Photodynamic therapy of esophageal varices: experimental studies in animal veins, and first clinical cases

BACKGROUND AND STUDY AIMS: Endoscopic injection sclerotherapy and endoscopic variceal ligation have been found to have shortcomings in the treatment of esophageal varices. In this study the effectiveness of photodynamic therapy (PDT) in the obliteration of veins was investigated to evaluate its potential in the treatment of esophageal varices. METHODS: Auricular margin veins of rabbits were irradiated by copper vapor laser after intravenous injection of 10 mg/kg of hematoporphyrin monomethyl ether (which is a hematoporphyrin derivative) into the rabbits. Control groups included rabbits that received irradiation only, that received injection of photosensitizer only, and that received injection sclerotherapy (using sodium morrhuate). The treated areas were observed macroscopically and also identified using with ultrasonic miniprobe. Biopsies were performed and the specimens were examined microscopically after hematoxylin-eosin staining and Victoria blue staining. In addition, two patients with newly visible veins within the esophageal wall after endoscopic injection sclerotherapy underwent PDT. Intravenous injection of 5 mg/kg of hematoporphyrin monomethyl ether was given, and the newly visible veins were endoscopically irradiated by copper vapor laser. Endoscopic re-examination was performed 1 month later to evaluate the therapeutic effect. RESULTS: Thrombi of the auricular margin vein were formed and blood flow was obstructed after PDT. Thrombus formation and diffused necrosis of adjacent tissue was found after injection of sodium morrhuate. On ultrasonic examination, the lumina of the veins showed a slightly higher echo after PDT compared with a lower echo before treatment, which was another sign of thrombus formation. The rabbit ears showed a diffused low echo after injection of sodium morrhuate, indicating diffuse necrosis. On microscopic observation, destruction of the endothelium and formation of thrombus was seen after PDT. Further observation of specimens stained with Victoria blue showed that the layer of elastic fiber was intact. After injection of sodium morrhuate, extensive necrosis of tissue was seen microscopically. No macroscopic, ultrasonic, or microscopic change was found in the rabbits that received irradiation only or injection of photosensitizer only. The rate of thrombus formation in rabbits that received PDT was significantly higher than that in the rabbits that received irradiation only or injection of photosensitizor only ( P = 0.015, P = 0.015), and comparable to that in the rabbits that received sclerotherapy ( P = 0.467). In the clinical study, at endoscopy 1 month after PDT both the number and the "red sign" of newly visible veins were found to have decreased. No adverse effect was found. CONCLUSION: PDT can destroy the endothelium of the vein, result in thrombus formation, and eventually obliterate the vein. It is potentially a new method for the treatment of esophageal varices.     

Endoscopic findings of bleeding esophageal varices and experimental study

It has been considered that the rupture of esophageal varices occurs with high incidences, and once bleeding occurs it sometimes cause fetal massive bleeding. However, from our experiences with the active application of emergency endoscopy, the incidence of bleeding from varix was unexpectedly low. From these results, we studied the rupture signs of esophageal varices in experiments on dogs and clinical cases. The actual rupture signs of varices were summarized as active bleeding, adhesion of fresh clot, mucosal protrusion in a conical shape and white discoloration of its top area and mucosal slight elevation and attachment of fibrin thrombi. Further studies, however, are required to determine whether there are any varicose bleedings which do not show the above rupture signs.     

ESVD联合EIS治疗食管-胃连通型静脉曲张的安全性及可行性分析

目的 探讨内镜下贲门胃底静脉曲张精准断流术(ESVD)联合内镜下食管静脉曲张硬化剂注射治疗术(EIS)在食管-胃连通型静脉曲张治疗中的临床疗效及安全性.方法 选择该院肝硬化合并食管-胃连通型静脉曲张破裂出血的患者260例,根据不同治疗方法分为3组:食管静脉曲张套扎治疗组(EVL组)、EIS治疗组(EIS组)及ESVD联...     

食管静脉曲张硬化治疗的临床意义

目的　评价应用硬化剂治疗食管静脉曲张破裂出血的临床效果及安全性。方法　 114例门脉高压并发食管静脉曲张患者 ,非随机施行三种治疗方法 ,其中 78例为经内镜注射硬化剂治疗组。该组中 46例活动性出血行急诊治疗 ,32例行预防出血治疗。结果　急诊止血者 44例出血终止。 78例患者随访 1～ 5年 ,再发生曲张静脉破裂出血率为 7 7% ,曲张静脉消失率 83%。结论　内镜下注射硬化剂治疗食管静脉曲张破裂出血方法简单、安全、可靠     

心腔内超声成像适用切面的实验研究

目的通过动物实验探讨心腔内超声的适用切面。方法应用AcuNav心腔内超声探头对9只实验犬进行心脏成像检查。结果探头分别在右房、房室环、右室内3个节段,以不同角度成像,可以完成对整个心脏的扫查获得相应心内结构。结论心腔内超声可以从多角度高质量成像,且成像安全,有着重要的应用前景。     

肝、脾硬度预测食管胃底静脉曲张及出血风险

目的 探讨肝脏、脾脏硬度诊断乙型肝炎（简称乙肝）肝硬化患者食管胃底静脉曲张（EGV）和评估静脉曲张破裂出血风险的价值。方法 对71例确诊为乙肝肝硬化患者行胃镜、声脉冲辐射力弹性成像（ARFI）等相关检查,对EGV程度分级并测定患者的肝、脾脏剪切波速度（SWV）,绘制ROC曲线,比较其诊断EGV和评估静脉破裂出血高风险的价值。结果 有EGV乙肝肝硬化患者的肝脏SWV（LSWV）和脾脏SWV（SSWV）均高于无EGV乙肝肝硬化患者（P均<0.001）;以胃镜结果为金标准,LSWV、SSWV诊断EGV的ROC曲线下面积（AUC）分别为0.877和0.910（P均<0.001）,最佳界值点分别为2.01 m/s和2.84 m/s,敏感度为93.5%和76.1%,特异度为76.0%和92.0%;其预测静脉曲张破裂出血高风险的AUC分别为0.882和0.914（P均<0.001）,最佳界值点分别是2.27 m/s和2.94 m/s,敏感度为77.1%和85.7%,特异度为83.3%和91.7%。结论 肝脏、脾脏硬度有助于诊断乙肝肝硬化患者EGV以及预测静脉曲张破裂出血风险。     

Interposition mesocaval shunt for bleeding esophageal varices: clinical, hemodynamic, and metabolic changes.

Twenty-three patients bleeding from varices had mesocaval H-grafts using Dacron prosthetic material. There were 21 men and two women with ages ranging from 37 to 60 years. There were 11 elective and 12 emergency procedures. Five patients (17%) were classified as Child's class A, seven (34%) as class B, and 11 (49%) as class C. An operative mortality of 17% was noted in the entire group, with one late death due to hepatic failure. All deaths occurred in emergency cases belonging to class C. Technical difficulties were encountered more often in the hands of less experienced surgeons. A high rate of shunt patency and minimal problems with postoperative encephalopathy were noted despite abnormal results of ammonia tolerance tests postoperatively. Lack of hepatopedal flow was noted postoperatively compared with preoperative angiograms. There were no serious adverse effects from diversion of blood from the liver in our surviving patients. The interposition mesocaval shunt is a technically safe and easy procedure in the hands of experienced surgeons. We continue to recommend the mesocaval shunt until other methods prove better than this operation.     

Relationship of radionuclide liquid bolus transport and esophageal manometry

Using simultaneous esophageal manometry and radionuclide transit studies, we compared liquid bolus transport with the various parameters of esophageal contractions. Study subjects included seven normal individuals, six patients with the "nutcracker esophagus" (mean distal peristaltic amplitude greater than 180 mm Hg), and three patients with spastic motility disorders. Manometric studies were performed when the subjects were in the basal state and after intravenous administration of edrophonium and atropine. Simultaneous radionuclide studies were done with subjects in the supine position by swallows of 250 mu Ci technetium Tc 99m sulfur colloid in 10 ml water. We found that normal liquid bolus transport (less than 15 seconds) is primarily dependent on the presence of a peristaltic wave front throughout the esophagus. Above a threshold pressure of 30 mm Hg, liquid transport was not affected by amplitude (33 to 500 mm Hg) or duration (3 to 15 seconds) of esophageal contractions. Repetitive wave forms also gave normal transit times as long as the wave front was peristaltic in onset. There was a significant inverse correlation (-0.65; P less than 0.001) between liquid transit time and peristaltic velocity. Prolonged radionuclide transport (30 to less than 50 seconds) was observed only with nonperistaltic contractions and very low amplitude (15 to 30 mm Hg) peristaltic waves.     

食管静脉曲张硬化术的护理

食管静脉曲张破裂出血是肝硬化门脉高压症的严重并发症，直接威胁病人的生命，当前首选也是主要的预防和治疗方法就是食管静脉曲张硬化术（EVS）．我们对23例病人共进行EVS治疗60余次，体会到硬化前有针对性地做好心理护理及术前准备，术中密切配合、严密观察病情变化，硬化后采取有效的护理预防措施，是食管静脉曲张硬化术成功和病人康复的重要保证。