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 Table of Contents  
GUEST EDITORIAL
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 2-3

You can do it!


Director, Neeti Clinics, Nagpur, Maharashtra, India

Date of Web Publication23-May-2016

Correspondence Address:
Madan Laxman Kapre
Neeti Clinics (ENT), Neeti Gaurav Complex, 21, Central Bazar Road, Ramdaspeth, Nagpur - 440 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-8128.182847

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How to cite this article:
Kapre ML. You can do it!. J Head Neck Physicians Surg 2016;4:2-3

How to cite this URL:
Kapre ML. You can do it!. J Head Neck Physicians Surg [serial online] 2016 [cited 2019 Oct 16];4:2-3. Available from: http://www.jhnps.org/text.asp?2016/4/1/2/182847



Yes, you can do it! A message, a driving force, or conviction, call it what you may like; this statement is as true as the elements of the world. This belief will make you realize that if you have not done it that means you have just not willed it strong enough. I am grateful to the Editor-in-chief, Dr. Jyoti Dabholkar, for this guest editorial to share with you my journey of wanton desire to overwhelming conviction. Through this, I am sure you will also agree that evolving in isolation, as many of you may be facing right now, is not a handicap but an opportunity.

As one leaves the comfort zone of their alma mater - “The Teaching Institute,” one faces challenges of all sorts, some in the mind and some of kind. It is for my colleagues in this predicament that I address this submission. Most of us leave our training grounds and only the fortunate few will stay back and they will in turn groom our next generation. On one hand, you miss out on the privileges of working in the premier institution, whereas on the other hand, you get a unique opportunity of standing up to the demands of the situation and meeting these challenges squarely. Believe me, it will fetch rewards of its own kind.

I must admit that in my time of need when I myself was at such crossroads, FHNO has been a big game changer. From the role of a knowledge-seeker, you adorn the garb of a worker and yet, having done that, you never let go of the inquisitive academician in you. It is the fruitful exchanges between the two of these kinds that the FHNO brings about. FHNO, the great initiative of Prof. Tiwari, Prof. Shenoy, Prof. Iyer, and several others who cannot be mentioned for the sake of space rather than intent, has grown from a humble beginning in 2002 and now an august body nearing thousand. I, for one, am a great beneficiary of this organization and cannot miss an opportunity to pen my gratitude to FHNO comrades. Starting unashamedly as an otorhinolaryngologist, I grew up and kindled the inner voice of the head and neck surgeon within me. I am narrating my journey and putting up some thoughts that might prove to be a resource to you at crossroads in your career.

The first lesson to drive hard is building of a team. Rome was not built in a day and neither by the likes of Julius Caesar alone. We need to group together to grow in the beginning and later separate ourselves into niche areas of specific interest. Growing from a “One-man army” into a solid band of 17 surgeons and cushioning into thyroid surgery in the later part of my career can serve as an example of the same. There has to be an integrated team effort from the pathologists, radio-diagnostic experts, co-surgeons, anesthetists, reconstructive and maxillo-facial colleagues, and health-care workers to ensure all-round management and care to the patients.

Opportunity knocks but once they say. True as it is, the knock is heard only by a few and by the law of Karma, these few who respond diligently, keep getting these knocks again and again. So, for me, it was Melghat with thyroid surgical workshops to begin with, then, oral submucous fibrosis (OSMF) by a privilege of working in tobacco epicenter of our country and even the lack of frozen section to address the issue of resection margins. What is important is to seek your own avenue, respond to the calling, and eventually transform adversity into advantage.

Over the past 21 years of philanthropic work at Melghat, the team of doctors from the Rotary Club of Nagpur South has conducted 2018 surgeries, examined 25,432 patients in the out-patient department, and provided food and clothing to all these patients and their relatives as well. The complications encountered have been a meager 165, of which 95.76% were minor ones warranting only minimal conservative management. The dedicated thyroid workshop has been running successfully since the past 15 years and has been drawing eager delegates from all nooks and corners of the country and some from overseas also. There have been 214 surgeries demonstrated and 648 surgeons trained in all aspects of management of thyroid disorders through this program. We have been fortunate to receive continuous support and encouragement from national and international faculty. Our motto has been to acquaint the novice surgeons with techniques and nuances of thyroid surgery and instill the confidence in them with the appropriate training, so that they too can perform safe and correct thyroid surgeries at their centers. The average size of goiter in this patient population is 8 cm. We have had no major morbidity or mortality in our experience in this region, except one young woman who died of hypocalcemia 11 months after a total thyroidectomy for a massive ungradable multi-nodular goiter. I call her my guru as she taught me a lot on the perils of mismanagement of parathyroids and their blood supply during thyroid surgery. This made me go back to the anatomy halls and work harder on understanding the vasculature of parathyroids. I took a clue from Prof. William Halstead's observation on Prof. Theodore Kocher and Prof. Billroth. While the meticulous surgeon Kocher experienced complications of myxoedema, the patients of the flamboyant surgeon Billroth experienced tetany. Realizing the difference between these two is the key to drop my own results of postoperative hypocalcemia to decimal figures. Through the same obsession on thyroid and parathyroid anatomy, I was prompted to publish a surgical atlas to share my dissection experiences with all my fellow surgeons.

Another topic that is very dear to me is the treatment of OSMF. With over 5 million cases prevalent in the country, there are very few surgeons willing to take on the challenge posed by this surgery and still fewer who will be doing it the right way. We present our results of 356 cases treated at our center by a single primary surgeon between 1999 and 2013. After experimenting with several options for trismus release and repair, I also developed a unique local rotation flap, the mandibular muco-periosteal flap, which served as a formidable reconstructive option in many cases. From a disappointing success rate of 35% for Grade IV trismus, we have now graduated to improvement rates of nearly 70–80%. This learning curve is yet another story of honest auditing of surgical work and adapting from one's experiences of failures. The ships are not built to look pretty at the harbors, so are surgeons tested only in the turbulent waters of surgeries which are otherwise doomed to failure and given up on by the majority.

How true is the dictum, “Necessity is the mother of invention.” Today, we all acknowledge the importance and aid of frozen section during surgical excision and its influence on our intraoperative decision-making. However, unfortunately, these facilities are not available to us in our region. Not getting bogged down by this handicap, we adopted and developed the technique of intraoperative crush imprint cytology to assess surgical margins and nodal positivity. When we compared these results with the final histopathology and published our early work in 2004, we found a heartening 97% sensitivity and 100% specificity in 178 cases. We are currently analyzing our complete dataset which includes over 1400 cases over 14 years, and early results are satisfactory (sensitivity 94% and specificity 98%). We greatly encourage the active involvement of our pathologist in surgery and similarly as surgeons also help in the grossing rooms in the evening. It is such a direct dialogue and feedback between the surgeon and pathologist that enabled the success story of this technique.

Coming back to FHNO which I consider as my alma mater, during my active years in the organization, yet another objective was put on the agenda while holding the presidential mantle. Raising the bar of academics where it matters, the smaller primary surgical centers cater for more than two-thirds of the head and neck cancer burden of the country. We conducted various workshops at such less privileged centers and sometimes in extremely compromising infrastructures. The FHNO stalwarts have taken the message of “You Can Do It” across the length and breadth of the country. Be it the desert of Rajasthan or the water-logged Kaziranga; be it the awesome Dharamshala or the God's own country Kerala, FHNO has spread the science, craft, and philosophy of head and neck cancer surgery and educated thousands. Above all, the message is loud and clear - To do a good surgical job, all you need is a bit of stainless steel, but more importantly some nerves of steel! You have them in plenty. Identify your potential and do justice to the maker's gift. Browsing through the archives of FHNO and reliving the past 15 years, how strongly one gets driven to admire, accolade, and stand up in stupendous respect to all the thinkers, workers, and comrades in arms at FHNO. Yes, my friends we have done it. From a small group of like-minded surgeons to an army of specialists dedicated to head and neck cancer care. My kudos to you all. Yes indeed, “We have done it!”




 

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