Kazushige Beppu

Exclusion of nonisolated splenic vein in distal splenorenal shunt for prevention of portal malcirculation.

In an attempt to prevent portoprival malcirculation after distal splenorenal shunt (DSRS), a splenic hilar renal shunt (HRS) with proximal flush ligation of splenic vein was designed. To accomplish this procedure, two methods were compared: HRS alone (Group A) and HRS plus proximal flush ligation of the splenic vein (Group B). In Group A, which included 20 cirrhotic patients with esophageal varices, angiographic as well as pulsed Doppler flowmetric follow-up study revealed a portal thrombosis in two patients and severe narrowing of a portal vein in another two. Considerable stealing flow was observed in these four patients. In the Group B series, which included 33 cirrhotic patients, there were no gross changes in the portal hemodynamics. Normal prograde portal flow was confirmed by Doppler flowmeter in this series including 14 patients of more than 8 months after surgery. When the amount of nonisolated splenic vein embedded in the pancreas is minimized, portal malcirculation after distal splenorenal shunt can, to a great extent, be prevented.

The natural history of nonalcoholic cirrhosis

SummaryTo assess the natural history of non-alcoholic liver cirrhosis, one hundred and eighty medically treated Japanese cases, including 110 accompanied by esophageal varices were investigated retrospectively. Among those patients with varices fifty-one (46.4%) bled from the upper gastrointestinal (GI) tract and thirty-two (29.1%) from esophageal varices, while GI bleeding was found in only six out of 70 patients without varices. The GI bleeding rate was the highest in patients with varices and concomitant hepatoma (76.5%). The mortality rate of the GI bleeders was 68.6% in patients with varices and 33.3% in patients without varices. The mortality on the first variceal bleeding episode was 65.6%, and another 25.0% had rebleeding from varices, resulting in a one-year survival of 9.4%. The ten-year cumulative percentage of variceal bleeding was 61.2% in patients with varices, and that of occurrence of hepatoma was 50.7% in total of 180 patients.This study revealed that the non-alcoholic cirrhotic patients have a highly rate of complication by hepatoma and that the development of hepatoma doubles the risk of varix rupture.

Decreased arteriovenous flow resistance in the left gastric venous area in cirrhotic patients

Abstract. To assess the relationship between the fluid mechanics in the left gastric venous area and the portal trunk, manometric measurements were made in patients with or without cirrhosis of the liver. In ten normal subjects, temporary portal vein occlusion produced comparable elevation in both the occluded left gastric venous pressure (OLGP) and the portal vein pressure (PVP); 152–4129 mm of water in OLGP and 115–452 mm of water in PVP. In sixty cirrhotic patients, however, the portal vein occlusion resulted in far less increase in OLGP than that in PVP; 281–365 mm of water in OLGP and 281–540 mm of water in PVP. In other words, regarding pressure measurements, the relationship was ‘separated’ in cirrhotics, but ‘continuous’ in normal subjects. Mathematical analysis of the data using a modification of Wheat‐stone bridge model suggested that the arteriovenous flow resistance in the left gastric venous area of cirrhotics was reduced to less than one fifth of that in the controls. It would appear that the increased flow capacity as a result of a reduced arteriovenous flow resistance is responsible for the functional ‘separation’ from the portal trunk.

Eradication of esophageal varices with repeated injection sclerotherapy in inoperable patients.

SummaryEsophageal varices in 50 cirrhotic patients were treated with repeated injection sclerotherapy. Eradication of varices was achieved in 27 patients (54.0%) with a mean of 4.5 injections (range 2–12) after a mean period of 3.1 months (range 1–11). There was no variceal bleeding in these 27 patients once eradication had been achieved, with a mean follow up period of 5.6 months, although bleeding occurred in 5 of the same group before eradication of the varices had been achieved, during an average of 3.1 months, and in 6 of the remaining 23 patients (10 episodes) with residual varices after a mean of 4.7 injections (range 2–12) in a mean period of 12.2 months (range 1–33).Esophageal varices can thus be eradicated with repeated injections and bleeding from recurrent esophageal varices can be prevented in many patients after eradication has been achieved.

Development of erosive gastritis in a canine model of esophageal varices

We designed a reproducible canine model of esophageal varices, based on the concept of a regional hyperdynamic state in the upper stomach. Arterialization of the left gastric vein concomitant with the distal splenorenal shunt led to a stable hyperdynamic state and reproducible esophageal varices occurred. In the long-term follow-up of these dogs with varices, the erosive gastritis seen in the upper stomach learly resembled clinically observed lesions. Hemodynamic and morphological studies revealed that gastric mucosa of these animals was in an ischemic state, even though there was a remarkable increase in blood flow in the submucosal area. It is suggested that the decrease in mucosal blood flow, as induced by the hyperdynamic state caused erosive gastritis.

Hyperdynamic circulation in the left gastric venous area in patients with portal hypertension: Angiological assessment

The time of appearance of the left gastric vein on serial celiac arteriograms in patients with portal hypertension and esophageal varices was compared with that of the portal vein to assess regional hemodynamics in the left venous portion of the stomach, an area located in close proximity to the varices. In two thirds of all the patients with cirrhosis or non-cirrhotic idiopathic portal hypertension (IPH), the left gastric vein was visualized earlier or simultaneously than or with the portal vein, while in all but one patient with prehepatic portal obstruction, there was a delayed opacification of the left gastric vein. These results suggest the presence of a hyperdynamic circulatory state which promotes venous hypertension in the left gastric venous area of the stomach of a considerable number of patients with cirrhosis or IPH. In such a hemodynamic state, selective decompression of varices can be achieved by a left gastric venous caval shunt.

A case with Budd-Chiari syndrome associated with pregnancy.

症例は34歳女性.妊娠32週で性器出血し,部分前置胎盤早期剥離の診断で帝王切開を受けた.術後急速に大量の腹水貯留を来し,利尿剤に抵抗性であった.腹水の性状は滲出性であり,腹腔鏡肝生検で肝うつ血の所見が認められた.下大静脈造影で下大静脈の総腸骨静脈からの入口部より肝静脈流入部までの閉塞が証明され,下大静脈閉塞を伴う,Budd-Chiari症候群と診断された.妊産婦は,凝固因子の増加,線溶能の低下,血小板粘着能の上昇など血栓を形成しやすい状態にある.本例は,部分前置胎盤早期剥離と帝王切開に伴い,組織トロンボプラスチンが血中へ大量流入し,急速に血栓が形成されたものと推定された.妊娠を契機に発症したBudd-Chiari症候群は1980年までに約30例が報告されているが,本邦では,初めての報告である.

Plasma exchange therapy for post-operative hepatic failure.

術後肝不全に対する血漿交換療法は,黄疸や肝性脳症等の肝不全症状が確立した時点でこれを施行しても救命の可能性は少ない.しかし我々は,血漿中Lecithin cholesterolacyltransferase (LCAT)活性を指標として早期に肝不全発症を予知し,非代償性になる以前に血漿交換を施行したところ,14例中5例(36%)に生存を認め,4例(29%)に1ヵ月以上の延命効果を認めた.我々の用いた適応基準は,1)LCAT活性0値により肝不全発症を予知し,2)群姓脳症grade 1ないし2(Sherloek),3)プロトロンビン時間35%以上,4)総ビリルビン値10mg/dl未満内に施行することであった.また施行中の有効性判定指標として,LCAT活性値が上昇してくるものは効果が期待できた(100%, n=5).肝硬変症等の術後に発生する肝不全は,血漿交換療法を早期に適切に用いることにより救命される可能性が大きいことを示した.