Forget keyhole, new PINHOLE surgery is even less invasive
So why are so few hospitals offering it?
EVERYTHING was fine during the birth of Sarah Johnston’s baby — until doctors tried to deliver the placenta. As her daughter, Lottie Olivia, exercised her lungs for the first time, Sarah began bleeding uncontrollably.
‘I gave birth at about 5pm after a long day in labour. I was exhausted but so happy,’ recalls Sarah, 35, a primary school teacher from Driffield, East Yorkshire, two years later.
Then it all went wrong. One minute Sarah and her husband, Steve, were gazing entranced at their first baby — and the next Sarah was all but unconscious and being rushed to theatre.
Over the next hour she lost four-and-ahalf litres of blood. A doctor told Steve, a 35-year-old police officer, that Sarah had suffered a post-partum haemorrhage due to a retained placenta, and the problem was life-threatening.
The placenta is usually delivered spontaneously after birth — it is described as ‘retained’ if it remains inside the mother’s body for longer than an hour. This is quite common, affecting three in 100 deliveries, and most can be quickly resolved by the obstetrician or midwife detaching the placenta.
But one in five women, like Sarah, have a placenta that sticks so firmly to the womb that removing it results in haemorrhage. In the past, the only lifesaving option has been an emergency hysterectomy to remove the womb. This is a high-risk procedure, with seven in 100 women dying.
Yet at the last minute, Sarah was offered a minimally invasive procedure that significantly lowers the risk of dying compared with a hysterectomy, and leaves a scar just a few millimetres long (furthermore, the woman keeps her womb).
Sarah was treated with the help of interventional radiology (IR). Here, scans such as X-rays, CT or MRI are used to identify the cause of the problem. Then tiny devices are inserted into the body via the blood vessels — usually through a 2mm cut in the groin. The instruments are fed in using catheters that are as thin as a strand of hair.
Interventional radiology is sometimes called ‘pinhole surgery’, because unlike keyhole surgery, it requires no major cutting, stitches or general anaesthetic. The technology significantly reduces rates of infection and recovery time.
The best known form of interventional radiology is coronary angioplasty, where a tiny balloon is opened up inside a narrowed artery to squash back the fatty deposits that are blocking it; the artery may then be held open with a tiny piece of scaffolding, a stent — although this is largely provided by specially trained cardiologists rather than interventional radiologists.
Interventional radiologists offer several other procedures, including treating uterine fibroids (benign growths in the womb) by injecting molecules that clot the blood in the arteries that supply them.
The technique is also used as an emergency treatment for internal bleeding — tackling the problem using clotting agents such as gels or foams, as well as clamps, stitches or tiny metal coils to repair a breach in the artery wall.
As well as post-partum bleeding like Sarah suffered, this type of interventional radiology is used for internal bleeding in the lower gastro- intestinal tract — the gut — as a result of internal haemorrhoids or inflammatory bowel disease ( which affects 30,000 people a year), and rarer causes of internal bleeding caused by trauma, such as a traffic accident.
The benefits notwithstanding, two recent reports suggest hundreds of thousands of suitable patients are missing out on it every year. One in four hospitals that admit patients with internal bleeding from the lower gastrointestinal tract do not offer interventional radiology, according to a report by the independent charity, the National Confidential Enquiry Into Patient Outcome And Death. And this is despite the fact that interventional radiology is recognised as the vital next treatment to try if standard treatment with endoscopy — a thin tube inserted directly into the gut — fails. As a result, major surgery, involving cutting open the gut, with higher risks of infection and slower recovery time, becomes the only option. ‘The truth is, patients who could be treated with interventional radiology are having major surgery not because it’s the best option but because it’s the only treatment available,’ says Dr Simon McPherson, coauthor of the new report and a consultant radiologist at Leeds Teaching Hospitals NHS Trust.
The situation with out-of-hours interventional radiology is even worse, with one in two hospitals admitting patients with lower gastro-intestinal bleeds unable to offer it on evenings and at weekends, the report found.
Meanwhile, a survey by NHS Improving Quality (a body set up to improve the health service) found that just one in three emergency departments provide out- of- hours interventional radiology for trauma victims.
And crucially, only 44 per cent of obstetric units offer round-the- clock interventional radiology, despite evidence-based guidelines, published by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2007, requiring all hospitals to arrange a ‘continuous on- call interventional radiology service’ — or to ensure there was an arrangement for patients to be treated at nearby hospitals.
Eight years on, ‘it’s still very much a postcode lottery as to whether a woman in Sarah’s situation is offered the minimally invasive procedure that preserves her fertility and perhaps even her life’, says Professor Duncan Ettles, consultant radiologist at Hull Royal Infirmary, who treated Sarah. And Sarah knows how lucky she was. ‘It turns out I was at one of the best hospitals for interventional radiology,’ she says. ‘Before the birth, availability of out-of-hours interventional radiology would never have been a reason to choose a maternity hospital. I now know it should be on every woman’s list.’
Henry Annan, an obstetrician at Whipps Cross University Hospital NHS Trust and a spokesman for the RCOG, says ‘ finance is a major factor in providing any healthcare’, and suggests that while the technology is expensive, severe postpartum haemorrhage is a rare event.
Yet cost is not the only reason, says Professor Anna-Maria Belli, a consultant radiologist at St George’s Hospital in London. ‘Some obstetricians would prefer to do a hysterectomy than ask another specialty to help. It is particularly frustrating when this happens, despite interventional radiology being available.’
It doesn’t help that even some doctors seem unaware of interventional radiology. In December 2013, Sylvia Bailey, a 59-year-old shop assistant from Crawley, West Sussex, was admitted to hospital after a bad fall breaking her ankle, which was required surgery.
At the time, she was recovering from knee-replacement surgery carried out the previous July, which meant she was taking anticoagulants to thin her blood and prevent clots. This medication raises the risk of internal bleeding.
Following her ankle surgery, Sylvia began bleeding internally as a result of the fall, and deteriorated rapidly. Her life was at risk because of the anti- coagulants she was taking.
A week after she broke her ankle, she was given a blood transfusion and further medication to make her blood clot. But it looked hopeless: the surgeon told her husband, John, to prepare for the worst.
TEN minutes later, however, the same surgeon returned with a different story. ‘It seemed as though he’d just heard from a colleague about interventional radiology,’ says John.
Sylvia was transferred from the hospital in Redhill, Surrey, to the interventional radiology department at St George’s. She was taken on the half-hour drive by ambulance ‘on the point of death’, says John. ‘ She was telling us: “Goodbye. I am shutting down, I love you.”’
On New Year’s Day, Professor Belli and her team stemmed the bleeding from two arteries in Sylvia’s abdomen using an injection of filler particles. After several weeks in hospital, Sylvia was discharged, and has since returned to work part-time at B&Q.
The Royal College of Radiologists wants round-the-clock interventional radiology services at every hospital trust — with a call for an increase in 220 consultant radiologists to bring the number to 670 in the UK. But there aren’t enough trained interventional radiologists to achieve this — nor are there likely to be.
A faster route to greater availability could be establishing a national system of interventional radiology networks, where a single rota of radiologists provides emergency cover across several neighbouring hospitals — a system one in four hospitals is already using.
The British Society of Interventional Radiology is against such a stop-gap — with concerns that it’s too risky to transfer patients, such as Sylvia, who have severe internal bleeding, to another hospital, even when it’s close by.
Yet one leading interventional radiologist, who asked not to be named, says the real reason why networks won’t take off has nothing to do with patient safety. ‘There are so many advantages to building networks,’ he says. ‘But NHS hospitals at the moment have to compete with each other for funding and co-operation goes against the grain.’