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.     

Prognostic blue varices as a discriminant factor of variceal hemorrhage: amendment of the criteria of endoscopic findings of esophageal varices

Up until now, the endoscopic findings related to hemorrhage from esophageal varices have been red color signs (RCS) and the fundamental bluish color (Cb) of the varices. Although most investigators agree with the former, there is considerable dispute regarding the latter "blue varices". In order to identify the "risky" type of blue varices, prognostic varices (P-Cb) were specifically defined as being featured by a fully expanded appearance with a glossy surface, like an over-inflated balloon. Three hundred and nineteen collected patients with esophageal varices, including 114 bleeders, were retrospectively assessed and the P-Cb was found to have a significant correlation to the bleeding history. The P-Cb should be taken into account when attempting to predict bleeding of blue varices. The general rules for recording endoscopic findings of esophageal varices, as determined in 1980, should thus be amended.     

Transvenous sclerotherapy for huge oesophagogastric varices using open injection sclerotherapy

BACKGROUND: The optimum procedure for long-term management of oesophagogastric varices when endoscopic sclerotherapy or ligation fails is yet to be established. This report describes a new procedure for treating huge oesophagogastric varices by open injection sclerotherapy. METHODS: Twenty-three patients with huge oesophagogastric varices underwent laparotomy and devascularization of the upper stomach with splenectomy. The left gastric vein was catheterized for repeated injection of 5 per cent ethanolamine oleate during the postoperative period. RESULTS: In all patients, the varices were eradicated after a mean of 3 sessions of sclerotherapy. There were no deaths or major complications during the mean follow-up period of 41 months. Small recurring varices in two patients were treated successfully by endoscopic sclerotherapy and interventional radiology. CONCLUSION: Open injection sclerotherapy is an effective and safe procedure for the treatment of huge oesophagogastric varices.     

The sources of recurrent hemorrhage during long-term sclerotherapy

The sources of recurrent hemorrhage during long-term sclerotherapy undertaken by a single surgeon were studied prospectively in a consecutive series of 53 patients for a period of 2 to 6 years. Recurrent hemorrhage, defined as upper gastrointestinal bleeding requiring transfusion or hospitalization or both, in the course of chronic sclerotherapy was investigated aggressively by means of endoscopy and the findings archived with videotape recording. In 24 patients 51 episodes of recurrent hemorrhage developed in the entire series. On the basis of endoscopic findings and serial comparison of videotape recordings, the most common source of recurrent hemorrhage was the original varices, which accounted for rebleeding in 18 patients. The risk of such bleeding was highest in the first month, diminishing thereafter until total variceal eradication. Rebleeding after eradication of varices was always from sources other than varices, as regenerated vessels were small and infrequent and never the source of bleeding. Continued sclerotherapy ultimately achieved total variceal eradication in 15 of 18 patients with variceal rebleeding. Sclerotherapy alone was successful in eradicating all varices in a total of 38 patients in this series, the mean time required being 13 +/- 4.1 months. Rebleeding from sources not amenable to sclerotherapy was treated with porto-azygos disconnection (6 patients) or distal splenorenal shunts (3 patients). There were 12 deaths: four attributed to hemorrhage (3 after surgery), five from liver failure, and three late deaths from causes not due to liver disease. Recurrent hemorrhage per se during the course of sclerotherapy may not be taken as a sign of treatment failure but must be vigorously investigated, since findings profoundly affect management and outcome.     

Rupture of rectal varices treated with endoscopic variceal ligation

We report here 3 cases of rectal varices treated with endoscopic variceal ligation and discuss the pathogenesis, treatment, and prognosis of rectal varices with referring to previous reports. Of the 3 patients, 2 had been diagnosed as liver cirrhosis and 1 as extrahepatic portal hypertension. All of the 3 patients had previously undergone treatment of esophagogastric varices. The rupture of rectal varices appeared to have some relationship with the treatment of esophageal varices. In previous reports, 73% of patients with ruptured rectal varices treated with endoscopic injection sclerotherapy or endoscopic variceal ligation had undergone treatments of esophageal varices. The endoscopic treatments resulted in a favorable prognosis in 2 patients. Although no fatality from endoscopic injection sclerotherapy or endoscopic variceal ligation has been reported, 1 of the present 3 cases died of liver failure.     

The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices

The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.     

Treatment of bleeding esophageal varices: sclerotherapy or surgery?

To evaluate therapeutic options to improve the prognosis of haemorrhage from oesophageal varices, a study was performed on 422 patients observed from 1983 to 1998. Patients were classified according Child-Campbell method after improvement of general conditions (class A: 7%; B: 68%; C: 25%). Thirty-two patients (7.8%) died during emergently pharmacologic treatment in the first 24 hours; 182 patients (44.6%) because of persistent haemorrhage underwent endoscopic sclerotherapy. In 164 (90.1%) bleeding stopped and 14 cases (7.6%) underwent emergency surgical treatment (9 splenectomies and splenorenal shunts, 5 mesenterico-caval shunts). Teu other patients (with rebleeding 3-7 days after sclerotherapy) underwent emergency surgical treatment (7 azygos-portal thoracotomic deconnections, 3 splenectomies and spleno-renal shunts). The rates of therapeutic success were respectively 80% for surgical treatment and 90% after sclerotherapy. Factors of prognostic improvement of these emergently disease are examined. The advantages of both endoscopic and surgical treatment are outlined.     

Endoscopic sclerotherapy in the management of esophageal varices in 61 children with biliary atresia

Sixty-one children who have survived 2.5 years or more after corrective surgery for biliary atresia were prospectively followed by endoscopy. Esophageal varices were detected in 41 patients (67%), 17 of whom (28%) had experienced episodes of variceal hemorrhage. Control of variceal bleeding was achieved by endoscopic injection sclerotherapy in all but one child who died from hemorrhage before the completion of treatment. Complications of the technique comprised episodes of bleeding before variceal obliteration (7), esophageal ulceration (5), and stricture (3). These resolved with conservative management and without long-term sequelae. During a mean follow-up period of 2.8 years after variceal obliteration, rebleeding from recurrent esophageal varices developed in only one child and responded to further sclerotherapy. These results are better than those following surgical procedures for portal hypertension in biliary atresia, and therefore endoscopic sclerotherapy is recommended as the treatment of choice.     

New approach in the management of oesophageal varices

Combined therapy consisting of sclerotherapy, embolization and splenopneumopexy was established for the treatment of oesophageal varices. These procedures were safely performed in 16 patients. No serious complications and no recurrent bleeding have been observed. The varices disappeared or were significantly improved as determined by periodic endoscopic evaluations. Portopulmonary shunt by splenopneumopexy is an alternative technique in the eradication of varices following sclerotherapy.     

Extrahepatic portal hypertension: long-term results of surgical treatment.

Long-term results of surgical treatment were analysed in 42 patients with extrahepatic portal hypertension treated in the Department of Surgery, Institute of Haematology in Warsaw in the period 1971-1987. In all, 71 operations were carried out, and 20 patients were treated by endoscopic sclerotherapy of oesophageal varices. Recurrence of haemorrhage was found in 6 out of 11 patients 54% after venous shunting, in 13 out of 17 patients (76%) after treatment by ligation of oesophageal varices and in 32 out of 35 patients (91%) after splenectomy. Following repeated sclerotherapy of oesophageal varices, recurrence of haemorrhage occurred in 3 out of 20 patients (15%). During 17 years four deaths occurred (10%) none of which was due to haemorrhage from oesophageal varices. The authors conclude that the method of repeated sclerotherapy is presently the most effective way of preventing haemorrhage from oesophageal varices and consider this form of management as the treatment of choice in patients with extrahepatic portal hypertension.     

Sonographic evaluation of the portal venous system after elective endoscopic sclerotherapy of esophageal varices

Summary In order to evaluate possible changes in the portal venous system after endoscopic sclerosis of esophageal varices, 25 cirrhotic patients underwent abdominal ultrasonography before the first session of sclerotherapy and after eradication of esophageal varices had been achieved. The caliber of the portal, splenic, and superior mesenteric veins was measured sonographically in each case. Sonographic results were compared statistically before and after sclerotherapy. Neither evidence of significant variations in the caliber of the portal veins nor thrombotic obliteration was seen. These results support the view that sclerotherapy has no significant negative side effects on the portal venous system.     

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.     

Acute bleeding varices: a five-year prospective evaluation of tamponade and sclerotherapy.

In a five-year study of massive upper gastrointestinal hemorrhage, 143 patients had esophageal varices diagnosed on emergency endoscopic examination. Seventy-one patients had active bleeding from varices and required Sengstaken tube tamponade during at least one hospital admission. The remaining patients included 33 with variceal bleeding which had stopped and 39 who were bleeding from another source. Sixty-six of the former group of 71 patients were referred for emergency injection sclerotherapy. These 66 patients were followed prospectively to August 1980, and had 137 episodes of endoscopically proven variceal bleeding requiring Sengstaken tube control followed by injection sclerotherapy during 93 separate hospital admissions. Definitive control of hemorrhage was achieved in 95% the patients admitted to the hospital (single injection 70%; two or three injections 22%). The death rate per hospital admission was 28%. No patient died of continued variceal bleeding, and exsanguinating variceal hemorrhage no longer poses a major problem at our hospital. The combined use of initial Sengstaken tube tamponade followed by injection sclerotherapy has simplified emergency treatment in the group of patients who continue to bleed actively from esophageal varices, despite initial conservative treatment.     

Prognostic blue varices as a discriminant factor of variceal hemorrhage: Amendment of the criteria of endoscopic findings of esophageal varices

Up until now, the endoscopic findings related to hemorrhage from esophageal varices have been red color signs (RCS) and the fundamental bluish color (Cb) of the varices. Although most investigators agree with the former, there is considerable dispute regarding the latter “blue varices”. In order to identify the “risky” type of blue varices, prognostic varices (P-Cb) were specifically defined as being featured by a fully expanded appearance with a glossy surface, like an over-inflated balloon. Three hundred and nineteen collected patients with esophageal varices, including 114 bleeders, were retrospectively assessed and the P-Cb was found to have a significant correlation to the bleeding history. The P-Cb should be taken into account when attempting to predict bleeding of blue varices. The general rules for recording endoscopic findings of esophageal varices, as determined in 1980, should thus be amended. The Co-Operative Study Group included: Director, Kiyoshi Inokuchi, MD; members, Kaichi Isono, MD (Chiba Univ), Seiichiro Kobayashi, MD (Tokyo Women’s Med Coll), Ken Morita, MD (Nippon Univ), Terukazu Muto, MD (Niigata Univ), Fusahiro Nagao, MD (Jikei Med Coll), Keizo Sugimachi, MD (Kyushu Univ) and Mitsuo Sugiura, MD (Juntendo Univ)     

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.     

Mechanical tracheal obstruction due to an intramural esophageal hematoma following endoscopic variceal sclerotherapy.

Endoscopic injection sclerotherapy is widely used as treatment for bleeding esophageal varices. Esophageal intramural hematoma is a rare complication following endoscopic injection sclerotherapy. Patients present with pain and dysphagia due to esophageal obstruction. We present the first reported case of respiratory failure resulting from an intramural hematoma causing posterior tracheobronchial compression. Although patients with alcoholic cirrhosis and bleeding varices requiring respiratory support generally have a poor prognosis this may be an occasion when ventilatory support may be expected to be easily withdrawn after hematoma resolution.     

Delayed dysphagia after sclerotherapy of esophageal varices. Review]

167 of 189 patients were followed prospectively after sclerotherapy of oesophageal varices between 1982 and 1989. 18% developed a stenosis of the lower oesophagus causing dysphagia: 3 of these 30 strictures were malignant and 27 were benign. The former are probably not related to sclerotherapy. 17 of the latter responded to a modified diet and the other 10 required endoscopic dilatation. This was done successfully on an out-patient basis without complication in all cases. We conclude that dysphagia after sclerotherapy of oesophageal varices is common; it is usually caused by a benign stricture: if severe, it responds to endoscopic dilatation.     

Ten years experience with paravariceal injection sclerotherapy of esophageal varices in children

Esophageal varices in 59 consecutive children with portal hypertension were treated by paravariceal injection sclerotherapy. Repeated injections were performed using a special rigid instrument under general anesthesia. In children older than 10 a flexible endoscope was used without general anesthesia. Using 0.5% Polidocanol, a fibrous layer protecting varices against the further bleeding was produced in 59 children. Complications during treatment included hemorrhage, esophageal ulceration and stricture, each in two children. 55 children have been followed for 6 months to 10 years after two phases of paravariceal injection following the first phase of treatment. Three rebleeds have occurred in this group. Sclerotherapy was repeated. Thereafter, using a regular endoscopic control every year, no rebleeding occurred. Four children with liver cirrhosis died of liver failure. All other children except four foreign ones could be followed. 51 of them (86%) are alive.     

Treatment of hepatocellular carcinoma with esophageal varices

This report describes 53 patients with hepatocellular carcinoma (HCC) complicated with esophageal varices. Esophageal varices were due to cirrhosis of the liver in all cases. Hepatic resection and blocking operations such as Sugiura procedure, transabdominal esophageal transection or Hassab's operation were performed for the treatment of HCC and esophageal varices in 6 cases with satisfactory results. Non-operative treatments such as TAE or arterial infusion chemotherapy for HCC and blocking operations for esophageal varices were performed in 17 cases. Late deaths were recognized in 10 cases. Causes of late deaths were carcinoma of the liver in 7 cases and ruptured varices in only 1 case. In 13 cases with severe hepatic failure, only endoscopic sclerotherapy was performed for the treatment of esophageal varices. However 8 cases of 13 had rebleeding from esophageal varices and died after sclerotherapy. We concluded that effective treatments for HCC complicated with esophageal varices were to perform both the hepatic resection and the blocking operation and these treatments prolong the long-term survival of patients with HCC with esophageal varices.     

Endoscopic ethanol injection treatment for bladder cancer

One invasive and 4 superficial bladder cancers were treated by local injection of absolute ethanol through an endoscope. With the patient placed in the lithotomy position, an endoscope was introduced after mucosal anesthesia with xylocaine jelly. According to the usual manner of retrograde catheterization, a 23G syringe needle attached to a 5F ureteral catheter was advanced into the base of the tumor and through the needle absolute ethanol was injected. This treatment is characterized by endoscopic delivery of ethanol as with sclerotherapy for esophageal varices to obtain a potent necrotizing effect as achieved by transcatheter embolization of ethanol for the treatment of renal cell carcinoma. As a rule, this technique does not require any anesthesia other than mucosal anesthesia with xylocaine jelly and can be done repeatedly and very easily, thus having a high cost effectiveness. This treatment serves as a good palliative therapy for invasive bladder cancers, because of its rapid achievement of hemostasis and reduction of the tumor masses. Furthermore, this treatment is just as effective as standard transurethral resections to eradicate superficial bladder cancer, even though the treatment may have to be repeated.