Susumu Shibuya

Correlation between Endoscopic and Angiographic Findings in Patients with Esophageal and Isolated Gastric Varices

Background/Aim: The correlation between angiographic vascular patterns and endoscopic findings in portal hypertension is not sufficiently known, and knowledge of the vascular anatomy may contribute to an improvement in endoscopic embolization and transjugular retrograde obliteration procedures. We propose a new vascular map that should prove useful for this purpose. Methods: Between April 1985 and December 1997 we performed percutaneous transhepatic portography in a selected group of 75 patients (16 women and 59 men), aged 43–71 years, from whom informed consent was obtained. All patients had been diagnosed endoscopically as having either esophageal or isolated gastric varices. According to the Child-Pugh classification, class A, B, and C cirrhosis was seen in 19, 40, and 16 patients, respectively. We created a vascular map of esophageal and isolated gastric varices, based on the opacification of the portal venous collaterals on percutaneous transhepatic portography. We compared the patients in both variceal groups in terms of portal venous pressure, main blood supply, and drainage routes. Results: We found that the portal collateral system was divided into two systems: the portoazygos venous system and the portophrenic venous system. The former contributed to the formation of esophageal and cardiac varices and the latter to the formation of isolated gastric varices located at the fundus or at both the cardia and fundus. The left gastric vein participated as blood supply in 70% of the isolated gastric varices and in 100% of the esophageal varices (p < 0.01). The posterior gastric vein participated as blood supply in 70% of the isolated gastric varices and in 24% of the esophageal varices (p < 0.01). We classified the main blood drainage routes of isolated gastric varices functionally into three types: gastrorenal shunt (85%), gastrophrenic shunt (10%), and gastropericardiac shunt (5%). The portal venous pressure in patients with esophageal varices was 358 ± 66 mm H2O, whereas in patients with isolated gastric varices it was 262 ± 44 mm H2O (p < 0.01). Conclusion: We suggest that this new vascular map will be useful in endoscopic embolization and transjugular retrograde obliteration procedures for esophageal and isolated gastric varices.

Transjugular retrograde obliteration for gastric varices

Abstract. We evaluated the transjugular retrograde obliteration (TJO) in treatment of gastric varices with gastrorenal shunt. Twenty patients with posthepatitic cirrhosis were included in this study. A cobra-shaped 5 French occlusive balloon catheter was inserted into the gastric varices or gastrorenal shunt through the internal jugular vein. As the sclerosants, absolute ethanol and 5% ethanolamine oleate with iopamidol were injected into the varices to make thrombi. In all cases, gastric varices were obliterated successfully. Endoscopic examination 3 months after treatment revealed the complete eradication of gastric varices in all cases. No major complications during or after therapy were observed. We think that TJO can be an effective method for the treatment of gastric varices with gastrorenal shunt.

Short-Term Hemodynamic Effects of Transjugular Retrograde Obliteration of Gastric Varices with Gastrorenal Shunt

Objectives: The purpose of this study was to investigate the short-term effects on portal hemodynamics of transjugular retrograde obliteration (TJO) of gastric varices with gastrorenal shunt. Methods: Thirty patients with gastric varices and a gastrorenal shunt were included in this study. The patients ranged in age from 42 to 75 years (16 men and 14 women), and according to Child’s classification, class A, B and C cirrhosis was seen in 1, 13 and 16 patients, respectively. The portal blood flow was measured by an ultrasonic duplex Doppler system, and the wedged hepatic venous pressure was measured by hepatic venous catheterization, before and after TJO. Results: Complete obliteration of the gastrorenal shunt and gastric varices was revealed by retrograde inferior phrenic venography and computed tomography after TJO in all cases. The wedged hepatic venous pressure was significantly increased the day after TJO compared with that before therapy (257 ± 71 vs. 307 ± 73 mm H2O, p < 0.01). The portal venous flow was significantly increased 1 week after TJO compared with that before therapy (744 ± 190 vs. 946 ± 166 ml/min, p < 0.01). The serum albumin levels before and after TJO were 3.0 ± 0.4 and 3.1 ± 0.5 g/dl, respectively, and the total bilirubin levels were 1.5 ± 0.7 and 1.5 ± 0.8 mg/dl, respectively, neither of these parameters changing significantly. The plasma ammonia levels before and after TJO were 109 ± 62 and 67 ± 31 μg/dl, and the indocyanine green retention rates at 15 min were 31 ± 13 and 24 ± 13%, both showing a significant change (p < 0.01 and p < 0.05, respectively). Conclusions: We conclude that TJO increases portal blood flow which contributes to the decrease in plasma ammonia levels and the indocyanine green retention rate, although increasing the wedged hepatic venous pressure.

Role of percutaneous transhepatic obliteration for special types of varices with portal hypertension

The treatment of special types of varices with portal hypertension has not yet been established. We were able to control 13 cases of special types of varices by percutaneous transhepatic obliteration (PTO). These 13 cases consisted of 2 esophagojejunal varices after total gastrectomy for gastric cancer, 1 stoma varices after abdominoperineal excision for rectal cancer, 2 mesenteric varices with encephalopathy, 1 gastric variceal rupture, 1 gastrorenal and gastroazygos shunt with encephalopathy, 3 giant bar-type esophageal varices, 2 isolated gastric varices with gastropericardiac shunts, and 1 isolated gastric varices with gastrophrenic shunt. The special types of varices were successfully embolized in all cases and there were no complications. We conclude that the PTO is still an effective and safe treatment for special types of varices with portal hypertension.

Urgent Transjugular Retrograde Obliteration for Prophylaxis of Rebleeding from Gastric Varices in Patients with a Spontaneous Portosplenorenal Shunt

Background: Bleeding isolated gastric varices with a spontaneous portosplenorenal shunt are difficult to control. The urgent use of transjugular retrograde obliteration (TJO) to prevent early rebleeding and to improve early mortality has not yet been demonstrated. We report our experience with this technique in patients with isolated gastric varices after treatment of acute bleeding. Methods: We reviewed our experience of 6 patients with isolated gastric varices with a spontaneous portosplenoral shunt treated with TJO after treatment of acute bleeding. We basically applied endoscopic glue embolization using cyanoacrylate monomer for treatment of acute bleeding. TJO was a method using an occlusive balloon catheter to control a spontaneous portosplenorenal shunt flow while injecting sclerosant retrograde into the gastric varices. Results: Treatment of acute bleeding was achieved immediately by endoscopic glue embolization, endoscopic variceal ligation, and ligating the varices with sutures following anterior gastrotomy in 4, 1 and 1 patients, respectively, and then TJO was performed. Permanent hemostasis and variceal eradication was achieved in these 6, and they all survived. They were alive for 6–66 months without gastric variceal recurrence. Conclusions: We conclude that urgent TJO is effective in the prophylaxis of early and late rebleeding from isolated gastric varices in patients with a spontaneous portosplenorenal shunt.

Appendiceal stump abscess as an early complication of laparoscopic appendectomy: report of a case.

Abstract.We report the case of an appendiceal stump abscess that was treated by relaparoscopy 4 days after a laparoscopic appendectomy (LA). Surgeons should be aware of the possibility of appendiceal stump abscess occurring as an early complication of LA. When performing LA, the appendiceal stump should be as short as possible, and the ligation of the root of the appendix should be only moderately tight, so as not to cause ischemic change of the stump, indicated by discoloration or edema. The insertion of a drain for monitoring exudate, as well as sonography, and relaparoscopy are helpful for diagnosing and treating this complication.

Blood Supply Routes of Recurrent Esophageal Varices following Endoscopic Embolization

Background/Aim: The blood supply routes of recurrent esophageal varices following complete endoscopic embolization (EE) are not yet known. The purpose of this study is to identify these blood supply routes by comparing endoscopic varicography and percutaneous transhepatic portography (PTP). Methods: Eleven cases of recurrent esophageal varices following EE are included in this study. The blood supply routes of primary and recurrent varices were analyzed by comparing the varicography obtained at the initial and repeat EE with PTPs before and after the initial EE. Results: Endoscopic varicography at the time of initial EE could show the vessels of the left gastric vein (LGV) system, such as the cardiac branch of the LGV, and the cardiac venous plexus (CP) in 100% of cases, and the trunk of the LGV in 73% (8/11) of cases, whereas the posterior gastric vein was seen in only 18% (2/11) of cases. PTP performed 2 weeks after the initial EE confirmed that the routes visualized by endoscopic varicography could be obliterated in 10 of 11 cases. The blood supply routes of recurrent varices, demonstrated by varicography, were the vessels of the short gastric vein (SGV) system, such as the fundic branch of the SGV or the posterior gastric vein in 82% (9/11) of cases, and the partially reformed fine CP in 27% (3/11) of cases. Varicography revealed the remnant vessels of the LGV in only 1 case. Conclusions: The primary esophageal varices are supplied with blood mainly from the cardiac branch of the LGV through the CP. However, the blood supplies of recurrent varices following EE come from the fundic branch of the SGV or the posterior gastric vein. We conclude that three-dimensional obliteration of esophageal varices and their feeders, the LGV and SGV systems, is completed by initial and repeat EEs.

Percutaneous transhepatic obliteration for esophagojejunal varices after total gastrectomy

Abstract. A 59-year-old man experienced hematemesis 5 years after a total gastrectomy and Roux-en-Y esophagojejunostomy for carcinoma of the cardia. Endoscopic examination revealed the esophagojejunal blue small varices with cherry-red spots. Percutaneous transhepatic portography showed that the varices were supplied by the vein of the ascending jejunal limb. The 3-French microcatheter was inserted into this vein through the 5-French catheter, and 0.5 mL of absolute ethanol and 2 mL of ethanolamine oleate with iopamidol were injected, which visualized the esophagojejunal varices and obliterated varices at the same time. There were no complications during the operation, and the subsequent clinical course showed no further bleeding. We conclude that percutaneous transhepatic obliteration with a 3-French microcatheter is one of the most effective means of treating esophagojejunal small varices arising after a total gastrectomy.

Short-Term Portal Hemodynamic Effects of Endoscopic Embolization for Esophageal Varices

Background/Aim: Endoscopic embolization (EE) is a specialized treatment that obliterates esophageal varices along with their associated blood supply. The purpose of this study was to investigate the short-term effects of EE for esophageal varices on portal hemodynamics and liver function. Methods: Thirty patients with esophageal varices were included in this study. The portal blood flow was measured by an ultrasonic duplex Doppler system before and after EE. EE was performed by freehand intravariceal injection of 5% ethanolamine oleate with iopamidol with the aid of a balloon attached to the tip of an endoscope under fluoroscopy. Results: For the blood supply system, endoscopic varicography at the time of EE was able to show the vessels of the cardiac branch of the left gastric vein in 93% of the cases, the cardiac venous plexus in 90%, the trunk of the left gastric vein in 27%, the lesser curvature branch of the left gastric vein in 10%, the fundic branch of the short gastric vein in 13%, and the posterior gastric vein in 13%. For the blood drainage system, endoscopic varicography was able to show the paraesophageal vein in 39% of the cases, the inferior phrenic vein in 17%, and the mediastinal vein in 13%. No clotting was detected after EE in the intra- and extraportal veins in any of the cases. The flow velocities in the main portal vein before and after EE were 14.2 ± 3.2 and 15.5 ± 3.5 cm/s, respectively, showing no significant change. The cross-sectional area of the portal vein before and after EE was 0.96 ± 0.21 and 1.04 ± 0.23 cm2, and the flow volume of the portal vein was 817 ± 288 and 930 ± 189 ml/min, both also showing no significant change. The blood laboratory parameters showed no significant change after EE. Conclusions: We conclude that neither portal blood flow nor liver function were damaged by EE, although both the varices and their associated blood supply were obliterated.

Percutaneous transhepatic obliteration for isolated gastric varices with gastropericardiac shunt: case report

Management of isolated gastric varices with a gastropericardiac shunt (GPS) has not yet been established. We were able to control a case of isolated gastric varices with a GPS by percutaneous transhepatic obliteration (PTO) using a microcatheter. In this case, the main blood drainage route was not a gastrorenal shunt, so transvenous retrograde obliteration could not be performed and PTO using the microcatheter was applied. Percutaneous transhepatic splenic venography revealed that the gastric varices came from the posterior gastric vein and the main drainage route was a GPS. Gastric varices and their blood supply were superselectively embolized using platinum microcoils and absolute ethanol. Portal venous pressure did not change after PTO because the route from the left gastric vein to the azygos venous system was preserved. Computed tomography 7 days after PTO revealed that the gastric varices were completely obliterated by the thrombi. Plasma ammonia level, arterial ketone body ratio, and indocyanine green retention rate at 15 min were improved. We conclude that PTO using a microcatheter is a rational, effective, and safe therapy for isolated gastric varices with a GPS.