INDIAN DOCTORS WHIP UP MEDICAL BREAKTHROUGHS

By Ramesh Menon (Guest Writer)

India throws up surprises all the time. It is an amazing country. It does not have the best medical research facilities in the world. The medical fraternity in fact, struggle with the basics in numerous government hospitals that await finance for expansion plans. With exploding populations, hospitals in small towns, cities and metros are not able to cope up with the pressure of increasing patients and modern complicated illnesses. Drug companies are raking in the moolah but are not ready to invest in research as much as they should. In fact, they spend more on marketing keeping short term gains in focus.

Despite all this, Indian doctors are among the most respected in the world. They have down the years brought quality healthcare to India with their innovations which are seen as modern medical miracles.
Medical breakthroughs in India are helping many patients see a new day. Despite lack of encouragement and recognition, doctors are innovating throwing up a new hope.

In 2004-05, public spending on health was just 0.94 per cent of India’s gross domestic product. Now, India hopes to increase its allocation for health to two to three percent of its GDP in the next five years. International publication Lancet has pointed out that India's health services in the public sector was grossly inadequate. Yet, miracles happen! Here are some of them:

Robotic Liver Transplant
Doctors at the Medanta Medicity Hospital in Gurgaon on the outskirts of India's capital, for the first time in October 2011, performed a robotic liver transplant surgery. It saved the life of Ziad, a four year old. He was suffering from a rare genetic disorder that resulted in liver cancer. Ziad suffered from Tyrosinemia, a disease where the liver is unable to digest proteins. Doctors used the Da-Vinci robot on 36 year old Rahmatullah who donated 20 per cent of his liver to his nephew. 

A.S. Soin, Chairman of the Medanta Liver Institute, who led the team of surgeons, said that robotic surgery was normally performed for operations related to the kidney, heart and other gynecological operations. He said that by the liver transplant, hopes had increased about its precision and at the same time, also encouraged donors as it cut down on surgery related troubles.

It was veritably a second life for Ziad. His father, Mohd. Zakir Hussain and mother, Mehe Zabinthen, were living in Muscat, the capital of Oman, when Ziad was found to have developed rickets. When his liver condition deteriorated, his parents brought him to India. Doctors decided to go in for the robotic surgery and triumphantly performed the first such robotic liver transplant.

Technology is the mantra for these surgeons. They have used machines similar to the ones we often used to see in sci-fi films and dismiss as fiction. Using robots, doctors reached into the intricate parts of a human body and forever changed the way precision surgery is done.

Robotic Cardiac Surgery
It was Dr. Naresh Trehan who pioneered robotic surgery of the heart in India way back in 2002. He did it at the Fortis Escorts Heart Institute in Delhi. It did not come as a surprise as he had performed thousands of complicated surgeries including coronary artery bypass grafting, heart valve repair and repairing of holes in the heart.

Robotic surgeries have transformed healing bringing rapid relief to the patient making it easier for those who have to provide after operation care. In short, innovation is the name of the game. In the years to come, robotic surgery will revolutionize specialized healthcare in India.

While robotic technology in India will make waves, it requires doctors to be properly trained. Many Indian urologists have winged to the United States to train in robotic surgery, but chances are they would stay back as the demand for them there is great. The US has over 400 robots operating today. It is also expensive and can be supported only in highly specialized high flying hospitals that charge a hefty bill to the patient. But India can hardly afford to ignore the robotic revolution that has punctuated the United States, Europe, Asia and Latin America.

Fractional Flow Reserve
When Dr. K.M. Cherian performed the first Coronary Artery Graft in 1975 at the Southern Railway Hospital in Chennai, few visualized how it would revolutionize cardiac care. Three and a half decades later, heart care has become specialized and precise. There is advanced technology, cardiac care and surgical skills available that makes detection faster and easier. For example, doctors today use the Fractional Flow Reserve (FFR) a guide wire-based procedure, which accurately measures blood pressure and flow through a specific part of the coronary artery.

The FFR is done through a standard diagnostic catheter during a coronary angiogram. The measurement of FFR is useful in assessing whether or not to perform angioplasty or stenting on “intermediate” blockages. “The point of opening up narrowing or blockages in the coronary arteries is to increase blood flow to the heart. But a number of studies have shown that if a ‘functional measurement’, such as FFR, shows that the flow is not significantly obstructed, the blockage or lesion does not need to be angioplastied and the patient can be treated safely with normal medical therapy,” says Dr. Manjinder Sandhu, Head, Cardiology, Artemis Health Institute, Gurgaon.

Normally, when blood supply to the heart is to be analyzed, it is done by the conventional method of coronary angiography which indicates if there are blockages. To assess the severity, the patient could be subjected to stress exercises and then the blood supply to the heart is checked. A radioactive labeled tracer is injected and this is picked up by a camera and that indicates which part of the heart had received reduced blood supply during the stress exercise. 

There is another method today where a special wire called Doppler pressure wire which has a sensor at the tip that would give the pressure measurement ahead of the blockage with a catheter positioned at the origin of the artery. Doctors therefore have the advantage of having two pressure measurements before and after the blockage. It is the ratio of the measurements that is called the Fractional Flow Reserve. It came into vogue in recent years and has been of great help to determine if the blockage is significant enough to be opened up or just needs medicine. It presently costs about Rs.50,000 and is yet to catch up, but certainly will as patients today are getting more aware of medical procedures and how they can cut down costs of not agreeing to surgeries that are not even required.

This procedure, available at the Artemis Health Institute, can dramatically change the treatment of patients by avoiding an angioplasty or by changing the decision from Bypass Surgery to Angioplasty. “For example, if one encounters a blockage in an angiography which appears to be 70%, then, most interventional cardiologists would be tempted to stent it. But, on the other hand, if one does a FFR measurement, it is possible that it may show that functionally the blockage is not significant and so the patient might be better off with medicines alone. It can save the patient unnecessary expenditure,” points out Dr. Sandhu. A study abroad showed that two thirds of the patients who went through this procedure were found that they did not even need an intervention with stents or balloons.

First Awake Cardiac Bypass Surgery
A team of surgeons at the Wockhardt Hospital and Heart Institute, Bangalore, led by Dr. Vivek Jawali, performed the first minimal invasive coronary bypass surgery without putting the patient under general anesthesia or ventilator support. Mohan Patel, the 78-year-old patient, a smoker, had multiple complications including diabetes, renal problems and blockages in the carotid arteries supplying blood to the brain. His lungs were unable to tolerate general anesthesia and the multi-organ dysfunction made him unfit for the heart-lung machine. Therefore, a stay-awake surgery was performed. Patel knew that without a bypass surgery he would die. He was awake during the surgery and even spoke while the procedure was on.

A Chinese doctor watched the operation live so that he could get familiarized to do similar surgeries abroad. He spent over three months in Bangalore studying modalities. Dr. Jawali says that the challenge is to operate the patient in the morning and discharge him in the evening using modern techniques of surgery like robots.

Cyberknife Radiosurgery
Nearly 75,000 die every year due to cervical cancer. At the All India Institute of Medical Sciences, biochemists, microbiologists and gynecologists have detected the most common HPV virus that causes this cancer that largely affects sexually active women.

The Apollo Specialty Cancer Hospital in Chennai were among the first to launch the CyberKnife technology in India that helped to precisely target radiation to cancer cells so that healthy tissue would not be affected. The CyberKnife Robotic Radiosurgery is a non-invasive system can treat tumors. It uses continual image guidance technology and computer controlled robotic mobility to automatically track, detect and correct the tumor in real time as the treatment goes on. The high dose radiation with pinpoint precision minimizes damage to the surrounding healthy tissue.

It came as such a great boon as it cut out after effects that used to be the bane of radiation for a lot of cancer patients. The non-invasive option, though more expensive, cut down the misery of cancer patients. It was one more way to beat cancer.

Pratap C. Reddy, managing director and chairman, Apollo Hospitals, maintains that the CyberKnife system aided to deliver highly precise radio surgical treatment to patients with tumours. The hospital's doctors will now use CyberKnife radio surgery for lung, liver and prostate treatment as well as head, neck and spine treatments. In the years to come, the CyberKnife technique will be widely used as lung cancer incidence is increasing every year.

Heart and Lung Transplant
Technology is making waves. Twenty years after he did the first Coronary Artery Graft, Dr. Cherian found he could do much more using advanced technology. He performed the first heart transplant at his International Centre for Cardio-thoracic and Vascular Diseases in Chennai. That was not all. He also conducted the first bilateral lung transplant, the first pediatric heart transplant as well as the first heart and lung transplant. For numerous Indian doctors like Dr. Cherian, all they needed was an opportunity. They fought the realities of having few resources at their command to make India stand out with its organ transplants, test tube babies and stem cell advances.

Detecting Cancer Early
The standard procedure for detecting early cancer is to get a mammogram done. However, it cannot be done frequently because radiation from x-rays could actually be counter-productive. Mammograms do not work accurately as they miss fast growing cancers. It can also be ineffective in dense breasts for women under 45. For a country like India, a mammogram is expensive to set up and deliver at the ground level especially in rural India where 85 per cent of its population lives. India therefore needs a different procedure which is cheap and effective.

Dr. Bhawna Sirohi, Head, Medical Oncology, Artemis Health Institute, Gurgaon, says that an exciting possibility is in a new tool called Breastlight. It is similar to a powerful torch with a bright-red beam. If shown under the breast, it lights it up with a glow. If there are cancer cells within, they will stand out as black. It is easy to use as it is a hand held device. But it is yet to be popularly known in India. In a recent study conducted at the Sunderland City Hospital in the United Kingdom found that Breastlight picked up 67 per cent of malignant tumors. Another similar study in Ghana had a success rate of 96 per cent.

The torch can even spot tiny lumps – as small as 7mm – which are not considered large enough to be felt during a physical examination. It can show up cancer cells long before you can feel it as a lump through the skin.

Dr. Sirohi says what excites her is that she could check 200 women with Breastlight in a day and the chances of detecting cancer was much more brighter at an early stage as it was so easy to operate. “It can even be handled by a trained anganwadi worker and this could greatly help in detecting cancer in rural areas where medical facilities are poor. I want to get it validated in India through trials as it has such huge advantages. We need to be able to develop and deliver on cost –effective screening and treatment strategies for India as we have to try and make the best of what resources we have. Screening with the help of Breastlight is not only inexpensive, but an effective tool. Points in favor of using this are – there is no radiation exposure to the patient, it is a handheld device, it can be used as often as possible in any remote location, healthcare workers can be trained easily to differentiate between a normal breast and a cancerous one,” she said.

If this strategy is proven in other studies, many lives could be saved at little cost, especially in developing countries like India where majority of cancer patients are discovered when it is too late. Such a simple device can reach out to vast populations in India with very little investment. Setting up mammogram facilities on the other hand can be almost impossible in far flung rural areas.

Again, there is good news for breast cancer patients from Dr R.A. Badwe, the Director of the Tata Memorial Hospital in Mumbai. He and his colleagues have shown that with the use of a single injection of hydroxy-progesterone costing Rs.100, survival rates improved by almost 9% in select cancer patients. This is significant as drugs costing lakhs of rupees are usually administered to breast cancer patients.

Liver Transplant
The transplantation of solid human organs was undoubtedly one of the greatest medical breakthroughs of this century. The first successful liver transplant in India was performed on two year old Sanjay Kandaswamy at the Indraprastha Apollo in Delhi over a dozen years ago. But even today, transplant of human organs in India has not taken off in the way it should as there is a serious shortage of donors.

But some innovative ideas have emerged. In April 2011, doctors at Medanta’s Institute of Liver Transplantation did what seemed impossible. They transplanted the left side of a live upside down so that it could fit and replace the right side of the patient's liver. The operation, a first in India, gave a new hope to Y.P. Singh, a banker from Bihar in his late fifties. Singh was suffering from terminal liver failure and doctors feared he would not survive beyond a few weeks. A search for a donor proved futile. So, Preeti, his daughter and Atul, his son, decided to donate their liver as they had matching blood groups.

Normally, the donor donates his right lobe which is about 65 per cent of the whole liver as that is what is required to make it work. However, being children both had small livers. Therefore, chief surgeon, Dr. A.S. Soin chose to perform a “dual left lobe transplant”, where each donor had to donate only about 35% of their liver and these were transplanted into the recipient. As the two children only donated a small part of their liver, they were safe.

Dr. Soin led a team of 40 surgeons, anesthetists and operation theatre staff for the complicated procedure that took 16 hours and was conducted simultaneously in three operation theatres. Hepatologist Dr. S. Saigal, Surgeons, Dr. R. Kakodkar and Dr. R. Mohanka and Anesthetist Dr. V. Vohra were part of the team that operated upon Singh. But, they first rehearsed it under simulated conditions on the CT scan console. It was a proud moment for doctors in India when they pulled it off successfully.

Polypill Fights Numerous Ailments
Patients who suffer from numerous disorders like hypertension, diabetes and heart disease have to consume a lot of pills daily. Often, they forget. It is also very expensive. But they have help at hand. Hyderabad-based Dr. Reddy’s Laboratories has now produced a polypill that will combine four medicines used to treat heart disease - aspirin, (which acts as a blood thinner); two anti-hypertensives (to reduce blood pressure) and a statin (to lower lipid levels). In many ways, an idea like this will be a veritable boon to many as it combines the properties of many drugs, cheaper than blockbuster drugs and more effective. For instance, the cost of a month's medication of the polypill is likely to be less than Rs.100, almost one-third the cost of its component medicines taken individually.

This means a lot in India as the incidence of heart disease is increasing by the year. The National Commission on Macroeconomics and Health estimates that the number of Indians suffering from heart disease is set to grow to 62 million by 2015. According to the World Health Organization, 17 million people die of heart disease and strokes every year and as many as 80% of these are in developing countries.

Two professors at London’s Wolfson Institute of Preventive Medicine, Nick J. Wald and Malcolm R. Law claim that such a pill can prevent 80% of heart attacks and that anybody with cardiovascular disease could take it, as could everybody over 55. They wrote in the British Medical Journal that it would be acceptably safe and with widespread use, would have a greater impact on the prevention of the disease in the Western world than any other single intervention.

Such a pill can make a great difference to countries like India where thousands battle with multiple ailments and are not able to meet rising medical bills.

Tissue Glue Used for Holding Intraocular Lens
Fibrin glue, made from blood plasma, is usually used to arrest bleeding and seal tissues in intricate surgeries. Doctors at the Dr. Agarwal’s Eye Hospital and Eye Research Centre, Chennai, used fibrin glue for the first time to fix the intraocular lens (IOL) of a four year old child as it was moving around after transplantation. Anandi’s eye was damaged when bursting crackers during Diwali. A plastic lens was surgically implanted. The doctors dispensed with the usual method of stitches as it was biodegradable and as one of the doctors said, “One does not know what will happen after 40 years.” The lens was put in place with the help of the glue. Earlier the treatment of IOL was a challenge for ophthalmologists as there was no guarantee that it would work. Dr. Amar Agarwal who performed the Glue Assisted Suture-less IOL implantation, said that with this technology, patients with intraocular lens capsules missing could be treated. The glue technique would also ensure that the lens stayed where it was implanted.

Surgery to Control Diabetes
One of the biggest advances was the control of Diabetes (Type 2) by Laparoscopic (Key-hole) Surgery. Done at the Kirloskar Hospital’s Laparoscopic Surgery Centre for the first time by a team of specialists from Hyderabad led by Dr. Surendra Ugale, the Ileal Transposition Surgery (small intestinal switch), has brought hope to diabetics. The procedure shortens the intestinal tract between the stomach and terminal ileum and shifts it into an upper area and puts it in line again. The process controls Type II diabetes by facilitating insulin secretion in the presence of undigested food.

Gene That Causes Brain Disorder
Scientists led by Arun Kumar, Department of Molecular Reproduction, Development and Genetics, Indian Institute of Science and Satish Girimaji, Department of Psychiatry, National Institute of Mental Health and Neurosciences at Bangalore discovered a new gene that causes microcephaly, a congenital disorder characterized by smaller than normal sized brain and retardation. One in every 50,000 to 1,00,000 live births ends up with microcephaly. What is significant is that the discovery may help develop a regular clinical screening tool to detect this disorder at the fetal stage and aid expectant mothers in detecting this deformity.

Microcephaly is known to be caused by environmental and genetic factors. Among the environmental factors are intrauterine infections, alcohol, drugs taken during pregnancy, prenatal and exposure to radiation. Till now, four genes were known to cause microcephaly. The team located the fifth gene known to cause this disorder in India called STIL. Owing to the smaller size of the brain, patients have mild to severely low IQ. Patients remain mentally challenged for life.

Fighting Impotence
Dr. Sudhakar Krishnamurti, andrologist, micro surgeon and sexual medicine consultant, was one of the first Indian doctors to practice exclusive clinical andrology, the branch of medicine and surgery that deals with disorders of the male sexual and reproductive system. It was he who started penile duplex Doppler evaluation, Rigiscan monitoring and phalloarteriography for impotence. He has performed the first microsurgical varicocelectomy and the first microsurgical revascularization (bypass) operation for impotence.

Recognizing his pioneering work, the Urological Society of India conferred on him the ‘Innovations in Urology’ and ‘State-of-the-Art Lecture’ awards. He also got the prestigious Herbert Newman award for original clinical research in the field of impotence for having described a new penile dermal flap operation for Peyronie’s disease that can cause impotence.

Indian doctors are today recognized to be among the best in the world. In fact, this is what is giving medical tourism a boost in India. But the fact remains that thousands of them are winging to the west as there are better research facilities, monetary gains and working conditions. At the moment, there are over 59,000 Indian educated physicians working in the United States, United Kingdom, Canada and Australia. It almost seems that India is providing doctors to the developed world.

Thousands of doctors have migrated to the west in the last few years. Indian policy makers need to imaginatively think of how to create attractive clinical opportunities in India to correct the situation. Indian doctors can be among the leading ones in the world with their innovations. The faster we realize this, the better it will be for Indian healthcare.