Question 1

How do you control fibrosis, meaning adhesions in the lung, following resection of empyema, and is lung transplantation possible after pulmonary tuberculosis?

Dr. Shaiwal Khandelwal · Accepted Answer

After empyema surgery in young patients, I perform both a visceral and a parietal decortication. Adhesions will form after decortication, without doubt, and they are very dense. The aim of empyema surgery is to prevent fibrothorax, even though adhesions will form. Lung transplantation after pulmonary tuberculosis is very challenging, particularly if the patient has developed fibrothorax. A unilateral lung transplant may be possible, but it depends entirely on the individual case; I cannot make a generalised statement for this condition.

Question 2

Is lung transplantation possible for international patients in India?

Dr. Shaiwal Khandelwal · Accepted Answer

The government does not allow a cadaveric lung transplant for an international patient; it was done earlier, but not now. Only living donors are allowed, and living donation follows its own legal approvals.

Question 3

How do you avoid the laryngeal nerves while operating in the thoracic region using robotic tools, and is the robot able to resect tumours completely when they are closely related to sensitive areas like the laryngeal nerves?

Dr. Shaiwal Khandelwal · Accepted Answer

The strength of the robot is its vision. Even nerves that are difficult to identify by VATS are seen very clearly with the robotic system, and the robot also allows a very fine dissection. These nerves are therefore better identified and better dealt with on the robotic system.

Question 4

How far away is xenotransplantation, using organs harvested from animals?

Dr. Shaiwal Khandelwal · Accepted Answer

For lung transplantation, xenotransplantation is still limited to the animal labs, and I do not see lungs being harvested from animals for transplantation into living humans in the near future. What Western countries are doing instead addresses a different problem: donor lungs are often not optimised because of trauma, aspiration or infection, so many are rejected, and the transplant has to be performed at odd hours whenever an organ becomes available, to limit the cold ischaemia time. Ex vivo lung perfusion (EVLP) answers this: the harvested lung is brought to the laboratory, perfused and optimised. It has greatly increased the utilisation of these very precious organs and allows the surgery to be done electively, in the morning. EVLP is very expensive, even for Western countries.

Question 5

Is it possible to invent artificial lungs, and is any research going on?

Dr. Shaiwal Khandelwal · Accepted Answer

There are devices such as Novalung and ECMO, which you may call artificial lungs, but they are only a transition to tide the patient over; they cannot be used permanently.

Question 6

For doctors practising in resource-constrained settings, what is the trigger or the symptom threshold that should tell them a case is complex enough that it may need to be referred abroad, even if they aren't fully sure and want to check first?

Dr. Shaiwal Khandelwal · Accepted Answer

Technology has made the world smaller, so practically all of us now live next door to each other. Whenever you face a situation and need an opinion, you can approach us by email or WhatsApp, and I assure you we will answer the query within 24 hours. Doctors can then investigate or treat the patient where they are, if the technology and facilities are available. If the facility or expertise is not available locally, the patient can come to us; otherwise we can guide and handhold the doctor to treat the patient locally.

Question 7

Can you elaborate on surgery for hyperhidrosis: how patients are selected and how the procedure is performed?

Dr. Shaiwal Khandelwal · Accepted Answer

Surgery should not be offered to every patient. There must be a detailed assessment, and the patient should have exhausted all non-surgical treatments: oral medication and local treatment such as creams and Botox. Only for high-grade hyperhidrosis, where the hands are literally dripping, should surgery be offered. Patients with mild to moderate hyperhidrosis should be advised lifestyle modification and local treatment. Every form of surgery has some side effects, so the outcome of dry hands has to be balanced against them; a patient with very severe hyperhidrosis will accept those side effects. The aim is to minimise side effects, which cannot be made zero. We do that by identifying the ganglia properly with robotic surgery, which is very difficult by VATS. I identify the fourth ganglion, divide the sympathetic chain close to the third ganglion and perform a grey ramicotomy of the third ganglion. This technique is giving me very good results.

Question 8

Approximately how many thoracic surgery patients from Africa have you treated, given that you practise in New Delhi?

Dr. Shaiwal Khandelwal · Accepted Answer

I have operated on a great many patients from various African countries. I have not had the good fortune of visiting Africa myself, but I have been fortunate to serve many patients from Africa. Most have come to us for bronchiectasis and for various tumours of the lung and chest cavity.

Question 9

Do you perform heart transplants for patients from Africa?

Dr. Shaiwal Khandelwal · Accepted Answer

I do not do heart surgery, but I am closely attached to the unit that performs heart transplantation. The left ventricular assist device (LVAD) now offers an alternative for many patients, and heart transplants have dropped because of it. Getting a donor heart for an international patient is not possible, because Indian patients get priority. Many international patients do come to Max Hospital for an LVAD, which has very good outcomes in heart failure.

Question 10

What are the success rates of lung transplantation?

Dr. Shaiwal Khandelwal · Accepted Answer

It depends on the pathology. Cystic fibrosis has among the best long-term results, and for pulmonary hypertension the results are good. For other conditions, outcomes vary with the individual disease pathology.

Question 11

Could you hold occasional medical camps, coming to Africa for a week to perform specialist surgeries there?

Accepted Answer

Surgery is not only the surgeon's skill: it also depends on the operating theatre infrastructure and the technical staff around it, and not everything can be exported. What we do instead is organise online OPDs. Patient details and reports are shared in advance, a schedule is agreed, and the African doctor partner invites the patients to the OPD. Together, the African doctor partner and the Indian specialist counsel the patients and determine which cases can be treated locally and which genuinely need to travel to India.

Question 12

What is the cost of thoracic surgery in one sitting?

Dr. Shaiwal Khandelwal · Accepted Answer

It really depends on the case. I understand it is a genuine question, but the cost for a lobectomy is different, for decortication it is different and for sympathectomy it is different, so I cannot give one figure that covers everything. I am not involved in the financial aspect: the hospital's finance department prepares the estimate for each case and communicates it to the Jivo team.

Live Discussion with Dr. Shaiwal Khandelwal