小探头超声用于胃底静脉曲张诊断及判断组织粘合剂疗效的初步评价

目的 与常规内镜下肉眼判断比较,评价小探头超声检查在诊断胃底静脉曲张及评价内镜下组织粘合剂治疗疗效中的临床价值。方法 １０例临床诊断为肝硬化的患者于内镜治疗前先行胃底腔内小探头超声检查,随后对诊断存在胃底静脉曲张的患者行内镜下组织粘合剂治疗,而后即刻再行小探头超声检查以观察其疗效。结果 常规内镜下肉眼判断与小探头超声检查对胃底静脉曲张的诊断准确率分别为７０％（７／１０）和１００％（１０／１０）;后     

Long-term results of endoscopic histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices--a 10-year experience]

BACKGROUND/AIMS: Gastric variceal bleeding is an infrequent but serious complication of portal hypertension. Endoscopic injection of Histoacryl (N-butyl-2-cyanoacrylate) has been approved as an effective treatment for gastric variceal bleeding. The aim of this study was to evaluate the long-term efficacy and safety of the endoscopic injection of Histoacryl for the treatment of gastric varices. METHODS: Between January 1994 and January 2005, eighty-five patients with gastric varices received endoscopic injections of Histoacryl. Among these 85 patients, 65 received the procedure within 1 week after gastric variceal bleeding, and 13 received as a prophylactic procedure. According to the Sarin classification, 32 patients were GOV1 and 53 were GOV2. Most of the varices were large (F2 or F3, 75 patients). The average volume of Histoacryl per each session was 1.43 ml. Among 85 patients, 72 patients were followed-up and the median duration was 24.5 months. RESULTS: The rate of initial hemostasis was 98.6% and recurrent bleeding occurred in 29.2% (21 of 72). When rebleeding occurred, 76.2% was within 1 year after the initial injection. Treatment failure-related mortality rate was 1.4% (1 of 85). Twenty-seven patients died, mostly due to hepatocelluar carcinoma or liver failure. Two patients experienced pulmonary embolism and one experienced splenic infarction. They recovered without specific treatment. Rebleeding rate had a tendency to increase in patients with hepatocelluar carcinoma (p=0.051) and GOV2 (p=0.061). CONCLUSIONS: Histoacryl injection therapy is a effective treatment method for gastric varices with high initial hemostasis rate and low major complications.     

Study of hemodynamic changes in portal systemic shunts and their relation to variceal relapse after endoscopic variceal ligation combined with ethanol sclerotherapy

Background Among the factors influencing variceal relapse after endoscopic treatment, portal hemodynamic changes, especially in portal systemic shunts, could be the most important factor because hemodynamics are directly related to the development of esophageal varices. We aimed to clarify the influence of endoscopic treatment for esophageal varices on portal systemic shunts as well as its predictive value for variceal relapse. Methods Fifty patients who underwent combined endoscopic variceal ligation and injection sclerotherapy were examined with sonography and portography. Results Decrease of diameter, hepatopetal flow direction in the left gastric vein, or the presence of non-varices portal systemic shunt were sonographic findings related to a low incidence of variceal relapse. The presence of blood flow in and around the esophagus on venograms was highly predictive for variceal relapse. In patients with such venograms, non-varices portal systemic shunts did not develop. Conclusions Sonographic assessment of hemodynamic changes in portal systemic shunt could be useful for estimating the results of endoscopic treatment for esophageal varices.     

Catheter US probe EUS evaluation of gastric cardia and perigastric vascular structures to predict esophageal variceal recurrence

BACKGROUND: This study assessed the risk of recurrence of esophageal varices by evaluating the severity of cardia vascular structures in patients with portal hypertension by EUS with a catheter US probe before endoscopic variceal ligation. METHODS: Thirty consecutive patients with esophageal varices at high risk for bleeding were studied. Simultaneous conventional endoscopy and EUS with a 20 MHz catheter US probe were performed before endoscopic variceal ligation. By catheter US probe EUS findings, vascular structures in the gastric cardia were classified into 2 grades, mild and severe, and the relationship between the catheter US probe EUS findings and the recurrence rate of esophageal varices was analyzed. RESULTS: Catheter US probe EUS before endoscopic variceal ligation demonstrated cardial submucosal varices in all patients, whereas conventional endoscopy revealed cardial varices in only 21 patients (70.0%, NS). Patients with recurrent esophageal varices after endoscopic variceal ligation were more likely to have severe-grade perforating veins before treatment than those without recurrence (71.4% vs. 12.5%, p < 0.01). Patients with severe as opposed to mild-grade perforating veins before treatment had a significantly higher recurrence rate (90.9% vs. 21.0%, p < 0.01%). CONCLUSIONS: Catheter US probe EUS findings for cardial vascular structures before treatment are useful for predicting the likelihood of recurrence of esophageal varices.     

Esophageal variceal ligation for acute variceal bleeding: results of three years' follow-up.

BACKGROUND/AIMS: Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation. METHODS: Twenty-one liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were treated by endoscopic variceal ligation. These patients received regular follow-up and detailed clinical assessment of at least 24 months. RESULTS: Twenty-one eligible patients were followed up for a mean of 44.45 months (range 33.5-64 months). The mean number of sessions required to obtain eradication was 3.57+/-1.99 (range 1-8). Esophageal varices could be obliterated within 11.57+/-6.8 weeks (range 3-30). The percentage of variceal recurrence during follow-up was 57.14% (12/21) after endoscopic variceal ligation. Recurrence were observed in a mean of 34 months (median 29 months). Rebleeding from esophageal varices appeared in four patients (19.04%). The appearance rates of portal hypertensive gastropathy and fundal gastric varices after varice obliteration were found to be 45.45% (5/11) and 25% (3/12), respectively. CONCLUSIONS: Based on the results of long-term follow-up of endoscopic variceal ligation, although the percentage of variceal recurrence was high, endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions. Furthermore, endoscopic variceal ligation had a lower rate of rebleeding and of development of fundal gastric varices, but high portal hypertensive gastropathy.     

The effects of chronic endoscopic variceal sclerotherapy on portal pressure in cirrhotics

The effect of obliterating esophageal varices by endoscopic sclerotherapy on portal pressure was prospectively studied in 11 cirrhotic patients with variceal hemorrhage. Portal venous pressure gradient, determined as the difference between transhepatic portal and hepatic vein pressure, increased by a mean of 31.1% +/- 14.5% in 8 (73%) and decreased by a mean of 30.1% +/- 11.7% in 3 (27%) patients, with no statistically significant change overall (P = 0.1). These changes in portal venous pressure gradient occurred despite an improvement in the laboratory and clinical parameters of hepatic function. Deep abdominal sonography with color flow imaging at variceal obliteration showed patent paraumbilical veins in 6 (55%) patients, 3 of whom had decreases in portal venous pressure gradient (29%, 19%, 42.5%) at variceal obliteration. In 5 (45%) patients without patent paraumbilical veins, a statistically significant increase in portal venous pressure gradient between initial endoscopic variceal sclerotherapy and variceal obliteration was noted (P = 0.008). Rebleeding (single episode in all 4 patients, before obliteration in 3 patients) occurred in those with an increase in portal venous pressure gradient; all patients with portal venous pressure gradient decreases were nonbleeders. No correlation between changes in portal venous pressure gradient and time to variceal obliteration, number of sclerotherapy treatments, or rebleeding episodes was observed. Thus, an increase in portal venous pressure gradient was noted in the majority of patients at variceal obliteration. Although the portal venous pressure gradient decrease may be explained by a patent paraumbilical vein, the mechanism of portal venous pressure gradient increase is not clear. It is speculated that this portal venous pressure gradient increase may be caused by an increase in collateral resistance or flow or a combination of both, resulting from obliteration of esophageal varices by endoscopic sclerotherapy.     

Formation, hemodynamics and new management options for gastric varices

Abstract   Gastric varices develop in patients with portal hypertension, including liver cirrhosis, idiopathic portal hypertension as well as left sided-local portal hypertension such as splenic vein thrombosis or splenic AV malformation. The inflow vein is the left gastric vein, posterior vein, or short gastric vein, while the outflow vein is the gastro-renal shunt in most of the patients with gastric varices. The form of the gastric varices is classified into three types of venous dilatation; tortuous type, notched type and tumor type according to the shape and size of the varices. The location is classified into five sites; the posterior site, anterior site, greater curvature site and lesser curvature site of the cardiac area, and the fundic area. The risk of the rupture depends on the mucosal factor of the varices as well as the location and the form. The hemostasis rate has been improved to 94–97% with the usage of the endoscopic occlusive agent such as Histoacryl. It is absolutely necessary to eradicate the gastric varices within a few weeks after rupture of the gastric varices. There are new management options such as laparoscopic Hassab's operation or balloon-occluded retrograde transvenous obliteration of the varices (B-RTO). The 5-year cumulative rate of the non-variceal bleeding is more than 90% after the B-RTO as well as after surgery. Further prospective clinical trials are to be investigated for an evidence-based medicine.     

Endoscopic ultrasonography in the diagnosis and management of portal hypertension. Where are we next?

Endoscopic ultrasonography has recently emerged as an accurate, non-invasive and reproducible alternative means of providing data for patients with portal hypertension. It is well established that endoscopic ultrasonography is more sensitive than endoscopy in the diagnosis of gastric varices. Dilated venous abnormalities outside the gastrooesophageal lumen, which cannot be diagnosed by endoscopy, are readily visible with endoscopic ultrasonography or miniature probes. Endoscopic ultrasonography is also useful to predict the risk of variceal recurrence and thus the risk of rebleeding after endotherapy which cannot be reliably predicted using endoscopy alone. The introduction of echo endoscopes equipped with Doppler facilities has allowed the sonographic visualisation of the vessels and the evaluation of vascular blood flow along with possible morphologic and haemodynamic changes after endoscopic or pharmacological therapy. However, despite its theoretical advantages, relative evidence suggests that in the clinical setting of portal hypertension, endoscopic ultrasonography remains an investigational tool with limited clinical applications.     

Emergency balloon-occluded retrograde transvenous obliteration for gastric varices

Background We evaluated the efficacy of emergency balloon-occluded retrograde transvenous obliteration (B-RTO) performed within 24 h after initial hemostasis for the prevention of rebleeding from ruptured gastric varices. Methods From December 1995 to March 2003, 11 patients who had undergone B-RTO within 24 h after the control of gastric variceal bleeding at Maebashi Red Cross Hospital were investigated. They were followed up for complete eradication, recurrence of varices, and rebleeding. Efficacy was determined by endoscopic examination and computed tomography. Results The 4 patients with acute bleeding from ruptured gastric varices were treated with endoscopic therapy—endoscopic variceal ligation (EVL) in 2 patients, and clipping treatment in 2. Initial hemostasis was achieved in all 4; the other 7 patients had already stopped bleeding at endoscopy. After hemostasis was achieved, emergency B-RTO was immediately performed within 24 h and was successful in all 11 patients. Ten (90.9%) of the 11 gastric varices were obliterated and the other 1 (9.1%) was diminished in size. During the mean follow-up period of 1136 days, no rebleeding or recurrence as found. Four patients died during the follow-up period, but none died from variceal bleeding. Survival rates were 90.9% and 70.7%, respectively, at 1 year and 3 years. In 6 patients, development of esophageal varices appeared during the follow-up period, all of which were controlled by usual endoscopic therapy. No severe side effects were found after the B-RTO treatment. Conclusions Emergency B-RTO is an effective treatment for the prevention of rebleeding from ruptured gastric varices.     

Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety

BACKGROUND: The long-term efficacy and safety of the endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) were evaluated to define its role as the initial treatment for bleeding gastric varices. METHODS: Ninety patients with bleeding gastric varices underwent endoscopic injections of Histoacryl for hemostasis within a 6-year period. Histoacryl was injected intravariceally as a 1:1 mixture with Lipiodol. Among the 90 patients, 5 had active bleeding and 85 had recent bleeding. Most of the varices were large (F2 or F3, 85 cases). The most common locations were the fundus and the posterior wall of the proximal body (94.4%). After Histoacryl injection, patients were followed endoscopically with retreatment as necessary. RESULTS: The rate of hemostasis at 1 week was 94.4%. Recurrent bleeding occurred in 23.3% of the patients from 3 days to 16 months after the initial injection. Recurrent bleeding was stopped with reinjections of Histoacryl in 16.7% of the patients. The rate of definitive hemostasis was 93.3% (84 of 90). The treatment failure-related mortality rate was 2.2% (2 of 90). To date, 35 patients have died, mostly as a result of malignancy or liver failure, and 55 are still alive. The determining factor for long-term survival was the underlying disease leading to portal hypertension. There were few long-term complications except for Histoacryl cast extrusion-related mucosal defects. CONCLUSIONS: Endoscopic injection of Histoacryl is highly effective for the treatment of bleeding gastric varices, with rare complications both acutely and long term. This treatment modality is appropriate as the first choice for bleeding gastric varices.     

内镜组织黏合剂注射联合套扎序贯治疗食管胃静脉曲张疗效观察

背景：临床上对胃静脉随张（GV）合并食管静脉曲张（EV）的内镜治疗方法和治疗时机选择尚未统一。目的：探讨内镜组织黏合剂注射联合套扎序贯治疗食管胃静脉曲张的疗效及其最佳时机。方法：2007年1月。2009年6月南京医科大学第一附属医院56例内镜检查确诊为GV活动性出血合并中重度EV者纳人研究,其中26例于GV组织黏合剂注射1周后行EV套扎（A组）,30例注射后立即行EV套扎（B组）。回顾性分析两组患者的止血率、治疗相关并发症发生情况、治疗后1个月内和6个月内再出血率以及食管胃静脉曲张改善有效率。结果：A组与B组问止血率（96．2％对96．7％）和食管胃静脉曲张改善总有效率（GV：72．7％对72．0％;EV：81．8％对84．0％）无明显差异,A组治疗后1个月内和6个月内再出血率均显著高于B组（1个月内：26．1％对10．3％,P〈0．05;6个月内：45．5％对32．O％,P〈0．05）。两组均无明显治疗相关并发症发生。结论：内镜GV组织黏合剂注射后立即行EV套扎序贯治疗食管胃静脉曲张安全、有效．值得在临床上推广应用。     

Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience

Background and Aim: Balloon‐occluded retrograde transvenous obliteration (B‐RTO) is a new alternative treatment for gastric varices (GVx), but the long‐term efficacy is not known. We investigated the long‐term effects of B‐RTO on rebleeding, prevention of first bleeding, mortality and occurrence of risky esophageal varices (EVx). Methods: B‐RTO was performed in 68 cirrhotic patients with GVx. Twenty patients had recent bleeding, transiently treated by endoscopic Histoacryl injection or balloon tamponade. Forty‐eight patients had varices likely to bleed, but no bleeding. After B‐RTO, the recurrent bleeding, occurrence of EVx and mortality over the long‐term were evaluated. Results: B‐RTO was successfully performed in 63 of 68 patients (92.6%). Varices eradication was confirmed by endoscopy in 61 of 63 patients (96.6%). During follow up, GVx bleeding occurred in two patients (3.2%). The 8‐year cumulative rebleeding rates of patients with bleeding and risky GVx were 14% and 0%, respectively. Risky EVx occurred in 10 patients (17%) and the cumulative occurrence rate was 22% in 8 years. The cumulative occurrence rate of risky EVx was higher in GVx with EVx (GOV2‐GVx) compared to GVx without EVx (IGV1, P < 0.05). No ectopic variceal bleeding occurred. No patients died from variceal bleeding. Hepatocellular carcinoma was the only significant prognostic factor (P < 0.05). Conclusion: B‐RTO is beneficial over the long‐term, despite worsening EVx in some patients, because of excellent treatment efficacy and improved mortality. We believe that B‐RTO can become a first‐choice radical treatment following hemostasis for gastric variceal bleeding and prophylactic treatment for risky GVx.     

内镜治疗食管静脉曲张对门脉高压性胃病的影响

探讨内镜下硬化剂(EST)和套扎(EVL)治疗食管静脉曲张术后对门脉高压性胃病(PHG)和胃底静脉曲张(GV)的影响,对21例注射硬化剂治疗和27例套扎治疗的共48例患者进行了1年的内镜随访,观察PHG和GV的程度。结果在接受治疗3个月和1年后,PHG发生率较治疗前(35％,17/48)明显增加,分别为75％(36/48)和87％(42/48);GV较治疗前(17％,8/48)增多,分别为33％(16/48)和43％(21/48)。结论:食管静脉曲张的内镜下硬化剂和套扎治疗将加重PHG和GV且有可能增加PHG和GV的出血机会。     

Extensive portal and splenic vein thrombosis: differences in hemodynamics and management

BACKGROUND/AIMS: To assess the incidence of extensive portal and splenic vein thrombosis in patients with extrahepatic portal vein obstruction and determine the differences in presentation, portal hemodynamics and management as compared to patients with portal vein thrombosis alone. METHODOLOGY: 118 patients of extrahepatic portal vein obstruction presenting with variceal hemorrhage, having received no definitive treatment prior to presentation were divided into two groups--with portal and splenic vein thrombosis and with portal vein thrombosis, based on ultrasonography and splenoportography. Collateralization patterns on splenoportography were studied. Results of endoscopic variceal sclerotherapy were compared. RESULTS: Portal and splenic vein thrombosis was seen in 39 patients. Collateralization in case of portal and splenic vein thrombosis, in contrast to portal vein thrombosis, was predominantly left sided (74% vs. 9%, p < 0.0001). Fundal gastric varices were seen more often in patients with portal and splenic vein thrombosis (28% vs. 11%, p = 0.02), developing even after variceal obliteration, though obliteration was achieved in fewer sessions. Surgery for control of variceal bleed was performed more in the portal and splenic vein thrombosis group (33% vs. 15%, p = 0.02), especially for gastric varices (28% vs. 9%, p = 0.006). CONCLUSIONS: Portal and splenic vein thrombosis is present in 33% of patients with extrahepatic portal vein obstruction. Hemodynamic patterns differ, accounting for the preponderance of gastric varices on presentation in patients with portal and splenic vein thrombosis and an increased need for surgery.     

Endoscopic ablation with cyanoacrylate glue for isolated gastric variceal bleeding

BACKGROUND: Endoscopic ablation with cyanoacrylate glue may achieve gastric variceal obliteration. A prospective evaluation of its therapeutic effects on bleeding gastric varices was conducted, focusing on endoscopic features. METHODS: Thirty-seven patients with bleeding gastric varices underwent endoscopic ablation with cyanoacrylate. RESULTS: Patients with localized-type gastric varices (n = 14) had a better clinical course in terms of recurrent bleeding, variceal eradication, and survival than those with diffuse-type gastric varices (n = 23) after endoscopic ablation with cyanoacrylate. These clinical effects were related to the vascular anatomy of the gastric varices as determined by varicography and 3-dimensional CT. Type 1 vascular anatomy (one varicose vessel without noticeable ramifications) was much more common (86%) in localized-type gastric varices, whereas type 2 vascular anatomy (multiple varicose vessels with complex connecting ramifications) was found almost exclusively (91%) in diffuse-type gastric varices. CONCLUSIONS: Endoscopic ablation with cyanoacrylate is an effective and safe procedure for patients with bleeding gastric varices. Determination of variceal anatomy may be useful for improving treatment strategies for such patients.     

The effects of endoscopic variceal ligation and propranolol on portal hypertensive gastropathy: a prospective, controlled trial

BACKGROUND: Endoscopic treatment of esophageal varices may accentuate portal hypertensive gastropathy. The impact of the combination of band ligation and propranolol on this condition remains unknown. METHODS: Patients with history of variceal bleeding were randomized to receive band ligation alone (control group, 40 patients) or a combination of band ligation and propranolol (propranolol group, 37 patients). Serial endoscopic evaluation of gastropathy was performed. Gastropathy was classified into 3 grades and scored as 0, 1, or 2. RESULTS: Before endoscopic treatment, 17% of the control group and 22% of the propranolol group had gastropathy (p = 0.78). The occurrence of gastropathy after endoscopic treatment was significantly higher in the control group than in the propranolol group (p = 0.002). Serial endoscopic follow-up revealed that the mean gastropathy score was significantly higher in the control group than in the propranolol group (p < 0.05). In patients with gastropathy the gastropathy score reached a peak at 6 months after endoscopic treatment in both the control and propranolol groups (85% vs. 48%, respectively). After variceal obliteration, accentuation of gastropathy was significant in the control group (p < 0.01) but not in the propranolol group. Gastropathy was less likely to develop in patients who developed gastric varices. Esophageal variceal recurrence was not related to the development of gastropathy after variceal obliteration with banding. Only one patient in the control group bled from gastropathy. CONCLUSION: Band ligation of esophageal varices may accentuate gastropathy, which in this study was partly relieved by propranolol.     

A case of successful endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate for ruptured duodenal varices]

Duodenal varix is a rare cause of hemorrhage in patients with portal hypertension, however their rupture is serious and often life threatening. Treatments for duodenal variceal bleeding include endoscopic procedures, surgery, or interventional radiologic procedures. We report a case of duodenal varices rupture in a 45-year-old man with alcoholic liver cirrhosis who presented with melena and dizziness. Emergent upper endoscopy revealed large nodular varices with a ruptured erosion on the top in the distal second portion of duodenum. Two consecutive injections with 1.0 mL of n-butyl-2-cyanoacrylate (Histoacryl; Braun-Melsungen, Germany) mixed with 1.0 mL of lipiodol (Laboratoire-Guerbet, France) were performed intravariceally and achieved successful hemostasis. This suggests that endoscopic injection sclerotherapy with histoacryl may be an effective therapeutic option for the control of ruptured duodenal variceal bleeding.     

ENDOSCOPIC SCLEROTHERAPY FOR ESOPHAGO-GASTRIC VARICES: A CRITICAL REAPPRAISAL

Amongst the many non-surgical techniques for the treatment of variceal bleeding, endoscopic sclerotherapy (EST) has shown great promise. EST can successfully obliterate esophageal varices and prevent variceal rebleeding. It is also very effective in the control of active bleeding from esophageal varices. The technique of EST is simple and can be carried out with a conventional, forward viewing, flexible endoscope and a teflon injector. Weekly intravariceal injections of an aqueous sclerosant are prefer-rable. Though complications of EST in experienced hands are low, prophylactic EST at present should be advocated only to patients at high risk of bleeding. While controversy exists, most reports indicate that EST improves survival of patients with portal hypertension who have bled from esophageal varices. With regular follow-up endoscopics, recurrence of varices and bleeding from them can be substantially reduced. Sclerotherapy may successfully obliterate gastric varices in some patients either following EST for esophageal varices or by direct gastric variceal injections. For the long-term management of portal hypertension, combination of pharmacotherapy before as well as after eradication of esophageal varices, needs proper evaluation.     

Endoscopic ultrasonograph evaluation of vascular structures in the gastric cardia predicts esophageal variceal recurrence following endoscopic treatment

Background and Aim: In patients with portal hypertension, early recurrence of esophageal varices often occurs following endoscopic variceal ligation therapy or ligation and injection‐sclerotherapy combined treatment. To assess the recurrence risk following endoscopic treatment, this study investigated the association between recurrence‐free time and severity of esophagogastric vascular structures before treatment as determined by endoscopic ultrasonography. Methods: Sixty‐three patients with esophageal varices at high bleeding risk were treated by endoscopic variceal ligation therapy or ligation and injection‐sclerotherapy combined treatment. Before the treatment, conventional endoscopy and endoscopic ultrasonography with a 20‐MHz catheter probe were performed. Submucosal, perforating and adventitial veins in the esophagus and gastric cardia were examined. According to the endoscopic ultrasonography findings, the vascular structures were classified into two grades: mild and severe. The relationships between the endoscopic ultrasonography grades and variceal recurrence‐free time were analyzed by the Kaplan‐Meyer method. Results: Patients with severe as opposed to mild grade perforating veins in the gastric cardia had a significantly shorter recurrence‐free time (P < 0.05). Those with severe paracardial veins also had a significantly shorter recurrence‐free time (P < 0.01). Conclusion: Endoscopic ultrasonography analysis for gastric cardial vascular structures before endoscopic treatment can be useful to predict the recurrence of esophageal varices.     

Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension

AIM:To propose a less invasive surgical treatment for schistosomal portal hypertension.METHODS:Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study.Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein.During the procedure,direct portal vein pressure before and after the ligatures was measured.Upper gastrointestinal endoscopy was performed at the 30th postoperative day,when esophageal varices diameter were measured and band ligature performed.During follow-up,other endoscopic procedures were performed according to endoscopy findings.RESULTS:There was no intra-operative mortality and all patients had confirmed histologic diagnoses ofschistosomal portal hypertension.During the immediate postoperative period,two of the ten patients had complications,one characterized by a splenic infarction,and the other by an incision hematoma.Mean hospitalization time was 4.1 d(range:2-7 d).Pre-and post-operative liver function tests did not show any significant changes.During endoscopy thirty days after surgery,a decrease in variceal diameters was observed in seven patients.During the follow-up period(57-72mo),endoscopic therapy was performed and seven patients had their varices eradicated.Considering the late postoperative evaluation,nine patients had a decrease in variceal diameters.A mean of 3.9 endoscopic banding sessions were performed per patient.Two patients presented bleeding recurrence at the late postoperative period,which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient.Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion.CONCLUSION:Ligature of the splenic artery and left gastric vein with supraumbilical laparotomy is a promising and less invasive method for treating presinusoidal schistosomiasis portal hypertension.