California Archives - Atabak Allaei, MD: Vascular & Image Guided Specialist | Los Angeles CA

Endoscopic Gallstone Removal

Codeholic Admin — Mon, 20 Mar 2023 06:27:18 +0000

Percutaneous Endoscopic Gallstone Removal

Non-Surgical Endoscopic Gallstone Removal

Gallbladder stones, known as cholelithiasis, can be asymptomatic or cause abdominal pain and infection. Gold standard treatment is to remove the gallbladder.

Patients who cannot undergo surgical gallbladder removal, can end up with a tube in their gallbladder called a cholecystostomy. This is not ideal as these tubes have to be changed for life and can become a burden on the family and patient. The cholecystostomy tube cannot be removed because of the risk of recurrent pain and symptoms.

Percutaneous endoscopic gallstone removal is a non-surgical technique that preserves the gallbladder by removing the stones through the tract using different methods. There may also be stones in the bile ducts, known as choledocholithiasis, that can also be removed. This treatment is also starting to be offered to patients who can also have surgery.

The procedure is performed by a specialty trained Board Certified Interventional Radiologists, a medical doctor who is trained doing procedures with the use of X-rays and other advanced imaging to see inside the body and treat conditions without surgery. The Interventional Radiologist uses direct visualization with a small camera and X-ray guidance from a fluoroscopy machine that allows for control of the instruments used to remove the stones.

Candidates for Percutaneous Gallstone Removal

Endoscopic gallstone removal has traditionally been offered to patients who are not able to have traditional gallbladder removal surgery or who have bile duct stones that cannot be removed in the standard fashion. These patients have had symptomatic gallstones that require treatment.

Gallstones can cause pain that is usually on the right side or middle of your upper belly, may be constant or worse after a heavy meal, may sometimes feel more like fullness than pain, may be felt in your back and in the tip of your right shoulder blade. Other symptoms may include nausea, vomiting, fever, and chills. The symptoms of gallbladder problems may look like other health problems. Always see your healthcare provider to be sure.

If you have had a gallbladder drain placed for gallstones but cannot get your gallbladder surgically removed, then you are potentially a candidate for this procedure.

Recently this procedure has also started to be offered to patients who are surgical candidates but for personal, dietary or religious reasons they do not want their gallbladder removed.

Gallstone removal is a safe and effective procedure when performed by an experienced Interventional Radiologist with an understanding of the techniques to reduce complications.

Success Rate of Percutaneous Gallstone Removal

Endoscopic and fluoroscopic-guided gallstone removal is highly successful, with complete stone removal from the gallbladder or bile ducts occurring in 80% of cases. Once the stones are removed from the gallbladder and bile ducts there is no reason for removal of the gallbladder or requiring a drain. Recurrent formation of stones is possible.

Endoscopic Gallstone Removal: Procedure Details

Percutaneous endoscopy is performed through the existing gallbladder drain tract. If you don’t have a gallbladder drain, this will need to be placed.

After 4-6 weeks a tract will form around the gallbladder drain, this is required to prevent any leakage of stones or bile into the abdomen. Once it is confirmed that there is a formed tract, the endoscopic procedure can then be schedule.

Sometimes the size of the drainage catheter is increased prior to removal of the stones so that the tract is larger to accommodate the camera. This depends on the size of the stones.

On the day of the procedure, the drain is exchanged for a larger temporary access into the gallbladder that will fit the endoscopic camera. Iodinated contrast material maybe injected into the bile ducts to locate gallstones that maybe causing blockage. Small stones are removed using a basket that fits through the camera. Other stones can be washed out by irrigating the gallbladder with saline or water.

Larger stones can be fragmented under endoscopic guidance with a precisely directed holmium laser. The gallbladder is filled with sterile water prior to fragmentation as the laser beam is absorbed by water, preventing damage to the gallbladder wall.

On average, it takes two sessions to clear patients of their stones if there is a large stone burden. After the stones are removed, the tube will stay in place for a couple of weeks to ensure the gallbladder/bile system is still intact and functioning normally. Once this is confirmed, the tube is then removed. The tract heals and closes on its own and does not require any suture or surgery.

Preparing for Gallstone Removal Procedure

Prior to the Procedure

You may not eat or drink eight to 12 hours prior to the procedure.

If you are on blood-thinning medication you may be asked to stop it prior to the procedure.

During the Procedure

You will be asked to change into a gown before the procedure.

Labs will be obtained.

You will be given a sedative by the anesthesiologist, who will be present to monitor your vital signs during the examination. Typically the procedure is done with a “twilight sedation.”

After the Procedure

This is an outpatient procedure and does not require hospital stay.

You will remain in a recovery room until most of the effect of the sedative has worn off.

Because of sedation used during the procedure, you’ll need to make plans to have someone take you home.

Gallstone Removal Procedure: Risks

Discomfort at the insertion site

Infection

Nausea

Bleeding

Bile duct or gallbladder injuries like perforation

Gallstone Removal Procedure: Results

The procedure is highly successful in the right candidate. This renders patients tube and gallstone free. Risk of recurrent gallstones is unknown.

The following are x-ray images of the bile ducts, showing a gallbladder with a large stone prior to and following removal by percutaneous cholangioscopy.

This picture shows a gallbladder with a large stone. The arrow points to a smaller drainage catheter that was inserted to relieve pressure.

Following the percutaneous cholangioscopy procedure, the drainage catheter can be removed.

This image shows the gallbladder after the gallstone and drainage catheter’s removal.

The post Endoscopic Gallstone Removal appeared first on Atabak Allaei, MD: Vascular & Image Guided Specialist | Los Angeles CA.

Non-Surgical Gallstone Removal Cholangioscopy

Codeholic Admin — Sat, 08 Aug 2020 09:01:46 +0000

Non-Surgical Gallstone Removal

Gallstones

Non-Surgical Gallstone Removal

Percutaneous endoscopic procedure is a technique that can be used to treat patient that have gallstones, known as cholelithiasis, but cannot undergo surgery for gallbladder removal due to other medical issues. Often times these patients end up with a gallbladder drain, a cholecystostomy tube, that cannot be removed because of the risk of recurrent pain and symptoms.

There may also be stones in the bile ducts, known as choledocholithiasis.

This procedure is performed by our trained interventional radiologists, a doctor who uses X-rays and other advanced imaging to see inside the body and treat conditions without surgery. Our interventional radiologist using direct visualization with a camera and X-ray guidance from a fluoroscopy machine that allows for control of the instruments used to remove the stones.

Non-Surgical Gallstone Removal and Choledoscopy Candidate

Endoscopic gallstone removal is typically for patients who are too old or high risk to have traditional gallbladder surgery or who have bile duct stones that cannot be removed in the standard fashion. Sometimes this treatment can be offered to patient who have strong medical, religious or personal reasons for not wanting their gallbladder removed.

If you have had a gallbladder drain placed for gallstones but cannot get your gallbladder surgically removed, then you are potentially a candidate for this procedure.

Our specialist has treated a number of patients who are over 80 years old and too sick to undergo surgery. The lower risk profile makes this an ideal procedure for older patients or those with a number of medical issues to undergo surgery. Since this procedure can be performed with twilight sedation, this also eliminates the risks of general anesthesia and intubation. This is a safe and effective procedure when performed by our experienced interventional radiologist with an understanding of the techniques needed to reduce complications.

Non-Surgical Gallstone Removal Procedure

Percutaneous endoscopy is performed through the existing gallbladder drain tract. If you don’t have a gallbladder drain, this will need to be placed.

Sometimes the size of the drainage catheter is increased prior to removal of the stones so that the tract is larger to accommodate the camera. This depends on the size of the stones.

How to Prepare for Non-Surgical Gallstone Removal Procedure

Prior to the Procedure

You may not eat or drink eight hours prior to the procedure.

If you are on blood-thinning medication, ask your provider if you need to stop it prior to the procedure.

During the Procedure

You will be asked to change into a gown before the procedure.

Labs maybe obtained.

You will be given a sedative by the anesthesia nurse, who will be present to monitor your vital signs during the examination. Typically the procedure is done with a “twilight sedation.”

After the Procedure

This is an outpatient procedure and does not require hospital stay.

You will remain in a recovery room until most of the effect of the sedative has worn off.

Because of sedation used during the procedure, you’ll need to make plans to have someone take you home.

What are the Risks?

Discomfort at the insertion site

Infection

Nausea

Bleeding

Bile duct or gallbladder injuries like perforation

Results:

We have successfully treated many patients with complete removal of the gallstones. This has rendered them tube free, which is a huge relief for patients and their family.

Gallstones

Non-Surgical Gallstone Removal

There may also be stones in the bile ducts, known as choledocholithiasis.

Non-Surgical Gallstone Removal and Choledoscopy Candidate

If you have had a gallbladder drain placed for gallstones but cannot get your gallbladder surgically removed, then you are potentially a candidate for this procedure.

Success Rate of Non-Surgical Gallstone Removal Cholangioscopy

Endoscopic and fluoroscopic-guided gallstone removal is highly successful, with complete stone removal from the gallbladder or bile ducts occurring in 80% of cases. This has a significant impact on patients and their family who are left to care for the drainage catheter, which would be otherwise for the rest of the patient’s life. After the procedure, the catheter can be removed allowing the patient to have a better quality of life.

Non-Surgical Gallstone Removal Procedure

Percutaneous endoscopy is performed through the existing gallbladder drain tract. If you don’t have a gallbladder drain, this will need to be placed.

Sometimes the size of the drainage catheter is increased prior to removal of the stones so that the tract is larger to accommodate the camera. This depends on the size of the stones.

On the day of the procedure, the drain is exchanged for a larger temporary access into the gallbladder that will fit the endoscopic camera. Iodinated contrast material maybe injected into the bile d

ucts to locate gallstones that maybe causing blockage. Small stones are

removed using a basket that fits through the camera. Other stones can be washed out by irrigating the gallbladder with saline or water.

How to Prepare for Non-Surgical Gallstone Removal Procedure

Prior to the Procedure

You may not eat or drink eight hours prior to the procedure.

If you are on blood-thinning medication, ask your provider if you need to stop it prior to the procedure.

During the Procedure

You will be asked to change into a gown before the procedure.

Labs maybe obtained.

You will be given a sedative by the anesthesia nurse, who will be present to monitor your vital signs during the examination. Typically the procedure is done with a “twilight sedation.”

After the Procedure

This is an outpatient procedure and does not require hospital stay.

You will remain in a recovery room until most of the effect of the sedative has worn off.

Because of sedation used during the procedure, you’ll need to make plans to have someone take you home.

What are the Risks?

Discomfort at the insertion site

Infection

Nausea

Bleeding

Bile duct or gallbladder injuries like perforation

Results:

We have successfully treated many patients with complete removal of the gallstones. This has rendered them tube free, which is a huge relief for patients and their family.

The above information is not all inclusive of the risks, alternatives and benefits. It is not meant to be a substitute for informed discussion between you and your doctor, but can act as a starting point for such a discussion. There are complications possible with any medical procedure. Overall, minimally invasive procedures have a lower complication rate than open surgeries.

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Peripheral Arterial Disease

Codeholic Admin — Mon, 13 Mar 2017 16:45:41 +0000

Peripheral Arterial Disease

Peripheral Arterial Disease (PAD)

PAD refers to plaque formation in the arteries of the arms and legs. It usually happens because your arteries harden and narrow. (That’s called atherosclerosis). Smoking, high blood pressure, high cholesterol, and not being active are the main causes.

If you have diabetes, you’re more likely to get a worse case of peripheral artery disease that improves less with treatment.

Symptoms

When atherosclerosis narrows the long arteries of the legs, your leg muscles don’t get enough blood flow. As a result, you may feel muscle pain. It usually comes on with exercise and stops when you rest.

It can affect different muscle groups, including:

Calf (most common)
Buttock and hip
Thigh
Foot (less common)
Some people feel burning or numbness. Others have severe blockages with no pain at all, usually because the body grows blood vessels that go around the blockages.

Other signs and symptoms of peripheral artery disease include:

Wounds that heal poorly
Legs are cooler than the arms
Shiny skin over the legs
Loss of hair on the legs
Fainter pulse in the feet

Diagnosis

The tests you’ll take to see if you have peripheral artery disease are simple and painless.

Doctors usually start by checking your “ankle-brachial index,” which compares your blood pressure at your ankle and upper arm. Those measurements should be about the same. If your blood pressure in your ankle is a lot lower, you may have peripheral artery disease.

If your case is severe, you may take a type of X-ray called an angiogram to see exactly where the blockage is. Your doctor will inject a dye into a blood vessel to help show what’s going on.

Treatment

You can do a lot to stop peripheral artery disease in its tracks, such as:

Exercising
Controlling your cholesterol and blood pressure
Not smoking
Eating a healthy diet
The drug cilostazol eases symptoms in many people. Pentoxifylline is another that can improve symptoms in people with poor circulation. Doctors may also prescribe aspirin or other anticlotting drugs.

For severe peripheral artery disease, your doctor may recommend surgery or less invasive procedures to bypass a blocked artery and restore blood flow. See treatment options here.

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Varicocele

Codeholic Admin — Mon, 13 Mar 2017 16:44:16 +0000

Varicocele

A varicocele is the swelling in the scrotum caused by a collection of abnormally large bloods vessels (veins) in the scrotum. This is due to dilatation of the testicular vein which drains the scrotum and testicle and is a form of varicose vein. They are often described as feeling like “a bag of worms”.

A varicocele occurs in approximately 1 in 8 men and it is usually first noticed between the ages of 12 to 28. The incidence is noted to be higher in infertile couples, often up to 30%.

They usually occur on the left hand side but can occur on both sides of the scrotum. They occur more frequently on the left side as a result of the differing anatomy of the veins from which varicoceles result on the left hand side of the body compared to the right.

Symptoms

Pain:

This is often described as a discomfort or aching sensation particularly by the end of the day when the person has been standing or sitting for a long period of time. This is thought to be due to increasing pressure in the varicocele due to increased blood pooling.

Infertility:

There is an association between infertility and varicoceles. Most men with varicoceles are not infertile. However, if one has a varicocele,then there an increased chance of infertility. Among infertile couples, the incidence of a varicocele is about 30%. It is thought that the increased blood flow around the scrotum is responsible for raising the temperature in the testicles and results in defective sperm formation.

Varicoceles may cause decreased sperm count, decreased motility of sperm, or an increase in the number of deformed sperm.

Testicular atrophy:

Another symptom of varicoceles is the shrinkage of the testicles, also known as atrophy. This may recover following treatment.

Varicocele embolization

This is a non-surgical, day case procedure which is performed by an interventional radiologist. By this procedure, the vein is blocked internally, therefore accomplishing what a urologist does surgically, but without the need for surgery in the scrotum.

Surgical treatment

This is performed by a urologist, usually under general anesthesia or sedation. Then an incision is made into the skin above the scrotum. The offending veins are identified and tied off with sutures. Recovery time is often two to three weeks. A keyhole operation is also possible using a laparoscope as is used for other common operations like gallbladder removal.

Advantages of embolization over surgery

No surgical incision or sutures.
As effective as surgery.
Day case procedure with no overnight stay.
Short recovery period of one to two days.
Hardly any complications. Infection has not been reported.
If a patient has varicoceles on both sides, both can be treated at the same time.

How effective is varicocele embolization?

Varicocele embolization is as effective as surgery for the treatment of varicoceles as measured by improvement in pain, semen analysis and pregnancy rates. In one study pregnancy rates were as high as 60 percent. Another study showed that sperm parameters improved in 83 percent compared to 63 percent for surgery. Patients who have had both procedures express a preference for embolization.

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Uterine Fibroid Embolization

Codeholic Admin — Mon, 13 Mar 2017 16:39:37 +0000

Uterine Fibroid Embolization

Uterine Fibroids

Uterine fibroids are benign growths of the uterine muscle occurring in 30-40% of women. The etiology of fibroids remains the subject of research but genetics is an important factor. The tumors are sensitive mainly to estrogen and progesterone. Most fibroids do not cause any problems and do not require treatment. Some fibroids, however, can cause heavy periods which can lead to anemia and debilitation, or if the fibroids grow large they can lead to ‘compression syndrome’ in which adjacent organs may be compressed such as the bladder leading to frequency of urination, the bowel leading to constipation and bloating. Fibroids may press on nerves causing backache and sciatica and can cause cosmetic unsightliness by bulging the abdomen.

Uterine Fibroid Embolization

Uterine fibroid embolization, or UFE , is performed by interventional radiologists, who consults to evaluate whether UFE is right for the patient. Interventional radiologists are physicians who use X-rays and other imaging techniques to see inside the body and guide tiny catheters and other micro-tools to perform fibroid embolization and treat other conditions without surgery.
Uterine fibroid embolization is not performed by gynecologists, who, for various reasons, may sometimes not discuss it as a possible option for their patients with fibroid tumors. This may occur because gynecologists are not familiar with the procedure or the favorable results of clinical studies. Sometimes they are unaware that UFE is an FDA-approved treatment for fibroid tumors, and may mistakenly tell patients that it is “experimental”. In fact, the procedure has now been recognized by the American College of Obstetrics and Gynecology as a treatment for fibroid tumors. More information is available on the ACOG site.

UFE has several advantages over the other treatments for uterine fibroids.

It involves no blood loss, no stitches or surgical incision (only a small nick in the skin), no abdominal scar, no general anesthesia, no prolonged hospital stay, and no burning or scraping the lining of the uterus.
Uterine fibroid embolization requires much less time off work than hysterectomy (a few days to a week, versus six weeks or more).
One advantage compared to myomectomy is that uterine fibroid embolization can be used to treat all fibroids at the same time, regardless of their size or location in the uterus.
Unlike treatment with Lupron, premature symptoms of menopause are not usually induced. The materials used for uterine fibroid embolization are well tolerated and FDA-approved for embolization.
The cost of UFE varies, but is comparable to or less than the cost of hysterectomy or myomectomy. Papers on this topic are available at these professional publication sites:  Hysterectomy paper | Myomectomy paper (links to publication sites)
In the few cases that fibroid embolization is not successful and surgery is needed, the operation is typically easier after UFE, with much less bleeding.

How Uterine Fibroid Embolization is Performed

Uterine fibroid embolization blocks, or “embolizes” the blood vessels that “feed” the uterine fibroid, causing it to shrink. The interventional radiologist performs the fibroid embolization through a tiny tube called a catheter which is inserted into an artery at the top of the leg. The patient is given a local anesthetic to numb the skin and a mild sedative, so the procedure is not painful. A special X-ray machine that creates moving pictures in “real” time enables the doctor to see the catheter as it is guided through the blood vessels and into the uterine artery. A contrast agent, or dye, is injected to highlight the blood vessels in the uterus to create an “arteriogram,” an X-ray that maps the arteries feeding the fibroids.

The final step in fibroid embolization is the injection of tiny particles through the catheter. The particles lodge in the blood vessels feeding the fibroids and cut off their blood supply, but the uterus and ovaries are spared. After uterine fibroid embolization, the fibroids begin to shrink. The catheter is removed and the patient is observed overnight, and usually goes home the next day. The fibroids continue to shrink for several months after fibroid embolization.

https://allaeimd.com/wp-content/uploads/2017/03/UFE.mp4

Who Should Have UFE

Patients who have symptomatic uterine fibroids (abnormal bleeding, pain or other symptoms) may be considered for UFE. Each woman is an individual, and should discuss the potential risks and benefits of UFE and other treatments with her doctors to decide which option is best for her.

UFE and Pregnancy

Women who wish to have children usually are advised to consider myomectomy first, since it is the current recommended therapy. Since UFE also spares the uterus, it may be an option for some. In some cases, the number, size, or position of the fibroids make myomectomy difficult, and increase the likelihood that a hysterectomy will eventually be required. In some patients, fibroids have recurred after myomectomy. For these women, UFE may be a reasonable choice.
The effect of UFE on fertility cannot be predicted in any particular case, and more studies are needed before UFE can be recommended as the first choice for women who desire pregnancy. Nonetheless, many women have reported successful pregnancies after UFE. A small percentage of women experience the onset of menopause after the procedure. This is uncommon in women under the age of 45 but increases as women approach the normal age of menopause. I n one study (.pdf file), 17 pregnancies were reported by women after they had the procedure. Of these, 14 resulted in live births and 3 in miscarriage. One of the women who gave birth to a healthy baby after UFE had suffered 9 miscarriages before she had the procedure.

Postmenopausal women usually are not considered for UFE, since fibroid symptoms tend to lessen or go away after menopause. Recent studies have shown, however, that UFE can be very effective in post-menopausal women.

Success Rates

In approximately 80-90 percent of cases, UFE successfully treats bleeding, pain and other symptoms of fibroids.
The procedure is considered successful if symptoms are gone or greatly improved at three to six months after UFE and no other (surgical) procedure is needed. Abnormal fibroid bleeding usually stops within one to two months, but it may stop immediately. On average, fibroids shrink from approximately 40 percent to 60 percent in six months, and they may continue to shrink for a year or more. Symptomatic improvement may occur independent of the amount of shrinkage.

Avoiding the Risks of Surgery

UFE is an especially good option for women with medical conditions that might increase the risks and complications of surgery. Also, since there is virtually no blood loss or need for transfusions with UFE, it may be ideal for patients who wish to avoid transfusion for health or religious reasons.

Complications and Side Effects of UFE

The low incidence of serious complications that has been reported with Uterine Fibroid Embolization makes this procedure relatively safer than surgery.

Almost all patients have crampy pelvic pain for six to twelve hours after UFE, which is controlled with pain relieving medication. This may be managed with an epidural catheter, or an IV pain medicine pump (PCA). One-third of patients may have a low-grade fever for a week or two, which usually is treated with Ibuprofen. A brief, self-limiting syndrome of high fever and elevated white blood cell count that subsides on its own is experienced by a small percentage of patients. The procedure may cause mild, spotty bleeding for a few months or a brown discharge. Patients are carefully screened for infections before UFE and antibiotics are given during the procedure to decrease the probability of infection. Delayed infections may occur in 3-4 percent of patients, which can be successfully treated with antibiotics in the majority of cases, but occasionally require hysterectomy. There have been reported cases of patients who stopped menstruating temporarily after the procedure, and some patients have gone into menopause, but this is uncommon in women under the age of 45. It is more common in older women who are approaching menopause. Nonetheless, premature menopause must be considered a potential risk.

Damage to other pelvic organs during UFE is extremely rare. This is a potential risk, however, and has been described in pelvic embolization done for other reasons, such as cancer. This is an extremely unlikely occurrence in the hands of a well-trained interventional radiologist.

Although there is some risk associated with all medical procedures, UFE has been shown to be safer and have fewer risks and complications when compared to surgery such as hysterectomy or myomectomy to treat fibroids. If the risk of death from hysterectomy is 1/1000 or 1/1500, the risk of death from UFE might be less than 1/10,000.

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Ovarian Vein Embolization/Pelvic Venous Congestion

Codeholic Admin — Mon, 13 Mar 2017 16:39:21 +0000

Ovarian Vein Embolization / Pelvic Venous Congestion

Pelvic Congestion Syndrome

Pelvic congestion syndrome is a condition that is caused by what are basically ‘pelvic varicose veins’. Due to differences in anatomy of the pelvis, it usually affects females more than males. As with varicose veins in the legs, if the valves fail in the pelvic veins, blood that should be pumped out of the pelvis and back to the heart stays inside dilated varicose veins within the pelvis. This both stops the normal blood circulation to the pelvic organs and also causes these large varicose veins to push on the pelvic organs – the bladder, bowel, vagina and also the pelvic floor.

The symptoms of pelvic congestion syndrome predominantly come from the weight of the blood pushing on these structures.

‘Pelvic’ – means that it relates to a condition of the pelvis
‘Congestion’ – meaning too much blood in the veins and hence the venous circulation is “congested”
‘Syndrome’ – means a collection of different symptoms and signs

Who gets symptoms from Pelvic Congestion Syndrome?

Pelvic congestion syndrome affects women in their childbearing years. It is uncommon for girls to get pelvic congestion syndrome before puberty, as the pelvic organs and blood supply have not increased due to the effect of female hormones. Similarly, it is uncommon to get pelvic congestion syndrome after the menopause, as when the female sex hormones reduce sufficiently, the blood supply to the pelvis also reduces. However it is possible to get pelvic congestion syndrome postmenopausally if the veins have been very dilated.

What are the symptoms of Pelvic Congestion Syndrome?

The symptoms of pelvic congestion syndrome are mainly those caused by the pressure of the venous blood in the dilated pelvic varicose veins pressing on the pelvic organs. As such they can include:

aching or dragging feeling in the pelvis, particularly on standing. This is due to the weight of blood in the pelvic varicose veins weighing heavily on the pelvic floor which is made of muscle. It is usually worse around the time of the period
irritable bladder sometimes giving stress incontinence, due to the weight of the pelvic varicose veins on the bladder
irritable bowel due to the weight of the pelvic varicose veins on the rectum
discomfort on sexual intercourse medically referred to as ‘deep dyspareunia’

How do I know if I have pelvic congestion syndrome?

Unfortunately many of the symptoms of pelvic congestion syndrome are variable and also can occur with other conditions. Usually patients have already seen their doctors and gynaecologists and have been told that there is nothing wrong with them.

One easy test to diagnose varicose veins of the pelvis is by a transvaginal duplex ultrasound. MRI or CT can also identify these abnormal veins.

What is Ovarian Vein Embolization?

Unlike the veins of the leg, which are surrounded by subcutaneous fat, the pelvic veins have got very sensitive organs and vital structures around them. As such, we cannot use the heat producing method such as laser, which might end up burning the ovaries, uterus, vagina, bowel, bladder or indeed the ureters, nerves or arteries. Therefore to be able to treat these veins successfully, we need to be able to close them without using heat.

Open surgery or laparoscopic surgery is not particularly useful to treat pelvic veins. Firstly, the pain and complications from open surgery is not needed. Secondly, it is exceptionally difficult to get to the very small veins involved deep in the pelvis by using open surgery or laparoscopy.

By using x-ray guided venography, we are able to place very thin catheters directly into the veins that need treatment. Once the catheter is in place, a combination of foam sclerotherapy and insertion of a specialist inert metal coil can be placed into the vein, closing it and stopping the pelvic vein reflux.

Although some patients are concerned about having coils placed into their pelvic veins, the actual metal involved is less than the clips used in many surgical procedures such as laparoscopic hernia repair or laparoscopic gallbladder removal and far far less than the metal used in a hip replacement or other joint replacement procedure.

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Gastric Varices (CARTO/BRTO/PARTO)

Codeholic Admin — Mon, 13 Mar 2017 16:37:15 +0000

Gastric Varices (CARTO/BRTO/PARTO)

Gastric Varices

Varices are dilated vessels which may rupture, causing variceal bleeding. Gastric variceal bleeding describes the bleeding that occurs when dilated vessels in the stomach rupture, and is associated with high morbidity and mortality rates. One of the major possible complications of portal hypertension is gastric variceal bleeding; portal hypertension refers to high blood pressure in the liver. BRTO/CARTO/PARTO are minimally invasive techniques used to treat gastric variceal bleeding.

Balloon-occluded retrograde transvenous obliteration (BRTO)

Coil-assisted retrograde transvenous obliteration (CARTO)

Plug-assisted retrograde transvenous obliteration (PARTO)

What is retrograde transvenous obliteration?

The procedure involves blocking the dilated vessels, reducing the risk of rupture. It can be used in addition to or as an alternative to TIPS, which is the primary treatment for gastric varices. TIPS aims to relieve the pressure on the dilated vessels by creating new connections between blood vessels in the liver using a shunt.

How does the procedure work?

The interventional radiologist will insert a catheter (a thin, flexible tube with a tiny balloon at one end) through a vein in your thigh or neck and guide the catheter to the liver using fluoroscopyfor guidance. The catheter is then directed to the gastrorenal or gastrocaval shunt and the blood flow is blocked.

The interventional radiologist will then perform a venography, which is a type of imaging technique in which X-rays are used to see the vessels clearly. This will allow the interventional radiologist to confirm exactly which vessels need to be treated and if there are any other abnormal or dilated vessels which have not previously been identified. A medication will then be injected into the dilated vessels through the catheter, until they are completely filled.

Another venography will then be performed, to confirm that the blood flow in the shunt has stopped.

Why perform it?

You may be advised to undergo this procedure if you are at risk of or already have gastric variceal bleeding and hepatic encephalopathy as well as a gastrorenal shunt. Hepatic encephalopathy refers to the worsening of brain function that is caused by a damaged liver.

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Denver Shunt

Codeholic Admin — Mon, 13 Mar 2017 16:35:49 +0000

Denver Shunt

Peritoneovenous shunting (PVS) with the Denver® shunt

A specially designed silicone medical device consisting of a pump chamber with two catheters, the Denver ® shunt transfers fluid from the peritoneal space to the circulatory system. This
allows the patient to maintain the critical protein and nutrients in the peritoneal fluid, and normal flow through vital organs.

Benefits of PVS:

• Retains nutrients
• Increases renal blood flow
• Improves mobility and respiration
• Relieves massive, refractory ascites
• Increases effective blood volume
• Increases diuresis

Successful physician and patient experience with the Denver shunt has continued to grow over the past decades, in the U.S. and internationally. For patients with refractory ascites, consider peritoneovenous shunting with the Denver shunt.

PVS has been shown to be beneficial:

• For both malignant and non-malignant ascites
• As an alternative to conventional (repeated)
paracentesis procedures
• For patients awaiting liver transplant

How is the Denver Shunt placed?

The Denver shunt may be placed via the internal jugular or subclavian route. Historically, a surgical approach was used. However, during the past decade, percutaneous placement has become more common to minimize patient trauma and procedural risk. Denver shunt placement with the percutaneous technique is a minimally invasive procedure. Dr. Allaei provides the percutaneous method in the Southern California region.

How does the Denver shunt work?

The Denver shunt consists of a pump chamber attached to two catheters. Inside the pump chamber are either one or two valves (depending on the specific shunt your doctor has chosen for you) that permit fluid flow in only one direction. The shunt is implanted internally, so nothing will show outside your body. One end of the catheter is placed in your abdomen and the other in one of your veins. The pressure of the ascites in your abdomen forces the fluid to flow through the shunt into your circulatory system. This allows you to retain the proteins and nutrients from the fluid in your body, while it helps relieve the discomfort associated with chronic ascites. The shunt works automatically, but you will need to pump the chamber every day to help avoid clogging and keep the shunt working.

Liver Cirrhosis TIPS Procedure

Codeholic Admin — Mon, 13 Mar 2017 16:34:32 +0000

Liver Cirrhosis TIPS Procedure

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

TIPS is an abbreviation for Transjugular Intrahepatic Portosystemic Shunt, a procedure that helps correct blood flow problems in the liver by connecting two blood vessels with an implanted device:

Transjugular through the jugular vein
Intrahepatic within the liver
Portosystemic from the portal vein to the general circulation
Shunt a channel for blood to flow

What is cirrhosis and portal hypertension?

The liver is the largest organ in the body, weighing about three pounds, and is responsible for over 500 functions. Most of the blood that leaves the stomach and the small intestines must pass through the liver. Cirrhosis of the liver occurs when normal liver tissue is damaged and replaced by scar tissue. Most of the blood flowing through the liver comes from the portal vein, and in a cirrhotic liver, the scar tissue significantly slows the flow of blood from the portal vein through the liver. This reduction of blood flow due to cirrhosis causes a large difference in the pressure of blood entering the liver and the pressure of blood exiting the liver to return to the heart. This difference in pressures is called portal hypertension.

Due to reduced blood flow through the liver, blood must now find a different way to reach the heart. The body diverts blood away from the liver by increasing blood flow through vessels surrounding the stomach and lower portion of the esophagus. This increased blood flow changes these vessels into swollen, twisted, and weak veins called varices. Varices can potentially rupture leading to bleeding which requires immediate medical attention. Another complication of portal hypertension is called ascites. Ascites is the accumulation of fluid in the peritoneal cavity which can cause abdominal swelling. Your doctor can provide you with additional information about these complications.

Treatment Options

For a person who has progressive or worsening liver cirrhosis and portal hypertension there are several treatment options available: 1. Your doctor may put you on medication in combination with a low salt and restricted protein diet. 2. You may require additional procedures to treat the complications of your liver cirrhosis such as: • Needle drainage of ascites fluid accumulating in your abdomen • Treatment of enlarged veins in your esophagus or stomach with banding or injections through a flexible scope 3. If the above treatments are ineffective, a TIPS procedure, open surgical interventions, or liver transplantation may be required

How does a TIPS help a person with portal hypertension?

A TIPS procedure creates a new channel to route blood flow through the damaged liver and into the main blood vessels that lead blood back to the heart. A TIPS stent placed inside this channel allows a portion of excess blood to bypass the liver, reducing portal hypertension and the associated complications.

What are the benefits of TIPS?

There are several benefits to having a TIPS procedure to correct blood flow problems in the liver and treat the consequences of portal hypertension such as ascites and varices. The TIPS procedure is a minimally invasive procedure which reduces recovery time and the time spent in the hospital. The TIPS procedure routes a portion of the excess blood flow through the liver and reduces the portal hypertension, so that alternative treatments such as medications, paracentesis for ascites, and the treatment of varices may be needed less frequently or not at all. Your doctor will provide more information regarding your TIPS treatment plan.

What happens during a TIPS procedure?

The TIPS procedure is accomplished through a minimally invasive procedure under general anesthesia and is performed by specially trained doctors (sometimes known as interventional radiologists) in the interventional radiology suite or occasionally the operating room of the hospital. You will not have anything to eat or drink for several hours before the procedure. During the TIPS procedure, you will be connected to monitors to track your heart rate and blood pressure. You will also have an intravenous line in your arm to administer medications during the procedure. An introducer sheath is placed through a small skin puncture in the jugular vein usually on the right side of the neck. The entire TIPS procedure is performed through this introducer sheath. The doctor will use X-ray pictures and X-ray dye (also called contrast dye) to guide the procedure. A long thin needle is next guided through the introducer sheath to the hepatic vein. Using X-ray guidance, the needle is directed from the hepatic vein into the portal vein creating a tunnel between the hepatic and portal veins. A special balloon is used to enlarge the liver tunnel and the doctor inserts the TIPS stent into the tunnel to help it remain open (Figure 1). When the procedure is finished, blood flow and pressures will be measured from the portal vein across the TIPS stent to the hepatic vein. At the completion of the procedure, only the TIPS stent will remain in your body. A TIPS procedure typically takes 2–3 hours to perform.

What are the risks of TIPS?

While all surgical procedures have risks, the risks associated with a TIPS procedure include:1 • Damage to blood vessels • Fever • Hepatic encephalopathy • Infection, bruising, or bleeding • Reactions to medicines or the dye • Stiffness, bruising, or soreness in the neck Rare risks are: • Bleeding in the belly • Blockage in the stent • Cutting of blood vessels in the liver • Heart problems or abnormal heart rhythms • Infection of the stent • Death Everyone is different, so there may be additional risks that are not mentioned here. The risks to each individual should be discussed in more detail with your doctor.

Following the TIPS procedure

The typical hospital stay after the TIPS procedure is one to three days or possibly longer. During that time, your doctor will monitor blood pressure and may conduct an ultrasound study of the liver and stent to make sure the device stays open. After going home, a diet low in protein and salt may be suggested. In addition, medications may be prescribed to minimize the accumulation of blood toxins. Contact your doctor immediately if you experience disorientation or confusion. It’s important that the TIPS is carefully monitored over the following three years. Advised follow-up may include check-ups at one month, six months, and each year after that. The follow-up exams may consist of routine X-rays, an ultrasound study and blood tests. Please ask your doctor if you have any questions regarding these tests and exams

How will I know if the TIPS is working?

The symptoms of portal hypertension that you have experienced may get better or go away. The swollen blood vessels may shrink and not be as prone to bleeding, which means you may not experience additional bleeding episodes. There may also be a reduction or complete resolution of the fluid that accumulates in the abdomen, which may reduce or eliminate the need for removing the fluid by paracentesis. Of course, if your symptoms get worse, you should contact your doctor immediately

For more information please see

American Liver Foundation www.liverfoundation.org
European Association for the Study of the Liver (EASL) www.easl.eu
Society of Interventional Radiology www.sirweb.org
US National Library of Medicine www.medlineplus.gov
US Department of Health and Human Services Food and Drug Administration www.fda.gov
W. L. Gore & Associates, Inc. www.goremedical.com

The post Liver Cirrhosis TIPS Procedure appeared first on Atabak Allaei, MD: Vascular & Image Guided Specialist | Los Angeles CA.

Metastatic Tumor Ablation

Codeholic Admin — Mon, 13 Mar 2017 16:10:58 +0000

Metastatic Tumor Ablation

What is percutaneous ablation?

Our high resolution imaging technology enables visualization of the tumor and accurate placement of the ablation probes without the need for surgical incision. There are different methods of ablation including cryo, microwave and radiofrequency ablation.

What is cryoablation?

Cryoablation uses extremely cold temperatures to kill cancer cells. Doctors started using it to treat small kidney cancer tumors as early as 1999, and the results have been extremely impressive. To treat a patient with cryoablation, doctors create ice using specially designed probes, through which compressed gas is circulated. The ice is very precisely shaped and positioned by the doctor to freeze the tumor and destroy all of the cancerous tissue within the kidney, while healthy tissue and surrounding organs are protected.

What is microwave ablation?

A new technology, microwave ablation (MWA), destroys liver tumors using heat generated by microwave energy. With microwave ablation, the interventional radiologist inserts a small needle through the skin and into the tumor using CT or ultrasonic guidance to pinpoint the exact location of the tumor. Unlike the procedure done by a surgeon, this does not require an open incision to access the tumor. The probe produces intense heat that ablates (destroys) tumor tissue, often within 10 minutes.

What types of tumors can be ablated?

Any type of tumor can be ablated. However, large tumors or tumors next to vital structures may not be a candidate for this type of treatment.

What are the benefits of percutaneous ablation over surgery or open ablation?

Minimally invasive – less invasive than standard or laparoscopic ablation
A treatment that demonstrated 95%effectiveness in targeted tumors
Tissue-sparing treatment (targets mostly tumor tissue)
Clinical data supports safety and effectiveness
Decreased blood loss versus surgery (including laparoscopic surgery)
Performed on an outpatient basis or requiring just one overnight stay
Shorter recovery time
Can be used when other treatments, such as prior surgery, have failed
May be suitable for patients who cannot tolerate general anesthesia
Lower morbidity (side effects)
Can be repeated, should the cancer returns
Multiple tumors can be treated in one session

How long does the procedure take?

The procedure length will vary according to the size and location of the tumor, but usually lasts about one hour.

How long will I need to stay in the hospital?

Some cases are done on an outpatient basis, meaning you do not need to stay in the hospital overnight. Other doctors prefer their patients to stay in overnight (depending on other associated conditions). Your doctor will want to make sure that you are eating, drinking and comfortable before you leave the hospital.

How long before I can return to work and other activities?

Your doctor will advise you on when it is sensible for you to return to work and resume other activities since this will depend on your general health and the work you do. Usually, patients are back to their normal day-to-day activities within two weeks of the procedure – often sooner.

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