1 /14 BUENAS TARDES LUIS FERNANDO GARCIA V Cirujano Vascular Hospital Militar-Clínica Colombia-Clinica de Marly 2 /14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? CLINICA Multiparidad “Dismenorrea” : Dolor premenstrual pélvico tipo peso y en MMII “Dispareunia” : Dolor Poscoital Várices mediales al tendón aductor y cara posterior de muslo Síntomas urinarios - Rectales Hemorroides Dolor pélvico crónico TRATAMIENTO MEDICO Acetato de medroxiprogesterona: suprime la función ovárica. no siempre es efectivo. Dihidroergotamina vasoconstrictor solo es efectivo en la fase aguda y solo por pocos días. La eficacia de los aines no ha sido probada. Abordaje Extraperitoneal Manejo Laparoscopico EMBOLIZACION CT and MRI of Pelvic Varices in Women Fergus V. Coakley, .Shaju L. Varghese, and Hedvig Hricak Abstract: Pelvic varices in women consist of tortuous and dilated parauterine an d ovarian veins and have a characteristic appearance at CT and MRI. Imaging is critica l in the evaluation of pelvic varices, both to prevent confusion with other conditions an d because pelvic varices may be secondary to serious underlying pathology. Additionally, primary pelvic varices are associated with the pelvic pain syndrome, and patient s with the pelvic pain syndrome may benefit from therapeutic venous embolization . Secondary pelvic varices are rarely associated with pelvic pain. Secondary causes of pelvic varices include inferior vena caval obstruction, portal hypertension, increase d pelvic blood flow, and vascular malformations . Occlusion of the inferior vena cava may be due to chronic thrombosis, intracaval tumor, extrinsic compression, o r surgical ligation In summary, primary pelvic varices and the pelvi c pain syndrome are associated, although the two can occur independently . The etiology of both conditions is unknown. Structural and functional causes have bee n proposed . Pelvic varices are common in pregnancy and the postpartum period (7), due to the physiological increase i n blood flow to the gravid uterus 9 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? Prof. Abraham Lechter 10/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? Prof. Abraham Lechter 10/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? Anatomy of the gonadal veins : A reappraisal A. Lechter, MD, G . Lopez, MD, C . Martinez, MD, and). camacho, MD, Bog„ta . Ulm bin Variations in anatomy were found quite frequently during bilateral gonadal vein dissection and resection for pelvic varices in the past 5 years (120 cases) . In about on e fourth of the cases, routine gonadal phlebography was not technically feasible or did r of correlate exactly with the operative findings. Some cases of male varicocele showe d recurrence after surgery . These facts, in addition to the scarce information provided b y anatomy textbooks, induced us to study thoroughly the gonadal veins . One hundre d cadaver dissections (200 veins) were done for length, diameter, number, and location of valves and collaterals, number of trunks in each side, and mode of termination in th e renal vein and vena cava . Topographic division of the veins by thirds facilitated the information . Variations from the classic anatomic description were encountere d frequently. As to the number of trunks, at the middle third, where the vein is usuall y divided, only 60% have one trunk on the left and only 75% have one on the right side . The rest are multiple; as many as four and six trunks in the lower third were found. The knowledge of these anatomic variations, not clearly described before, is of grea t importance to both surgeons and invasive radiologists and conducive to successfu l results . (SURGERY 1991 ;109:735-9. ) 11/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 12/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? LES VARICES VULVAIRE S P.A. OUVRY *, P.A.G. OUVRY et A . DAVY Les varices vulvaires sont plus fréquentes qu'on ne le pensait classiquement, elle s peuvent étre génantes . Lemur recherche doit faire partie de l'examen clinique de tout e femme enceinte et de toute multipare surtout s'il existe chez elles d'autres signe s d'insuffisance j sance veineuse. Phléhologie, 1991, 44, n°2, 375-380 . 13 14 15 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? We do not recommend the use of coil occlusio n alone in this situation since we believe that due to thei r relatively inert quality, which causes little endothelial damage, they may allow late recanalization throug h their metallic architecture . Ovarian Vein Embolization for th e Treatment of the Pelvic Congestio n Syndrome. Part II : Diagnosis, Treatment , and Clinical Impact Patrizio Capasso Louisiana State University Medical Center, New Orleans, LA, US A INTERVENTION Vol 4 No 4 2001 16 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 17 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? INSUFFISANCE VEINEUSE PELVIENNE chez la FEMME PRÉSENTANT des VARICES PERINÉALES . CORRELATION ANATOMO-CLINIQUE , TRAITEMENT par EMBOLISATION et RESULTAT S (31 CAS). D. CRETON', L HENNEQUIN PHtEBOLOGIE E 2003, 56, N° 3, Le syndrome de congestion pelvienne ne dépen d pas seulement de ('insuffisance veineuse ovarienne. II dépend souvent d'une insuffisance veineuse mixte ovarienne et hypogastrique. Dans la série de Maleux [11 ] il n'y avait pas de corrélation entre I'amélioration clinique et ('l'aspect uni ou bilatéral de I'embolisatio n mais, dons cette série, les explorations n'avaien t concerné que les veines ovariennes. CONCLUSION La présence de varices non saphéniennes à la racine de la cuisse associée à une symptomatologie d'insuffisance veineuse pelvienne (score > 8) chez la jeune femme en activité génitale nécessite une exploration veineuse pelvienne. La symptomatologie, en effet, est un tres bon signe d'insuffisance veineuse pelvienne chez l a femme jeune en activité génitale. Compte tenu des nombreuses connexions veineuses pelviennes, les 4 axes veineux pelviens devraient étre explorés systématiquement . Les résultats précoces sont trés satisfaisants sur la symptomatologie mail les résultats sur les récidives ne sont pas évaluables aujourd'hui . C'est la raison pour laquelle les indications chez la femme ménopausée sont plus discutables car I'embolisation, dons ce cas, n'aura d'action ni sur la symptomatologie, ni, en ( 'l'absence d'étude à long terme, sur la prévention de la récidive . .~~. • 18 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 19 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 20 21 22 Ovarian Vein Embolization for th e Treatment of Pelvic Congestion Syndrome: Longi-Term Technical and Clinical Results MATERIALS AND METHODS : We performed ovarian vein embolization in 41 patients (mean age, 37 .8 years; range, 30-58 years) : 32 patients underwent unilateral embolization and nine patients underwent bilateral embolization. All had lower abdominal pain and pelvic varicosities were found on retrograde ovarian vein venography. Embolization was performed with a mixture of enbucrilate and lipiodized oil in all but one patient, in whom enbucrilate an d minicoils were used. Initial technical success rate and clinical followup(1-6>i. months; mean, 19.9 months), conducted with use of mailed questionnaires, are reported . RESULTS: Initial technical success rate was 98%. Immediate complications were noted in two patients (4%) in the form of migratio n of some fragments of glue (used as embolic agent), which was treated conservatively . Clinical follow-up reveals variable symptomatic relief in 9 .7% of cases and a total relief of symptoms i n 58.5% of cases . Results in patients who had insufficient ovaria n veins bilaterally were no better than those in patients for whom only the left ovarian vein was found insufficient. CONCLUSIONS: Transcatheter embolization of the ovarian veins is a safe and feasible technique leading to complete relief of symptoms in more than half of cases . No statistically significant difference in clinical outcome could be noted between patients presenting with bilateral insufficient ovarian veins, who underwent bilateral embolization, and patients presenting with an insufficient 23 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 24 25 26 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 27/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 28/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 29/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? S 3456 iniciales, 232 estudios relevantes, 13 con criterios S Todos con mejoría en dolor S Seguro con buen resultado en 98% pacientes S Complicaciones S Migración de coils a pulmón 1.4% S Perforación de vena blanco 0.6% S Sin diferencia entre agentes de oclusión 30/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 31/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? 32/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? Conclusion This systematic review reports on 13 studies evaluating trans- venous occlusion of incompetent pelvic veins in women with CPP and pelvic congestion syndrome. All included studies reported improvements in the frequency and severity of pelvic pain symptoms after treatment. However, all 13 studies were of poor methodological design with significant bias that limited the value of the evidence to healthcare planning. Technical success in terms of the initial occlusion of target veins was high (98–100%) with few and minor complications. There were no deaths or serious morbidity. The impact on quality of life was not assessed in any of the included studies. Well-designed epidemiological studies are urgently needed to establish the frequency of PVI in women with CPP. RCTs are required to explore the role of transvenous occlusion of incompetent pelvic veins in women with CPP. 33/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? ANTECEDENTES Profesor Abraham Lechter realiza por primera vez una ligadura de venas gonadales por Laparotomia en 1985 El Servicio instaura la ligadura extraperitoneal de las venas gonadales, realizandose el último caso en 2009 2006 se inician primeros casos de Ligadura Laparoscopica 2007 se inicia el estudio y recolección de datos Se excluye la Cirugía Abierta del estudio y del Servicio 34/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? METODOLOGIA Ensayo Clínico Controlado Aleatorizado Se estudiaron 268 pacientes entre 2007 y 2013 (134 cada grupo) Formulario Recolección de Datos Inclusión Estudio : Diagnóstico Clínico - Duplex Flebografía Diagnóstica previa a Intervención Aleatorización para ser incluido en una rama del estudio 35/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? Resultados N: 268 36/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? Resultados - Costos N: 268 37/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? Conclusiones No diferencias significativas en variables demográficas Excelente control sintomático del Síndrome de Congestión Pélvica con las dos técnicas sin diferencia significativa Baja recidiva en las dos técnicas No complicaciones mayores en ninguna técnica Corta incapacidad y bajo uso de analgésicos Costos similares, ligeramente más elevado en el grupo de embolización 38/14 DEBEMOS TRATAR LA INSUFICIENCIA GONADAL? Conclusiones No hay estudios que demuestren la indicación o no de manejo de las varices pélvicas. Si hay beneficio con el manejo. Manejo ideal es institucional 39/14 GRACIAS GRACIAS