Hiroya Wada

Effects of endoscopic injection sclerotherapy on portal hypertensive gastropathy: a prospective study

The effect of endoscopic injection sclerotherapy (EIS) for esophageal varices on portal hypertensive gastropathy (PHG) was investigated in 137 patients who underwent EIS from July 1987 to March 1990. Two groups, PHG(+) (N = 35) and PHG(-) (N = 102) were distinguished by endoscopic findings obtained before EIS. PHG was classified into four grades by endoscopy scored as 0, 1, 2, or 3. The PHG score significantly worsened after EIS (p < 0.01), and PHG became worse 6 to 9 months after the eradication of varices followed by gradual improvement. Recurrent small veins, which required additional EIS, appeared more frequently in the PHG(+) group (p < 0.05). New gastric varices appeared or gastric varices enlarged after EIS more frequently in the PHG(+) group (7 patients, 20.0%) than in the PHG(-) group (12 patients, 11.8%), but this was not statistically significant. Thus, frequent endoscopy after EIS is needed with special attention directed to development of PHG and gastric varices, especially for patients with PHG prior to treatment.

Anatomie resection for severe blunt liver trauma in 100 patients: Significant differences between young and elderly

The liver is the organ most commonly injured during blunt abdominal trauma. As our society ages, emergency surgery for active elderly patients increases, but data on aggressive emergency hepatic resection remain scarce in the literature. The purpose of this study was to determine whether the elderly (70 years of age or older) can tolerate major liver injury and subsequent hepatic resection. We investigated 100 patients who were treated by an anatomic resection for severe blunt liver trauma (29 elderly patients who were 70 years of age or older and 71 young patients who were younger than 70 years of age) in a retrospective study. The elderly patients were more severely injured as demonstrated by a higher Injury Severity Score, a lower Glascow Coma Scale, and lower survival (80.3% vs. 65.5%; p<0.05). The total number of associated injuries was greater in elderly patients. Motor vehicle accidents were responsible for 71.8% of the injuries in the young group, and the predominant mechanism in the elderly patients was also motor vehicle accidents (51.7%). The 71 anatomic hepatic resections performed on the young patients included right hemihepatectomy (n=45), left lateral segment resection (n=14), bisegmentectomy (n=5), and others. The 29 anatomic hepatic resections performed for the elderly patients were right hemihepatectomy (n=15), left lateral segment resection (n=5), left hemihepatectomy (n=4), and others. Pneumonia, subphrenic abscess, and urosepsis occurred at a significantly higher frequency in elderly patients than in young patients. Our data clearly indicated that (1) the mechanism of injury, grade of associated intraabdominal injuries, distribution of surgical procedures, and complications differ significantly between young and elderly patients; and (2) the survival rate (65.5%) in elderly patients may be sufficient to consider anatomic hepatic resection to be a useful, safe procedure.RésuméLe foie est l’organe le plus souvent lésé lors des traumatismes fermés de l’abdomen. En raison du vieillissement de notre société, le besoin d’envisager une chirurgie d’urgence pour les gens âgés augmente. Cependant, les données dans la littérature sur les résections hépatiques agressives en urgence sont très rares. Le but de cette étude a été de déterminer comment le sujet âgé de 70 ans ou plus supporte des lésions hépatiques majeures et ensuite comment il supporte une résection hépatique en conséquence. Nous avons revu rétrospectivement les dossiers de 100 patients traités par résection réglée pour traumatisme fermé sévère du foie (29 patients âgés qui avaient 70 ans ou plus, et 71 patients plus jeunes, moins de 70 ans). Les patients âgés de 70 ans ou plus avaient des lésions plus graves comme on pouvait le constater par un score ISS plus élevé, un score de Glasgow plus bas, et un taux de survie plus bas (80.3 vs. 65.5%, p<0.05). Le nombre total de lésions associées était plus élevé chez les patients plus âgés. Les accidents de voitures étaient responsables de 71.8% des lésions chez les plus jeunes; ils étaient également la cause principale chez les personnes âgées (51.7%). Parmi les 71 résections hépatiques réglées chez le sujet jeune, on note, parmi les interventions principales, l’hémihépatectomie droite (n=45), la résection segmentaire latérale gauche (n=14) et la bisegmentectomie (n=5). Parmi les 29 résections hépatiques réglées chez les sujets plus âgés, on note principalement l’hémi hépatectomie droite (n=15), la résection segmentaire latérale gauche (n=5) et l’hémihépatectomie gauche (n=4). On a noté plus de complications comme l’infection pulmonaire, les abcès sous-phréniques et les infections urinaires chez les patients plus âgés que chez le patient plus jeune. Nos données indiquent clairement que: (1) le mécanisme des lésions, le degré des lésions intra-abdominales associées et les complications diffèrent significativement entre les patients ages et jeunes, et (2) le taux de survie (65.5%) chez les patients plus âgés est une preuve que la résection hépatique réglée chez le sujet est utile et sure.ResumenEl hígado es la víscera que con más frecuencia se lesiona en los traumatismos cerrados de abdomen. Dado que nuestra sociedad envejece más, la cirugía de urgencia en pacientes añosos es cada vez más frecuente. Sin embargo, la bibliografía sobre las resecciones hepáticas urgentes es escasa. El objetivo del trabajo fue averiguar si los viejos (de 70 o más años) pueden o no soportar traumatismos hepáticos mayores, así como la subsiguiente resección hepática. Se estudiaron retrospectivamente 100 pacientes que por grave traumatismo cerrado de hígado requirieron una resección hepática anatómica (29 tenÍan 70 o más años y 71 menos de 70 años). Los pacientes añosos presentaron traumatismos más graves como demostraba su alta puntuación en la escala ISS, la baja puntuación en la GCS y la escasa supervivencia (80.3 vs 65.5%, p<0.05). El número total de traumatismos asociados fue mayor en los pacientes añosos. Los accidentes viarios fueron la causa etiológica más frecuente tanto en los traumatizados jóvenes (71.8%) como en los viejos (51.7%). En pacientes jóvenes se practicaron 71 hepatectomías anatómicas que comprendieron: hemihepatectomía derecha (n=45), resección segmenteria lateral izquierda (n=14), bisegmentectomía (n=5) y otros tipos de resección. En ancianos, se realizaron 29 resecciones hepáticas anatómicas: hemihepatectomía derecha (n=15), resección segmentaria lateral izquierda (n=5), hemihepatectomía izquierda (n=4) y otros tipos de resecciones. Complicaciones tales como pneumonías, abscesos subfrénicos, urosepsis, fueron mucho más frecuentes en los pacientes añosos. Nuestros hallazgos demuestran: (1) que el mecanismo del trauma, el número de lesiones traumáticas asociadas intraabdominales, el tipo de intervención quirúrgica y las complicaciones son totalmente diferentes en pacientes jóvenes que en los viejos y (2) que la supervivencia (65.5%) en los pacientes añosos es alta, por lo que la resección hepática anatómica puede considerarse un procedimiento útil y seguro.

Features of early gastric cancer detected by modern diagnostic technique.

To ascertain how the clinicopathologic features of early gastric cancer detected by current diagnostic tools had changed clinical features, we compared 711 early gastric cancer patients with 933 advanced gastric cancer patients regarding age, sex, and tumor location. We found that the proportion of early gastric cancer cases did not change according to age. However, the proportion of early gastric cancer cases in the proximal part was significantly lower than that observed in the distal part (p < 0.01). We conclude that recent diagnostic improvements have rendered age no longer a major deterrent for early detection of gastric cancer. However, a careful examination of the proximal stomach is called for because it is so hard to detect small lesions in that area.

Temporary Deterioration of Pulmonary Functions after Injection Sclerotherapy for Cirrhotic Patients with Esophageal Varices

In 34 cirrhotic patients with esophageal varices, a significant but temporary deterioration in pulmonary function tests occurred 24 h after endoscopic injection sclerotherapy using 5% ethanolamine oleate. Included were vital capacity, forced expiratory volume in 1 s, closing volume/vital capacity and arterial oxygen content. Twenty-four hours after the sclerotherapy, the patients complaining of postinjection retrosternal pain had a larger fall in vital capacity and forced expiratory volume in 1 s than did the patients without pain. Before the injection sclerotherapy, 11 of 34 patients had an arterial hypoxemia (PaO2 less than 80 mm Hg). In these patients, there was a significantly (p less than 0.001) higher value of closing volume before sclerotherapy and there were larger changes in both closing volume (p less than 0.01) and arterial oxygen content (p less than 0.01) 24 h after the injection sclerotherapy than in the patients without hypoxemia. Reversion to a state before sclerotherapy was attained 7 days after the sclerotherapy. Thus, patients undergoing sclerotherapy for bleeding esophageal varices should be closely monitored with regard to pulmonary function.

Comparative effects of 5% ethanolamine oleate versus 5% sodium morrhuate for sclerotherapy of oesphageal varices

Forty‐five cirrhotic patients with oesophageal varices were randomized to receive endoscopic injection sclerotherapy with either 5% ethanolamine oleate (EO), or 5% sodium morrhuate (SM). In the EO group, there was a statistically significant higher rate of disappearance of red colour signs on the varices a week after the initial session of sclerotherapy than in the SM group (91.3%vs 45.5%, P < 0.05). A jet‐like bleeding from injection sites at the second session of sclerotherapy occurred in three patients in the SM group and they experienced blurred vision. There was no such occurrence in the EO group. Oesophageal bleeding requiring blood transfusion during the course of repeated sclerotherapy occurred only in the SM group (five patients): bleeding was from a partly thrombosed varix and in four was from oesophageal ulcers.