Systematic review of the safety and efficacy of foam sclerotherapy for venous disease of the lower limbs

Background: Foam sclerotherapy is a potential treatment for lower limb venous disease. Methods: A systematic review, with no restriction on study design, to assess the safety and efficacy of foam sclerotherapy. Results: 69 studies were included. For serious adverse events including pulmonary embolism and deep vein thrombosis, the median event rates were less than 1%. Median rate for visual disturbance was 1.4%. Median rates for some other adverse events were more common, including headache (4.2%), thrombophlebitis (4.7%), matting/skin staining/pigmentation (17.8%) and pain at the site of injection (25.6%). Median rate for complete occlusion of treated veins was 87.0% and for recurrence or development of new veins was 8.1%. Evidence from meta-analysis for complete occlusion suggests that foam sclerotherapy is associated with a lower rate compared with surgery (RR 0.86, 95% CI 0.67 to 1.10) and a higher rate compared with liquid sclerotherapy (RR 1.39, 95% CI 0.91 to 2.11). However, there was substantial heterogeneity across the studies in the meta-analysis. Conclusion: Serious adverse events were rare. There is insufficient evidence to reliably compare the effectiveness of foam sclerotherapy with other minimally invasive therapies or surgery. Evidence from high quality randomised controlled trials is required.This manuscript is based on a systematic review commissioned and funded by the National Institute for Health and Clinical Excellence (NICE) through its Interventional Procedures Programme. The Health Services Research Unit is supported by a core grant from the Chief Scientist Office of the Scottish Executive Health Department

Foam sclerotherapy : the Maltese experience

Objectives: To describe demographics and outcomes of a new sclerotherapy service – Foam sclerotherapy (FS), for venous disease at Mater Dei Hospital, Malta Methods: The data of a consecutive series of patients undergoing FS were prospectively entered into a database and the results analysed. Medical notes of patients were also reviewed. Patients underwent detailed venous duplex scanning before and after each intervention and at follow-up visits. Results: 121 patients underwent a total of 204 FS procedures between November 2008 and October 2011. 22% were male and 78% of the procedures were done in female patients. 151 (74%) of procedures were done in patients above the age of 50 years. 74(37%) interventions were for recurrent varicose veins and 113(55%) for chronic venous insufficiency (CEAP4-6). 77 (38%) patients had active or healed venous ulceration as the indication for treatment. 83% of ulcers healed after foam sclerotherapy during the follow up period. 88.3% (143/162) of veins treated were completely occluded while 11.7% (19/162) were partially occluded. In the majority (64%) only one treatment session was required. One patient sustained an anaphylactic reaction to the sclerosant. No deep vein thromboses, cardiovascular events, pulmonary embolism or other major complications were reported. Skin staining was reported in 21.5% of cases. Conclusions: Foam sclerotherapy is a safe and cheap treatment modality resulting in high rates of venous ulcer healing and successful venous occlusion and a very low complication rate. The success rate of foam sclerotherapy in Malta is comparable to that reported in the literature.peer-reviewe

Simultaneous microsurgical spermatic vein ligation and sclerotherapy - A combined procedure for the treatment of recurrent or persistent varicocele

Objectives: Microsurgical ligation as well as antegrade sclerotherapy have been established in varicocele treatment. The aim of this study was to evaluate whether a combination of microsurgery. and sclerotherapy can: provide a safe and effective treatment of varicocele recurrence or persistence. Methods. Nine patients with, recurrent or persistent varicoceles were operated by means of the combination method. Under microscopic control varix veins were ligated selectively preserving: lymphatics and arteries. Ectopic veins as a possible source for varicocele persistence or recurrence were also ligated. Finally, an intraoperative venography with subsequent sclerotherapy was, performed through one of the dissected veins. Results. Despite: difficult anatomical situations after previous surgical interventions, the operations were perform, ed successfully without any complications. Clinical controls showed varicocele disappearance without damage of the testis. No varicocele recurrence or persistence was observed. Conclusions. This method combines the advantages of both methods. Precision of the microsurgical technique is combined with velocity of sclerotherapy. Thus, it may represent an Interesting alternative to conventional operation methods especially in the treatment of recurrent or persistent varicoceles. Copyright (C) 2001 S. Karger AG, Basel

Changing perspectives on liver transplantation in 1988.

After liver transplantation for cancer, there is a high incidence of disease recurrence within 18 to 36 months for most tumors, although there are a small number of long-term survivors. An extended resection of the upper abdominal viscera with replacement by a liver-pancreas cluster is being tried in Pittsburgh for lesions which have not been successfully managed with liver transplantation alone. Despite a high incidence of graft reinfection after liver transplantation for hepatitis B virus (HBV) related disease, a significant proportion of patients achieve long-term survival. Hyperimmune globulin and interferon have been of little benefit in preventing reinfection. Clinical trials with a human monoclonal antibody to HBsAg are in progress. Transplantation for alcoholic liver disease has been considered controversial. However, survival after liver transplantation for Laennec's cirrhosis is comparable to survival after liver transplantation for other chronic, benign, and non-HBV related liver diseases. Sclerotherapy followed by liver transplantation is the treatment of choice for patients with acute hemorrhage from esophageal varices and end-stage liver disease. Sclerotherapy alone or followed by selective shunting is an appropriate alternative in patients with good hepatic reserve. Only 25% of infants with biliary atresia benefit from portoenterostomy. To meet the demand for small infants waiting for transplantation, several transplant programs have successfully expanded their efforts to use partial (reduced) liver grafts. Cyclosporine and low-dose prednisone remain the basis for immunosuppression after liver transplantation. However, nephrotoxicity and hypertension are frequent and troublesome side effects of cyclosporine. Triple and quadruple drug regimens have been increasingly popular in an effort to minimize cyclosporine toxicity. Phase 1 clinical trials with a new drug, FK506, recently began in Pittsburgh. Hyperacute rejection of the liver has been demonstrated in animal models and has been strongly suspected in recent clinical descriptions of acute hemorrhagic necrosis after liver transplantation. So far, only transplantation across an ABO incompatibility has been identified as a risk factor for hyperacute rejection. The new preservation solution developed by Belzer and associates at the University of Wisconsin has significantly extended the preservation time for liver grafts, and improved the quality of liver preservation

GIANT CYSTIC HYGROMA COLLI IN AN ADULT- A RARE CASE REPORT

Cystic hygroma (lymphangioma) is often a benign congenital malformation of the lymphatic system that occurs as a result of sequestration or obstruction of lymphatic vessels. Theselesions are usually discovered in infant or children younger than two years of age.Occurrence in adults is uncommon, and fewer than 100 cases of adult lymphangioma have been reported in the literature (1,2) . The objectives of this case report are to present theclinical history and surgical findings, review of literature and the unique problems encountered in the surgical management of this particular patient

Cost-effectiveness of treatments for superficial venous refluxin patients with chronic venous ulceration.

Background Venous leg ulcers impair quality of life significantly, with substantial costs to health services. The aim of this study was to estimate the cost‐effectiveness of interventional procedures alongside compression therapy versus compression therapy alone for the treatment of chronic venous leg ulceration. Methods A Markov decision analytical model was developed. The main outcome measures were quality‐adjusted life‐years (QALYs) and lifetime costs per patient, from the perspective of the UK National Health Service at 2015 prices. Resource use included the initial procedures, compression therapy, primary care and outpatient consultations. The interventional procedures included superficial venous surgery, endothermal ablation and ultrasound‐guided foam sclerotherapy (UGFS). The study population was patients with a chronic venous ulcer who were eligible for either compression therapy or an interventional procedure. Data were obtained from systematic review and meta‐analysis of RCTs. Results Surgery gained 0·112 (95 per cent c.i. −0·011 to 0·213) QALYs compared with compression therapy alone, with a difference in lifetime costs of €−1330 (−3570 to 1262). Given the expected savings in community care, the procedure would pay for itself within 4 years. There was insufficient evidence regarding endothermal ablation and UGFS to draw conclusions. Discussion This modelling study found surgery to be more effective and less costly than compression therapy alone. Further RCT evidence is required for both endothermal ablation and UGFS

Lymphangiography to treat postoperative lymphatic leakage: a technical review.

In addition to imaging the lymphatics and detecting various types of lymphatic leakage, lymphangiography is a therapeutic option for patients with chylothorax, chylous ascites, and lymphatic fistula. Percutaneous thoracic duct embolization, transabdominal catheterization of the cisterna chyli or thoracic duct, and subsequent embolization of the thoracic duct is an alternative to surgical ligation of the thoracic duct. In this pictorial review, we present the detailed technique, clinical applications, and complications of lymphangiography and thoracic duct embolization