These have been looked at and there's meta analysis of over a thousand patients that shows that this is a highly effective way to control pain if offered early. The later you offer this, these blocks,
the less effective they are. But 70 to 90% of patients experienced either partial or complete pain relief at some time prior to their death.
This is basically kind of your anatomy in hemodynamics.
Celiac axis gives supply to the spleen, gives supply to the hepatic artery, and there's increased flow to the spleen for some reason. Then flow goes back from the gut and spleen back to the hepatic graft by the portal vein. This is kind of your general circulatory
kind of hemodynamics. What the Japanese for years have been talking about was a small for size graft, a completely different syndrome, called small for size graft. In other words the liver is actually too small
for the amount of portal flow that's coming to it. It's an undersized graft. So for example, a transplant in a kid put in an adult. The liver is too small for the amount of portal flow that's actually coming at it.
And what they found out was that there was slow flow in the hepatic artery as well, and they didn't know how that went about. So for years, the Germans were talking about splenic steal, and the spleen is stealing blood flow, the Japanese were talking about
there's a small size graft and there's increased portal flow, but as a coincidence we're looking at hepatic or slow arterial flow. Then, kind of the Americans came along and actually put it all together for them. This is probably a constellation of syndromes and problems
that are occurring at the same time. One can predominate, one can be the only sole problem, or it could be a group of problems. What happens when you increase flow to the liver by the portal vein, there is actually something
called the HABR, the hepatic artery buffer response. This is a partly-reciprocal, poorly understood relationship between the portal vein and the hepatic artery. If you increase portal flow to your liver right now when you eat, if you take a big meal,
portal flow will increase to your liver and your hepatic artery's gonna slow down, because 20% of flow to the liver is from the artery, and 80% goes from the portal vein. If you eat a lot, your portal vein flow increases, your hepatic artery compensates by dropping down to
maintain that flow to the liver. That's kind of a partly-reciprocal relationship. So when you put a small graft in a patient, with relatively high flow, too much flow for the portal vein, the hepatic artery slows down. Okay?
So this is not just a steal phenomenon, this may also be a response or a reflex response to a high flow situation. The graft- and just to add a little bit more detail to this- the graft could be small, or the graft could be non-compliant and poor.
A poor graft, as well, can do the same thing. So it could be a big graft that's not functioning that well, and/or stiff, that would do the same thing as well. Okay? So increased portal flow, decreased hepatic arterial flow.
I mean I just thought I'll show you that second clip, how natural it can actually look to cross one's arms but then she opened it up and it's very hard to then not follow along, so that's how you sometimes can save the day
in a fast way. Now dealing with pain and that's something I think that gets to all of us emotionally, I mean we are gonna be poking people and there's certain things of how we feel about
what the patient should be experiencing. We've done several large clinical trials so we had the opportunity to look at the standard of care groups of those where patients could get as many drugs as they wanted and if I were to ask you, just by show of hands,
what do you think hurts the most? Okay angiography? Large core breast biopsy? Tumor embos? Okay well it's kind of like, what I thought too. However if you plot onto this graph
on the X axis is the time zero you wheel a patient into the room and on the Y axis is their self reported pain. We ask them like every end of 15 minutes, by the way we don't say how bad is your pain, we say what is your comfort level on a scale
of zero to 10, no pain at all and worst possible, and zero no anxiety at all, 10 worst possible. And what you find out is, I mean there are these three curves going up over time and the blue line is the tumor embos, the red one is the angio renal and the yellow
is the breast biopsies, there's really no difference. And furthermore when we dug deeper into this data not only is this increase in pain over time, this trend relatively independent of how hard you poke somebody, but also independent of how many drugs they get.
Actually there's a somewhat inverse relationship between the amount of drugs people get and how much pain they experience over time that is sent. And the question is why is that the case? So from nature we are used to always assume the worst
and similar curve applies, although with some differences for anxiety but there's an increase in anxiety over time in the case under standard of care and I think it goes all down, that's one explanation (mumbles), he's a surgeon in (mumbles) uses,
he says, you know, hundreds and thousands of years our ancestors, let's say who walks through the Savannah and one behind hears a little noise and says, oh this could be a tiger, perhaps I should look around and do something about it and the other one says it's just the wind it's not a big deal.
You can see that being a little paranoid over time still probably translates into higher longevity and the ability to create offspring so we are all deriving from the somewhat more paranoid people that particularly, in a setting of ambiguity, we assume it's hurting
or it's bad or it's dangerous to us and it's a protective mechanism of the subconscious. That is going to happen. Furthermore, once there had been one painful stimulus then all subsequent stimuli are going to be interpreted as being painful or even more painful
and there have been studies done where they hook people up to a machine with little flashing lights and the first time they got a little shock and the next time just the little lights were flashing and they experiencing more and more pain with the little lights flashing even though
there weren't any more shocks. So that's what you have to deal with and this is what we all know. If you do a case that's over in 15 minutes it's not that big a deal. It's like you're in hour number one,
where you now are number two or in hour number three. That's when certainly everybody can get really, really stressed out. However, the good news is if right at the beginning you do something, you say to the patient something in words but also in your behavior
that reframes this experience this doesn't happen. And this is kind of the secret sauce, all you need to do is do something at the beginning, at time zero, and then you don't get this blue line on the standard of care where the pain keeps going up
over time, time, time, time. If you do some empathic attention the increase is not as steep but if you do some comforting words at the beginning, these are IR data in interventional radiology, you can go on for ever.
I mean it's just like a very different atmosphere in the room and very similar for anxiety. We've found similar responses in a trial we did with breast biopsies and tumor embolizations under standard of care pain to go up,
getting better if you give some empathic attention but anxiety dropping down very quickly while this patient is still on your table and actually even though the whole thing is called Comfort Talk you're gonna end up to talk much less
because the idea is to get that patient on autopilot as fast as you can, particularly in MRI. You wanna have them in there doing their own thing, having, as we shall say, their own experience while you can start to do all your paperwork
and your reconstructions and whatever you need to do.