Outcome of injection sclerotherapy using absolute alcohol in patients with cirrhosis, non-cirrhotic portal fibrosis, and extrahepatic portal venous obstruction

Complications of alcohol injections for Morton’s neuroma

Introduction

Morton’s neuroma (MN) is a neuropathic metatarsalgia that causes pain in the plantar aspect of the forefoot generally between the third and fourth metatarsal heads. Treatment can be nonoperative or surgical. Among nonoperative procedures, alcohol injections are still commonly used as considered simple, relatively safe and well-tolerated treatment. However, they present transient and minor complications.

Methods

Two hundred patients with a diagnosis of MN underwent ultrasound-guided injections with a 47.5% alcohol solution between 2013 and 2020. We reviewed the current literature to highlight the known complications of this treatment, comparing them to the complications developed by our patients.

Results

Three patients out of 200 patients, developed necrosis of skin and subcutaneous tissue not described in previous studies about MN.

Conclusions

Our study focuses attention on the complications subsequent to the alcohol injection therapy for MN. Patients and surgeons should be aware that in a small number of cases this therapy can be burdened by necrotic complications of the skin.

Effects of alcohol injection in rat sciatic nerve as a model for Morton's neuroma treatment

BACKGROUND

Previous studies have shown that the injection of dehydrated alcohol has been successful for the treatment of Morton's neuroma in the foot. In this study, we determined the cellular effect of injection of alcohol into and around the sciatic nerve of rats and measured the extent of cell necrosis and/or any associated histologic or inflammatory changes.

METHODS

Twenty-two male (~375 g) Wistar rats were randomized into 2 groups each receiving alcohol injections into or around the sciatic nerve after nerve exposure under sterile technique. Group 1 rats were injected with a 0.5 ml solution of 0.5% Marcaine in the left sciatic nerve as a control group. In the right sciatic nerve a 0.5 ml solution of 4% ethanol with 0.5% Marcaine was injected. Group 2 rats received 0.5 ml of 20% ethanol with 0.5% Marcaine injected into the left sciatic nerve and 0.5 ml of 30% ethanol with 0.5% Marcaine injected into the right sciatic nerve. In each group, the rats were placed in 3 subgroups: intraneural, perineural, perimuscular injections. All rats were sacrificed and tissue harvested for histologic evaluation at day 10 post injection.

RESULTS

No evidence of alcohol-associated cell necrosis, apoptosis, or apparent inflammation was observed in histologic specimens of any injected nerves, perineural tissue, or muscles in controls or experimental groups regardless of concentration of ethanol injected on day 10.

CONCLUSION

We concluded that alcohol injection (≤30% ethanol) into and/or around the sciatic nerve or the adjacent muscle of rats has no histologic evidence of necrosis or inflammation to the nerve or surrounding tissue. There was no observable histological change in apoptosis, or cell number, in response to the alcohol injection.

CLINICAL RELEVANCE

The lack of any measureable changes in nerve or adjacent muscle histology with ethanol injection into the rat sciatic nerve (and surrounding tissues) raises questions about the efficacy of using ethanol injections in the treatment of Morton's neuroma in human clinical practice.

Historical overview and review of current day treatment in the management of acute variceal haemorrhage

Variceal haemorrhage is one of the most devastating consequences of portal hypertension, with a 1-year mortality of 40%. With the passage of time, acute management strategies have developed with improved survival. The major historical treatment landmarks in the management of variceal haemorrhage can be divided into surgical, medical, endoscopic and radiological breakthroughs. We sought to provide a historical overview of the management of variceal haemorrhage and how treatment modalities over time have impacted on clinical outcomes. A PubMed search of the following terms: portal hypertension, variceal haemorrhage, gastric varices, oesophageal varices, transjugular intrahepatic portosystemic shunt was performed. To complement this, Google™ was searched with the aforementioned terms. Other relevant references were identified after review of the reference lists of articles. The review of therapeutic advances was conducted divided into pre-1970s, 1970/80s, 1990s, 2000-2010 and post-2010. Also, a summary and review on the pathophysiology of portal hypertension and clinical outcomes in variceal haemorrhage was performed. Aided by the development of endoscopic therapies, medication and improved radiological interventions; the management of variceal haemorrhage has changed over recent decades with improved survival from an often-terminating event in recent past.

Surgical and endovascular treatment of severe complications secondary to noncirrhotic portal hypertension: experience of 56 cases

BACKGROUND

Major complications of noncirrhotic portal hypertension (NCPH) include bleeding esophagogastric varices, hypersplenism, ascites, and bowel ischemia under acute circumstances. The aim of this article is to determine the outcomes of surgical and endovascular treatments for severe complications from NCPH.

METHODS

From January 2000 to June 2011, 56 patients with symptomatic NCPH underwent open surgery or endovascular thrombolysis. The medical records were retrospectively reviewed. Of the 56 patients, there were 39 males and 17 females. The mean age was 21 years, ranging from 2 to 54 years. Forty-one of them were diagnosed to have prehepatic portal vein obstruction (PHPVO), 9 had Budd-Chiari syndrome (BCS), and 6 had noncirrhotic portal fibrosis (NCPF). All patients were symptomatic from 5 days to 14 years (mean 25 months). Portosystemic shunt (PSS) was primarily performed in 49 patients. Shunts were as follows: 35 mesocaval; 7 splenorenal; 4 portocaval; 2 paraumbilical-jugular; and 1 portal to right atrial. Esophagogastric devascularization was performed in 3 patients, but was converted to mesocaval shunt later in 2. The remaining 4 patients with acute superior mesenteric vein (SMV) and portal vein thrombosis were treated with endovascular catheter-directed thrombolysis. Warfarin was prescribed to all the patients for at least 6 months. Mean follow-up was 57 months, ranging from 2 to 125 months. The outcomes, focusing on 30-day mortality, recurrent bleeding, and hypersplenism, were recorded.

RESULTS

In the 49 patients undergoing primary PSS, the shunts remained patent and there was no recurrent variceal bleeding during the follow-up. All 3 patients with esophagogastric devascularization had recurrent variceal bleeding at 8, 13, and 24 months postoperatively. Two of them were converted to mesocaval shunt, and 1 died before redo operation. Thrombolysis in all 4 patients with acute SMV and portal thrombosis was technically successful. Three of the 4 survived without complications and 1 died from small bowel infarction due to recurrent thrombosis 40 days later. In the 47 patients with hypersplenism, mean platelet counts increased from 43×10(9)/L to 239×10(9)/L 2 weeks after surgery. Ascites in 30 of the 31 patients disappeared within 2 months after PSS. There was no postoperative encephalopathy, and perioperative 30-day mortality was 0%.

CONCLUSIONS

PSS can be employed to treat bleeding esophagogastric varices and severe hypersplenism secondary to NCPH. Post-PSS encephalopathy is less of a concern in NCPH patients with normal liver function. Endovascular catheter-directed thrombolysis via superior mesenteric artery is a useful alternative treatment for acute portal and/or mesenteric venous thrombosis.

Noncirrhotic portal hypertension

Portal hypertension is characterized by an increase in portal pressure (> 10 mmHg) and could be a result of cirrhosis of the liver or of noncirrhotic diseases. When portal hypertension occurs in the absence of liver cirrhosis, noncirrhotic portal hypertension (NCPH) must be considered. The prognosis of this disease is much better than that of cirrhosis. Noncirrhotic diseases are the common cause of portal hypertension in developing countries, especially in Asia. NCPH is a heterogeneous group of diseases that is due to intrahepatic or extrahepatic etiologies. In general, the lesions in NCPH are vascular in nature and can be classified based on the site of resistance to blood flow. In most cases, these disorders can be explained by endothelial cell lesions, intimal thickening, thrombotic obliterations, or scarring of the intrahepatic portal or hepatic venous circulation. Many different conditions can determine NCPH through the association of these various lesions in various degrees. Many clinical manifestations of NCPH result from the secondary effects of portal hypertension. Patients with NCPH present with upper gastrointestinal bleeding, splenomegaly, ascites after gastrointestinal bleeding, features of hypersplenism, growth retardation, and jaundice due to portal hypertensive biliopathy. Other sequelae include hyperdynamic circulation, pulmonary complications, and other effects of portosystemic collateral circulation like portosystemic encephalopathy. At present, pharmacologic and endoscopic treatments are the treatments of choice for portal hypertension. The therapy of all disorders causing NCPH involves the reduction of portal pressure by pharmacotherapy or portosystemic shunting, apart from prevention and treatment of complications of portal hypertension.

Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment

The Asian Pacific Association for the Study of the Liver (APASL) Working Party on Portal Hypertension has developed consensus guidelines on the disease profile, diagnosis, and management of noncirrhotic portal fibrosis and idiopathic portal hypertension. The consensus statements, prepared and deliberated at length by the experts in this field, were presented at the annual meeting of the APASL at Kyoto in March 2007. This article includes the statements approved by the APASL along with brief backgrounds of various aspects of the disease.

Noncirrhotic portal hypertension

Portal hypertension is characterized by an increase in portal pressure (>10 mm Hg) and could be a result of cirrhosis of the liver or noncirrhotic diseases. Noncirrhotic portal hypertension (NCPH), as it generally is termed, is a heterogeneous group of diseases that is due to intrahepatic or extrahepatic etiologies. In general, the lesions in NCPH are vascular in nature and can be classified based on the site of resistance to blood flow. Noncirrhotic portal fibrosis and extrahepatic portal vein obstruction are two diseases that are common in developing countries; they most often present only with features of portal hypertension and not of parenchymal dysfunction. These are described in detail.

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Non-cirrhotic portal fibrosis

Non-cirrhotic portal hypertension (NCPH) comprises of diseases having an increase in portal pressure (PP) due to intraheptic or prehepatic lesions, in the absence of cirrhosis. The lesions are generally vascular, either in the portal vein, its branches or in the perisinusoidal area. Because the wedged hepatic venous pressure (WHVP) is near normal, measurement of intravariceal or intrasplenic pressure is needed to assess portal pressure. The majority of the diseases included in the category of NCPH are well characterized disease entities where portal hypertension (PHT) is a late manifestation and hence, these are not discussed. Two diseases which present only with features of PHT and are common in developing countries are NCPF and extra-hepatic portal vein obstruction (EHPVO). Non-cirrhotic portal fibrosis is a syndrome of obscure etiology, characterized by 'Obliterative portovenopathy' leading to PHT, massive splenomegaly, repeated well tolerated episodes of variceal bleeding and anemia in young adults from low socio-economic strata of life. The hepatic parenchymal functions are nearly normal. Jaundice, ascites and hepatic encephalopathy are rare. Management of variceal bleeding remains the main concern as nearly 85% of patients with NCPF present with variceal bleeding. Endoscopic variceal ligation or sclerotherapy are equally effective in about 90-95% of the patients. Gastric varices are seen in about 25% patients and a bleed from them can be managed with cyanoacrylate glue injection or surgery. Other indications for surgery include failure of endoscopic therapy to control acute bleed and symptomatic hypersplenism. The prognosis of patients with NCPF is good and 5-years survival rates in patients in whom variceal bleeding can be controlled is about > 95%.

Non-cirrhotic portal fibrosis: current concepts and management

Non-cirrhotic portal hypertension (NCPH) comprises diseases having an increase in portal pressure (PP) due to intraheptic or prehepatic lesions, in the absence of cirrhosis. The lesions are generally vascular, either in the portal vein, its branches or in the perisinusoidal area. Because the wedged hepatic venous pressure is near normal, measurement of intravariceal or intrasplenic pressure is needed to assess PP. The majority of diseases included in the category of NCPH are well-characterized disease entities where portal hypertension (PHT) is a late manifestation and, hence, these are not discussed. Two diseases that present only with features of PHT and are common in developing countries are non-cirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO). Non-cirrhotic portal fibrosis is a syndrome of obscure etiology, characterized by 'obliterative portovenopathy' leading to PHT, massive splenomegaly and well-tolerated episodes of variceal bleeding in young adults from low socioeconomic backgrounds, having near normal hepatic functions. In some parts of the world, NCPF is called idiopathic portal hypertension (IPH) or 'hepatoportal sclerosis'. Because 85-95% of patients with NCPF and EHPVO present with variceal bleeding, treatment involves management with endoscopic sclerotherapy (EST) or variceal ligation (EVL). These therapies are effective in approximately 90-95% of patients. Gastric varices are another common cause of upper gastrointestinal bleeding in these patients and these can be managed with cyanoacrylate glue injection or surgery. Other indications for surgery include failure of EST/EVL, and symptomatic hypersplenism. The prognosis of patients with NCPF is good and 5 years survival in patients in whom variceal bleeding can be controlled has been reported to be approximately 95-100%.

Sclerotherapy in noncirrhotic portal fibrosis

Endoscopic sclerotherapy has emerged as an effective and safe mode of treatment for long-term management of esophageal varices due to cirrhosis of liver and extrahepatic portal venous obstruction. There are few studies that have evaluated the role of sclerotherapy in the management of esophageal varices in patients with noncirrhotic portal fibrosis (NCPF). We report our results of long-term sclerotherapy in patients with NCPF. Seventy-two consecutive patients (men 29, women 43; age 32.9 +/- 11.8 years) with recurrent variceal bleeding due to NCPF were entered into the sclerotherapy program. Forty-eight patients received intravariceal absolute alcohol and 24 patients received intravariceal sodium tetradecyl sulfate (STD). Variceal obliteration was achieved in 65 (90.3%) patients with a mean of 5.7 +/- 3.0 (range 1-14) sessions. These patients were followed-up for a mean of 21.4 +/- 20.4 (range 1-96) months. Thirteen (17.3%) patients had episodes of upper gastrointestinal bleeding during sclerotherapy. Rebleed after obliteration was seen in 6 (9.2%) patients. Sclerotherapy was associated with a significant reduction in bleeding rate (bleeds per month per patient) during sclerotherapy and after obliteration of varices as compared to presclerotherapy period (P < 0.000001 for both). Recurrence of esophageal varices after obliteration was seen in 9 (13.9%) patients with reobliteration of varices in five patients in whom sclerotherapy was attempted. Complications including esophageal ulcer and stricture formation were seen in 18 (25%) and 4 (5.6%) patients respectively; strictures were restricted to patients who received absolute alcohol. Two (2.77%) patients died of massive upper gastrointestinal bleed during follow-up. We conclude that sclerotherapy is an effective and safe modality in the prevention of variceal bleeds in patients with NCPF.