Diet for a healthy pregnancy
For a mum-to-be, it is even more important to have a well balanced diet, as what you eat has to meet the needs of the mother as well as the developing baby in the womb. In the first trimester most of the physical and mental growth of the baby takes place, one should be very careful in terms of health and diet. During these 1st three months, important organs and the nervous system are developed, hence it is essential to eat a balanced diet from the beginning. The baby takes up room in the abdomen leaving less space for the stomach and thus making it harder for one to eat also leading to morning sickness, yet one need to eat nutritious diet to ensure proper growth and development of the baby.

A nutritious diet includes adequate amount of proteins, fats, carbohydrates, minerals and vitamins, selected from five basic groups – fresh fruits, vegetables, whole grain products, proteins (meat, fish, pulses, and lentils), milk and other dairy products. Eat a variety of food as possible but in moderation, as too much of any food can cause excessive weight gain. Try and eat 3 big meals and 3 small meals throughout the day.

Some essential nutrients to be considered while planning the diet:

Folic acid: it is one of the key ingredients required for the development of the nervous system. Deficiency of folic acid in first few weeks would cause neural tube defect and other birth defects like cleft lip and congenital heart disease. At least 4 mg of folic acid should be consumed from the day of conception and during the first trimester. Natural sources of folic acid – dark green leafy vegetables, liver, yeast, beans, citrus fruits and now also available in fortified bread and cereals. As folic acid is easily destroyed while cooking, best is to either steam the vegetables or eat them raw. Folic acid supplements can be taken under your physician’s supervision.

Iron: iron aids the production of hemoglobin. As the blood volume increases during pregnancy, hemoglobin levels should also increase, for which the iron requirement also increases. An average woman needs about 15 mg of iron daily and during pregnancy the requirement doubles up to 30-50 mg per day. Include food rich in iron like – potatoes, raisins, dates, broccoli, green leafy vegetables, whole grain breads, meat and iron fortified cereals. Iron derived from food is not enough to combat the need hence iron supplements should be consumed under the guidance of your physician. Iron is best absorbed when taken along with vitamin C, hence the supplements should be consumed with an orange or sweet lime juice. Also certain medications, calcium rich food, caffeinated drinks and antacids inhibits absorption of iron so should be avoided with iron supplements.

Calcium: it is essential for the development of bones and teeth of the baby. It starts forming about the eight week of pregnancy. One needs about double (1200 mg) the quantity of calcium than normal. One needs to consume at least 3 servings of milk and milk products. Apart from dairy products foods high in calcium are – green leafy vegetables, salmon, tofu, broccoli, peas, okra, beans, brussel sprouts, sesame seeds, bok choy, almonds.

Proteins: Protein is most important nutrient required for the proper development of the baby. Eat variety of protein rich foods to ensure adequate protein intake. Incorporate vitamin B6 along for proper utilization of protein. Sources – nuts, peas, lentils, beans, dairy products, egg white, fish and meat. Animal sources are also high in fat, so choose lean cuts of meat and limit your intake.

Vitamin A: essential for the embryonic growth of the baby, for the development of heart, lungs, kidneys, eyes and bones, the circulatory, respiratory and the central nervous system. Vitamin A is also essential during the third trimester as after the birth of the baby, it helps mother with the postpartum repair. But Vitamin A intake should not exceed the recommended dosage (750mg /2500 IU). Over dose of vitamin A can cause birth defects and liver toxicity.

Vitamin C: it helps in development of a strong placenta, improves your immunity thus prevents infections, it also enhances iron absorption. As vitamin C is not restored in our body, a daily supply is essential. A considerable amount of vitamin is lost in prolonged storage and while cooking, hence it is best to eat fresh food and steam the vegetables or eat them raw. Sources – fresh fruits like – strawberries, raspberries, kiwi, grapefruit, passion fruit, orange, sweet lime etc, fresh vegetables – green leafy vegetables, beans, broccoli, Brussels sprouts, cabbage, tomatoes etc.

Fiber: constipation and piles are most common conditions during pregnancy; high fiber diet should be consumed to prevent it. Sources- fresh fruits and vegetable, brown rice, beans, nuts, cereals and pulses are very good sources of fiber.

Water: pregnant women should drink at least 8 to 10 glasses of water per day. It plays important role during pregnancy – carries nutrients from mother’s food to the baby, it prevents constipation, piles, UTI and during last trimester drinking enough water prevents from dehydration and thus prevents contractions and premature labor. Juices can replace for fluids but they are high in calories and one can gain extra weight. Tea, coffee and aerated drinks cannot be included in total amount of fluids as they contain caffeine which reduces the amount of fluid in our body.

Certain foods are no no during pregnancy:-

Canned and processed food
Spicy food
Tea, coffee, aerated drinks. Caffeine is linked to low birth weight, it is also one of the cause for miscarriage.
Hot chocolate, sugary foods like cakes, candies, sodas, colas.
Reduce salt intake, especially when you have swelling and high blood pressure during pregnancy. Do not completely avoid salt as it is an important nutrient.
Shark, swordfish, marlin, they may have high levels of mercury.
Raw sea food such as oyster and sushi.
Raw or undercooked meat, poultry and eggs, they may contain bacteria which can harm your baby.
Certain cheese like brie and camembert and blue veined cheese like stilton, they all contain listeria, a bacteria that can harm your unborn child.
Liver and liver products as they are high in retinol a form of Vitamin A, too much of this vitamin is not good for the development of the baby.
Junk, fatty and sugary food.
Do not eat left over, frozen and deep frozen food.
Avoid alcohol and tobacco during pregnancy. It is known to cause physical defects and learning disabilities and emotional disturbances in children. If you have to drink, u can have no more than one or two units of alcohol and not more than twice a week. DON’T GET DRUNK.
Do not go on diet during pregnancy can harm you and the developing baby. Remember weight gain during pregnancy is a very positive sign for a healthy pregnancy.

Treat yourself occasionally

If you are pregnant does not mean that you have to give up all your favorite food. Once in a while you can enjoy the luxury of an ice cream or desserts, but it should not be the mainstay of your diet. But when you occasionally indulge, don’t feel guilty. ENJOY EVERY BITE!

Dr Varsha B Patel
www.homeotouch.com

Over Weight is now a main issue of great concern in our day to day life,whether child or adult or a retired person or old every body now is concerned for this.It is a known fact that Overweight is related to bad physique,uglylooking,inferiority complex,a psychological complex leading neropsychiatric disease mixed with anxiety,depression, sleepnessness,bad performance in day to day activities,less concern for education,sports ,l azyness and no interst in personal and physical meeting leading to overeating and viceversa gaining more weight.Beside this aspect of Weight concerns in our middle aged and youngesters,it is of our concern in aged person as it is directly related to Diabetes,Hypertension(High BP)leading cause of more hear attack,Chest pain,Storke and paralysis, Kidney Failure,clogging and blockage of Arteries, changes in vision,sedantry habits,addictions, psychosomatic and sexual diseases beside arthritis,pain over heels and knee joinst and over accidents and skin diseases.

I know each and everyone of us (including me) at some point in our lives are fighting the “battle of the bulge”, hence it is a worth writing on this topic.
Another reason for this writing is the fact that notwithstanding the “magical guaranteed weight loss” as advertised as we regularly see in print or electronic media,internet or socalled practitioners of different types like yoga,acupressure,reki,physical educator,gyms and physical training centres, Exercise centres and instrument sellers and companies of different type of weight reducing machines and devices and beauty ayurvedic,homeo and ingenious and allopathic centres are claiming and attracting every set of people and now senior Doctors are running a camp of Obesity reducing surgeries through laproscopes (Mini Hole surgeries )with a surest gurantee of melting down few KGS in few days.But is it so easy! or so safe without any side effects ? Let me be a party pooper here by saying emphatically…there are no and I mean NO SHORT CUTS.EVERY TIME WE RESORT TO THESE DEVICES EITHER MOST OF THE ARE SHORT LASTING OR WE HAVE TO BEAR SOME SIDE EFEFECTS IF WE ARE NOT VERY MUCH DEDICATED FOR OUR EFFORTS TO REDUCE OVERWEIGHT SERIOUSLY,SO WE GAIN WHAT WE LOOSE IN EARLY DEDICATION.

So let us see why this is such a big problem and what are some of the factors that play a role in weight gain. I would call it weight gain rather than obesity because the term obesity does not include overweight people by definition.

This brings us the fundamental question, when would one be called normal / overweight/ obese or morbidly obese? This classification is based on BMI or Body Mass Index, which is basically a product of a person’s bodyweight divided by a person’s height. A BMI of 18-25 is normal, 25-28 over weight, 28-35 obese and above 35 morbidly obese.

You can calculate your BMI using this online link on any health portal website.


Why does one gain weight? This is a question the answer to which each and everyone wants to know, because if we know the answer to this, very easily we can avoid the causes thereby avoiding weight gain.

Sounds pretty simple, doesn’t it?? Sadly it isn’t that simple.

But to take a common analogy that I give to my patients’ weight gain is like a bank balance, there are only to ways to increase your bank balance (weight) either you earn more (increased intake) or spend less (decreased output).

But sadly I’m sure all of us agree it’s easier to gain weight (except for the lucky few who have genetics on their side), than increase your bank balance. Now once we have the grass root level basic fundamental cause of weight gain let us examine a few reasons as to why and how it actually happens.

INCREASED INTAKE / WRONG INTAKE / IMPROPER INTAKE

As you can see from the heading, it is not only increased intake but also the intake of wrong kinds of food and improper intake, which also contributes to weight gain.

1.Over eating: Though most of us tend not to agree to it, it is often the most common cause for weight gain. Every time you have that extra spoonful, it adds up in the long run. It is said that after a meal one should feel that he can have a little more…. that, is the time one should stop. But more often than not, we stop when we feel full and that is already too much.

2. Fast food: Fast food is fast to make and convenient to eat can be eaten on the move but more often than not is full of fats/cheese & salt.
Anyone who has read science in school knows that fat has more calories (9Kcals/gm) as compared to protein (4Kcals/gm) or carbohydrates (4Kcals/gm). So, the more fats you eat the more calories you are putting in. Carbohydrates are easy to absorb and after your basic energy requirements are met, are converted to fat for storage.

Chips – a favorite amongst most is another common cause. An old saying for them, which holds very true, is “ A minute on your lips & a lifetime on your hips”, hence avoid them.
Increased salt intake causes more water retention in the body and hence is also an important factor for weight gain.

3.Improper timing: The time of a meal also is an important factor. Food should be eaten at least 2 hours before one goes to bed to allow digestion to occur properly. So, siesta’s after a heavy lunch or eating just before going to bed are not such good ideas after all.
There is research also to suggest that, the later in the night one eats, the more chances are that all that food is being converted to fat. So, having “ a midnight snack or munchies” is again not such a great idea.

4.Alcohol: Alcohol has often been blamed for gaining weight but the gain in weight is more related to the increased snacking, which goes along with consumption of alcohol.

5.Fizzy Drinks: These are aerated drinks with empty calories, which are of no use and add up to the over all “Bank Balance of Calories”. Instead, substitute it with fresh fruits or fresh lime, which is much healthier but of course try and avoid excess salt or sugar in them.

DECREASED OUTPUT:

This is now turning out to be an important part of the whole weight gain process, especially so in youngsters and children.

1.Sedentary lifestyles: Now with the comfort levels increasing, activity has reduced. We use the lifts instead of stairs, vacuum cleaners instead of brooms, cars instead of walking, etc. The amount of calories burnt per day is decreasing with more mental activity than physical.
Some amount of physical activity is needed daily to keep the Basal metabolic rate higher so that you can burn more calories. Of course though ideal, considering family and work pressures, it is understandable that a regular gymming schedule is not always possible.
But, one can incorporate small things into the daily schedule to increase the output like taking the stairs instead of the lift, walking to the nearby store instead of driving, morning or evening walks, etc which do not take up too much of your time but help in spending those calories.

2. Children especially should have some regular physical activity in their daily schedule or we are going to be waking up to a generation of overweight youngsters. It is already happening in the west and is a major health hazard. We can see it happening around us in India too.

Real games instead of Video Games, fruits instead of chips or pizza & fruit juices instead of a fizzy drink should be the mantra for the kids.

MEDICAL CONDITIONS FOR WEIGHT GAIN:

There are a few medical conditions that can be a cause for weight gain. These are usually hormonal imbalances. The most common being:

1.Hypothyroidism: Here there is a decreased secretion of “Thyroid Hormone” which is responsible to maintain the Basal Metabolic Rate and hence there is a tendency towards weight gain. This is a treatable condition and after proper tests to find out the hormonal levels, replacement of the hormones causes a reduction in weight.

2. PCOD: Poly Cystic Ovarian Disease or PCOD is another condition associated with weight gain. Here again the hormonal imbalances cause weight gain and the weight gain in turn worsens the PCOD. Medical & surgical options are available for treatment of this condition. A curious thing seen here is that weight reduction helps with the gyneacological condition with normalization of hormones.

3. Adrenal Hormonal Imbalance: This also can cause weight gain because of water retention.

WEIGHT GAIN & DIETING

A lot has been written n said about dieting and weight loss. Every other person is an expert in some sort of a diet. But a recent study has brought the proper perspective, as I have been saying for quite some time now, its not what kind of a diet you follow but the total intake versus the total output.

So whether it’s a low carb diet, a low fat diet or an only protein diet, it doesn’t really matter. What matters is,the total amount of calories going in.

Crash Dieting is a not a way to loose weight at all. You might loose weight initially but you are loosing muscle bulk and replacing it with fat. And most of the food that one eats gets converted to fat directly because of the body’s survival mechanisms. Secondly, with crash dieting there is a tendency to alternate binging with crash dieting and this doesn’t help.

So, what one needs is a proper balanced diet according to the work he or she does, which has all the necessary nutrients.

TREATMENT OPTIONS

I’m sure all of us have heard or read quite a bit on the treatment options. I’m not going to discuss exercise, lifestyle modification and diet control which are essential to all treatments as an adjunct.
For the ease of understanding, I will divide the treatment options according to the BMI.

BMI of 25-28(30) – Overweight Category:

This is the category for which we have the most number of options.

1. Isometric Exercise/ Non Surgical Body Contouring – This is an option where in, with the help of targeted muscle stimulation & Infra red waves, isolated areas of the body are treated to achieve targeted contouring and inch loss. Here the patient comes in twice or thrice a week to the center, where the machine does the work for them and helps to achieve targeted contouring.

Very good for people in whom muscle laxity is a cause for bad body contour especially in the tummy area. Also very good immediately post pregnancy to help reduce the flab and tighten the muscles which have become loose post pregnancy and child birth

2. Ultrasonic Lipolysis: This involves breaking down the fat cells directly with the use of a non-invasive ultrasonic wave. The patient comes in once a month for the treatment, which lasts 45 mins to an hour. The released fat has to be reabsorbed and excreted by the body. It works well for small isolated areas like the saddlebags, lower tummy. This doesn’t work for large areas.

3. Injection Lipolysis or MESOTHERAPY: This involves giving multiple injections in the target areas to help dissolve fat in that area. The injection is usually of a derivative of Soya protein, which helps the cell membranes of the fat cells to break down and release the fat into the body. This is absorbed by the body and excreted.

It requires injections maybe once a month for 4 or 5 times. It works well if given properly and for small areas like the double chin or the saddlebags. Contrary to what people might claim it is not for large areas. Complications in the form or small injections abscess or collections of liquefied fat, which may require drainage, are occasionally seen.

4. LASER Lipolysis: This is a minimally invasive procedure which involves insertion of a small LASER probe in the affected area help break down the fat cells in the track of the probe thereby releasing fat into the body which is reabsorbed and excreted. This is also an office procedure and requires multiple sittings maybe a month apart.

Works well again for isolated areas like double chin, cheek fat, saddlebags, arms, etc. Large volume Lipolysis again is technically possible to a certain extent but not practical. The patient does need to use pressure garments, should have the patience to wait for the results for a few months and of course undergo multiple sittings.

5. Liposuction: This is a surgical procedure where a cannula is inserted under the skin by small 1-1.5 cm incisions in hidden areas to suck out the fat. This again is a procedure for body contouring. Though one does loose weight, he will loose more in inches

There are various techniques like the mechanical, ultrasonic, VASER, power assisted. All these are different methods of suction depending on the type of probe used to breakdown the fat cells.

As regards to the technique there is also the tumescent technique which is the preferred technique nowadays and basically involves infiltrating large volumes of saline along with some drugs to help minimize bleeding and trauma to other structures in the vicinity.

Liposuction can also be classified according to the volumes to be removed. Small, moderate or mega liposuctions. Small volume suction can be done under local anaesthesia. Moderate volumes can be done under local anaesthesia with sedation or general anaesthesia depending on the patient’s comfort level. Mega liposuctions require anaesthesia, hospitalizations and in some rare instances blood transfusions.

Internationally, the accepted volumes of fat that can be safely sucked out at one sitting is @ 8% of body weight in men and @ 9-10% of body weight in women. This is because of the fact that men tend to have an equal amount of fat inside the abdomen, whereas in women most of the fat is extra abdominal and also the fat that men have more fibrous fatty deposits. Hence, women are good candidates for liposuction.

Problems after liposuction are because of the swelling. Here as the fat is physically being sucked out, the effects are noticed immediately, but in a few days swelling sets in and takes around a month before significant changes can be felt. This also depends on the areas targeted and the amount removed. Full healing takes around 3-4 months and during this period the patient needs to wear a pressure garment to help the skin shrink. Some amount of unevenness maybe present which gradually settles with time and massages.

Rarely in smokers, there maybe areas of skin necrosis. Sometimes especially with large volume liposuctions, there maybe some collection of fluid called seroma’s which might require drainage.

BMI of 30-35 – Obese Category:

This category is the so-called “Grey Zone” of weight loss treatments. As these patients are not yet candidates for a Bariatric procedure and the procedures for the overweight category cannot fully help in treating these patients. But increasingly we are seeing patients in this category.

In these patients it has to be a combination of procedures and sometimes multiple sittings are needed to get the desired changes.

More often than not we do large volume liposuction in such cases, maybe one or two sittings with a gap of 6 months in between combined with a proper diet and exercise schedule. The procedure of Liposuction has already been discussed.

BMI of 35 and more – Morbidly obese Category:

These patients have other metabolic problems along with the fact that they are overweight. These are candidates for Bariatric procedures that are procedures aimed at reducing the intake drastically (Gastric banding or Sleeve gastrectomy) or reducing absorption of food (Gastric & Duodenal bypass procedures).

These are major surgeries and have to be done in specialized centers and involve a multidisciplinary approach with the involvement of plastic surgeon, gastroenterologist, psychiatrist, dietician, physical therapists, anesthetists, etc. This itself is a topic by itself.

The aim of this blog was to try and bring things into perspective for a person looking at weight loss or to just get in shape. Ultimately, “ a Stitch in time does save Nine”! So the earlier we wake up to the fact that weight is becoming a problem to all of us, the better it is. If not to reduce, at least try and modify our lifestyle and being about some changes in how we do things, it might help prevent the problem from becoming worse, where a much more drastic and major procedure might be required.

As you must have seen in the course of the blog that, this is not a simple topic and I have not even scraped the surface of the problem. But, the aim is to try and simplify things so one can understand what are the little things we can do to bring about a bigger change.

Whatever said and done, all the procedures are only an adjunct to lifestyle modification to get the full benefits in the long run. Change in dietary habits, maintaining a negative intake output balance, increasing physical activity will all go a long way in helping one keep fit and stay healthy.Simple formula is enought your ouput or expenditure should be more than your input or intake,a strong mind with dedication brings change drasitically but one fact is common in India after heart attack or Kidney failure or Stroke many Obese becomes thin dur to strong dedication and confrmed rigid power of determination to reduce weighrt ,so be positive result must come.


So let us bring about the change… by being the change!!!!
DR.D.R.NAKIPURIA
SILIGURI

In UPA II Government ,some Minister are adamant to bring so much new conception in name of serving poor,rural,farmer and unemployed people of our country forgetting basic infrastructure, fasibilty, econmical viability ,its sustainibilty, acceptance,discimination against rich-poor,urban rural etc., and actual its performance in presence of open corruption,expoitation and tendency to earn money and poser forgetting basic Norm and value of Human life and society.Our present Central Health Minister Mr.Gulab Nami Azad first scapped MCI to grab such agency in Ministry clutch to regulate Medical Education,registration and giving license to run or open New Medical Colleges in INDIA ,an Industry of thousand of crores of Rupees.On May03,2010,Ministry bring "CLINICAL ESTABLISHMENT ACT" to regulate private Hospital and Clinics in name of better service to society and poor persons but Government own Hospital and agencies has been exlcuded from any improvement or screening or any desire or will for improvement as no body can check it whcih serve maximum number of people of our country and almost 90% of our poor people.Government agencies intervention and checking will increas more courruption by Babus and bureaucrats making Private hospitals more and more costly as Government cannot run without them as rich ,havenots,these babus,Politicians,Ministers hardly go to govt.hospitals for their treatment. secondly it is mostly run by Qualified Doctors who treat and cure these patients and if they are not relieved or are not treated well their reputation and complains with in present Laws is enough to deal this but Government wants supervision by Bureaucrats not expert in Medical science by bringing License system upbringing advance rich or MNC Centres to exist and closer of small units making Medical treatment more and more costly.
Similiarly "BACHELOR OF RURAL HEALTH CARE(BRHC) COURSE to produce Rural doctors has been prepared by MINISTER' S MCI on the basis of sending more and more Doctors in Rural areas as no Doctor wants to stay in rural areas,socially this theme may appear popuistic but infact it is faraway from true ,now a days under NRHM Scheme many Doctors are serving Rural areas because of good connectivity and communication facilities in rural areas,secondaly a discrimination between rural and urban people regarding dealing patients should not be done as it will not be accepted by rural people who will not like to get treated by these Rural socalled semieduca,if new medical colleges are open in rural areas where rural students should be admitted,or making compulsory of every physician toserve 02-3 years in rural areas as practised in MBBS course in Maharasthra befor getting final registration or before getting permannat service or promotion or adding more seats in medical colleges and giving it to strictly rural students could save our society from such ill educated doctors who need even a training of more than 4and 1/2 yrs to know better such advancing Medical science and where every body has got right to get best and equal oppurtunity atleast in field of Health and Education.When most of our youths are shifting to urban sides from villages because of lack of infrastructure and less development of Agriculture based Business and factories in rural areas and where farmers are doing day light suicide because of unability to run their livehood from agriculture and these Doctors willremain at rural areas appear only bubble declartaion.
On paper this syllabus is for the three-year course and this rural medical practitioners is ready in MCI premise. It promises to do away with what's "unnecessary" in the four-and-a-half-year MBBS course and prepare "hands-on" doctors at the primary level. The Medical Council of India (MCI), which has prepared the syllabus, has differentiated between BRHC and MBBS doctors by not allowing the former to use the prefix 'Dr' to their name. Instead, they will have BRHC suffixed to their name.
. This new category will be drawn from 10+2 students from rural areas/districts and 25 will be chosen district-wise after an exam. They will be trained at community colleges by practicing or retired doctors from nearby district hospitals. Their practice will be confined to that area and registration will be for one year only. The course will include 10 things: Community medicine, internal medicine, pediatrics, surgery, orthopedics, obstetrics and gynecology, ophthalmology, ENT, radio-diagnosis and dentistry. It will be divided into three phases. In the first, students will study the health problems of the community, basic principles of diagnosis and prevention of common rural aliments such as malaria, anemia, hookworm, kala-az ar, TB and diarrhoea. Phase II w ll involve taking patient history, basic clinical examination and management of diseases. They will be tied up with national health programmes. Phase III will deal with training to prevent basic health problems. The curriculum will do away with many unnecessary aspects in the MBBS course such as in pharmacy and anatomy.
Using "DR" is not trheatening to MBBS or any other practising Doctor as Educated Doctors know they got prestige and recognition respect from Society because of their knowledge not because of "DR"word as many teachers and many other practitioner use ths "DR" word before their name but such anme never disturb theri practice or reputation.
Secondly to produce Doctors without basic knowledge of Anatomy(Structure of Our Body Body parts and Organs ,Physiology(Function of our Body's different organs)Pathology(Basic cause of Disease)and Pharmacy(Knowing details of Medicines and their reaction) is like to fdrive an aircraft without knowledge of Airspacing,to drive car,bus,scooter without knowledge of driving and of road,it will kill all passengers and even persons on the road.
Therefore ,Government should think thrice to bring such populistic looking novice lucrative dreams in to action as instead of improving our society such programmes and course will destroy basic fabric of equality in our society and it will be a discovery of Atomic missiles which may give pride to humanity but may devast and finish whole Humanity if Blast takes place willingly or unwillingly.it is not a prestige issue for IMA or MBBS DOctors but it is a prestige for every citizen who has got a right to have good treatment and care whether he stays in rural or urban area.
dr.D.r.Nakipuria

MI – DVR(Minimally Invasive Double valve Repair)

Rajendra Vasaiya, Mch, Vihar Shah-MD(anesthesiologist)
Sunil vyas,M.Sc,PGDPT (perfusion technologist)

BACKGROUND: Minimally invasive double valve surgery is relatively lesser known in this part of the globe.. Here we are reporting a case of double valve surgery using minimally invasive approach.


METHODS: A 31yrs old female with post CMV(12yrs back), post MTP(22-days back) status with Hb%=7.3gm was admitted for DVR Gradient across aortic valve=55mm Hg with grade II -AR and MVA=0.8 cm. She had past H/O MTP twice due to her cardiac condition. . A 4 inch size skin incision is made. Sternum is cut with oscillating saw up to the 3rd ICS. Adhesion due to previous surgery were removed, adhesion from Aorta,,PA,&RA are also removed very carefully. Cannulation was carried .through femoral artery and two stage venous cannula in to RA Venous cannula was delivered out from the future drains tube site just below xyphoid. 1st cardioplegia was delivered antigrade in to the aortic root, rest were delivered directly in to the ostea . .Fusion between RCC & NCC up to the mid point was released, partial fusion between RCC & LCC also released. Annulus found to be dilated which was tackle later on after mitral valve correction. Mitral valve was approach through aortic aortic opening, LA was also incise. Complete MV was not seen even through this incision due to previous CMV. Through aortic opening and LA MV and its subvalver apparatus were inspected and decided to go for MV commisurotomy and release of chordal and papillary fusion.Valve is check for any leakage . Now aortic annular dilatation is dealt with reduction annuloplasty using 4-0 teflon pledgated prolien suture.t.
Immediate and late post operative period was smooth and uneventful. Ventilator was removed 3hrs after surgery.On day one blood loss was 120ML.Two units of blood was required post operatively.PCM was given as pain killer.Pnt was shifted to the ward on2nd POD ,and was discharged on 4th POD

REASULT: DVR can be carried out without much of the difficulty using minimally invasive approach. .In this particular patient post operative blood loss was significantly low. Requirement of post operative analgesia is also less. It gives patient a sense of INTACT CHEST.

CONCLUSION: Minimally invasive double valve surgery can be carried out without much difficulty with numerous advantages.

JOURNEY THROUGH MIDCAB (1997 to 2009)
TYRO TO VIRTUOSO (STUDY OF 159 MIDCAB)

BACKGROUND: - MIDCAB CABG in triple vessel disease is remained dream to many Cardiac surgeons. Difficulties and short comes exist. How to overcome and accomplish a complete and satisfactory revascularization is the most important goal of a Bypass surgery. Technical difficulties and its solution are described.

METHOD: - Since 1997, we started sternal sparing MIDCAB CABG. Till 2009 we have done 159 patients.70 patients were operated for SVD (58 CABG, 12 redo CADG), 32 cases for DVD (29 CABG, 3 redo CABG), 57 cases of TVD (55 CABG, 2 redo CABG). For initial two yrs. it was limited to SVD, mostly CTO of LAD. 1st case of redo CABG was carried out in 1999. Gradually field was expanded to DVD and since last 4 yrs. TVD cases are also incorporated. It also includes 10 cases of endarterectomy. One case with CMV and CABG. Patients’ age range between 32 – 92 yrs. LVEF = 25% (10 – 55%), 3 patients with EF of 10% were offered CABG with stem cells implantation. As much as 4 vessels were grafted. Patients overweight have no contra indication. Additional plural adhesion is also not a contra indication. Among TVD 20% had varying degree of left main disease (50 – 96%). 1 patient weighing 114 kg was also operated.

RESULT: - There was 1 mortality in a redo CABG group. The patient died on 6th POD due to VTVF. One case of TVD shows ST- elevation for 24 hrs, post operatively which subsided later on (peri operative MI). 1 patient required re-exploration due to bleeding from mammary bed. Average requirement of BT was 1.5 bottles per patient. Transfusion requirement usually depends upon pre operative HB level. Average hospital stay was 4 days (36 hrs to 6th POD). No major wound complication is seen. Average incision size is 3.5 inches (2.5- 4.2 in.). Conversion to mid sternotomy was required in 1 patient.

CONCLUSION: - Sternal sparing MIDCAB can be carried out in all but cardiogenic shock group of patients. We found it is particularly advantageous to old debilitating patient more so with farer sex group of patient. It can b learnt only by self indulgence. This method is not described anywhere in known literature. It is little time consuming and requires great deal of skill and patience on part of operator.