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The story of the Carcinoma of the Oesophagus: the misadventures
Dr. Rathin Datta
The story of  the Carcinoma of the Oesophagus: the misadventures
PHOTO : Carcinoma of the Oesophagus. Picture source : Internet

My journey started in June 1954, when after passing the First MBBS exam of the University. I was the University topper that year. Our clinical classes in the third year started. Vividly remember the initial class in Medicine by Prof. Nityn Gupta FRCP, a teacher,with a rare dramatic style of teaching.

Panama hat wearing Prof Gupta’s entry into the class room was unforgettable. The first subject he picked up to teach us was Dysphagia, ie difficulty in swallowing. The classification of dysphagia that he drew up in the board---I can still recall.

Prof Gupta had a bad heart; he passed away that same year, He had told us that most serious cause of dysphagia was Oesophageal Carcinoma and that there was, till then no treatment and asked us to promise that we shall find out the cure . We all had promised.

The misadventure of the Year 1960, month of July:

Venue was Surgical unit, one of Assam Medical Colleges, Dibrugarh, the pride of Assam in the North East..It was said that, an Amcol Grad was highly considered even in the English Royal College in London.

Proof :
The Chairman of the board of examiners of the Fellowship examinations told me so on the 19th may, 1965, the day I cleared the Fellowship Exam  and became an FRCS Eng. Three out of the 16(sixteen) examiners offered me Registrar’s job in their own units.

I was too home-sick to say “Yes” to the offers. I had the return ticket bought for flying back to India on June 30, which was in my pocket. (More over I was already a Registrar in good Surgical unit in a large hospital in Lancashire).
 In 1960, my appointment was also as the Registrar of Surgery, at the Assam Medical College at Dibrugarh my Alma Mater. The chief was an aristocrat, the Professor of clinical surgery holding a PG degree of FRFPS, not equivalent in status to FRCS, but  who could tell him that! He would claim to be the best in the business.

I was his pet till somebody told him during the 60’s Bongal Kheda riot that I was not am Assamese, but a Bengali. My boss was a Bengali hater and immediately changed his attitude toward me.

The case history: Massacre at the Operation Theatre

A tea garden labour-sardar, Kenaram Munda was admitted with history of increasing Dysphagia (difficulty in swallowing).After admission I had passed an the Oesophagoscope  to confirm that he had  cancer of the esophagus in the middle third-biopsy , histology confirmed  that it was  Columner cell Carcinoma”, of the middle third of esophagus. Kenaram was a heavy smoker and an alcoholic, but a pleasant man. We became friends.

Our Professor was excited, declared that  he will perform a Radical Esophagectomy. In the OT next week it was a virtual massacre. After the Thoracotomy (i.e. opening the thorax),it was seen that the Cancerous growth had involved the Aorta ,the main blood vessel  which carries the blood supply from the heart to the Abdomen and the lower limbs were infiltrated by the cancer tissue.

I, as the first assistant suggested abandoning the procedure and close up. The boss disagreed and tried sharp-dissection of the growth out from the Aorta and in doing so his knife entered the thoracic Aorta. The profuse bleeding that ensued killed Kenaram Munda  in less than 10 minutes: a “Table Death”.

The Professor put the whole blame on the assistants and went home. I was upset as during those days I had become very fond of Kenaram. The very unpleasant atmosphere  of Surgical unit  became intolerable: I decided to sail, to the  UK for the FRCS. In December, resigned my job and left for London----it was “sea voyage “.

The status of FRCS in 1950s and ‘60s:

The study of Surgical Sciences is endless, it is like crossing  an ocean in a paddle boat, an endless perilous journey. During the examination for the fellowship (popularly known as the FRCS exams), candidates from the subcontinent who travel to UK after completing the Graduation in a third world country like India/ Pakistan, Ceylon, Egypt, were doubly handicapped, difficulties were the cultural shock, the language barrier, the accent, the technical superiority to surmount, finally the subject  Surgery  itself, a massive subject to grasp.

Surgery was not easy. Many of the aspirants would give up, facing  a pass rate of  less than 10%, disheartened most of  them, either gave up permanently or switched  over to other easier subjects or joined private practice(become a GP).
The primary FRCS exam was tough, few could clear in first chance and among those who did pass  the  clearest made the usual mistake of straight-way starting  the attack for the final fellowship (i.e. used to go hammer and  tong) for Final FRCS, and fail repeatedly, may be after  5 to20 attempts  could get past the Final FRCS exam.
The status and the procedure has undergone sea-change, MRCS has replaced fellowship which is now only conferred.

 Prof. Roland Thornley FRCS and the famed Thornley boys:

Obtained my entry to the famed Thornley’s unit of Surgery and Urology first as a House Surgeon, soon became the Registrar to become a “Thornley boy”, the prestigious band of trainee surgeons.

Mr Thornley was a brilliant Surgeon and a famed teacher, was one of the examiners of the Royal colleges of Surgeons. His one liner was: “master all the sub- specialties first boys and then only take the fellowship exam”; it may take 3 to 4years.There is no short cut to the Fellowship i.e. pass the FRCS.  His everyday ward round used to be for us, a rehearsal of the final fellowship exam. So my  target year for the Final fellowship became June, 1965.

We, the trainees, the house staff and the Registrars dreaded the rounds, called it the Grand round, but also enjoyed the same immensely gaining confidence by every day. Mr T. (as he was known behind him) used to find short term jobs/attachments for his pet boys so that his boys could obtain over all trainings.

I became his pet boy, became one of the famed “Thornley boys” and by the middle of ’64 Mr.T had seen to it that I had trained in all sub-specialities, only the CTVS i.e. Cardio thoracic and vascular surgery remained. In March ’64, the Boss found a good job  for me as the Registrar,  in a   thoracic unit in the Christy’s hospital known as the  leading cancer Hospital outside USA.

The following six months I was busy .I tried to pick up as much experience in thoracic malignancy as much as was possible.

Mr Thornley suddenly succumbed to a massive heart attack in August’64, the reign of the Thornley-boys ended in the District and General Hospital, in the outskirt of  the Great City of Manchester. 

I left the Cardio thoracic unit in September, leaving the training in Cardiothoracic Surgery halfway and joined the 15 weeks (4 months) course for FRCS  in the Royal college of  surgeons  of Edinburgh. My weakness in Cancer of Oesophageal surgery covered having participated nearly 40 cases with the master surgeons on the Subject.

Cancer of Oesophagus( and Gastro-oesophageal junction):

It is the 6th commonest malignancy in humans, after 50th year of age, is a morbid disease with a grim prognosis, has a tendency of Occult metastasis (cause of large percentage of failures) now detectable by Positron emission tomography(PET) test which makes it possible to detect a spread, not possible to detect otherwise. A growth remains symptom less till 2/3 of the lumen is obliterated, so detection is nearly always late and post operative results get poorer with lost time .It is common among Alcohol and tobacco abusers and follow usually Reflux oesopagitis or Barrett’s oesophagitis.

In highly selected cases 5 year Survival rate is less than 30 percent .Appoximately in India in 2012 nearly 4.5 lakh cases were detected, but only few were operable.


Edinburgh/Royal College of Surgeons/1964 September:

Obtained admission in the RCS to attend the final FRCS  course of 15 weeks to prepare and polish my knowledge for the final exam. There Dr. Eva  Dastoor, a Parsi surgeon from Bombay met me. She was a brilliant thoracic surgeon, but was unable to pass the FRCS exam due to her weakness in General   Surgical sciences and orthopaedic surgery.

She sought my help after she noticed that I was topping the weekly tests. She met me in the college diner and requested to make her my partner. She had more than two unsuccessful attempts at the Felloships exams already and wanted help to make up her deficiencies in the General Surgery, Orthopaedics, Surgical anatomy and Pathology, and  needed help.

She was from a super rich Parsi family  of Bombay and lived in Edinburgh, in a luxury apartment  with a battery of servants and had her own driver for her luxury American Car.(I incidentally lived in the college accommodation for the Post.

Grads in  Sutties Hotel, a 3-star hotel and drove a little luxury sports car, the  Mini Cooper .I would  help her in Surgical anatomy  and  in general Surgery, orthopaedic, plastic and pediatric surgery and she in  return filled my deficiency in CTVS (cardio-thoracic-vascular surgery).
Effortlessly we passed the fellowship exam in Edinburgh in  march 1965,otherwise a very tough examination. Eva did not want to bother trying the other fellowships, I completed the Glasgow and the England (the London FRCS) in may 1965.
In the mean time I had helped Eva, who was a pretty Parsi women with marble white skin, marred by profuse pock marks in her face. We could get her face overhauled by the famous Plastic surgeon Professor Wallace who in addition trimmed Eva’s long Parsi nose to a beautiful Anglo-Saxon type. Eva became a real beauty. I had in the past had trained under Prof. Wallace  and hence did the favour.
I  returned to India in 1965 June. I was selected for a specialist Surgeons post of   CHS, while in England  and was posted in the GB Hospital as Senior Specialist Surgeon, in a  CHS  (central health service post) on the 6th June.

The next misadventure (GB&VM group of hospitals)

September 1965, GB Hospital, Agartala:

I had by then spent nearly 3 months in GB Hospital, no bigger than a district hospital in a larger state in India . The Medical Superintendent was Dr.SK Datta  (popularly known as Sankar Datta, was my senior in the Medical college and was a brilliant student and footballer,and also a reputed physician.

We met in the corridor, “how about doing a esophagus now, Rathin? How about it Sankarda? I am ready.”

 I replied, “Come and see”. He took me to his ward.

There was Mr Bichitra Biswas, a thin wiry man of 70,sitting on his bed .All tests that were possible had been done. Brought to my side, I passed an oesophagoscope---there was the growth in the lower end of esophagus and stomach(Carcinoma lower end of esophagus, confirmed). After adequate transfusion, we went in.

It was easy. The lower 6” of the esophagus was mobilized and along with the part of the fundus of the stomach, which  was removed en-bloc. The cut end of stomach was made into a tube and brought up to the thorax and joined up with the cut end of the esophagus in a neat anastomosis (esophago Gastrostomy).

Sankarda was pleased impressed and was about to leave. Dr.Choudhury, the anesthetist requested him to stay, I knew the reason instantly and tried to “thump” the heart. No response. Mr Biswas’s heart stopped before my eyes, my second  DOT  i.e. death on the table, from Ventricular fibrillation as there was no defibrillator or anti arrhythmic agents.

“Table-Death upsets a surgeon most”.

A note on Ventricular fibrillation:
VF is  the condition of heart when there is unco-ordinated contraction of Cardiac muscles of the ventricles of the heart making them quiver rather than contract properly Ventricular fibrillation is the most common condition identified before a cardiac arrest and death.
                                        
Mr Biswas  died after a successful surgery as the Hospital did not have defibrillation facility, but I was the operating  surgeon.

Dr. Rathin Datta, FRCS (England, Edinburgh & Glasgow).FFIMS (Athens) 

Surgeon & Sports Medicine Specialist, Retd. Chief Advisor of Surgery, GB & VM Hospitals, Govt of Tripura

Padmashree Awardee, winner of the Bangladesh Liberation war honour 

This article also published in Facebook www.facebook.com/tripurainfoway simultaneously.

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