoma don’t typically have symptoms, those with angle closure glaucoma may experience severe eye pain accompanied by nausea, blurred vision, rainbows around lights, and a red eye. This problem is an emergency and should be treated by an ophthalmologist immediately. If left untreated, severe and permanent loss of vision will occur in a matter of days.
Secondary Glaucoma
This type occurs as a result of another disease or problem within the eye such as: inflammation, trauma, previous surgery, diabetes, tumour, and certain medications. For this type, both the glaucoma and the underlying problem must be treated.
Congenital
This is a rare type of glaucoma that is generally seen in infants. In most cases, surgery is required.
Signs and Symptoms
Glaucoma is an insidious disease because it rarely causes symptoms. Detection and prevention are only possible with routine eye examinations. However, certain types, such as angle closure and congenital, do cause symptoms.
Angle Closure (emergency)
* Sudden decrease of vision
* Extreme eye pain
* Headache
* Nausea and vomiting
* Glare and light sensitivity
Congenital
* Tearing
* Light sensitivity
* Enlargement of the cornea
Detection and Diagnosis
Because glaucoma does not cause symptoms in most cases, those who are 40 or older should have an annual examination including a measurement of the intraocular pressure. Those who are glaucoma suspects may need additional testing.
The glaucoma evaluation has several components. In addition to measuring the intraocular pressure, the doctor will also evaluate the health of the optic nerve (ophthalmoscopy), test the peripheral vision (visual field test), and examine the structures in the front of the eye with a special lens (gonioscopy) before making a diagnosis.
The doctor evaluates the optic nerve and grades its health by noting the cup to disc ratio. This is simply a comparison of the cup (the depressed area in the centre of the nerve) to the entire diameter of the optic nerve. As glaucoma progresses, the area of cupping increases. Therefore, a patient with a higher ratio has more damage.
The progression of glaucoma is monitored with a visual field test. This test maps the peripheral vision, allowing the doctor to determine the extent of vision loss from glaucoma and a measure of the effectiveness of the treatment. The visual field test is periodically repeated to verify that the intraocular pressure is being adequately controlled.
The structures in the front of the eye are normally difficult to see without the help of a special gonioscopy lens. This special mirrored contact lens allows the doctor to examine the anterior chamber and the eye’s drainage system.
Treatment
Most patients with glaucoma require only medication to control the eye pressure. Sometimes, several medications that complement each other are necessary to reduce the pressure adequately.
Surgery is indicated when medical treatment fails to lower the pressure satisfactorily. There are several types of procedures, some involve laser and can be done in the office, and others must be performed in the operating room. The objective of any glaucoma operation is to allow fluid to drain from the eye more efficiently.
Conclusion
In short glaucoma is potentially blinding disease with practically no symptoms till a very advanced stage. Regular eye check up is necessary to detect this disease. Once detected a prompt treatment either medically or surgically will reduce the chances of blindness.
By: Dr. Sachindra Laishram, Consultant Ophthalmologist,
Shija Eye Care Foundation, a unit of Shija Healthcare and Research Institute |
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