Early and late complications of endoscopic oesophageal varices sclerotherapy

We report the complications of perendoscopic sclerotherapy observed during treatment of oesophageal varices in 104 patients and 409 sclerotherapy sessions. Complications were related to each individual session and to the aim of the treatment (therapeutic or prophylactic). Major complications occurred in 17.3% of the patients treated: 13 cases of severe bleeding and 5 of oesophageal stricture. Conservative therapy stopped haemorrhage in all but 4 patients, who died of uncontrolled bleeding (3.8%). Three oesophageal strictures recovered spontaneously, while the remaining two required endoscopic dilations. Minor complications occurred after 102/409 sessions (24.9%). Epigastric and/or retrosternal pain developed after 17.6% of the sessions, oesophageal ulcerations after 12.5%, fever after 11.7% and transient dysphagia after 3.7%. Bleeding was observed only in Child's category C patients who underwent therapeutic treatment. The risk of bleeding remained unchanged until complete eradication of varices was achieved. The incidence of minor complications did not correlate with the progression or the aim of the treatment.     

Reflux esophageal stricture--a review of 30 years' experience in children

PurposeStrictures of the esophagus in children may have multiple etiologies including congenital, inflammatory, infectious, caustic ingestion, and gastroesophageal reflux (peptic stricture [PS]). Current literature lacks good data documenting long-term outcomes in children. This makes it difficult to counsel some patients about realistic treatment expectations. The objective of this study is to evaluate our institutional experience and define the natural history and treatment outcomes.MethodsA retrospective review of clinical data obtained from children who underwent dilation for PS was performed.ResultsOver the past 30 years, 114 children and adolescents received 486 dilations. The most common indications for stricture dilation were PS (42%) and esophageal atresia (38%). Other lesser indications included congenital, foreign body, corrosive, cancer, radiation, allergic, and infectious. This review focuses on the 48 children with PS. Of the children with PS, a congenital anomaly was identified in 23 children; and 12 had neurologic impairment. Average age at presentation was 10.2 years (range, 0.5-18.3 years). Most patients had had symptoms for many months before diagnosis. Peptic stricture was most common in the lower esophagus (n = 39). However, middle (n = 8) and upper (n = 1) strictures were occasionally identified. Noncompliance with medical therapy was a challenge in 12% (n = 5) of children. Children with a PS received a median of 3 dilations, but a subset of 5 patients with severe strictures underwent up to 48 dilations (range, 1-48). Repeated dilations were required for a median of 20 months (range, 1-242 months). Among patients receiving esophageal dilation for PS, 94% required an antireflux procedure (19% required a second antireflux surgery). A subgroup of patients (n = 10) was identified who required extended dilations, multiple surgeries, and esophageal resection. This subgroup had a significantly longer period of symptomatic disease and increased risk of esophageal resection compared with those patients requiring fewer dilations. Surgical resection of the esophageal stricture was ultimately required in 3 children with PS after failure of more conservative measures.ConclusionChildren and adolescents presenting with reflux esophageal stricture (PS) frequently require antireflux surgery, redo antireflux surgery, and multiple dilations for recurrent symptoms. We hope that these data will be of use to the clinician attempting to counsel patients and parents about treatment expectations in this challenging patient population.     

Injection sclerotherapy for esophageal varices.

Thirty-five consecutive patients with bleeding esophageal varices were treated by repeated endoscopic injection sclerotherapy. During each session the varices were injected with 14 +/- 4.2 ml (mean +/- SD) of 5% ethanolamine oleate submucosally or intravariceally. The varices were obliterated in 31 (89%) patients. On average 3.3 +/- 2.4 sclerotherapy sessions were required for eradication of the varices. Mild fever was noticed almost in every patient after sclerotherapy. Mediastinitis was a complication in one (2.8%) patient. Esophageal stricture ensued in two (5.7%) patients which did not require treatment. The cumulative survival rates at 1, 2, 3, 4 and 5 years were 83%; 65%; 52%; 52% and 47% respectively. The corresponding 95% confidence intervals were (0.7, 0.96); (0.48, 0.8); (0.34, 0.7); (0.3, 0.74) and (0.22, 0.7). Sclerotherapy is an effective and safe method to treat bleeding esophageal varices.     

Transmural varices ligation and fundoplication as an emergency operation in acute esophageal varices hemorrhage]

In patients with bleeding esophageal varices the main purpose of the treatment is to stop the bleeding at a justifiable risk. The so-called blocking procedures reach this purpose most consistently. We report the results on transmural variceal ligation plus fundoplication in 16 patients in whom the bleeding esophageal varices were not stopped by conservative means. 75% of these patients belonged to group B and C in Child's classification. Postoperative lethality was 18,7%, in all cases bleeding was stopped. These results favour trasmural varices ligation as an emergency procedure in bleeding esophageal varices.     

Esophageal sclerotherapy: an effective modality in children

During the past five years, sclerotherapy has been used at our institution in 13 children for the management of recurrent major variceal bleeding. The varices were secondary to extrahepatic portal hypertension in seven patients and to intrahepatic portal hypertension in the remaining six. Sclerotherapy was performed under direct vision using either rigid or flexible endoscopic equipment, and the sclerosing agents were injected directly into the varices. The average age at initiation of sclerotherapy was 9 years (range: 1 to 19 years). The follow-up has ranged from 2 to 4 1/2 years with a mean of 3 1/2 years. Complete obliteration of all varices was obtained in eight of these patients. Two children have minimal residual varices, in one of whom 17 sclerotherapy procedures have been performed to date. One additional patient had a severe episode of bleeding during esophagoscopy, and transesophageal ligation of varices was required for control. Two patients have died following initiation of sclerotherapy. In neither case was the death the result of bleeding esophageal varices or a complication of endosclerosis. Bleeding from varices was the major clinical problem in all of these children, and this problem has been largely corrected by the sclerotherapy program. With one exception, there have been no episodes of variceal bleeding requiring transfusion in these patients following initiation of this therapy. One child developed an esophageal ulcer postinjection, but none have developed esophageal strictures. One patient developed an allergic reaction to the sclerosant that was treated during subsequent injections with prior administration of an antihistamine (diaphenhydramine chloride) and steroids.(ABSTRACT TRUNCATED AT 250 WORDS)     

Gastroesophageal reflux and sclerotherapy strictures

The development of esophageal stricture is common following endoscopic variceal sclerotherapy (EVS). Gastroesophageal reflux may be at least partly responsible. Twelve randomly selected male patients underwent chronic EVS for the management of bleeding esophageal varices. Six patients developed strictures during or after EVS, six did not. There were no significant differences between stricture and nonstricture patients during 24 hour esophageal pH monitoring. Three of the six stricture patients and four of the six nonstricture patients had an abnormal amount of reflux. Gastroesophageal reflux occurs frequently in patients undergoing EVS, and it is not likely to play a major role in EVS stricture formation.     

Hepatic vein anastomotic stricture after living donor liver transplantation

This report discusses the pathophysiology of and therapeutic methods to address hepatic vein anastomotic stricture after living donor liver transplantation (LDLT). From 1994 to 2002, our 15 LDLTs using the lateral segments or left lobes included four recipients who experienced 28 occurrences of this complication after the operation. The period between LDLT and the first stricture was 4.0 +/- 1.2 months. The age of the affected recipients (31.0 +/- 8.2 years) was significantly higher than that of the nonaffected patients (7.0 +/- 4.1 years, P < .05). Graft liver/standard liver volume ratio was 39.1% +/- 3.8% in the former and 77.9% +/- 12.7% in the latter cases (P < .05). Initial symptoms of stricture were ascites (42.9%), abdominal distention (42.9%), liver enzyme elevation (10.7%), and gastrointestinal bleeding (3.6%). In addition, 14 of 28 stricture cases (50%) showed increased blood trough levels of tacrolimus. Doppler ultrasonography was used for diagnosis, and balloon dilatations performed in all stricture patients, thereby hepatic significantly reducing venous blood pressure from 33.5 +/- 1.7 to 20.3 +/- 1.5 cmH2O. All patients finally resolved the strictures after several treatments. The stricture after LDLT was associated with small-for-size grafts, suggesting that liver regeneration may lead to anatomical changes and strictures. Since tacrolimus is metabolized by the liver, its blood trough level is one initial symptoms of stricture. Balloon dilatation was useful and safe as the treatment, while problems have been reported after stent insertion in the hepatic vein.     

A hepatologist's view of variceal bleeding

Patients with cirrhosis and esophagogastric varices have a 25% to 33% risk of initial variceal bleeding, a risk of up to 70% for recurrent variceal bleeding, and an associated mortality of up to 50%. Based on a review of prospective randomized trials, control of acute variceal bleeding should involve vasopressin plus nitroglycerin as indicated for minor bleeding episodes, sclerotherapy for more severe bleeding episodes, and staple transection of the esophagus for patients who do not respond to these initial measures. Emergency portasystemic shunt surgery cannot be recommended at this time. For prevention of recurrent variceal hemorrhage, the data support the use of nonselective beta-adrenergic blockers (propranolol or nadolol) for patients with good liver function (Child's class A and B) and the use of chronic sclerotherapy to obliterate esophageal varices for patients with decompensated cirrhosis (Child's class C). Surgical procedures should be reserved for failures of medical management. The use of beta-adrenergic blockers offers the most promise for prevention of initial variceal bleeding.     

Manometric evaluation of esophageal motility in patients submitted to prophylactic variceal sclerosis

Summary Sclerotherapy of esophageal varices is an effective hemostatic treatment and may also prevent bleeding. In our study, we examined the effects of prophylactic sclerotherapy on esophageal motility in 15 patients with Child's A cirrhosis of the liver. All the patients underwent three manometric measurements, performed respectively before the sclerotherapy, I week after the eradication of varices, and 3 months later. The results of our study show that prophylactic sclerotherapy of esophageal varices does not significantly change the resting pressure and length of the lower esophageal sphincter. Neither the amplitude nor the duration of the postswallowing esophageal peristaltic waves is significantly influenced by sclerotherapy. However, sclerotherapy produces a significant increase in tertiary contractions in the distal esophagus, which could explain the onset of dysphagia among patients in whom postsclerotherapy stricture is not evident.     

Follow-up of patients after variceal eradication. A comparison of patients with cirrhosis, noncirrhotic portal fibrosis, and extrahepatic obstruction.

One hundred one patients, 54 with cirrhosis of liver, 31 with noncirrhotic portal fibrosis (NCPF), and 16 with extrahepatic obstruction (EHO), were followed up at monthly intervals for a mean (+/- SD) period of 17.9 +/- 4.8 months after achieving total variceal eradication with endoscopic sclerotherapy. Recurrence of esophageal varices was seen in 19 (18.8%) patients, 12 with cirrhosis and seven with NCPF, within a mean (+/- SD) period of 5.7 +/- 1.6 months. No patient with EHO showed recurrence. Three (2.9%) patients rebled from the recurred varices. Mean (+/- SD) number of sclerotherapy sessions and the amount of absolute alcohol required for eradication of recurred varices were 1.6 +/- 0.8 and 3.6 +/- 1.8 ml, respectively. Dysphagia and esophageal stricture were present in 15 (14.9%) patients with nearly similar frequency in patients with cirrhosis, NCPF, and EHO. Dysphagia in four patients with stricture improved without dilatation. While there were no deaths in patients with NCPF and EHO, 11 patients with cirrhosis died. There was significant (p less than 0.01) improvement in the liver status of surviving patients with cirrhosis after variceal eradication. It can be concluded that variceal recurrence and rebleeding are not major problems after sclerotherapy. Sclerotherapy probably helps in spontaneous improvement of the liver status of surviving cirrhotics and reduces long-term morbidity and mortality of patients with NCPF and EHO.     

Esophageal motility: effects of injection sclerotherapy

The purpose of this project was to evaluate the acute and chronic effects of sclerotherapy on esophageal motility and function. We studied motility in eight patients before and after injection sclerotherapy of esophageal varices. We injected the varices with 5% sodium morrhuate twice during the first week and then at 1, 2, 3, and 6 months. Lower esophageal sphincter pressure, contraction wave amplitude, and duration were not altered by sclerotherapy. However, the length of the high-pressure zone increased significantly from 3.6 +/- 0.3 cm to 4.2 +/- 0.2 cm during the first 3 days after initial treatment, and sclerotherapy caused considerable distortion of peristaltic wave form. Also, esophageal peristaltic velocity decreased in three patients who complained of dysphagia and subsequently developed esophageal stricture. The strictures have responded well to dilatation, and in two patients velocity has even returned toward the baseline value. Reflux esophagitis has not been a problem. Esophageal motility is altered by sclerotherapy of esophageal varices. Stricture formation seems to be reversible after sclerotherapy is stopped or discontinued.     

Endoscopic dilation of gastroesophageal anastomosis stricture after gastric bypass

Background: The management of strictures after gastric bypass procedure using balloon dilation is described. Methods: A retrospective review of all dilations performed is presented. Balloon dilators were used, and all strictures were dilated initially up to 12 to 15 mm for 1 min. Results: The review included 24 patients with a mean age of 42.8 years and a mean body mass index of 49.6. All the patients except one were women. In terms of procedure, 67% required one dilation and 30% required two. In the first 3 months after surgery, 21 patients developed the stricture. Three patients (13%) had leaks. There was no endoscopic appearance suggesting the need for a repeated procedure. All the dilations were successful, and weight loss compared well with that in the rest of the patients. Conclusions: A successful technique for the treatment of anastomotic strictures after gastric bypass is presented. Most of the patients required one dilation. Most strictures appeared during the first 3 months after surgery. Female gender and leak may be high risk factors for the development of stricture.     

Gastric bleeding after endoscopic injection sclerotherapy for esophageal varices may be fatal.

Among 457 Japanese cirrhotic patients with esophageal varices, 28 (6%) bled from the upper gastrointestinal tract after the initial session of endoscopic injection sclerotherapy (EIS); 13 bled during the course of repeated EIS and 15 bled mainly from gastric lesions after eradication of the varices. Of these 28 patients, bleeding from gastritis occurred in 13 (46%), from esophageal varices in 10 (36%), from gastric varices in 4 (14%) and from gastric ulcer in one (4%). Six of 13 patients with gastritis-related bleeding and 3 of 4 patients with gastric variceal bleeding died of uncontrollable hemorrhage complicated liver failure, while 9 of 10 patients with esophageal variceal bleeding were controlled and reinjection was feasible. Ten (36%) of the 28 patients, with Child's grade B or C and severe ascites, died, mainly following bleeding from gastric lesions. This study shows that bleeding from gastric lesions after EIS can be uncontrollable and fatal in patients with poor liver function.     

Experience with 49 consecutive dacron interposition mesocaval shunts. A unified approach to portasystemic decompression procedures

In 1973, a plan was developed to manage all patients with bleeding esophageal varices who required portasystemic decompression with a Dacron interposition mesocaval shunt procedure. This paper has analyzed 7 years of such experience in 49 consecutive patients. Forty-eight were cirrhotic, 26 (53 percent) required emergency shunting, and 6 were in Child's class A, 13 were in class B and 30 were in class C. Overall, operative mortality was 11 of 49 patients (22.4 percent). Ten of the 11 deaths were of patients in class C and all but one of the patients (90.9 percent) had undergone an emergency operation. Sixteen patients had episodes of significant postshunt recurrent bleeding. Such bleeding occurring within 30 days of operation was a function of severe hepatic, hematologic, and general metabolic derangements. Recurrent hemorrhage occurring after discharge was a function of shunt thrombosis (four patients) or alcoholic recidivism. Twelve patients (31.6 percent) had significant postshunt encephalopathy. Cumulative 5 year survival was 49.3 percent. These data emphasize the high risk of mortality in class C patients operated on an emergency basis. Postoperative encephalopathy is a significant problem with this shunting procedure.     

A 15-year experience of injection sclerotherapy in adult patients with extrahepatic portal venous obstruction.

OBJECTIVE: The authors report a 15-year experience with injection sclerotherapy in the management of adult and teenage patients with esophageal varices due to extrahepatic portal venous obstruction (EHPVO). SUMMARY BACKGROUND DATA: Extrahepatic portal venous obstruction is an uncommon cause of esophageal varices and is associated with normal liver function. Effective control of variceal bleeding is the major factor influencing survival. The results of surgery have been unsatisfactory, and therefore, more conservative management policies have been adopted. METHODS: Fifty-five patients with proven EHPVO underwent repeated injection sclerotherapy via either a modified rigid esophagoscope under general anaesthesia or a fiber-optic endoscope under light sedation, using ethanolamine oleate as the sclerosant. RESULTS: Esophageal varices were eradicated in 44 patients after a median number 6 injections (range 1-17) over a mean of 12.5 months (range 1-48). The mean follow-up was 6.8 years (range 1.1-14.6 years). Eleven patients were admitted on eighteen occasions with bleeding from esophageal varices before eradication and there were seven bleeding episodes in six patients from recurrent varices after initial eradication. Complications related to sclerotherapy included injection site leak (6), stenosis (11) and mucosal ulceration (32) during 362 injection sclerotherapy episodes. Four patients died during the study period. CONCLUSIONS: Injection scelotherapy is the treatment of choice in most patients with EHPVO.     

The emergency portacaval H graft in alcoholic cirrhotic patients: influence of shunt diameter on clinical outcome

Emergency partial portal decompression was achieved with 8 or 10 mm portacaval H graft shunts combined with aggressive collateral ligation in 18 patients in whom bleeding esophageal varices could not be controlled medically. They were compared with 11 similar risk patients undergoing larger diameter portacaval H graft shunts (12 to 14 mm) for the same indications. Variables studied included 90 day operative mortality, hepatic encephalopathy rates, corrected portal pressure, and variceal re-bleeding. Operative mortality was similar in both groups and correlated strongly with Child's class. However, the incidence of portasystemic encephalopathy in survivors was significantly lower after partial decompression than after total decompression. No patient in either group rebled from varices. We conclude from our series of high risk alcoholic cirrhotic patients, that although mortality after partial and total portal decompression is similar, the lower incidence of encephalopathy in survivors suggests that partial decompression has advantages over total decompression when emergency control of variceal bleeding is necessary.     

Esophageal balloon dilation in children: prospective analysis of hemodynamic changes and complications during general anesthesia

STUDY OBJECTIVE: To investigate hemodynamic changes and complications in children during balloon dilation of esophageal strictures. DESIGN: Prospective, controlled study. SETTING: University teaching hospital. PATIENTS: 5 ASA physical status I and II pediatric patients with benign esophageal stricture related to ingestion of caustic substances. INTERVENTIONS: Anesthesia was induced with intravenous propofol two mg/kg and cisatracurium 0.2 mg/kg and maintained with 66% nitrous oxide and one minimum alveolar concentration of sevoflurane in oxygen. In each session, balloon size was increased until the stricture was opened. MEASUREMENTS AND RESULTS: A total of 18 sessions and 99 dilations in 5 children performed over a one-year period were included in the study. In 8 of 18 sessions, esophageal stricture was located in the middle one third of the esophagus; and in the others, in the upper one third. Four cases experienced bleeding; two cases, inability to ventilate due to obstruction of the endotracheal tube tip by the inflated balloon; and two cases, postextubation bronchospasm. In 95 of the 99 dilations, while the balloon was inflated, heart rate was faster and blood pressure increased significantly. CONCLUSION: Anesthesiologists should keep in mind the possibility of hemodynamic instability and possible endotracheal tube tip obstruction by the inflated balloon and safeguard the airway against bleeding, secretions, and radio-opaque fluid during esophageal balloon dilation.     

Infusion of sclerosant through direct cannulation of the coronary vein in the prevention and treatment of esophageal varices bleeding in portal hypertension

To control bleeding from esophageal varices in portal hypertension, infusion of sclerosant through direct cannulation of the coronary vein at splenectomy was carried out in 50 patients, either as an emergent procedure or during bleeding interval. In all cases complete obliteration of the varices was revealed by coronary venography after the infusion. Prompt control of bleeding was obtained in 94% of patients. Three Child C grade patients died within one month postoperatively. Rebleeding occurred in only 6.7% during a follow-up of 1-4 years (an average of 36.4 months). One, two, and three year complication-free survival rate was 97.5%, 95.6%, and 93.5% respectively. The procedure is thus considered satisfactory and recommendable.     

An analysis of prognostic examination in cirrhotic portal hypertension and hepatoma

With an increasing number of patients with advanced liver cirrhosis, the discrepancy between the preoperative examination and results of surgery for bleeding varices is widening. To correct this discrepancy, additional prognostic examinations to Child's criteria and routine hepatic laboratory tests were studied in our 246 cirrhotic patients with esophageal varices. These included wedged hepatic vein pressure, clearance and maximal removal rate of indocyanine green, and hepaplastin test. We performed the endoscope assisted terminal esophagoproximal gastrectomy with the EEA stapler gun with devascularization and splenectomy. No operative death and complications developed when the results of following 4 preoperative examinations were: wedged hepatic vein pressure below 400 mm of saline, peripheral disappearance rate (K) of indocyanine green above 0.04 min-1, maximal removal rate (Rmax) of the dye above 0.3mg/kg/min and hepaplastin test more than 40%. It is necessary for these indicators to be satisfied simultaneously prior to performing this surgery. In addition, these values should be changed a little in their critical limits when these cirrhotic patients also had hepatoma and were candidates for hepatectomy.     

Long-term follow-up of percutaneous transhepatic balloon cholangioplasty in the management of biliary strictures after liver transplantation

BACKGROUND: This study evaluated the efficacy of a protocol of initial balloon dilation for biliary strictures after liver transplantation. METHODS: Complete records from 96 patients with biliary strictures were retrospectively reviewed. Seventy-six patients received percutaneous transhepatic balloon cholangioplasty (PTBC) after initial placement of biliary drainage (percutaneous transluminal cholangiography [PTC]) tube. In most cases, three dilations were performed with a 4 to 8 week interval between procedures. Follow-up ranged from 6 months to 10 years. RESULTS: PTBC successfully treated strictures in 39 of 76 (51.3%) cases. Factors favoring successful PTBC included older age at transplant, shorter cold ischemic time, and single strictures. There were nine recurrent strictures after PTBC, all of which were successfully treated by nonoperative measures. The number of dilations performed affected both the likelihood of success and the long-term risk of stricture recurrence. Of the 37 PTBC failures, 14 underwent subsequent surgical revision. When both angiographic and surgical modalities were considered, treatment success was associated with first transplants, shorter cold ischemic time and operative time, and less intraoperative transfusion requirements. Factors associated with treatment failure included multiple, central hepatic duct, and intrahepatic strictures. PTC-tube independence was achieved in 51 of 76 (67%) patients using the combined approach of PTBC and surgery for PTBC failures. CONCLUSIONS: PTBC is an effective initial modality for treating posttransplant biliary strictures. Prolonged cold ischemic and operative times and multiple or peripheral strictures predispose to treatment failure. Solitary extrahepatic strictures that fail PTBC are salvageable with surgical revision with excellent results.