Niranjan Sharma

Injection Sclerotherapy for Esophageal Varices after Total Gastrectomy: Case Reports of Two Patients

Injection sclerotherapy was performed in two patients with esophageal varices who had undergone a total gastrectomy and Roux‐en‐ Y esophagojejunostomy for gastric cancer. Both of the patients were diagnosed as having postnecrotic liver cirrhosis due to serum hepatitis. The first patient developed esophageal varices after surgery. The second patient had recurrent esophageal varices after surgery for both gastric cancer and the esophageal varices. Five percent ethanolamine oleate was the sclerosant used together with the contrast medium iopamidol (5% EOI). After intravariceal injection, the flow of the sclerosant was followed by fluoroscopy. The esophageal varices were fed by the branches of the jejunal vein of the arcade of the ascending jejunal limb. The esophageal varices and branches of the jejunal vein were destroyed by three consecutive sessions of sclerotherapy. No complications occurred during or after the therapy. Therefore, injection sclerotherapy, along with varicealography, is one of the most effective methods of treating esophageal varices arising after a total gastrectomy.

Injection Sclerotherapy for Esophageal Varices Associated with Hepatocellular Carcinoma and Liver Cirrhosis

Survival period, causes of death and variceal rebleeding in 20 patients with esophageal varices associated with hepatocellular carcinoma and liver cirrhosis were analyzed to evaluate the effectiveness of injection sclerotherapy. The first injection sclerotherapy successfully stopped active variceal bleeding in all seven emergency cases. These were followed up as elective cases later on. The remaining 13 patients, who had a history of variceal bleeding, were treated as elective cases from the beginning. Endoscopic evaluation of the varices was performed at intervals of six months to one year, after the first sclerotherapy, and recurrence was treated by elective sclerotherapy. 85% of the patients died within one year. Three out of 20 cases were still alive until this study was performed. But, whereas 17 patients died mainly due to hepatic failure and hepatocellular carcinoma, only one patient died due to variceal rebleeding. No deaths were observed to have been directly due to sclerotherapy or its complications. Hence we think that injection sclerotherapy should be considered one of the treatments for esophageal varices in patients with hepatocellular carcinoma and liver cirrhosis.

Pathological Changes of Esophagogastric Varices After Endoscopic Sclerotherapy

In cases where gastric varices are contiguous with esophageal varices, it has been reported that most of the feeders of the esophagogastric varices are the left gastric vein and/or the short gastric veins [1, 2]. It was thought that the gastric varices are residual varices that sometimes become larger after the treatment of esophageal varices alone by injection sclerotherapy. Simultaneous obliteration of the gastric and the esophageal varices were obtained, when the sclerosant was intravariceally injected into their feeders during treatment for esophageal varices. At times, a histopathological study of esophagogastric variceal changes is not enough to predict the final outcome of the sclerotherapy. Therefore, the present study was carried out in an attempt to elucidate the pathological course of the esophagogastric varices after injection sclerotherapy.

Injection Sclerotherapy for Recurrent Esophageal Varices after Surgical Procedures

Abstract: Thirteen patients, who had recurrent esophageal varices after esophageal transection or esophagoproximal gastrectomy were treated by endoscopic injection sclerotherapy. Four patients successfully underwent emergency sclerotherapy to control active variceal hemorrhaging. Three of these patients and the remaining nine patients (including six rebleeding patients who were conservatively treated) underwent elective sclerotherapy. None of the patients had variceal rebleeding in the follow‐up study with sclerotherapies. Only one patient with recurrent varices did not undergo any additional sclerotherapy following emergency treatment. In this study, no deaths occured nor any major complications. Minor complications such as low grade fever and chest pain were observed, but they were transient and disappeared within 2 or 3 days without specific treatments. It is concluded that endoscopic injection sclerotherapy is considered to be the most effective procedure for recurrent varice following surgery.

Endoscopic Sclerotherapy for Esophageal Varices after Renal Transplantation: Report of One Autopsy Case

Abstract: Endoscopic sclerotherapy has been used to manage esophageal varices. Severe complications resulting from this therapy including renal dysfunction have been reported. Therefore, particular caution must be taken with patients who have serious renal damage. Sclerotherapy was performed for esophagogastric varices in a patient that had received a kidney transplant following chronic renal dysfunction. Ethanolamine oleate was used as the sclerosant, and contained a contrast medium for varicealography in order that the flow of the sclerosant be monitored by fluoroscopy. Varicography during the injection allowed us to stop injection into the varices and into the irregular passageways of the feeders to the varices before the agent entered the systemic circulation. There were no complications during therapy. The patient died due to respiratory failure 41 months after the first treatment. Macroscopic findings of the autopsied specimens showed no esophagogastric varices and microscopic findings showed organized varices with recanalization into the submucosal layer of the esophagogastric lesions. Injection sclerotherapy using varicography with sclerosant‐contrast medium mixture allowed treatment of this patient without incurring renal dysfunction.

A Clinical Study on the Diagnosis and the Treatment of Mesenteric Arterial Occlusion Compared with Strangulation Ileus.

腸間膜動脈閉塞症の早期診断ならびに治療方針の確立を目的として, 診断, 治療ならびに予後について, 本症と絞扼性イレウスを対比検討した. 対象は, 腸間膜動脈閉塞症 (1群) 12例と絞扼性イレウス (II群) 27例である. 背景因子としては, 年齢 (1群69±9歳, II群54±21歳), 開腹術の既往 (各17%, 74%), 心疾患の併存 (各75%, 22%), 身体所見では腹部圧痛 (各58%, 96%), 反跳痛 (各25%, 78%), 筋性防御 (各8%, 70%), 検査所見ではLDH≧5001U/l (各92%, 26%), 治療では, 広範囲腸管切除率 (各70%, 11%), 予後では, 死亡率 (各50%, 4%) において1群とII群間に有意差 (p<0.01) が認められた. 腸間膜動脈閉塞症は絞掩性イレウスに比べて, 広範囲腸管切除率は高く, 死亡率も高い. したがって, 高齢で, 開腹術の既往がなく, 心疾患の併存があり, 腹部所見が軽く, LDH≧5001U/lを呈すイレウス症例については, 腸間膜動脈閉塞症を積極的に疑い, 早期に血管造影検査を施行すべきである.

Esophageal ulcer due to ingestion of melted copper

We report a patient with esophageal stricture as a result of the accidental swallowing of melted copper by a 49-year-old male. As a result, esophagogastric ulcers developed and left a cicatrical stricture. The patient could only manage to swallow liquid food. Radiology of the upper gastrointestinal tract showed marked stricture of the esophagus from the middle thoracic portion to the esophagogastric junction and shortening of the lesser curvature of the stomach. The patient underwent a single-session total gastrectomy, and excision of the thoracic esophagus and construction of anterior thoracic esophagocolic and duodenocolic anastomoses were performed by right thoracotomy and laparotomy, respectively. Macroscopic findings of the surgical specimens showed extensive circular ulcers at the esophagus, and microscopic findings showed deep ulcers extending to the muscle layer with marked fibrosis. The postoperative course was uneventful.SummaryWe report a patient with esophageal stricture as a result of the accidental swallowing of melted copper by a 49-year-old male. As a result, esophagogastric ulcers developed and left a cicatrical stricture. The patient could only manage to swallow liquid food. Radiology of the upper gastrointestinal tract showed marked stricture of the esophagus from the middle thoracic portion to the esophagogastric junction and shortening of the lesser curvature of the stomach. The patient underwent a single-session total gastrectomy, and excision of the thoracic esophagus and construction of anterior thoracic esophagocolic and duodenocolic anastomoses were performed by right thoracotomy and laparotomy, respectively. Macroscopic findings of the surgical specimens showed extensive circular ulcers at the esophagus, and microscopic findings showed deep ulcers extending to the muscle layer with marked fibrosis. The postoperative course was uneventful.

Endoscopic Sclerotherapy for Esophageal Varices After Surgical Procedures for Congenital Biliary Atresia

Abstract: The effectiveness of injection sclerotherapy for esophageal varices due to congenital biliary atresia has not yet been established. Sclerotherapy was performed to treat esophageal varices in four children with variceal bleeding who had received a hepatic portoenterostomy for congenital biliary atresia. Ethanolamine oleate was mixed with a contrast medium for the varicealography in order to determine the flow of the sclerosant by fluoroscopy. Varicealography which was conducted during the injection allowed us to stop the procedure so that mixture would fill up the varix and its feeders but would not enter the systemic circulation. Between 0.5 ml to 2.0 ml of sclerosant was injected at the variceal puncture. There was one case bleeding from the esophageal ulcer. However, it was resolved by conservative treatment. All four children experienced no rebleeding after the therapy. Therefore, injection sclerotherapy using varicealography with sclerosant–contrast medium mixture is recommended for children who develop esophageal varices after surgical procedures for congenital biliary atresia.