Medical specialties make strides in treatment options

MAGNANT

Most people think of vein specialists in a limited fashion: those who treat varicose veins and get rid of ugly spider veins. But many patients who come in with swollen or achy legs, discolored skin around the ankles, or ulcerations on the shin which won't heal are, in fact, diagnosed with 'venous insufficiency.'

"It's also known as leaky veins," says Dr. Joe Magnant, M.D., a condition affecting 30 to 40 million American adults. Left undiagnosed and untreated, leaky leg veins can cause serious changes in the health of skin on the leg skin as well as other grave problems.

Veins in the legs must move blood uphill against gravity, toward the heart. "Your leg muscles pump when you're walking," says Magnant, "and veins have one-way gates with valves; they open back toward your pelvis. We have half a dozen segments in our legs, that allow blood to move back to the pelvis. So when we talk about leaky veins," he says, we're talking about those valves being broken."

Most of the treatments for conditions that fall under the umbrella of Venous Insufficiency are considered medically necessary; in other words, they are not cosmetic, and are covered by insurance. "There's a lot of disability, aches and hurts," says Magnant, of vein problems. The good news is that today, many of these problems can be corrected with far less trauma to the body than even 8 years ago.

COURTESY PHOTO OB-Gyn Dr. Kevin M. Fleishman with a patient. Women today have new treatment options available to them, Fleishman says.

"Procedures are much different today than they were in 2000," says Magnant, whose Fort Myers practice is called Vein Specialists. Before that time, bad veins had to be "stripped," or literally pulled from the legs, after incisions were made at the ankle, knee and groin. It was a painful procedure, with a long recovery. In 1999, the FDA approved what is called the "endovenous closure," or a sealing of a bad vein with heat, using a small needle and local anesthesia, versus being in the hospital with general anesthesia.

By 2001, a laser-based system was also approved, giving patients a second minimally invasive treatment option. In both cases, patients can usually return to work within a few days' time, a far cry from the dramatic days of vein stripping.

Medical technology and procedures are advancing so fast that it's difficult for consumers to keep up. This is the final installment of Florida Weekly's eight-part series examining what's new in medicine in Southwest Florida.

Leaky veins are detected with ultrasound. "It is the mainstay, the cornerstone of diagnosis," says Magnant, who says he is focused on the valves to see where they're leaking and how bad they're leaking, and then he determines the best course of action.

Still surgery for some

Although his treatment options usually work, there are those patients whose problems require surgery. Although Magnant is a board-certified vascular surgeon, he recently chose to dedicate his practice to outpatient, minimally-invasive treatments, so he refers certain cases to arterial surgeons.

Free screenings give patients the opportunity to learn that help is available for their painful conditions. Physicians are also becoming more educated about this specialty field, and new state-of-theart solutions for venous insufficiency.

Prevention

"In the past, there was nothing we could do unless patients had really bad problems," says Magnant, "so this technology has allowed us to be a bit more proactive and preventative in caring for patients. Insurance companies are starting to understand that. Why wait for an ulcer?" says the doctor. "It flies in the face of preventative screening we're doing for everything else."

Magnant sees a wide range of patient profiles. "We see young women who have the heavy "French legs," he says. "Big, swollen legs that don't really match their thighs - women in 30s and 40s, whose legs are killing them after noon. And we also see old folks with ulcers on their shin. With bad, leaky veins, they don't heal, they become a chronic ulcer," he says.

Vein problems are often hereditary, but can also be the result of multiple pregnancies. "Once they're made worse, they generally don't go back to where they started," explains Magnant, who says that women with venous disease outnumber men 70 to 30.

Women particularly benefit from new era in medicine

"Minimally-invasive" is more than a buzz word in today's practice of medicine. Procedures which cause less trauma and promote quicker healing are so strongly preferred by patients and physicians that even surgeries as serious as hysterectomies are being replaced with new minimally-invasive variations.

"We've been doing the LSH for more than three years," says OB-Gyn Dr. Kevin M. Fleishman, of the laproscopic supracervical hysterectomy. "It's a much less invasive type of hysterectomy that's done through tiny little holes in the abdomen," he says. "We're doing it as an overnight stay in the hospital. Some places do it as out-patient," he explains, "but we like to keep a close eye on the patient overnight."

The LSH procedure leaves the cervix but removes the top of the uterus. "You have a quicker recovery," says Fleishman. 'You're going back to work in a week or two, versus six weeks (for the old surgery), depending on what you do. You can be back to a normal routine in one week. Patients are very happy with it."

Whether or not a woman is a candidate for this popular alternative to a traditional hysterectomy depends on what the problem is. "It depends on the indication," says Fleishman. Woman who have had several vaginal births, and have experienced a prolapse of the uterus are not a candidate, he explains.

Lightening up

Fleishman, who's with Physicians' Primary Care of Southwest Florida, says that women who experience extremely heavy menstruation (menorrhagia) also have a new treatment option. Endometrial ablation - destroying the inside lining of the endometrium (uterus) - is "done in the office or hospital, to decrease the volume of menstrual flow."

There are now actually several minimally invasive ways of accomplishing this task. Gynecare Thermachoice is an eight minute procedure using 200-degree water to treat the uterus while also preserving it. Novasure uses a net in the uterus which has electric current applied to it, cauterizing the uterus' lining. Hydrothermablation sears the uterine walls with heated saline, but preserves the ovaries, while cryoablation freezes the uterine walls.

These menorrhagia-solving procedures are for women who have definitely completed their child-bearing, but who have not yet begun menopause. "You should never conceive after a procedure like this," he says. Fleishman emphasizes that a physician should eliminate other reasons for heavy bleeding before performing endometrial ablation.

Birth control option

For women in their childbearing years who don't wish to become pregnant, an implantable contraceptive device gives them three years of protection that is "about ten times as effective as the pill," says Fleishman. Implanon, as it's called, is just as effective as tubal ligation, but is completely reversible; a doctor can remove it. Despite its effectiveness, "there are side effects," says Fleishman, "which include no periods, or continuous irregular light bleeding."

Tubal ligations can now be done right in the doctor's office. Called an 'essure procedure', the tubal occlusion procedure blocks the fallopian tubes without any incisions. "This is permanent birth control," says Fleishman. This new procedure is done in the doctor's office without any incisions, as opposed to the laproscopic tubal ligation, which required hospitalization and multiple incisions.

Fleishman and his professional colleagues, like their patients, are big fans of these minimally-invasive procedures.