CIRSE Fellowship report: Dr. Abu Saleh Esha

Dr. Abu Saleh Esha, a consultant IR at the Combined Military Hospital in Dhaka, Bangladesh, used his CIRSE Fellowship grant to attend a one-month observership at two centres in Istanbul, Turkey.

By Dr. Md Abu Saleh Esha

I am a consultant interventional radiologist (IR) and the team leader of the interventional radiology department of the Combined Military Hospital in Dhaka, Bangladesh.It is the largest hospital of the Bangladesh Armed Forces and takes care of all the complicated and referred patients to Dhaka, a mega city in South Asia with a population of about 200 million.

We have a small IR team, including two interventional radiologists, three IR nurses, two radiographers, and a few other supporting staff members. In our daily practice, we do many biopsies (such as lung, liver, renal bone etc.), chemo port and other line insertions, urointerventions like PCN & antegrade ureteral stenting, hepatobiliary intervention (PTBD, biliary stenting) and oncological interventions such as TACE and microwave ablation of solid organ tumours. We also do a limited number of neurointerventions with the help of the neurosurgical team.

We face many challenging oncological, trauma, and neurological cases, such as bleeder embolization and stroke patients’ management etc. We use a multidisciplinary (MDT) approach with our surgeons, clinician oncologists, and IRs to manage these complicated patients in a way that is focused on patient benefits.

Day to day at our hospital, the IR team takes an active role in patient management, participating in tumour boards, MDT meetings, and consultations. IRs help expedite the diagnosis of patients with suspected malignancies in our hospital by performing image-guided biopsies and providing image-guided long-term central venous access (PICC and chemo-ports), as well as hydro-marker insertion in breast lesions before chemotherapy. Most of our patients receive these essential procedures within seven days of presentation at our hospital, and we are able to initiate chemotherapy within two weeks. IRs also perform chemoembolization and ablation of feasible cases of liver and kidney tumours when decided upon at MDT meetings.

With Dr. Melih.

The daily work schedule board.

Sightseeing in Istanbul.

After applying for and receiving a CIRSE fellowship grant earlier this year, I travelled to Istanbul for a one-month observership with Dr. Melih Topcuoglu.

Dr. Melih Topcuoglu and his team have a well-organized IR centre in Yeditepe Hospital in the heart of Istanbul, where they deliver high-quality, patient-friendly interventional radiological care. Dr Melih also arranged for me to attend a two-week observation training in another large neurointerventional centre at the radiology department of Istanbul University – Cerrahpasa. My one-month observership in Istanbul has provided me with a great opportunity to learn the following from Dr. Melih Topcuoglu, Prof. Osman Kizilkilic, and their teams:

• Setup, workflow, clinical indications, and technical aspects of a wide variety of interventional procedures, including ablation therapies for benign and malignant tumours.
• Setup and workflow for angio suites
• Multidisciplinary (MDT) meeting set ups which provide the best-tailored plans for patients
• The setup of a well-run IR clinic and IR ward
• The process of patient follow-up

Dr. Melih Topcuoglu’s IR department manages a good number of patients every day. The IR department has one angiographic suite where most of the vascular and non-vascular procedures are performed from early morning till afternoon. Most biopsies and ablations are done in the CT room. There is an IR clinic almost every day where patients are evaluated by interventional radiologists and the treatment options are discussed with them. Large and complex cases which need the support of an anaesthesia team, such as ablation of critically located liver or kidney tumours, are usually performed in the morning. The afternoon is usually dedicated to the insertion of lines, biopsies, and fine needle aspiration cases.

The IR centre of the neuroradiology department of Istanbul University at Cerrahpasa has well organized department including two biplane angio suites, a preprocedural room, a post procedural observation room, and an IR clinic. With the help of a dedicated team of anaesthesiologists, complex case like embolization of carotid-caverneous fistulas, embolization of glomus Jugulare tumours, carotid angioplasty and stenting, and aneurysmal coiling usually are normally done as the first case of the day. Afternoons are usually dedicated to diagnostic cerebral DSA and refereed cases of lumbar puncturs. The IRs and their team of radiographic technicians and nurses were all great teachers and enthusiastic to share their knowledge and answer any questions I had. I felt very welcome as part of the team.

The angio suite in Istanbul. 

Ready to perform microwave ablation.

I was impressed and felt lucky to observe the technical skill and manoeuvres of catheters and wires by Prof. Osman Kizilkilic in different cerebral procedures. Another thing in our Indian subcontinent – angiography machines are usually manoeuvred by radiographic technicians, but in Istanbul, I have observed that the entirety of the procedure and angiographic machine manipulation is done by interventional radiologists.

I was able to observe an infant patient with retinoblastoma receive chemoembolization of a tumour by catheterization of the ophthalmic artery with inj Melphalan, a totally new experience for me. I also assisted a case of inferior petrosal sinus venous sampling for the localization of lesions for an infant with Cushing’s syndrome. Another case which provided me with practical experience was using hydrodissection to protect the laryngeal and pharyngeal structures during microwave ablation of a thyroid nodule of a young lady done by Dr. Melih Topcuoglu, assisted by me. I have also learned how to shape wire tips and catheters in cases of difficult to engage vessels. I also noticed the IR nurses and radiographic technicians were very prompt with patient care in case of any complications, and in handling the difficult and longstanding procedures with the physician. I had the opportunity to attend the multidisciplinary team meeting at neuroradiology department of Istanbul University-Cerrahpasa, where a grand discussion happened between the IRs and other clinicians. These are all important aspects which I need to consider when setting up an interventional service back in Bangladesh.

The way that IR has been incorporated into the patient journey at Yeditepe University Hospital and Istanbul University-Cerrahpasa has greatly pleased me. Interventional radiologists treat patients directly to explain and discuss treatment choices in the clinic or ward following referrals or consultations from other specialties. Additionally, IRs are permitted to admit patients under their care as inpatients. If the patient recovers well from the procedure, they can be sent straight home. The IRs decide on the required imaging and clinical follow-up schedule based on the clinical status. From the perspective of the patient, this smooth process makes it possible to comprehend the treatment plan and continuity of care more clearly. I had the pleasure of sitting in on the joint clinic where interventional radiologists and oncologists can assess the patient together and offer a tailored treatment plan.

In addition to patient care, Prof. Osman and Dr. Melih teach the fellows and resident IRs, and both of their teams are also active researchers and pioneers in innovative therapies in Turkey.

I am very grateful to CIRSE for the fellowship grant. I have learned and gained so much during my one-month observer ship with Dr. Melih and Prof. Osman’s departments, not only in terms of IR-related knowledge and insights but also many friendships and the chance explore many places and the delicious cuisine in Istanbul, a historic mega city between both Europe and Asia, straddling the Bosporus Straits. Everyone in Dr. Melih’s and Prof. Osman’s departments are friendly, compassionate, creative, and excellent mentors, clinicians, and scientists. Despite their extremely hectic schedule, they find time to care for their patients and their fellows, among many other responsibilities. Everyone on their teams is gregarious, committed, and full of enthusiasm. Any IR, especially those who are new and interested to build carrier in interventional radiology services, should visit Prof. Osman and Dr. Melih and their teams to see future IR!