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Surgery for Multiple Sclerosis
August 2, 2010   
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Doctors at the EuroMedic Vascular and Endovascular Surgery Clinic in the southern city of Katowice have found a new way to help patients with multiple sclerosis: they widen the patients’ jugular veins. So far, about 200 operations of this kind have been performed.

The surgery is based on restoring the patency of occluded jugular veins and widening them, the doctors say. The first such operation was performed at the Katowice clinic in October last year.

Katowice is one of three centers in the world, alongside centers in Italy and the United States, where this method is used. Patients come here for the procedure from Western Europe, Canada, the United States and the Middle East, mainly Kuwait. There have also been patients from China and Australia. The clinic says it receives about 50 new inquiries every day.

“The method certainly needs further improvement and observation of the results,” says Dr. Tomasz Ludyga, a vascular surgeon and head of EuroMedic. “Each case needs to be considered with great caution, with attention paid to possible complications. Nevertheless, observations so far suggest that the method is effective. In some cases, the results of the surgery have exceeded expectations—improving certain functions immediately, causing better visual acuity, eliminating muscular spasms in the lower limbs, reducing fatigue, and improving bladder function.”

The best effects are achieved in patients in the early stage of the disease, Ludyga says; then the symptoms disappear completely. If the disease has continued for a long time, however, and certain fixed neurological deficits have appeared, the improvement is less spectacular. Observations show that after the procedure, patients have less frequent relapses of the disease, according to Ludyga.

Fully evaluating the method’s effectiveness requires observations of more patients over a longer period, Ludyga says.

A vascular disease?

The Katowice method, coupled with observations from similar centers in Italy and the United States, may completely change the way doctors think about and treat multiple sclerosis, Ludyga says. The existing theory on why the disease develops may have to be discarded, he adds.

This new approach to the disease is due to Italian neurologist Paolo Zamboni from the University of Ferrara, who calls multiple sclerosis simply a “vascular disease.” He believes that the disease is caused by a chronic insufficiency of the veins in the chest and neck, or more precisely a narrowing of the veins carrying blood from the brain to the heart.

Based on earlier observations by an Austrian doctor, who noticed abnormalities in the jugular veins of multiple sclerosis patients, Zamboni began studying this issue himself. He noticed that these blood vessels were abnormally narrow and deformed in all the patients. Zamboni called this state chronic cerebrospinal venous insufficiency. It prevents proper blood outflow from the brain to the point of causing blood reflux. The intravascular pressure increases and various molecules permeate from the blood to the brain, including iron compounds, according to Zamboni. This leads to the development of inflammation in the nerve tissue, and consequently to nerve cell damage.

“Prof. Zamboni examined several hundred people in different stages of multiple sclerosis. He discovered these anomalies in 500 patients, which encouraged him to challenge existing opinions on the causes of the disease and thus on the ways in which it should be treated,” says Ludyga, who has been working with Zamboni from the very beginning.

The method used by the Italian doctor has also worked for patients with arteriosclerosis. Zamboni used the cardiological methods of balloon angioplasty and stents to expand jugular vessels—the veins that transport blood from the brain. Normally, heart surgeons use balloon angioplasty and stents to expand the arteries supplying blood to the heart, Ludyga says.

After two years of performing the procedures followed by observation, Zamboni reported an improvement in 73 percent of patients, according to Ludyga. Today the Italian neurologist is convinced that multiple sclerosis is a “cerebrospinal disease of venous insufficiency” and not an autoimmune disease, and that it can be treated effectively by surgery. The relatively simple procedure of expanding and clearing the veins restores the free outflow of blood from the brain and eliminates symptoms of multiple sclerosis, Ludyga says.

A small, flexible spring

The vein-clearing procedure is similar to the angioplasty surgery for patients with arteriosclerosis. The surgeon has to find the place where the vein is narrowed, and then introduce a stent—a small, flexible spring—to expand the vein. The operation takes about an hour and is performed under local anesthesia. The patient spends one day at the clinic and can then go home.

Before the procedure, patients are assessed in terms of their physical condition, mainly mobility. The same examination is carried out directly after the operation, and then a month, three months, six months and a year later—to check the long-term effect in terms of whether or not the procedure has restored the patency of the veins. According to the Katowice doctors, 90 percent of the patients who have undergone the surgery at the clinic have noticed an improvement. Sometimes this improvement was immediate, sometimes it took a few weeks.

The doctors from Italy have reported equally optimistic results. They have been observing their patients since the world’s first operation of this kind was performed almost two years ago, Ludyga says.

Cautious enthusiasm

The great interest shown in the new method is understandable, doctors say, but excessive enthusiasm is uncalled for. The Multiple Sclerosis Association of America, for example, has warned that Zamboni’s preliminary studies show that 47 percent of patients who have undergone surgery to eliminate the internal insufficiency of a jugular vein have experienced a relapse before the end of the study.

The Polish Multiple Sclerosis Society cautions on its website that the procedure only helps in the short term and does not protect the nervous system from further damage.

According to Dr. Jacek Zaborski, head of the neurology ward at the Międzylesie Specialist Hospital in Warsaw, patients should be warned that the new method is still at an experimental stage and its long-term benefits have yet to be proved.

Meanwhile, the Polish Multiple Sclerosis Society has petitioned the president, prime minister and health minister to provide funds for further research on the method. Multiple sclerosis affects about 2.5 million people worldwide. In Poland they number about 50,000; three-quarters go on a disability pension two years after being diagnosed with the disease.
Ewa Dereń


Factfile

The EuroMedic clinic was founded in 2000 as an initiative by doctors Tomasz Ludyga and Leszek Sedlak who had years of experience in vascular surgery. At first, the clinic confined itself to treating venous diseases. Today it comprises two hospital wards, including an invasive radiology unit. This allows the clinic to offer a full range of operations on peripheral arteries, especially for patients with limb ischemia, the doctors say.

The clinic performs operations such as bypass surgery and angioplasty with stent implants (limb arteries, jugular arteries and others) as well as stent-graft implantation for patients with aortic aneurysms. Apart from treating venous diseases, the clinic provides plastic surgery, general and laparoscopic surgery and orthopedic procedures. It also treats eye cataracts with the so-called phacoemulsification method. Phacoemulsification cataract surgery is a procedure in which an ultrasonic device is used to break up and then remove a cloudy lens, or cataract, from the eye to improve vision. The insertion of an intraocular lens usually immediately follows the procedure.
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