Endoscopic resection of carcinoma in situ of the esophagus accompanied by esophageal varices

Summary A case of carcinoma in situ of the esophagus accompanied by esophageal varices was treated by endoscopic mucosal resection using a transparent tube (EMRT) following eradication of the varices via injection sclerotherapy (EIS). Intravariceal injection sclerotherapy was performed for esophageal varices, and after eradication of the varices had been achieved, half of the circumferential esophageal mucosal resection of the cancer lesion was carried out. No serious complication such as perforation or mass bleeding was observed. Cancer-involved mucosa was completely resected and all specimens contributed well to accurate histopathological study, being diagnosed as intraepithelial squamous-cell carcinoma. The artificial ulcer recovered completely, showing no stenotic changes. Our conclusion from this experience is that EIS + EMRT is a valuable and minimally invasive treatment for patients exhibiting this disease, providing an accurate histopathological diagnosis.     

Extreme hyperbilirubinemia induced by endoscopic injection sclerotherapy in a patient with esophageal varices and thalassemia: Report of a case

We describe herein the case of a 57-year-old man with thalassemia who developed acute liver failure after undergoing endoscopic injection sclerotherapy (EIS) to control hemorrhage from a ruptured esophageal varix. The patient, who had been comfirmed as having liver cirrhosis due to chronic hepatitis C with thalassemia in 1989, was admitted to our department to undergo EIS for esophageal varices, at which time his serum total bilirubin level was 5.5 mg/dl. As a small amount of hematemesis occurred just after a percutaneous transhepatic portography was performed, emergency EIS was carried out, following which the serum total bilirubin level markedly increased, mainly with a direct fraction, until it reached 70 mg/dl. The patient eventually died from acute liver failure with extreme hyperbilrubinemia on the 27th day after experiencing hematemesis despite all treatment. This unfortunate case demonstrates that sclerotherapy could be an inappropriate method of treatment for patients with hemolytic disease.     

Management of urethral hemangiomas associated with Klippel–Trenaunay–Weber syndrome by endoscopic sclerotherapy

Klippel-Trenaunay-Weber syndrome (KTS) is an unusual congenital anomaly characterized by cutaneous hemangiomas, varicosities and bony hypertrophy of the extremities. Herein the case is reported of a 24-year-old man with urethral bleeding from hemangiomas associated with KTS that were successfully managed by endoscopic sclerotherapy. A 23-G puncture needle was inserted into the bleeding vein to inject a 5% solution of monoethanolamine oleate (Oldamine), which is typically used for sclerotherapy of esophageal vasix. At a 4-month follow-up, the patient only had slightly bloodstained urethral discharge, and is doing well. This is the first case reporting endoscopic sclerotherapy for a KTS-associated urethral hemangioma.     

超声引导下泡沫硬化治疗四肢血管瘤

目的探讨超声引导下注射泡沫硬化剂治疗四肢血管瘤的疗效。方法收集经超声确诊的四肢血管瘤患者30例,于超声引导下向血管瘤腔内注射聚桂醇泡沫硬化剂,随访8个月,观察治疗后血管瘤体积变化和临床症状改善情况,评价疗效,观察治疗相关并发症。结果对13例进行1次治疗、12例进行2次治疗、3例进行3次治疗、2例进行4次治疗;血管瘤体积缩小≥60%19例、缩小30%~59%7例、缩小1%~29%2例、无明显变化2例,临床症状消失14例、明显好转11例,症状无明显变化5例;25例治疗有效,有效率为83.33%(25/30)。所有患者均未发生严重并发症。结论超声引导下聚桂醇泡沫硬化剂治疗四肢血管瘤费用低廉、安全、有效,值得临床推广与应用。     

A prospective randomized controlled trial of sclerotherapy vs ligation in the prophylactic treatment of high-risk esophageal varices

Background: Endoscopic ligation (EVL) and endoscopic sclerotherapy (EIS) are both effective in the treatment of bleeding esophageal varices, but the efficacy of the two techniques in the prophylaxis of first variceal bleeding has not been investigated. The aim of this study was to investigate the frequency of first variceal bleeding, the recurrence of varices, and survival after treatment with the two techniques, as compared to a nontreated control group. Methods: A total of 157 patients with liver cirrhosis and advanced esophageal varices with no previous history of upper gastrointestinal bleeding were randomly assigned to either an EIS group (n= 55), an EVL group (n= 52), or a nontreated control group (n= 50). After the eradication of esophageal varices in the EIS and in EVL groups and in all control patients, the endoscopic examination was performed at 3-month intervals. Results: There were no significant differences between EIS and EVL in the eradication rate of esophageal varices (85% in the EIS group versus 81% in the EVL group). The mean number of sessions required to obtain eradication was lower in the EVL group than in the EIS group (4.8 ± 1.8 versus 6.2 ± 2.0; p= 0.0003), but the recurrence of esophageal varices was higher in the EVL group (31% versus 11%; p= 0.01). Total mortality was significantly lower in the EIS patients than in the controls (20% versus 38%; p= 0.04). It was also lower, but not significantly, in the EVL patients than in the controls (23% versus 38%; p= 0.10). A significant decrease in variceal bleeding was observed both in sclerotherapy cases (20%) and controls (54%; p= 0.0005) and in ligation cases and controls (29%; p= 0.01). No significant difference in bleeding episodes was observed between the sclerotherapy and ligation cases (p= 0.29). No serious complications were observed either in the EIS or EVL groups. Conclusions: EIS and EVL are similarly effective in the prevention of first variceal bleeding. The choice between EIS and EVL depends on the skill of the endoscopic unit. For highly experienced surgeons facing no complications, sclerotherapy seems to be preferable; for all others, it is technically easier to perform ligation. Received: 29 June 1998/Accepted: 18 September 1998     

Significance of embolization therapy for esophagogastric varices]

To evaluate the efficacy of the embolization therapy (Emb) for varices, we performed endoscopic injection sclerotherapy (EIS) alone and EIS combined with Emb. Various embolizations such as percutaneous transhepatic obliteration, splenic artery embolization and left gastric artery embolization have been employed. The efficacy rates were 76.5% of the patients in the EIS alone and 87.5% in the EIS with Emb group (EIS+Emb). The cumulative percentages of rebleeding at one year and 3 years were 23.1%, 34.6% in EIS alone, and 10.7%, 25.0% in EIS+Emb respectively. Especially in the patients with the Child C, there was significant difference in the efficacy rates: 60.0% (EIS alone) versus 88.9% (EIS+Emb), and recurrence rates within one year: 41.7% (EIS alone) versus 12.5% (EIS+Emb) (p < 0.05) and length of treatment free periods: 9.7 months versus 17.5 months (p < 0.01). After the treatments, improvement of Child's criteria was seen to be better in EIS+Emb than in EIS alone. The similar results have been obtained in the patients with hepatocellular carcinoma and with gastric varices. These results suggest that EIS should be combined with Emb to increase durability and to improve general condition.     

Endoscopic sclerotherapy in the combined treatment of portal hypertension in children]

The authors have performed 28 sessions of endoscopic sclerotherapy of dilated esophagus veins in children. The 70% ethyl alcohol was used. Six sessions were carried out in patients with gastroesophageal hemorrhage. In 22 patients the sclerotherapy was carried on according to plan. The fiber gastroscope with a standard injector was used. A conclusion is made of expediency of using endoscopic sclerotherapy in complex treatment of portal hypertension in children.     

Clinical evaluation of endoscopic injection sclerotherapy and esophageal transection]

We investigated the effects of EIS and esophageal transection on treatment of esophageal varices and the late result of EIS treatment group with that of surgical treatment group. One hundred and forty-seven patients underwent esophageal transection and 244 patients injection sclerotherapy in our institute. 1. The 5-year cumulative survival rate in patients with EIS was 58%, while 62% in those with transection. 2. Judging from the findings of varices after treatment which showed the negative red color sign, or changes from F2 or F3 to F1, the effect of two methods were 72% in operation group and 73% in EIS group, respectively. 3. There was no significant difference in the rates of rebleeding between EIS (7.8%) and operation (10.2%) groups. 4. Prognosis of esophageal varices treated with EIS or operation was considered to depend on the Child's classification. We conclude that endoscopic sclerotherapy should be considered to be the first choice of treatment for esophageal varices.     

Management of Variceal Hemorrhage in Children with Extrahepatic Portal Venous Obstruction-Shunt Surgery Versus Endoscopic Sclerotherapy

Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertention in children. Esophageal variceal hemorrhage is a major cause of morbidity and mortality in these patients. For many decades, portal systemic shunts were considered as the most effective treatment of variceal hemorrhage. Endoscopic injection sclerotherapy (EIS) was first introduced for emergency management of bleeding varices and subsequently as definitive treatment to prevent recurrent hemorrhage. The purpose of the study was to compare the safety and efficacy of shunt surgery and endoscopic sclerotherapy for patients with proven esophageal variceal bleeding due to EHPVO. The study was a prospective randomized study of 61 children with bleeding esophageal varices due to EHPVO carried out jointly by the department of General Surgery and Gastroenterology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, between March 2001 and September 2003. Thirty patients received surgery and other 31 patients received EIS. Overall incidence of rebleeding was 22.6% in sclerotherapy group and 3.3% in shunt surgery group. Treatment failure occurred in 19.4% patients in sclerotherapy group and 6.7% in shunt surgery group. The rebleeding rate of sclerotherapy is significantly higher than that of shunt surgery. However, the therapy failure rate of sclerotherapy is not significantly different from that of shunt surgery.     

超声介入硬化治疗大块型、巨块型肝血管瘤的远期疗效

目的研究超声介入硬化治疗肝血管瘤大块型、巨块型的临床价值和远期疗效。方法在超声引导下经皮肝穿刺由里向外,多点、多面向瘤体内注入硬化剂,按瘤体体积公式计算注药量,设计分次注药量。结果穿刺治疗3750例,消失率、基本消失率分别为大结节型98.45%、1.55%;大块型30.25%、31.65%;巨块型5.1%、0,巨块型中瘤体直径缩小1/2~2/3者占94.9%。穿刺治疗总有效率100%。并发肝内出血0.133%。结论超声介入治疗肝血管瘤大结节型、大块型为最佳治疗期,疗效满意,瘤体消失率高。远期观察无复发,对肝、肾功能无损伤,可达康复之目的。     

铜针疗法配合硬化剂治疗海绵状血管瘤

应用铜针疗法的基础上配合硬化剂注射治疗海绵状血管瘤。海绵状血管瘤应用铜针治疗时,拔针后从针眼里再注入硬化剂,这样,硬化剂很容易停留在已被铜针治疗过的血管瘤内,进一步破坏血管内膜,使血管瘤结成硬块最后被吸收。此法治疗３３ 例,除１ 例颈部胸骨切迹上血管瘤未治愈,余均取得满意效果。本方法疗效比单用铜针治疗或单用硬化剂治疗海绵状血管瘤效果更可靠。     

Esophageal variceal bleeding secondary to portal hypertension: endoscopic sclerotherapy as the first-step treatment

BACKGROUND: Variceal bleeding from the esophagus is an important cause of mortality and morbidity in children with portal hypertension (PHT). PATIENTS AND METHODS: A series of 69 PHT cases (41 intrahepatic, 28 extrahepatic) have been evaluated in our department since 1990. According to the Child-Pugh classification, 49 cases were in class A, 16 cases were in class B, and 4 cases were in class C at admission. In our protocol, endoscopic sclerotherapy is performed in all patients, and the diagnosis is achieved directly by diagnostic laparoscopy and fine-needle liver biopsy. The procedure is applied under general anesthesia, and 1% aethoxysclerol (polidocanol) is injected paravariceally and intravariceally with the use of a flexible endoscope. RESULTS: The Sugiura procedure was performed in nine patients who presented with recurrent bleeding episodes despite the strict sclerotherapy protocol. Liver transplantation was performed in two patients who were in Child class C. The total mortality rate in this series was 7% (5/69). CONCLUSION: Endoscopic sclerotherapy, as presented herein, decreases the need for additional surgical interventions in children with PHT.     

Comparative Study of Duplex-Guided Foam Sclerotherapy and Duplex-Guided Liquid Sclerotherapy for the Treatment of Superficial Venous Insufficiency

PURPOSE: To compare the preliminary results of hemodynamic changes between duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy. METHODS: Seventy Seven limbs in 77 patients with isolated greater saphenous vein incompetence were treated with duplex-guided sclerotherapy. Thirty Seven limbs were treated with duplex-guided foam sclerotherapy and the remaining 40 limbs were treated with duplex-guided liquid sclerotherapy. Pretreatment exam was performed using a color duplex scanner and air plethysmography. The sclerosing foam was produced by Tessari's method using 1% and 3% polidocanol. The varicose vein was injected with 2 mL of 1% polidocanol or 1% polidocanol foam, and then 1 mL of 3% polidocanol or 3% polidocanol foam was injected into the greater saphenous vein under duplex guidance. Venous obstruction and recanalization were screened by serial posttreatment duplex examination, and posttreatment air plethysmography analysis was performed 3, 6, 9, and 12 months after the sclerotherapy. RESULTS: Duplex scanning demonstrated complete occlusion in the greater saphenous vein for duplex-guided foam sclerotherapy in 25 limbs (67.6%), which was a significantly higher proportion than for the duplex-guided liquid sclerotherapy (7 limbs, 17.5%, p<0.0001). Recurrent varicose veins were found in 3 patient (8.1%) in the duplex-guided foam sclerotherapy group and 10 (25%) in the duplex-guided liquid sclerotherapy group at 1-year (p=0.048). In duplex-guided foam sclerotherapy, venous filling index values remained normal during the subsequent follow-up examinations, whereas in duplex-guided liquid sclerotherapy, venous filling index began to increase, and there was a significant difference at 6 months between duplex-guided foam sclerotherapy and the duplex-guided liquid sclerotherapy (p<0.0005). At 9 months, there was a significant difference in the residual venous fraction between the two groups, and the residual venous fraction value continued to improve in duplex-guided foam sclerotherapy (p=0.033). CONCLUSIONS: Duplex-guided foam sclerotherapy could have greater promise compared to duplex-guided liquid sclerotherapy in the treatment of superficial venous insufficiency.     

Selection of the treatment for esophagogastric varices

Summary In 57 cases with portal hypertensive disease, we investigated the intramural and extramural structure of the stomach and the esophagus by endoscopic ultrasonography (EUS). Variously developed intra- and extramural vascular structures had a relationship to the endoscopic variceal form, and communicating (inflow) vessels to varices were found in 28 of the 43 primary cases treated (65%). We then classified the esophagogastric varices into three types according to the vascular structure, such as the esophageal type, esophagogastric type, and solitary gastric type. Based on the analysis of these collateral structures, we selected the treatment as follows. In the esophageal type, which has a few inflow vessels, it is easy to eliminate the varices by obturating the inflow vessels by endoscopic injection sclerotherapy (EIS). In the esophagogastric type, which has many enlarged inflow vessels, the Hassab operation is effective in devascularizing the extramural inflow vessels, and the combination of EIS is necessary to sclerose the intramural varices. In the solitary gastric type, which is a part of the downward portosystemic shunt, the Hassab operation is recommended to prevent rupture of the varices for the subtype with intramural running vessels, but conservative therapy is enough for the subtype without.     

Better control of esophageal variceal bleeding by sclerotherapy followed by surgery

This paper reports the clinical results of a retrospective study comparing endoscopic injection sclerotherapy (EIS) and back-up surgical treatment after EIS in the management of acute variceal bleeding. The 74 patients included in the study were divided into 2 groups. Group I consisted of 41 patients who received EIS over a mean period of 2.2 sessions and Group II consisted of 33 patients who underwent EIS and subsequent surgical intervention, in the form of 19 distal splenorenal shunts and 14 nonshunting procedures. The overall percentage of patients in whom initial control of variceal bleeding was achieved was 91.8 per cent. Four of the Group II patients were saved by emergency nonshunting operations. Rebleeding was experienced by 4 (28.6 per cent) of the 14 patients who underwent nonshunting surgery but by only 1 (5.3 per cent) of the 19 patients who underwent selective shunt surgery. The cumulative survival in Group II was significantly superior to that in Group I with 2 year survival being achieved in 66.7 per cent of the Group II patients but in only 23 per cent of Group I patients. Thus, the combination of initial EIS and back-up surgical intervention may be more benefical than sclerotherapy alone for patients with acute variceal bleeding, while, the distal splenorenal shunt may be a more suitable surgical technique for patients having previously EIS.     

Therapeutic endoscopy in hemorrhages from varicose veins of the esophagus in patients with portal hypertension

The article discusses 6-year experience in the treatment and prevention of esophageal hemorrhage by endoscopic sclerotherapy using 96% and 70% ethanol as the sclerosant. There were 99 patients under observation whose ages ranged from 27 to 70 years, 74 were admitted to the clinic with profuse hemorrhage. Sclerotherapy arrested the bleeding in 65 (90%) patients. Seven patients died from persisting bleeding, 5 from increasing hepatic insufficiency, and one patient from perforation of the esophagus and purulent mediastinitis. After discharge from the clinic 54 patients were kept under observation for periods of 6 to 20 months; 16 episodes of bleeding occurred in 13 of them. Repeated sclerotherapy proved effective in 10 patients, 3 patients died from continuing bleeding and hepatic insufficiency.     

Better control of esophageal variceal bleeding by sclerotherapy followed by surgery

This paper reports the clinical results of a retrospective study comparing endoscopic injection sclerotherapy (EIS) and back-up surgical treatment after EIS in the management of acute variceal bleeding. The 74 patients included in the study were divided into 2 groups. Group I consisted of 41 patients who received EIS over a mean period of 2.2 sessions and Group II consisted of 33 patients who underwent EIS and subsequent surgical intervention, in the form of 19 distal splenorenal shunts and 14 nonshunting procedures. The overall percentage of patients in whom initial control of variceal bleeding was achieved was 91.8 per cent. Four of the Group II patients were saved by emergency nonshunting operations. Rebleeding was experienced by 4 (28.6 per cent) of the 14 patients who underwent nonshunting surgery but by only 1 (5.3 per cent) of the 19 patients who underwent selective shunt surgery. The cumulative survival in Group II was significantly superior to that in Group I with 2 year survival being achieved in 66.7 per cent of the Group II patients but in only 23 per cent of Group I patients. Thus, the combination of initial EIS and back-up surgical intervention may be more beneficial than sclerotherapy alone for patients with acute variceal bleeding, while, the distal splenorenal shunt may be a more suitable surgical technique for patients having previously EIS.     

Over-tube is preferable to free-hand technique to avoid recurrence of varices after endoscopic injection sclerotherapy. Prospective randomized trial.

One hundred and two patients undergoing sclerotherapy of esophageal varices, using 5% ethanolamine oleate, were randomly allocated to either the over-tube (O-T) or the free-hand (F-H) group, and 100 patients could be followed at monthly intervals for a period of 30.8 +/- 14.7 months (mean +/- SD) after the varices had been eradicated. Endoscopy performed one month after the final session of sclerotherapy revealed circumferential ulcers and scarring in the lower esophagus in 42 of 50 patients (84%) in the O-T group and in 16 of 50 patients (32%) of the F-H group, the difference being statistically significant (P less than 0.01). In the remaining 8 and 34 patients in the O-T and the F-H groups, respectively, a partly fibrotic residual mucosa was seen. There was a recurrence of the varices in the residual mucosa in 14 (28%) in the F-H group during the mean follow-up period of 25.6 months, while there were five patients (10%) with a recurrence of varices in the O-T group, the difference being statistically significant (P less than 0.05). The survival rates showed no statistical significance. Two patients in the F-H group had recurrent bleeding. We conclude that the over-tube technique of sclerosing esophageal varices reduces the rate of recurrence of the varices, in the long term follow-up, and after formation of a circumferential scarring in the lower esophagus.     

Therapeutic modality for esophago-gastric varices analyzed by endoscopic ultrasonography]

For 64 cases with portal hypertensive disease, we investigated the intramural and extramural structure of the stomach and esophagus by endoscopic ultrasonography (EUS). Variously developed intra- or extra-mural vascular structures had a relationship to the endoscopic variceal form, and the communicating (inflow) vessels to varices were found in 35 of 50 primary treated cases (70%). We classified the esophago-gastric varices into three types according to the vascular structure, such as the esophageal type, the esophago-gastric type and the solitary gastric type. From the analyses of these collateral structures, we should select a treatment as follows. In the esophageal type which has a few inflow vessels, it is easy to eliminate the varices by obturating the inflow vessels by endoscopic injection sclerotherapy (EIS). In the esophago-gastric type, which has many enlarged inflow vessels, the Hassab operation is effective to devascularize extramural inflow vessels, and the combination of EIS is necessary to sclerous the intramural varices. In the solitary gastric type which is a part of the downward porto-systemic shunt, Hassab operation is recommended to prevent the rupture of varices for the subtype with intramural running vessels, but conservative therapy is enough for the subtype without intramural running vessel.