By Katie Neith

The circulatory system is one of the body’s most essential components, delivering important nutrients to your organs. Arteries work especially hard, carrying oxygenated blood away from the heart and to the rest of your body.

Sometimes—perhaps because of all their hard work—a spot in an artery wall will become weak and balloon out, filling with blood. This is called an aneurysm. When an aneurysm in the brain ruptures, or tears, it is called a hemorrhagic stroke, according to Donald Larsen, M.D., interventional neuroradiologist and associate professor in the Keck School of Medicine of USC.

“Of all the strokes that occur, 15 percent are from a ruptured blood vessel and the other 85 percent are due to an occlusion—or blockage—of a blood vessel,” says Larsen. “So it’s not the most common cause of stroke.”

Nonetheless, ruptured brain aneurysms are extremely dangerous. In fact, 50 percent of people with a ruptured brain aneurysm die immediately, according to Larsen. Of those that survive, half have a stroke as a result and endure significant neurological distress.

He says that it is unclear exactly why brain aneurysms occur. But it is known that they have a higher rupture rate when they occur with high blood pressure and smoking, and when there’s a history of ruptured aneurysms in the family.

Luckily, a procedure honed over the past decade called coiling has made significant improvements in survival outcomes. According to one long-term study, called the International Subarachnoid Aneurysm Trial (ISAT), coiling is more likely to result in independent survival at one year than neurosurgical clipping, and the survival benefit continues for at least seven years.

“The goal of coiling is to fill the aneurysm, whether it’s ruptured or unruptured, from the inside and get it to clot off without the need for open surgery,” says Larsen. “In traditional treatment, a neurosurgeon would open up the skull, carefully expose the aneurysm and put a clip across the neck of the aneurysm.”

Coiling is a minimally invasive procedure developed in the early 1990s and FDA-approved in 1995. It uses specially designed soft coils of a platinum alloy to pack the aneurysm full. At the end of the packing process, approximately 30 percent of the aneurysm is filled with coil, the rest of it is trapped blood, says Larsen.

“The trapped blood forms a clot among the loops of the coils, preventing future rupture,” explains Larsen. “The coils stay in there for life.”

Coiling employs endovascular surgery techniques, a form of surgery that uses major blood vessels to access other regions of the body.

“Like a cardiologist, we enter the body through the femoral artery in the leg,” explains Larsen. “Then, we selectively catheterize the arteries in the neck, either carotid or vertebral arteries. Through that catheter, we insert a smaller catheter—about the size of angel hair pasta—which goes directly into the brain.”

He says that both catheters are delivered over a guide wire, the traditional way of advancing catheters through the arteries.

Because the entire surgery is done through a tiny hole in the femoral artery, the recovery time for this type of treatment is typically short.

“There is no outside intervention on the head or skull,” says Larsen. “For an unruptured aneurysm, patients are home the next day and almost always make a full recovery.”

Follow-up also tends to be minimal, he says. Less than 10 percent of the time, there’s some compaction of coils that requires an additional coil or two. For that reason, Larsen says patients are required to do follow-up angiograms at six months after the coiling procedure, and at one year.

“We do some follow-up angiography a few times after coiling, but after coiling, the aneurysm is protected from future rupture,” says Larsen.

He points out that not everybody is a candidate for coiling. At USC, an entire team takes into consideration various factors to decide whether an endovascular approach or a traditional neurosurgical approach would be most effective. Location is a large factor, says Larsen, as some aneurysms are easier for the neurosurgeon to put a clip on and some are harder and vice versa for coiling.

“We also look at the shape of the aneurysm and are looking for one that has a well-formed neck on it—like a light bulb or a cherry on a stalk,” says Larsen. “For aneurysms with a wider neck, we do have other mechanisms—we sometimes can put a stent across the neck and then fill it up with coils.”

Together, the team looks at all those factors and others, including whether the aneurysm is ruptured or not, and the age of the patient, to make the best treatment decision possible.

For more information on brain aneurysms, including possible symptoms and diagnostic procedures, Larsen recommends www.brainaneurysm.com.

September 29, 2008
by Angelica Urquijo

What if it was possible to undergo a root canal filling or tooth extraction without feeling the pinch of a needle or the after effects of general anesthesia? Hypnosis could uncover a new world for patients seeking dental care.

The soothing voice of your dentist could transport you into a state of mind that allows the dental professional to complete a procedure—whether it is a simple cleaning or a complex procedure that involves oral surgery—while you slip into a state of relaxation.

“Now as I count from one to 10, I can feel myself sinking more and more deeply into the quiet, relaxed, enjoyable feeling. More relaxed with each count.”

Wendy J.N. Lee listens to the words uttered by associate professor Peter Stone, D.D.S., as her body slips into a more comfortable position during a recent visit to the USC School of Dentistry. Lee, a USC cinema graduate student, filmed Stone’s hypnosis techniques for Say Aah, a documentary about her fear of dentistry.

Hypnosis in dentistry was first reported in Egypt more than 3,000 years ago. The demise of its practice occurred with Horace Wells in the 19th century, who initiated the use of nitrous oxide and ether during procedures.

In the years that followed, chemicals and general anesthesia became common practice, and hypnosis became a sleepy alternative to sedation.

Today, the USC School of Dentistry is the only dental school in the United States that offers formal training for dental professionals in the use of hypnosis.

Stone, who works in the division of health promotion, disease prevention and epidemiology, teaches “Modern Hypnosis for the 21st Century Dentist.” He has taught the techniques and applications of hypnosis since 1981 for the Southern California Society of Clinical Hypnosis.

“The time spent learning hypnosis not only makes a visit to the dentist more pleasant for the patient, but it also enhances a practitioner’s productivity, providing a stress-free environment for all,” he says.

“Working with nervous patients makes it difficult to carry out our job,” Stone explains. “Dentists by nature, we don’t like to hurt people – we’re trained to bring them relief from pain. When a patient is relaxed and calm, the procedure goes more smoothly and more quickly.”

Hypnosis could be a win-win for both patient and dentist. It’s a less expensive alternative to general or conscious sedation, which can cost hundreds of dollars.

“In the average patient, we can teach them to relax and control their fears 90 percent of the time. In a small group of patients, hypnosis allows them to control pain, bleeding or salivation during a procedure or speed up recovery time,” Stone says.

Stone shares his experience with one patient during oral surgery: “I remember telling my assistant, ‘If only John would stop bleeding, I could finish this procedure quicker and remove the root tip causing his pain.’ Instantly my patient stopped bleeding.”

The technique is also used to control gagging, bruxism (teeth grinding and clenching) or breathing problems. In addition, hypnosis can enhance memory of a pleasant visit to the dentist.

Each year, dentists from across the country and Canada travel to Los Angeles for the two-day hypnosis course taught by Stone at the USC School of Dentistry. The workshop provides dentists with the tools and skills they need to use hypnosis comfortably in their dental practice.

By Monday morning, these dentists are equipped with the knowledge they need to put their patients at ease.

Hala Al-Tarifi, a South Pasadena dentist, shares her experience: “I started implementing hypnosis in my office, and one of my patients slept through a crown prep.”

For more information, visit The American Society of Clinical Hypnosis at www.asch.net or the Southern California Society of Clinical Hypnosis at www.scsch.camp7.org.

You can also learn more about Lee’s documentary by visiting www.sayaahfilm.com.

September 22, 2008
by Sara Reeve

For the past 20 years, doctors around the world have been fine-tuning the art of minimally invasive surgery, a technique that has been around since the early 1900s, but only recently gained popularity with the advent of better technology.

Minimally invasive, or laparoscopic, surgery uses specialized techniques, miniature cameras with microscopes, tiny fiber-optic flashlights and high definition monitors to treat numerous ailments through small incisions. It has applications in many regions of the body, including cardiovascular, colorectal, gastrointestinal and urological, among others.

The benefits of laparoscopic surgery, as compared to open surgery, are less trauma, smaller scars, less blood loss and a faster recovery. In fact, some laparoscopic procedures can be done on an outpatient basis.

USC surgeon Namir Katkhouda, M.D., an international leader in the development of minimally invasive surgery, recently helped advance the field once again. He performed the first single-port-access laparoscopic surgery on the West Coast, removing the gallbladder of a 20-year-old female patient at LAC+USC Medical Center.

The surgical technique, first performed in 2007 by doctors at Drexel University College of Medicine, is a minimally invasive surgical procedure in which the surgeon operates through a single entry point, which in this case was a small incision in the navel.

“We are exploring a new world of surgery through one hole,” says Katkhouda, a renowned expert on laparoscopic surgery and professor of surgery and chief of the Minimally Invasive Surgery Program at the Keck School of Medicine of USC. He is also director of laparoscopic surgery at USC University Hospital.

Traditional laparoscopic gallbladder removal requires three to four incisions – one in the belly button and the others made through the lower chest and abdomen, resulting in multiple scars. Multiple incisions have been the common routine because several port placements were needed to facilitate movement.

“The single port does limit surgical movement, and so the surgeon needs to be very precise,” Katkhouda says. “But as long as it is done in a safe environment with experienced doctors, I think this technique is very promising.”

The patient experienced minimal discomfort and has a barely visible scar compared to traditional surgery techniques. The entire surgery took only 45 minutes, and the patient was able to leave the hospital within two hours to recover at home.

“Compared to traditional laparoscopic techniques, single-port access surgery offers patients the possibility of a better recovery, less pain and the added benefit of reduced scarring,” he says.

The gallbladder is a small, pear-shaped organ located below the liver in the right upper abdomen. It is part of the digestive system and its function is to store bile, a liquid made in the liver that helps the body digest fats.

Gallbladder removal is typically done to treat gallbladder disease caused by inflammation, infection, stones or obstruction of the gallbladder—conditions that slow or obstruct the flow of bile out of the gallbladder. Symptoms of gallbladder disease include, but are not limited to, abdominal fullness or gas, abdominal pain in response to fatty foods, chest pain under the breastbone, chills, fever, heartburn, nausea and vomiting.

Katkhouda believes that single-port access surgery is preferable compared to “natural orifice” (NOTES) procedures, in which surgeons enter through the mouth, rectum or vagina in an attempt to minimize scarring. Most of these procedures require extensive training and introduce the possibility of added complications.

“NOTES involves making holes in healthy organs and just doesn’t come naturally to surgeons,” Katkhouda says. “This new technique can be easily taught to experienced surgeons and has a lot of potential for a variety of surgeries.”

Katkhouda plans to utilize the single-port access technique for more gallbladder removals as well as appendectomies. Eventually, he would like to use the procedure to perform other surgeries, including cyst removals, anti-gastric reflux procedures and adjustable gastric band surgery.

“I’m excited to offer this procedure to additional patients,” Katkhouda says. “We’re really taking minimally invasive surgery to the next level.”

For more information or to make an appointment, visit www.DoctorsofUSC.com or call 800-USC-CARE.