The sterling mettle of Kerala’s public healthcare sector was on full view a few weeks ago when dangerous growth of a tumour called sacral chordoma was removed by a multi-disciplinary team of doctors of the Government Medical College, Thiruvananthapuram, in south Kerala, through a surgery lasting 17-hours.
Doctors from the Neurosurgery, Surgical Gastroenterology and Urology departments put their hands together to save the life of the 53-year-old man, a native of Palode village in the suburbs of the Kerala capital, in what turned out to be one of the rare surgeries performed at the hospital and in South India.
The patient was admitted to the hospital last July following the growth of the tumour, known medically as sacral chordoma. It all started with him experiencing difficulty in bowel movement, constant pain and inflammation on both legs.
The tumour, originating in the lower region of the spine, had spread to the surrounding areas, with serious implications for his survival. In order to avoid weakening of the spine after the surgery, screws and rods were fitted into his spine and pelvic bones. He was discharged after recuperation and physiotherapy.
The surgical team had as its members Dr. K.L. Suresh Kumar, Dr. B.S. Sunil Kumar, Dr. L. S. Jyothish, Dr. Sanu Vijayan, and Dr. V. Abhishek of the Department of Neurosurgery, Dr. Ramesh Rajan, Dr. Subhangar Saha and Dr. Riswaan of the Department of Surgical Gastroenterology, Dr. P.R. Saju and Dr. K.P. Nirmal of the Department of Urology, and Dr. Ushakumari and Dr. Jayachandran of the Department of Anaesthesia, besides a bevy of experienced staff at the premier government hospital in the State.
Dr. Ramesh Rajan spoke to Medical Tourism’s correspondent N. S. Arunkumar about the complex challenges that the surgery posed. Here are some excerpts:
N.S. Arun Kumar: Could you please explain how challenging this surgery was?
Dr. Ramesh Rajan: What we did in the case of this patient with chordoma of the sacral region was one of the coordinated procedures that are done in every major teaching hospital. What made this procedure a bit more special was that it was time-consuming and risky, which had to be performed from different positions at the operating-table.
Q: Can sacral chordoma be considered a life-threatening condition?
Dr. RR: Chordoma is a rare tumour, but one of the most common malignant (cancerous) type of tumours of the sacral region (lower back). They are locally malignant tumours which arise from the lower-most part of the spinal cord. They produce symptoms only when they start eroding the near-by sacral bone, rampaging the nerves that regulate the muscles controlling defecation or urination or the nerves controlling the muscles of the legs.
In more advanced stages, it starts bulging out, through the back of the body near the anus making it difficult for the patient to sit comfortably. This particular patient had all these symptoms when he was evaluated at the hospital.
Q: Is surgery the only option in such cases?
Dr. RR: The best results come when complete surgical excision is combined with radio-therapy. Unfortunately, proton radiotherapy is an expensive modality which is not easily available in India.
Q: When the patient presented himself at the hospital, what was he complaining about?
Dr. RR: The patient was experiencing difficulty while urinating and passing stool. There was severe pain in both legs, which had developed oedema. Investigations using X-Ray and MRI scan revealed the tumour. Biopsy of the bone marrow was carried out and the histological results revealed the sarcoma. Scanning results revealed that the tumour had its origin below the vertebral column.
Q: What role did each of the surgeons play once the procedure was on?
Dr. RR: Co-ordinated action of different specialities such as Neurosurgery, Surgical Gastroenterology, Urology and Anaesthesia Departments was necessary for the procedure, performed on 20-21 July, 2021, to be successful.
The team was led by Neurosurgeons Dr. K.L. Suresh Kumar, Dr. B.S. Sunil Kumar, Dr. L.S. Jyothish, Dr. Sanu Vijayan and Dr. V. Abhishek, as the main part of the procedure involved protecting the surrounding nerves as well as the stability of the pelvic bones.
From Surgical Gastroenterology, myself, Dr. Subhankar Saha and Dr. Riswan participated. From Urology Department came Dr. P.R. Saju and Dr. K. P. Nirmal. Dr. Ushakumari and Dr. Jayachandran participated from Anaesthesia Department.
Nurses who participated were Maya, Malini, Sibi, Sreelekha, Flora, Sheeja. Operation Theatre staff on duty were Pratheesh, Vishnu and Nibin. Scientific Assistant Resvi and Nisa, Anaesthesia Technician Sudheesh, also were part of the surgery making it a success.
Q: Does such surgeries take as long 17 hours as happened to be the case in this instance?
Dr. RR: Yes. Many surgeries lasting 8-10 hours are routinely performed in major hospitals worldwide. The focus of surgery has shifted from ‘speed’ which was the key-word about 40-50 years ago, when anaesthesia and post-operative care was not so well developed, to precision.
This procedure took longer hours as the patient was first operated through the abdomen in the superior position and then turned on to the prone-position to carry out the procedure from the back of the patient. Positioning an anaesthetised patient, position changes, securing air-ways, IV lines, reducing blood-loss etc., are all time-consuming.
Q: How does one identify sacral chordoma? And, also, would you comment on the perception that the private tertiary care facilities were better equipped to handle such cases?
Dr. RR: It is not possible for a lay-person to interpret a particular condition accurately. It is also not advisable. The main thing is that one should not hesitate to take medical opinion when one has significant unusual symptoms.
As far as modern medicine is concerned, there is no difference in the time of management of a particular clinical problem by institutions under the government and in the private sector. Of course, the ancillary facilities in the private sector are generally better maintained with a better ambience and comfort for the patient and bystander. This is often misunderstood as ‘better treatment’.
All that we can say is that the outcome of treatment is part dedication, part experience and part exposure to novel and standard methods of treatment. The Government Medical College, Thiruvananthapuram, is academically very much updated and we have a very experienced and dedicated team of physicians and surgeons in each department.
Here every diagnostic and treatment procedure happen in a very transparent manner. We are very humanitarian in our approach and we are also conscious about the financial situation of the patients. All that the patients have to do is to approach us. Early intervention is the key to prevention and management of any disease, including cancer.