23-Y-O single mother undergoes Guyana’s first partial skull transplant

Dr Amarnauth Dukhi and the medical team that performed the country’s first partial skull transplant

By: Lakhram Bhagirat

In what can only be considered a major success for Guyana’s healthcare sector, the country’s lone neurosurgeon Dr Amarnauth Dukhi successfully pioneered the first partial skull transplant on a 23-year-old single mother on Saturday last at the St Joseph’s Mercy Hospital.

The surgery lasted just about six hours and saw single mother Analisa Latchman receiving a specially-created skull implant after being diagnosed with craniofacial fibrous dysplasia.

Latchman is a mother of one who hails from Lima, on the Essequibo Coast, Region Two (Pomeroon – Supennam).

For years, she has had an indented left forehead and her eyes were receding into her skull. Recently, she started experiencing severe episodes of headaches which eventually got so bad that she would lose consciousness.

She visited a number of doctors who were unable to give a specific diagnosis. She did a number of CT-Scans and MRIs but no conclusive diagnosis was provided – all the while, her headaches intensified.

According to her cousin, Dr Sarah Lall Khan, Latchman would be cooped up in her room crying for pain. This led to her travelling to Georgetown to meet with a neurologist but like the many other doctors, no definitive diagnosis was provided.

Not being able to see her cousin in such excruciating pain, Dr Khan suggested they consult with Dr Dukhi just to get to the root cause of the headaches.

Analisa Latchman

“We brought all her scans. I spoke to him, told him her history and he listened to us and he had one look at the scan and when he looked at the scan – I didn’t even give him the reports for the scans – he was able to diagnose on the spot exactly what was wrong with Analisa. He pointed all these things to me and showed me the entire frontal lobe how it is being squeezed because of the bone pressing it back and causing the pain and abnormalities,” she recounted.

Following the diagnosis, Dr Dukhi immediately came up with a treatment plan. He explained that when he saw Latchman back in June, his immediate conclusion was that she was suffering craniofacial dysplasia. But, after looking over the various scans of her head, he realized that she was suffering from a rare craniofacial bone disorder called craniofacial fibrous dysplasia which is a bone disease of the face and skull that replaces normal bone with fibrous-type tissue.

He explained that this occurs in 10-15 in every 100,000 babies born with symptoms beginning as early as 2 years old while clinical signs of indentation commencing between 10-12 years old. As the patient begins to grow the signs of indentations become more pronounced.

It was the first time that Dr Dukhi was encountering a patient in Guyana with craniofacial fibrous dysplasia, and knew that he wanted to operate locally. However, he was also cognizant of the fact that a lot of preparation would have to be in place before he could have successfully pulled off such a groundbreaking procedure in Guyana.

He knew that Latchman would require a partial skull implant to ease the pressure on her brain and diminish her headaches. He then began constructing a 3D model of Latchman’s CT-Scans and realized that almost 40 per cent of her skull was sick and needed to be reconstructed

“The most initial aspect of things were to create a replacement for 40 per cent of Analisa’s skull. I did a CT scan and reconstrued it 3D and realized that almost 40 per cent of Analisa’s skull was sick. That osseous structure of her actual skull vault has now become fibrous and it was pulling her facial structure into the brain hence why she had an asymmetric facial look where he left side was more into the brain than her right side of her face was where it should be,” Dr Dukhi explained.

Dr Amarnauth Dukhi

There was also the issue of financing the surgery since Latchman is a single mother with very little access to the level of finances that was required. Dr Dukhi explained if the patient had to go overseas for the treatment then the minimum cost would have been US$200,000 but they were able to perform the surgery with a fraction of that cost.

Dr Dukhi approached the St Joseph’s Mercy Hospital, businessman and the Hospital’s Board Vice-Chair Chris Fernandes and others to assist the patient by covering part of the surgery. He then offered his services free of cost so that the mother could have a pain free life ahead.

Latchman was only required to pay US$11,000 (just over $2M GYD) for the implant and some operational costs while Fernandes covered the hospital costs.

After the issue of financing was sorted, Dr Dukhi partnered with NeuroSpine Services Inc based at the St Joseph’s Mercy Hospital where they began sourcing the skull implant for Latchman. They contacted KLS Martin – a US-based company that creates implants for the entire human body – and began the partnership.

Dr Dukhi had to send KLS Martin the 3D reconstruction of the CT-SCANS after which they used it as a guide to creating the implant.

“We were able to send that to KLS Martin and they actually reconstructed the 40 per cent of deficit that we would have provoked during surgery in Analisa’s head. That was amazing because that is very difficult to do without actually seeing the patient’s head but thanks to technology and CT-Scans and MRIs, this is possible and because we have these resources in Guyana it is important that we use them and we use our human resource capacity as we continue to develop health care both in the public and the private sector,” the neurosurgeon related.

The implant arrived in Guyana on Thursday last and the surgery commenced on Saturday at 07:00h at the St Joseph’s Mercy Hospital.

“It was a very technical surgery because we had to go all the way on the eye at the orbit. Imagine part of her eyes is now into her brain and we were able to reset her orbit where it was. So, if you look at Analisa now she actually had a nice looking forehead not that indented forehead anymore. Her orbit is back in place and she has good vision. It was tedious for me because it has two very important nerves that come out which is the facial nerve and the upper branch of the trigeminal nerve. We were able to dissect that very carefully and protect it so there were no injuries to her never so there were no repercussions in terms of who she was and her normal functions,” he noted.

While the surgery was a success, Dr Dukhi explained – like every brain or spinal surgery – it was very risky.

Due to the compression of Latchman’s skull, the layer of the brain that covers the brain that is called the dura was already thinning so Dr Dukhi had to be extremely careful in removing the sick section of her skill since any miscalculation would have resulted in damaging the dura and provoking brain damage. He decided that a bicoronal approach would have been the best way to remove the sick part of the skull and position the implant.

Dr Dukhi’s said it is important to note that his surgical team was dominated by women since he feels that women should have the power to be part of things that are generally seen as a male dominated field. His assistant surgeon, during the 6-hour long procedure, was Dr Anna Singh – whom he has been training for over 5 years.

It also included his female surgical nurses – Nurse Sharma and Nurse George, nurse anesthesiologist Martina and the only other male was Dr Fernandao – head of anaesthesia.

When asked about the risks of the surgery, Dr Dukhi said death is always the worst-case scenario in any neurosurgical intervention and explained further the risks associated with Latchman’s procedure.

Meanwhile, Latchman – who is recovering well – expressed her gratitude to the entire surgical team and all her donors. She spoke with the media via zoom.

“Special thank you to Dr Dukhi because I have visited so many doctors and go no help but the first visit to him, he told me about it and I must say that I am very grateful to him and special thank you to the Administration of St Joseph’s Mercy Hospital and Mr Fernandes,” she said.

St Joseph’s Mercy Hospital’s Deputy Chief Executive Officer, Deborrah Ramsay expressed the hospital’s happiness with the partnership while Fernandes hailed Dr Dukhi for pushing the boundaries.