Roberto N. Gonzales Jr, MD

Dr. Edgardo Penserga

Dr. Reynaldo Joson

Department of Surgery

Ospital ng Maynila Medical Center

Reprint requests:  Roberto N. Gonzales Jr. MD, Department of Surgery, Ospital ng Maynila Medical Center, Quirino Ave, Malate, Manila, Philippines

Email: ommcsurgery@yahoogroups.com

Sclerotherapy with Povidone Iodine of Ganglion Cyst

Abstract

BACKGROUND:  aspiration and drainage of Ganglion cyst using a needle/syringe to reduce the size and injection of sclerosant (povidone Iodine) to reduce the amount of fluid being produced. OBJECTIVE: To assess the efficacy of sclerotherapy with povidone-Iodine in the management of ganglion cyst. MATERIALS AND METHODS: Thirty nine patients underwent aspiration of ganglion cyst. Twenty three patients subsequently underwent sclerotherapy with povidone-iodine, the success rate of the proposed procedure was prospectively determined. RESULTS: Twenty three patients underwent sclerotherapy with povidone-Iodine; Seventeen patients (74%) had complete resolution of the cyst without recurrence. CONCLUSION: sclerotherapy with povidone-iodine after aspiration of ganglion cyst represents a less invasive and very promising alternative to surgical excision, showing the following advantages: Comparable success rate, no local anesthesia required, lesser  postoperative complications and  a superior cosmetic result. The method was highly accepted by all patients treated.

Key words: Sclerotherapy with Povidone Iodine of Ganglion Cyst

INTRODUCTION

A ganglion cyst is an example of synovial cyst that is formed as a consequence of the imbalance imparted in the normal homeostasis of synovial fluid secretion and reabsorption. It is the most common soft tissue tumors of the hand and wrist. They can occur in patients of any age, including children.Their contents are characterized as clear and highly viscous mucin that consists of hyaluronic acid, albumin, globulin, and glucosamine. Surgical treatment of a ganglion cyst is commonly performed but excision is associated with high recurrence rates. Some authors have reported alternative, less invasive treatment regimens such as aspiration.

Our current practice here at OMMC Department of surgery with regards to the management of Ganglion Cyst is aspiration of the cyst. However, the efficacy, success rate and other long term outcomes of the said procedures have not been evaluated until present. Some authors suggest injection of sclerosant  to reduce the amount of fluid being produced. Yet all clinical trials presented were all done abroad.

To date, however, there are no prospective clinical trial done in our setting to support this suggestion.

Key words: Sclerotherapy with Povidone Iodine of Ganglion Cyst

MATERIALS AND METHODS

All patients diagnosed with ganglion cyst involving the hands and wrists regardless of age and gender from January 1, 2007 up to August 31, 2007 will be included in the study. Patients who already underwent aspiration of the cyst at the time of initial consult and had recurrence were included in the study.
Patients will be informed of the ongoing study. Informed consent will be obtained. A prescribed operative technique will be made available. Under aseptic conditions, the ganglia were aspirated using #18 hypodermic needle. A mixture of 2 cc of 0.2% povidone-iodine and 1 cc 1% lidocaine (sclerosant)  will be  injected into the empty cavity (amount to be injected is determined by the amount aspirated) and a compression dressing  is applied for 24-48 hours. Mefenamic acid 500mg tab PRN was given for pain.

Follow-up

All patients were treated on an outpatient’s basis. Patients will be asked to come back for follow up after 1 week, 2 weeks, 1 month and 3 months. Patient’s phone no. will be taken to assure follow up. Recurrence will be assessed by physical examination. Re-appearance of lump will mean recurrence. Absence of lump  up to the period of 3 months after the procedure will mean no recurrence.

Key words: Sclerotherapy with Povidone Iodine of Ganglion Cyst

Definition of Terms

1. Ganglion cyst -  an example of synovial cyst that is formed as a consequence of the imbalance imparted in the normal homeostasis of synovial fluid secretion and reabsorption.

Synonyms: Tendon cyst, synovial cyst

2. Sclerotherapy- is the injection of a chemical irritant (sclerosing agent) into the cyst  to produce inflammation, a proliferation of connective tissue (i.e., fibrosis), and eventual obliteration of the lumen of the cyst.
3. Sclerosant - (sclerosing agent) a chemical irritant.
4. Recurrence - Re-appearance of lump, absence of lump  up to the period of 3 months after the procedure will mean no recurrence.

RESULTS

The study group consisted of 39 patients (age range, 18–59 years; median age, 38 years). (Table 1).

Thirty five patients  (89.7%) had recurrence and only four patient (10.3%) had resolution of the cyst  (Table 2)after aspiration. 

 Out of thirty five (35)  patients with recurrence, Twenty three (23) (66%) underwent sclerotherapy and twelve (12) (34%) underwent excision of cyst. (Table 3)

Out of 23(66%) patients who underwent sclerotherapy , only six (26%) had recurrence and a total of seventeen (74%)  had complete resolution of the cyst. (Table 4)

These reflect an overall success rate of the suggested procedure of (74%).

Common complications noted were (1) local erythema which were observed in eighteen out of twenty three patients, (2) recurrence which were observed in six out of twenty three patients.  No single patient involved in the study developed local abscess formation. (Table 5)

DISCUSSION

We have approximately 8-10 cases of Ganglion cyst per month (OMMC OPD census); these patients underwent aspiration of cyst as the initial procedure. Excision of the entire cyst is being offered for those patient who had recurrence and refused to undergo another aspiration procedure.  According to review of available literatures and current studies, aspiration of ganglion cyst has a recurrence rate of as high as 86%.  Excision of the entire cyst , on the other hand, had a recurrence rate of as high as 62%.

In one study done abroad a promising 3% recurrence rate was reported using aspiration with sclerotherapy (hypertonic saline as sclerosant) in the treatment of ganglion cyst.

A ganglion cyst is an example of synovial cyst that is formed as a consequence of the imbalance imparted in the normal homeostasis of synovial fluid secretion and reabsorption.

Sclerotherapy imparts local inflammatory reactions on the cyst capsule forming fibrosis and thereby obliteration of the cavities.

In conclusion, sclerotherapy with povidone-iodine after aspiration of ganglion cyst represents a less invasive and very promising alternative to surgical excision, showing the following advantages: Comparable success rate, no local anesthesia required, lesser postoperative complications and a superior cosmetic result. The method was highly accepted by all patients treated.

References

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Table 1. Distribution by Age and Sex

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Table 2.  Percentage Distribution of Recurrence Rate after Aspiration

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Table 3.  Percentage Distribution of Patients who underwent sclerotherapy vs excision

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Table 4. Percentage Distribution of Success Rate after sclerotherapy

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Table 5.  Distribution of complications  after sclerotherapy

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