Minor Surgery - Best treatment › Therapeutic skills
Injections
Joint injections
- Intra-articular (acromio-clavicular joint, shoulder joint, sterno-clavicular joint; interphalangeal joint, metacarpo-phalangeal joint, knee joint)
- Peri-articular (trigger finger, carpal tunnel syndrome, golfer’s elbow, tennis elbow, knee joint, plantar fasciitis)
For technical details concerning selected joint injections (the shoulder, elbow, wrist, knee, and ankle) see 'Skills': (Joint Aspiration and Injection)
Other injections
Sclerotherapy is a procedure used to treat blood vessels as well as vascular or lymphatic malformations in children and young adults. Injecting the unwanted veins with a sclerosing solution causes the target vein to immediately shrink, and then dissolve over a period of weeks as the body naturally absorbs the treated vein. In adults, sclerotherapy is often used to treat varicose veins and haemorrhoids (Wilmore DW (ed), 2004) .
Varicose veins
Sclerotherapy has been used in the treatment of varicose veins (Fig. 1) for over 150 years. It is less invasive than surgery, and has low rates of serious complications. Like varicose vein surgery, the technique of sclerotherapy has evolved during that time. Modern techniques including ultrasound-guided foam sclerotherapy (UGFS) are the latest developments in this evolution.
[Reproduced, with permission, from: http://medicine.ucsd.edu/clinicalimg (Catalog of Clinical Images by Dr. Charles Goldberg, MD; © Regents of the University of California)]
Sclerotherapy is the "gold standard" and is preferred over laser for eliminating large spider veins (telangiectasiae) and smaller varicose leg veins (Sadick N, Sorhaindo L. Laser treatment of teleangiectatic and reticular veins. In: Bergan JJ (ed), 2006) . Unlike a laser, the sclerosing solution additionally closes the "feeder veins" under the skin that are causing the spider veins to form, thereby making a recurrence of the spider veins in the treated area less likely.
Technique:
Multiple injections of dilute sclerosant (e.g. 5% sodium tetradecyl sulfate [STS]) are injected into the abnormal surface veins of the involved leg. The patient's leg is then compressed with either stockings or bandages that they wear usually for 2 weeks after treatment. Patients are also encouraged to walk regularly during that time. It is common practice for the patient to require at least two treatment sessions separated by several weeks to significantly improve the appearance of their leg veins.
Sclerotherapy should be done under ultrasound guidance after venous abnormalities have been diagnosed with duplex ultrasound. In US-guided sclerotherapy, ultrasound is used to visualize the underlying vein so the physician can deliver and monitor the injection. Foam sclerotherapy, which uses a foam to push blood aside, is useful for longer and larger veins.
UGFS using microfoam sclerosants has been shown to be effective in controlling reflux from the sapheno-femoral and sapheno-popliteal junctions (Kanter A, Thibault P, 1996) , and also in treating larger varicose veins, including the greater and short saphenous veins (Sadick N, Sorhaindo L. Laser treatment of teleangiectatic and reticular veins. In: Bergan JJ (ed), 2006) .
Technique:
in one study (Darke SG, Baker SJ, 2006) , polidocanol was foamed 1:3 with air. Under ultrasound control via ‘butterfly’ or Seldinger cannulation, 1 per cent foam was injected into superficial veins and 3 per cent foam into saphenous trunks, up to a total volume of 14 ml. Outcome was defined as complete when occlusion of the saphenous trunk and/or over 85 per cent of the varicosities was achieved, and partial closure when less. UGFS achieved early complete occlusion safely in over 90 per cent of legs with varicose veins (Darke SG, Baker SJ, 2006) .
Evidence:
A Cochrane Collaboration review of the medical literature concluded that "the evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins” (Tisi PV, Beverley C, Rees A, 2006) .
A second Cochrane Collaboration review comparing surgery to sclerotherapy concluded that sclerotherapy has greater benefits than surgery in the short term but surgery has greater benefits in the longer term. Sclerotherapy was better than surgery in terms of treatment success, complication rate and cost at one year, but surgery was better after five years. However, it was concluded that the evidence was not of very good quality and more research is still needed (Rigby KA, Palfreyman SJ, Beverley C, Michaels JA, 2004) .
Complications:
While rare, complications include venous thromboembolism, visual disturbances, allergic reaction, thrombophlebitis, skin necrosis, and hyperpigmentation. If the sclerosant is injected properly into the vein, there is no damage to the surrounding skin, but if it is injected outside the vein, tissue necrosis and scarring can result (skin necrosis occurs with 0.2% to 1.2% of sclerotherapy injections).
Haemorrhoids
Injection sclerotherapy is one of the older methods of conservative treatment of haemorrhoids. It has been widely used and the early results are considered satisfactory although the long-term results are not as good as expected (Kanellos I, Goulimaris I, Vakalis I, Dadoukis I, 2000) .
Sclerotherapy of haemorrhoids has the advantages of being cheap and easy to carry out in the outpatient setting (General Practice Notebook) . In this procedure, a small volume of an irritant solution is injected into the submucosa around the pedicles of the three major haemorrhoids.
There are two theories as to how it works (General Practice Notebook) :
- irritant solution causes a fibrotic reaction which obliterates the haemorrhoidal veins; this causes the vein walls to collapse and the hemorrhoids to shrivel up; or
- it precipitates local inflammation with retraction of the cushion by fibrosis; veins are relatively unaffected.
Indications: (General Practice Notebook) , (Kanellos I, Goulimaris I, Vakalis I, Dadoukis I, 2000)
- 1st degree haemorrhoids with bleeding as the most common symptom, in which conservative management has failed,
- 2nd degree haemorrhoids (usually with prolapse as the most common symptom) (Fig. 2).
[Reproduced, with permission, from: http://medicine.ucsd.edu/clinicalimg (Catalog of Clinical Images by Dr. Charles Goldberg, MD; © Regents of the University of California)]
Procedure:
- A proctoscope is inserted into the anal canal and the piles bulge over the proctoscope rim.
- An irritant solution (approximately 6 ml of 5% phenol in almond or arachis oil) is injected within 2.5 min into the submucosal layer just above th pectinate line, around the pedicles of the three major haemorrhoids. The injections should not be painful.
The patient may experience some discomfort for the first 2-3 days after the procedure. However, the discomfort usually resolves and the patient notes some benefit after 6-10 days. Treatment may need to be repeated, often up to three times with an interval of up to six weeks between injections.
Possible complications:
- a misplaced injection into the prostate; this is heralded by haematuria and fever; it usually settles without treatment,
- there were case reports on impotence (NOTE: the close proximity of the rectum to the periprostatic parasympathetic nerves defines an anatomical basis for this complication), hepatic abscesses, life-threatening retroperitoneal sepsis, and haemolytic uraemic syndrome.
Evidence (Porrett TR, Lunniss PJ, 2001)
A bulking agent and nurse-led education, advice and bowel habit retraining is as effective in reducing the incidence of bleeding from 1st and 2nd degree haemorrhoids as injection sclerotherapy. Patients who consult a nurse practitioner with symptomatic 1st and 2nd degree haemorrhoids feel more empowered in the long term. Non-invasive bowel retraining methods should be offered as an alternative to more traditional, invasive treatments for patients with symptomatic early haemorrhoidal disease. [Evidence level – Ib]
The treatment of haemorrhoids has undergone significant changes after introduction of new techniques during recent years (Gupta PJ, 2006) . Radiofrequency coagulation is a new approach for treating grade I and II haemorrhoids. In this procedure, the haemorrhoidal tissue is coagulated by a high frequency radio wave. The treatment of bleeding haemorrhoids is technically simple, therapeutically effective and virtually complication free. The equipment is portable, easy handling, long lasting, and needs only little maintenance.
