Chemical synovectomy with sodium morrhuate in the treatment of symptomatic recurrent knee joint effusion.

The aim of this study was to assess the efficacy and safety of intra-articular sodium morrhuate injections in the treatment of recurrent knee joint effusions. Ninety-eight knees of 92 patients (f = 59, m = 33) with knee arthritis of heterogeneous etiology were treated with chemical synovectomy (CSO). Of those, 39 patients suffered from rheumatoid arthritis (RA). The mean follow-up was 29.8 months. Clinical outcome was evaluated by analyzing subjective patient satisfaction, activity level, pain severity on the basis of the Visual Analogue Pain Scale (VAS), Lysholm and Gillquist score, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Fifty-seven percent of all patients and 67% of patients diagnosed with RA were satisfied with CSO. No significant effects on patient satisfaction by CSO were noted in patients older than 40 years. Overall, VAS, Lysholm and Gillquist score, and KOOS improved significantly at final review. The intra-articular application of sodium morrhuate is an effective and safe measure in the treatment of recurrent symptomatic knee joint effusions in young patients suffering from recurrent knee joint effusions.

Fluoroscopy-guided foam sclerotherapy with sodium morrhuate for peripheral venous malformations: Preliminary experience.

BACKGROUND: Ultrasound-guided foam sclerotherapy is a generally safe, cost-effective, and practical technique for the treatment of certain venous malformations; however, not all vascular malformation lesions are amenable to the ultrasound-guided method. Venous outflow of the sclerosing agent and extravasation are difficult to check when only ultrasound guidance is used. This study describes a new fluoroscopy-guided technique that uses standardized sclerosing foam for peripheral venous malformations. The short-term efficacy and safety of fluoroscopy-guided foam sclerotherapy for peripheral venous malformations was evaluated. METHODS: A retrospective review of a prospectively collected data was performed for 23 patients (9 males, 14 females) with limited (localized) venous malformations treated with foam sclerotherapy who were referred from January 2007 to December 2007. Median patient age was 21 years (range, 5 months-39 years). Lesion locations included extremities in 13, faces in eight, and trunks in two. The standardized sclerosing foam was prepared using Tessari's method to mix room air with 5% sodium morrhuate in a 4:1 ratio. Sclerotherapy was performed by the "filling-defects" technique under fluoroscopy. Postsclerotherapy surveillance was done at 6 months after the last session. Treatment response was assessed clinically and by means of lesion size measurement with magnetic resonance imaging. During the treatment and the follow-up period, adverse events and adverse drug reactions were recorded. Specific complications were classified as major or minor. RESULTS: A total of 58 treatment sessions were performed (mean, 3 sessions per patient; range, 1-6 sessions). At the 6-month follow-up, 15 patients (65.2%) showed a total disappearance of treated malformations, six (26.1%) showed a reduction in malformation size of >50%, and two (8.7%) showed a reduction in malformation size of

[Conservative local therapy of inflammation of joints: local invasive forms of therapy]. / Die konservative Lokaltherapie des entzündeten Gelenks: Lokal-invasive Therapieformen.

Local invasive procedures represent possibilities for the treatment of arthritic swollen joints without surgical interventions, when general measures alone are not successful and intra-articular injections are of utmost importance in this context. The differences between degenerative and rheumatologic diseases must be considered as well as possible specific adverse reactions, side effects and contraindications. The technical intervention is performed according to the guidelines of scientific societies such as the Scientific Medical Profession Society (AWMF). Cortisone and radiosynoviorthesis/chemosynoviorthesis are suitable for activated rheumatic and degenerative joints, low-grade radiation therapy or infiltration of hyaluronic acid is recommended for relief in cases of arthritic inflammation. The combination of arthroscopic synovectomy and subsequent radiosynoviorthesis in the early stages of rheumatically swollen joints show the best results with respect to regression prophylaxis and slowing the process of rapidly progressing destruction of chondral surfaces and distension of the capsules and ligaments.

Sclerotherapy of oral and facial venous malformations with use of pingyangmycin and/or sodium morrhuate.

Two hundred and sixty patients with oral and facial venous malformations received intralesional injections of either pingyangmycin, sodium morrhuate, or pingyangmycin alternating with sodium morrhuate. Results were rated excellent, good, fair, or poor, depending on clinical outcome. The prevalence of an "excellent" rating in the combined sclerotherapy group (82%) was higher than that in the pingyangmycin group (71%) and the sodium morrhuate group (61%). Swelling and pain following injection were commonly associated with the use of sodium morrhuate. Sclerotherapy with pingyangmycin or sodium morrhuate is an effective and safe treatment for oral and facial venous malformations. Alternate injection of pingyangmycin and sodium morrhuate appears to be more effective for venous malformations than using sclerosant alone.

Evaluation of a rabbit model for osteomyelitis by high field, high resolution imaging using the chemical-shift-specific-slice-selection technique.

The rabbit model of osteomyelitis introduced by C.W. Norden, based on injection of an infecting solution (Staphylococcus aureus, sodium morrhuate) into the tibia, was studied at 4.7 Tesla with a time-efficient chemical shift selective imaging technique, Chemical Shift Specific Slice Selection (C4S). The evolution of the disease over several weeks was followed on water-selective, fat-selective, and sum images obtained simultaneously with this imaging sequence. Experiments were performed either on different groups of rabbits at different times after infection with subsequent sacrifice of the animal and microbiological analysis of the infected tibia or on the same group of animals imaged several times after infection. Associated analysis of the water and fat selective images revealed marrow modifications very early (Day 5 after inoculation) demonstrating the high sensitivity of the employed imaging technique. Later on, bone modifications were best identified on the sum images. Additional experiments performed on animals injected with a noninfecting solution containing only sodium morrhuate showed however that the sclerosing agent alone can yield images similar to those produced by infection at early stages after inoculation. Therefore, the Norden model would not be suitable for monitoring quantitatively outcome of therapy by magnetic resonance imaging. It is however well adapted for the evaluation and optimization of MRI techniques or protocols intended to detect early changes of bone marrow produced by septic or aseptic infarct.

Varicose veins--primary treatment with sclerotherapy. A personal appraisal.

Varicose veins are a very common condition that presents in a variety of forms. Treatment modalities are variant and beneficial. The author reports on an experience of 25 years treating 20,000 patients using surgery and sclerotherapy with particular results using morrhuate sodium.

Prospective randomized comparison of esophageal variceal sclerotherapy agents: sodium tetradecyl sulfate versus sodium morrhuate.

We designed a prospective randomized study to evaluate differences in efficacy and complication rate between the two most commonly used sclerosing agents, sodium tetradecyl sulfate (STD) and sodium morrhuate (MOR). Of 41 patients with acute index variceal bleeding initially evaluated, 21 were randomized to receive 0.75% STD and 20 to receive 1.6% MOR diluted with 50% dextrose. Overall mortality for the STD group was 38% and that for the MOR group was 25% (NS). Control of acute bleeding was achieved in 86% of the STD patients and 90% of the MOR patients (NS). Overall, obliteration was achieved in only 33% of the STD group and 25% of the MOR group; but in those patients who remained in the study over 3 months, obliteration was achieved in 87 and 83%, respectively (NS). There was a trend toward higher rebleeding in the STD group compared with the MOR group (81% vs. 51%) (p = 0.078), but there was no significant difference between the STD and MOR patients with regard to transfusion requirements (8.4 units/patient vs. 8.7 units/patient), ulceration (53% vs. 40%), or stricture formation (9.5% vs. 0.0%). The results of this study suggest that STD and MOR are clinically equivalent sclerosing solutions, and that bias favoring use of one agent over the other may be unfounded.

Squamous cell carcinoma after endoscopic injection sclerotherapy for esophageal varices.

We report two cases of squamous cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. The interval between sclerotherapy and the development of carcinoma was 24 months in case 1 and 21 months in case 2. The sclerosant was 5% sodium morrhuate in case 1 (total dose, 10 ml) and 5% ethanolamine oleate in case 2 (45.5 ml). Although no recurrent variceal bleeding occurred after sclerotherapy, we could not perform any curative surgical treatment for esophageal cancer because of the advanced stage of the cancer and the severity of the accompanying liver dysfunction. It is difficult to determine the relationship between sclerotherapy and carcinoma; however, long-term surveillance is essential to avoid overlooking a neoplasm in the esophagus after endoscopic injection sclerotherapy.

Scintigraphic detection of pulmonary embolization of esophageal variceal sclerosant.

Intravariceal injection of a sodium morrhuate sclerosant solution, an effective therapy for bleeding esophageal varices, is complicated occasionally by fever and pneumonia. To determine if embolization of sclerosant to or through the pulmonary circulation occurs, chest scintigrams were performed following intravariceal injection of 1-3 mCi 99m-Tc-MAA mixed with 5-20cc of sclerosant in 18 patients undergoing a total of 25 sclerotherapy sessions. Sclerosant embolization was documented in 15/25 procedures (60%). Tracer localization in esophageal veins cephalad to the injection site (gastroesophageal junction) occurred in 2 studies. Atelactasis, effusion, or infiltrate on chest x-ray occurred after 6/25 procedures. Post-sclerosis fever (greater than 99.5 degrees F) occurred in 5/15 (33%) with embolization and in 1/10 (10%) without. However, neither x-ray abnormalities nor fever were positively correlated with sclerosant embolization. We conclude that embolization of sclerosant to the pulmonary arterial circulation occurs frequently. Chest radiographs may be negative despite significant embolization. We conclude that embolization of sclerosant to the pulmonary arterial circulation occurs frequently. Chest radiographs may be negative despite significant embolization.

Development of squamous cell carcinoma of the esophagus after endoscopic variceal sclerotherapy.

We describe the case of a 45-yr-old white male with portal hypertension and presumed Laennec's cirrhosis who developed squamous cell carcinoma of the esophagus 8 months after completion of a course of endoscopic variceal sclerotherapy. The epidemiology and natural history of esophageal cancer and their relationship to our patient are analyzed. This report emphasizes that squamous cell carcinoma of the esophagus should be considered in the differential diagnosis of postsclerotherapy dysphagia. Further studies will be required to determine whether or not esophageal variceal sclerotherapy is associated coincidently or causally with the development of squamous cell carcinoma of the esophagus in patients at increased risk for this condition.

Bilateral perinephric abscesses: a complication of endoscopic injection sclerotherapy.

Ten years after right hepatic lobectomy for primary hepatocellular cancer, a 45-yr-old black woman presented with bleeding esophageal varices. After five endoscopic injection sclerotherapy procedures using sodium morrhuate, she developed fever and elevated white blood count. Reendoscopy, chest x-ray, and upper gastrointestinal contrast x-rays showed no local complication. Urine analysis was normal, but CT scans, renal sonograms, and white blood cell radionuclide scan demonstrated bilateral perinephric abscesses. Percutaneous abscess drainage grew Streptococcus pneumoniae, normally found in the nasopharyngeal flora, which was probably a result of hematogenous spread. The perinephric abscesses were successfully treated with percutaneous drainage and antibiotics. Renal infection should be considered as a possible locus of distant blood-borne infection in patients who develop fever after endoscopic injection sclerotherapy.

Sodium morrhuate delivery to the lung during endoscopic variceal sclerotherapy.

We determined quantitatively the amount of sodium morrhuate that reaches the pulmonary vascular bed during endoscopic variceal sclerotherapy to ascertain whether this affects the diffusing capacity of the lung to carbon monoxide (DLCO). Eleven patients had measurements of DLCO and specific diffusing capacity (DLCO/VA) before and after sclerotherapy. In ten of these patients sclerotherapy was done using sodium morrhuate mixed with 99mTc-labeled albumin microspheres followed by quantitative radionuclide scanning. Most of the sodium morrhuate, 80 +/- 18% (SD) of the total dose, remained in the region of the esophagus. Only 20% of the injected dose reached the pulmonary circulation. There were no changes in DLCO or DLCO/VA. We conclude that most of the sclerosing solution injected during endoscopic variceal sclerotherapy remains at the site of injection. As a result, the pulmonary endothelium is exposed to small amounts of sodium morrhuate and no change in diffusing capacity occurs.

Chronic esophageal ulceration after endoscopic sclerotherapy.

Ulceration at the site of injection is a common sequel of endoscopic sclerotherapy. Most postsclerotherapy ulcers heal spontaneously, usually within 3 weeks. We report a patient who developed a large esophageal ulcer after sclerotherapy, which did not heal despite 2 years of aggressive medical therapy. He bled twice from the ulcer. This is the first report in which such an ulcer has been followed sequentially for 2 years and has remained unhealed.

Sodium morrhuate stimulates granulocytes and damages erythrocytes and endothelial cells: probable mechanism of an adverse reaction during sclerotherapy.

Stimulated by a patient with dyspnea, thrombocytopenia, and leukopenia after sodium morrhuate sclerotherapy, we studied the effect of this agent on the plasma coagulation and complement systems, the formed elements of the blood, and cultured human endothelial cells. The addition of sodium morrhuate to citrated plasma did not cause clotting or shorten the prothrombin time or partial thromboplastin time. Incubation of a 1:100 dilution of the clinical sodium morrhuate preparation in heparinized plasma led to a modest rise in [C3a]. The addition of the drug (dilutions 1:50 to 1:300) to granulocytes caused prompt aggregation (and, at the higher concentrations, granulocyte cytotoxicity [trypan blue exclusion; lactate dehydrogenase release]), but the same dilutions failed to aggregate platelets. However, 0.05% morrhuate added to washed red blood cells caused a prompt 84.0% (+/- 0.8% SEM) hemolysis, rendering the supernatant buffer a potent platelet aggregant. Not only was this sclerosing agent toxic to granulocytes and red cells, but a 1:1000 dilution of the drug also caused the destruction of 35.5% (+/- 6.6%) of cultured endothelial cells as measured by chromium 51 release. Three other agents in current use (ethanolamine oleate, sodium tetradecyl sulfate, and polidocanol) were studied and found to cause effects qualitatively similar to those of sodium morrhuate. We conclude that these drugs cause phlebosclerosis not primarily through induction of plasma coagulation, but by directly damaging endothelium and red cells, triggering platelets, and aggregating granulocytes at the venous wall endothelium. These effects likely derive from the surfactant properties of sodium morrhuate as well as its high arachidonate content.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of endoscopic variceal sclerotherapy on gas exchange and hemodynamics in humans.

Adult respiratory distress syndrome has been reported after endoscopic variceal sclerotherapy with sodium morrhuate. It has been proposed that sclerosant entering the pulmonary circulation during intravariceal injections may cause pulmonary hypertension and capillary injury. The purpose of this study was to determine whether variceal sclerotherapy with sodium morrhuate causes capillary injury or pulmonary edema in humans. We studied the effect of sclerotherapy on gas exchange and pulmonary and systemic hemodynamics in 8 patients who required endoscopic variceal sclerotherapy for treatment of variceal hemorrhage. The pulmonary vascular resistance index increased from 246 +/- 67 dyn X s X cm-5/m2 (mean +/- SEM) at baseline to a high of 303 +/- 85 dyn X s X cm-5/m2 60 min after sclerotherapy (normal range 250-500 dyn X s X cm-5/m2). Pulmonary artery pressure remained stable while cardiac index decreased by 12% over the same period. There were also small increases in systemic vascular resistance index and systemic arterial pressure after sclerotherapy. Although there was no change in arterial oxygen tension, the alveolar-arterial oxygen difference improved after sclerotherapy. These results indicate that variceal sclerotherapy with sodium morrhuate is associated with clinically insignificant changes in pulmonary and systemic hemodynamics. We did not detect evidence of acute lung injury after sclerotherapy.