Dr. Ajit Thapa - Interventional radiologist. MD, FVIR, EBIR

१ महिना पहिले Microwave ablation पद्धतिबाट कलेजो क्यान्सरको उपचारको पहिलो फलोअप र त्यस्तै अर्को क्यान्सरको सोही पद्धतिबाट सफल उपचार पश्चातको CT स्क्यान ।
बिना चिरफार सानो सुईबाट गरिने यो उपचार विधिमा क्यान्सरलाई केवल ५ मिनेट तताएर मारिन्छ।

Killing one more liver cancer with Microwave ablation.

Long-term follow up ( 2 years) of liver cancer near diaphragm. CT showing complete tumor death.
Treatment modality: combined MWA ( microwave ablation) and TAE( trans arterial embolization) .

BRTO
Cirrhosis को कारणले कलेजो मा ७५%रगत लाने नसा portal vein को प्रेसर बढ्नाले उत्त रक्तचाप घटाउन शरीरमा portal vein लाई systemic vein मा जोड्ने channels फुलेर आउँछ। कतिपय तेस्ता च्यानलले अन्ननली, पेट र अन्य सानोआन्द्रालाई बाटो बनाउँदै बग्ने गर्छ। यस्ता फुलेको रगतको च्यानल लाई varices भनिन्छ। Varices हरुको wall कमसलहुने हुनाले फुटेर रक्तश्राव हुने सम्भावना अत्यधिक हुन्छ। अन्ननलीका varices endoscopy मार्फत banding गरिन्छ भने पेटको varices लाई endoscopic glue, BRTO र TIPS जस्ता प्रक्रिया गरिन्छ । पेटको varices हरु प्राणघातक हुने सम्भावना बेसी हुन्छ। Interventional radiology बाट गरिने यो उपचार विधिहरु नसमा सानो सुई मार्फत नै सम्भव हुन्छ।
BRTO मा खुट्टा वा घाँटीको सिरानाली को बाटो systemic outflow मा balloon फुलाई बाटो बन्द गरेर पेट को varices भरी sclerosing औषधि राखिन्छ। यसरी यी सबै varices हरु बन्द हुन्छ र रक्तश्राव को जोखिम निउन हुन्छ ।
यो उपचार पद्दति विषेशगरी जापानमा प्रख्यात छ ।
यसरी हामीले विगत ५ वर्षमा लगभग २५ जाना cirrhosis बिरामी को सफल BRTO गर्न सम्भव भएका छौं।
२५ औं BRTO को Images।

Embolization for UGI bleed: Case - leukemic patient with low platelet and recurrent UGI bleed from duodenum. History of multiple embolizations, endoscopic clippings and multiple blood transfusions. Current endoscopy showing bleeding from clip area. Targetted embolization of GDA branch feeding clip area. Clinical hemostasis and no bleeding on check endoscopy.

"Varicose vein" सम्बन्धी जानकारी

Thermal ablation for Symptomatic Thyroid nodules: गलगाडले गर्दा लक्ष्यण भएका वा कस्मेटिक समस्या भएको बिरामीलाई बिना अपरेसन सुई द्वारा ablation गरेर सानो बनाउन सकिन्छ। बेहोस नबनाई गरिने यो पद्धतिले normal thyroid ग्रन्थिलाई असर नगर्ने हुनाले thyroid function preserve गर्ने गर्दछ। हाल यो उपचार बिधि नेपालमै उपलब्ध छ।

आन्द्रामा रगतको मसिनो नली फुटेर अत्यधिक रक्तश्राव भएको बिरामीलाई सानो पाइप ( Catheter)खुट्टाको नसा मार्फत छिराएर त्यो मसिनो सानो आन्द्राको नसलाई पत्ता लगाई रक्तश्राव point सम्म पुगेर glue मार्फत फुटेको नसा बन्द गरेको दृश्यहरु। यस्तो पद्धति cathlab मा इन्टरवेन्सनाल रेडियोलोजीका चिकित्सकहरुबाट गरिन्छ।

CT guided biopsy: शरीरको भित्रिभागमा रहेका संकास्पद गाँठाहरुलाई बिना चिरफार सुईको माध्यमबाट precisely लक्ष्य गरेर sample लिएर रोग निदान गर्ने यो interventional radiologic प्रविधि बेहोस नबनाई गरिन्छ।

NSVIR2023

सानो आन्द्रामा रगतको मसिनो नली फुटेर अत्यधिक रक्तश्राव भएको बिरामीलाई सानो पाइप ( Catheter)खुट्टाको नसा मार्फत छिराएर त्यो मसिनो सानो आन्द्राको नसलाई पत्ता लगाई रक्तश्राव point सम्म पुगेर glue मार्फत फुटेको नसा बन्द गरेको दृश्यहरु। यस्तो पद्धति cathlab मा इन्टरवेन्सनाल रेडियोलोजीका चिकित्सकहरुबाट गरिन्छ।

यसै साथ सबैमा "तिहार २०८०" को हार्दिक मंगलमय शुभकामना ।

"Interventional Radiology " International conference. This November

Pelvic congestion syndrome:

Pelvic Congestion Syndrome (PCS) or Pelvic Venous Congestion Syndrome (PVCS) is essentially varicose veins of the ovaries. Varicose veins are most commonly seen in the legs and are caused by the veins becoming less elastic resulting in abnormal flow of blood causing it to pool in certain areas, leading to enlarged painful veins. This is also what happens to the pelvic veins in pelvic congestion syndrome.

PCS most commonly occurs in young women, and usually in women who have had at least 2-3 children. During pregnancy the ovarian vein can be compressed by womb or increase in size because of the required increased blood flow. This is thought to damage the valves causing them to stop working resulting in abnormal blood flow backwards. This pressure build up causes the pain of PCS and may also cause visible varicose veins around the v***a, va**na, inner thigh, sometimes the buttock and down the leg(s).

The abnormal veins dilate and cause varicose veins around the o***y and uterus because the valves don’t work properly. Blood flow is in the wrong direction, pooling in the veins and causing them to enlarge.

IR treatment: Embolization – The gold standard for treatment is closure of the abnormal veins, similar to varicose veins in the legs. This is called “Ovarian vein embolization." This is an outpatient procedure that requires no sedation or general anesthesia. Read below for further details.

Benefits

Minimally invasive procedure ( just a pin hole in groin vein), done under local anaesthesia.
Fewer complications than traditional surgery. You also lose less blood, and the incision mark is not even visible. You won’t also need to stay in the hospital for long.
85 % of women who undergo the procedure report feeling much better within 14 days of the operation

Happy to share today's HCC follow ups showing complete response to locoregional therapies in inoperable cases.
1. cTACE for segment V HCC - 6th month
2. MWA and TAE for dome HCC- 9th month
3. Periportal HCC with no heat sinking in MWA 3rd month
Interventional radiology, 4th pillar in cancer care walking hand in hand with Oncology, Surgery and Radiotherapy to fight cancer.

Hydatid cyst भन्नाले Echinococcus granulosus नाम को कुकुरको दिशाबाट मान्छेमा सर्न सक्ने एकप्रकारको parasitic infestation हो । धेरै जसो यो मानिसको कलेजो मा बस्ने गर्छ। यसका विभिन्न stage हरु हुन्छन् जस मध्ये Gharbi १ र २ मा interventional radiology विधा बाट सानो सुईको माध्यमबाट यसको भित्री झिल्ली (जो सक्रिय हुन्छ) लाई विभिन्न chemical जस्तै Hypertonic saline, alcohol प्रयोग गरी निष्क्रिय पार्न सकिन्छ l तलको तस्वीर Gharbi २ प्रकारको Hydatid cyst को हो।
पाल्तु कुकुर घरमा छ भने कुकुर तिहारको नियमित deworming अनिवार्य गरौं।

Follow up CT showing complete death of liver cancer anter microwave ablation.

Microwave ablation: Heating tumor to death. Successful ablation of three liver cancers.


माइक्रोवेव ट्यूमर एब्लेशन (MWA) बारे केहि जानकारी

भन्नाले माइक्रोवेव प्रयोग गरी शरीर को ऐजेरु लाई तताएर मार्ने पद्दति हो । Ultrasound, CT को गाइडेन्समा सानो सुई (जसलाई माइक्रोवेव एन्टीना भनिन्छ) चालाबाट क्यान्सर सम्म पुर्याइन्छ र माइक्रोवेव जनरेटर मा जोडीन्छ । माइक्रोवेव प्रविधिले एन्टीना को टुप्पो र केहि सेन्टीमीटर वरिपरिको ट्यूमर तात्छ र निष्क्रिय हुन्छ ।

* कस्तो कस्तो क्यान्सरको यो पद्दतिबाट उपचार गर्न सकिन्छ ?
बिशेषगरी अपरेशन गर्न नसकिने ५ सेंटीमीटर भन्दा सानो कलेजोको क्यान्सरमा यो प्रविधि प्रख्यात छ । तर पछिल्लो समयमा मिर्गौलाको क्यान्सर, फोक्सोको क्यान्सर, Colloid thyroid nodules, Osteoid osteoma जस्ता ट्यूमरमा पनि प्रभाबकारी देखिएको छ ।

* कहिले कही अलि ठुलो ट्यूमरको लागि MWA लाई TACE (Transarterial chemoembolisation) सँग पनि जोड्न सकिन्छ ।

* यो पद्दतिको फाइदा हरु के के छन ?
चिरफार नगरी, Short acting anaesthesia मा, केवल ट्यूमरलाई target हुने उपचार भएकोले न्यूनतम जोखिम र सीघ्र recovery हुन्छ ।

* के यो सर्जरीको बिकल्प हो ?
हाल सम्मको उपचार निर्देशिकाले अपरेशनलाईनै प्राथमिक्ता दिएको छ । तसर्थ अपरेशन गर्न नमिल्ने कन्डीशनमा मात्र माइक्रोवेव एब्लेशन गर्नु उचित हुन्छ ।

"Interventional radiology & internal bleeding "
Internal bleeding is difficult to treat, however with morden CT scan most of the times we can localise the culprit artery. And under fluoroscopic guidance using small tubes introduced via groin vessel,these culprit tiny vessels can be blocked internally to control bleeding. This procedure known as embolization is done by Interventional radiologist in a Cathlab under local anesthesia.
Below pictures show bleeding source from one of the tiny vessels in kidney, which was selected using small tubes called catheters and bleeder vessel was occluded using metal coils. Last picture shows no more bleeding with preservation of almost 95% kidney.
In absence of this novel technique, nephrectomy (removal of bleeding kidney) would have been the only option if bleeding was unstoppable medically.

Managing cirrhosis complications
1. Microwave ablation for liver cancers
2. Occluding gastric varices by BRTO technique

Taking down Fundal gastric varices with potential of fatal GI bleed with
A. BRTO and
B. CARTO.

Balloon occluded transvenous Variceal obliteration abbreviated as BRTO is a Novel minimally invasive treatment of gastric varices due to portal hypertension. Gastric varices has high tendancy to life threatening bleeding and is challenging to treat. In BRTO outflow tract is occluded with a balloon then sclerosant is injected in the gastric varices from femoral vein minimising chances of bleeding and escape of sclerosant to lungs. This technique more popular in Japan also aids in improving liver function by increasing portal flow in liver. Other similar procedures are CARTO( Coil assisted retrograde transvenous variceal obliteration) and PARTO with utilises more advanced occlusion devises Coils and Plugs.

Cirrhosis complications managed by Interventional radiology
1. Cirrhosis causing high pressure in portal vein opens up vascular channels in body to reduce portal pressure and in stomach it's leads to fundic varices which can lead to life threatening bleeding. Endovascular occlusion of those shunts by IR by procedures like BRTO,CARTO and PARTO.
2. Cirrhosis leading to liver cancer, specially in Stage ( BCLC) B can be treated by Transarterial chemo embolization. Multiple liver cancers treated by this modality.
3. Portal hypertension causing enlarged spleen can cause reduced platelet counts due to excessive platelet destruction in spleen. Partial splenic embolization leading reduced functional splenic volume reduces platelet destruction , ultimately increasing platelet counts.
All vascular procedures done through pin hole size access in vessels in groin under local anaesthesia.

"Embolotherapy for multiple internal bleeding to control bleeding"
Transcatheter embolotherapy for bleeding is minimally invasive procedure to stop internal bleeding immediately through pinhole sized access in groin artery. These procedures are done under local anaesthesia under fluoroscopic guidance where bleeding point is reached through vascular path and selectively occluded by various embolization materials.

Microwave ablation: Heating tumor to death. Successful ablation of three liver cancers.


माइक्रोवेव ट्यूमर एब्लेशन (MWA) बारे केहि जानकारी

भन्नाले माइक्रोवेव प्रयोग गरी शरीर को ऐजेरु लाई तताएर मार्ने पद्दति हो । Ultrasound, CT को गाइडेन्समा सानो सुई (जसलाई माइक्रोवेव एन्टीना भनिन्छ) चालाबाट क्यान्सर सम्म पुर्याइन्छ र माइक्रोवेव जनरेटर मा जोडीन्छ । माइक्रोवेव प्रविधिले एन्टीना को टुप्पो र केहि सेन्टीमीटर वरिपरिको ट्यूमर तात्छ र निष्क्रिय हुन्छ ।

* कस्तो कस्तो क्यान्सरको यो पद्दतिबाट उपचार गर्न सकिन्छ ?
बिशेषगरी अपरेशन गर्न नसकिने ५ सेंटीमीटर भन्दा सानो कलेजोको क्यान्सरमा यो प्रविधि प्रख्यात छ । तर पछिल्लो समयमा मिर्गौलाको क्यान्सर, फोक्सोको क्यान्सर, Colloid thyroid nodules, Osteoid osteoma जस्ता ट्यूमरमा पनि प्रभाबकारी देखिएको छ ।

* कहिले कही अलि ठुलो ट्यूमरको लागि MWA लाई TACE (Transarterial chemoembolisation) सँग पनि जोड्न सकिन्छ ।

* यो पद्दतिको फाइदा हरु के के छन ?
चिरफार नगरी, Short acting anaesthesia मा, केवल ट्यूमरलाई target हुने उपचार भएकोले न्यूनतम जोखिम र सीघ्र recovery हुन्छ ।

* के यो सर्जरीको बिकल्प हो ?
हाल सम्मको उपचार निर्देशिकाले अपरेशनलाईनै प्राथमिक्ता दिएको छ । तसर्थ अपरेशन गर्न नमिल्ने कन्डीशनमा मात्र माइक्रोवेव एब्लेशन गर्नु उचित हुन्छ ।

Percutaneous internal drainage of urine crossing obstructed urinary pathway and the procedure is antegrade DJ Stenting done under local anaesthesia.
Percutaneous nephrostomy tube is drainage catheter placed from skin to divert urine when ureter ( tubular connection between kidney and bladder) gets obstructed or other causes of downstream urine obstruction.
PCN for long-term might be cumbersome to patients and to give better quality of life these procedures are also offered by interventional radiology.

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"Happy Buddha jayanti"

Chemoport removal after one year of chemotherapy.