Doctor in Aster Cmi Hospital
Cardiothoracic Vascular Surgery
Liver Transplant Surgery
Nuclear Medicine Physician
Naveen Kumar G
very very good and caring, friendly doctor, may god bless him
Very nice and she explained the problem indetail
The liver is the engine of the human body. It is basically composed of 2 types of cells (a cell is the basic building block of the human body) – hepatocytes (liver cells) and cholangiocytes (bile duct cells). It also has other supporting tissue and their respective cells. The hepatocytes are by far the most numerous cell type, not surprisingly tumours (otherwise called mass or lump. “Tumor” means lump in Latin), of this cell form the majority of abnormal growths in the liver. Abnormal growths can be benign (that is, they do not grow rapidly, spread to other parts of the organ or to other parts of the body) or malignant (grow rapidly, spread to other parts of the organ and to other parts of the body, i.e. cancer). These abnormal growths from liver cells are Focal nodular hyperplasia (FNH), Adenomas (the benign variety) and hepatocellular cancer (otherwise called Hepatoma/HCC, the cancerous type). What we need to recognize is that certain adenomas can turn into HCC, over a period of time. The other type of growths in the liver are those that have originated elsewhere in the body and spread to the liver, for example a growth of the breast spreading to the liver. These are in fact the commonest tumours of the liver. I will discuss these at a later date.
Benign growths of the liver
Common benign growths are Haemangiomas, FNH and Adenoma. Most of these are identified when a scan is performed as investigation for some other problem. Accurate diagnosis of the nature of these lumps is important to determine the type of treatment needed. This can be ascertained by a carefully selected scan like an Ultrasound, CT scan or an MRI. The technology of these scans is continuing to evolve and get better year on year. There are different types of Ultrasound, CT and MRI scans with different applications, based on whether contrast is used or not, the different phases of scanning, the type of MRI scanning sequence etc. Therefore, these scans although commonly available and used very frequently, need to be performed under the supervision of a team involving Liver doctors and radiologist who is well versed in the diagnosis of liver lumps, for accurate diagnosis without the need for unnecessary tests (Box 1).
Haemangiomas are by far the commonest. It is estimated that 5% of the adult population harbor this lump in their livers! They occur in both sexes and at all ages but are commonest between 30 to 50 years in women. Most of them are small, less than 4-5 cms in diameter and are are identified on Ultrasound. MRI and its various applications is the scan of choice for accurate diagnosis. This is crucial as most of them do not need treatment.
Focal Nodular Hyperplasia (FNH) are the second most common liver lumps. They are usually single and small (less than 4 cms) and occur in women between 35 – 50 years of age. About 2.5-3% of population harbor this lump in their livers. Special MRI techniques using special contrast agents is diagnostic and the findings are quite distinct from haemangiomas. Again treatment is not recommended apart from selected circumstances. Assessment in a dedicated Liver team is recommended for accurate diagnosis and a proper management plan to be formulated.
Hepatic adenomas (Hepatocellular adenoma, HCA) are rare lumps and occur in 0.2 to 0.3% of the population, again occurring mostly in young women during their reproductive period. They are again solitary and most usually 3-4 ms in diameter.
There are a couple characteristics which make this lump different from the previous 2, there is a strong relation between hormones the development of HCA and some of these HCA can turn into the malignant Hepatocellular carcinoma (HCC). Therefore, accurate characterization and diagnosis of these HCA is essential. Sometimes biopsy of the lump, molecular and genetic tests maybe necessary to determine if the HCA has a high chance of progressing to HCC. Imaging tests are generally adequate, contrast MRI Liver and its different techniques is accurate in diagnosing HCA and sub-typing it, however CT and contrast-enhanced Ultrasound is sometimes necessary along with MRI.
Generally, a HCA in a male is recommended for surgical resection. While in women, discontinuation of the OCP pill/ any other such hormone is recommended for a period of 6 months, if the HCA does not have any worrying features and size is less than 5 cms. IF HCA is larger than 5 cms and has features suggestive of a high risk for change to HCC, surgery is advised. Again these decisions have to be made as a part of a Multi-disciplinary team (Box 1)
Malignant growths beginning within the Liver
As mentioned earlier, usually malignant growths which are seen in the liver spread to it from elsewhere in the body. Hepatocellular cancer/Hepatoma (HCC) is the commonest malignant tumour beginning within the liver, as apposed to those that spread to the liver from elsewhere. It occurs between 40-70 years of age and occurs commonly in men. It is estimated that 17000 new patients develop this tumour every year in India. The vast majority (> 80%) of these develop in patients who have chronic liver disease (cirrhosis). Importantly the number of HCC cases is increasing year on year as cirrhosis due to fatty liver disease, Hepatitis B (3% of Indian population carry this virus, ie nearly 40 million individuals) and alcohol are continuing to increase in India. Nearly overall it is the 4th or 5th most common cause of cancer and the second most common cause of cancer-related death. This is continuing to increase too. We do not have a national policy in India to screen and diagnose these lumps in the liver at an early stage. Most patients present at a late stage when effective treatment is not possible.
Hepatitis B is a vaccine-preventable disease, there are good drugs to treat it and decrease the risk of cirrhosis and HCC in HBV patients, therefore it is important to test for this virus infection. The fatty liver disease can cause chronic liver damage and HCC, regular exercise and consuming a balanced diet can reduce the risk of fatty liver disease.
The usual mode of detection of these growths is when a scan is done for some other reason. Occasionally patients can develop pain in the abdomen or jaundice which leads to an investigation. The treatment of HCC depends on the extent of tumour, the extent of the chronic liver disease (the stage of cirrhosis) and the overall condition of the patient. These patients are best seen, assessed and treated in a team (Box 1) which specializes in the treatment of Liver disease.
The best treatment for HCC is surgery. However, this is suitable only for certain carefully selected patients. This can take the form of liver resection (where a portion of the liver with tumour is removed) or liver transplantation (where the whole liver is removed and a donated liver (full or partial) is replaced into the patient. Indeed surgical has excellent survival rates; more than 75% of patients survive for more than 5 years after resection or transplantation making treatment for these cancers one of the most satisfactory.
Other treatments which can be combined with surgery in selected patients or can be combined with patients not suitable for surgery are different types of Interventional radiological therapy – chemotherapy or radiotherapy delivered through fine catheters introduced into the blood vessels of the liver (TACE: Transarterial chemotherapy, TARE: Transarterial radiotherapy) and or heat energy delivered to the tumour area by means of carefully placed needles/probes (RFA: radiofrequency ablation, MWA: microwave ablation).
HCC is unique cancer as its treatment should be tailored to the patient, the treatments are varied and range from catheter-based non-invasive treatment to major surgery and transplantation. This necessitates that HCC patients are best managed in a multidisciplinary team which is highly skilled in and specializes in the management of liver diseases.
Box 1: A liver tumour multidisciplinary team – Integrated Liver Care team
The team should be one with expertise in the management of benign liver lesions and should include a Hepatologist, a Hepatobiliary & Transplant surgeon, Diagnostic and Interventional radiologists, Medical oncologist and a Pathologist.
Each member of the team must hold specific and relevant training, expertise and experience relevant to the management of benign liver lesions.
The team should be one with the skills required not only to appropriately manage these patients but also to manage the rare but known complications of diagnostic or therapeutic interventions.
In case you have a concern or query you can always consult an expert & get answers to your questions!
A cochlear implant is a small electronic device that can help improve the hearing of people with severe, irreversible hearing loss. Although a cochlear implant does not restore normal hearing, it can allow a person to hear and understand more speech than was possible with a hearing aid. For a child, this could mean an opportunity to develop listening and speech skills and the potential to attend school with hearing peers. For adults, a cochlear implant could reduce social isolation and improve communication.
The cochlear implant is a device that is placed in the inner ear. The implant system has three primary parts:
- Microphone and Transmitter —The headpiece and transmitter is worn above the ear to pick up sounds. These sounds are sent to a speech processor.
- Speech Processor — A speech processor is worn externally, behind the ear like a hearing aid, to convert sound into a digital code that is transmitted to an implanted stimulator.
- Implanted Stimulator — The implanted stimulator is a small component placed under the skin behind the ear. It receives a digital code from the speech processor and sends it to the auditory or hearing nerve.
The brain interprets this signal and it is recognized as sound. The small headpiece and transmitter is held in place by a magnet coupled the implanted stimulator, under the skin.
Tests are done to determine if a child is a candidate for a cochlear implantation. Patients are selected based on medical and hearing histories and test results as well as findings. The evaluation, which differs slightly for children and adults, includes the following: *
- Medical Evaluation — Conducted by the cochlear implant surgeon who will take the medical history, examine your ears and explain the surgical process.
- CT Scan of the Temporal bone and MRI Brain and Cochlear imaging - This computerized tomography (CT) scan allows the surgeon to evaluate the ear's internal structure, recommend which ear to implant and may provide information as to the cause of deafness.
- Audiological Evaluation — This evaluation involves a hearing test to confirm the type and degree of hearing loss, hearing aid evaluation to assess the benefit provided by a hearing aid and aided speech recognition testing to determine if a hearing aid might provide greater benefit than an implant.
- Psychological Screening — This screening is conducted by psychologist to assess the feelings about hearing loss and the cochlear implant, such as the reasons for seeking the implant and the expectations.
- Cochlear Implant Counseling — At this time, if one is a candidate for cochlear implant, possible benefits and limitations will be explained and one will be provided with information to select the device.
Implant surgery is performed under general anesthesia and takes about three hours. During the operation, a surgeon will anchor a receiver-stimulator device in the temporal bone in the skull and insert what is called an "electrode array" into the cochlea, the small snail-shaped structure in the inner ear that contains the hearing organ. First, an incision is made behind the ear to expose the temporal bone. The surgeon then positions the implant component against the bone. A hole is made in the temporal bone with a microscopic drill, allowing the surgeon access to the cochlea. A small hole is made in the wall of the cochlea and the electrode array is gently guided into the cochlea. The internal receiver is secured in place on the skull bone with sutures and the incision is closed. A sterile dressing is placed on the incision.
To qualify for a cochlear implant, patients must meet the following criteria:
Adults age 18 and older have:
- Overall good health
- Severe hearing loss in both ears
- Limited benefit from conventional hearing aids determined by a trial period, when appropriate, of about three months
- Psychological and emotional stability
- Realistic expectations of the implant
- No ear conditions or other medical conditions that would interfere with surgery
- Ability to participate fully in a follow-up
Children age 1 to 17 must have:
- Overall good health
- Severe hearing loss in both ears
- Limited benefit from conventional hearing aids
- Realistic expectations of the cochlear implant
- No ear conditions or other medical conditions that would interfere with surgery
- Family commitment to comply with all evaluations before and after surgery
- Enrollment in a post-operative rehabilitative and educational program that supports the use of cochlear implants and the development of hearing skills
Following surgery, patient will return home for four weeks to allow time for swelling to subside and the incision to heal. After several days, the incision may be wet during bathing or showering.
The externally worn speech processor is activated about four weeks after surgery. The processor converts speech into a special code for each user. The activation and programming is performed at the Hospital. Programming for each implant is customized for the patient and takes about six hours over a two-day period.
Visit at regular intervals for device checks and re-evaluation. During these visits, the implant and equipment are checked and performance is measured. Re-testing generally occurs at one, three and six months and one year following the initial device fitting. Then, semi-annual or annual evaluations are performed. Each session for adults involves about three hours.
Benefit from a cochlear implant usually improves with time but can't be guaranteed. Rehabilitation after surgery is key to maximizing the benefits of the cochlear implant. Most people with these implants are able to engage in hearing activities, such as listening to a Walkman, enjoying a movie, using a phone and participating in social activities. The motivation is critical to the success of the implant. Use the device during all waking hours, Listen, speak and interact with others as much as possible, Utilize visual cues when adjusting to the implant, but gradually decrease the use of visual cues when ready, Ask others to identify unfamiliar sounds so they become familiar.
Many people have questions about cochlear implants, how they work and what to expect from the surgery. Here are some common questions and answers-
Will a cochlear implant restore normal hearing for people who are deaf?
No, a cochlear implant does not restore normal hearing. It is a communication tool but not a "cure" for deafness. When hearing functions normally, parts of the inner ear convert sound waves into electrical impulses. These impulses are sent to the brain, where they are recognized as sound. A cochlear implant simulates that process. An implant, supplemented with listening therapy, can help people recognize sound, including speech.
Are there risks in cochlear implant surgery?
Risk is inherent in any surgery requiring general anesthesia. However, the surgical risks for cochlear implantation are minimal and most patients require only a one-day hospital stay and have no surgical complications.
Will I need more surgery as new technology becomes available?
The implanted unit is designed to last a lifetime. The externally worn speech processor, which is responsible for converting sound into code and sending the information to an internal unit, is dependent on software that can be upgraded as technology improves.
Will my child outgrow the internal device and require a new one?
No, the cochlea is fully formed at birth and the skull structures achieve almost full growth by age 2. The electrode array is designed to accommodate skull growth in children. Should I wait for new cochlear implant technology? No, the design of the surgically implanted receiver and electrode array has changed relatively little during the history of cochlear implants. However, speech-coding strategies, which are responsible for delivering the signal to the internal unit and are stored in the externally worn speech processor, have improved significantly over the years. The speech processor can incorporate new technology when available.
Can people with cochlear implants identify environmental noises as well as speech?
Cochlear implants provide a wide range of sound information. Performance in speech perception testing varies among individuals. With time and training, most patients understand more speech than with hearing aids and many communicate by telephone or enjoy music.
Can people with cochlear implants swim, shower and participate in sports?
Yes, people with implants can swim, shower and participate in virtually all types of sport activities when they are not wearing the external equipment. The only restriction relates to skydiving and scuba diving because significant changes in air pressure are not advised. Participation in all other athletic activities is unrestricted, although protective headgear is always recommended. In case you have a concern or query you can always consult an expert & get answers to your questions!