Takahiko Kawashima

Gastric Varices with Gastrorenal Shunt: Combined Therapy Using Transjugular Retrograde Obliteration and Partial Splenic Embolization

OBJECTIVE This study was prospectively conducted to evaluate the effectiveness of the combination of transjugular retrograde obliteration and partial splenic embolization in the treatment of gastric varices with gastrorenal shunt. SUBJECTS AND METHODS Between November 2002 and December 2006, 14 patients with gastric varices and gastrorenal shunt were treated by combining transjugular retrograde obliteration and partial splenic embolization (group 1). These patients were compared with 19 patients with gastric varices and gastrorenal shunt treated by only transjugular retrograde obliteration (group 2) for the disappearance rate of gastric varices, the cumulative survival rate, and the occurrence rate of esophageal varices after transjugular retrograde obliteration. Partial splenic embolization was performed 7-14 days before transjugular retrograde obliteration. No significant differences were seen between the two groups in terms of demographic data, including age, sex, and Child-Pugh classification. RESULTS The disappearance rate of gastric varices after transjugular retrograde obliteration was 100% in both groups. The 3-year cumulative survival rate after transjugular retrograde obliteration was 92% in group 1 and 95% in group 2. The 3-year cumulative occurrence rate of esophageal varices after transjugular retrograde obliteration was 9% in group 1 and 45% in group 2, a significant difference (p < 0.05). CONCLUSION The findings of this study indicate that partial splenic embolization contributed to preventing portal congestion after transjugular retrograde obliteration. We conclude that the combination of transjugular retrograde obliteration and partial splenic embolization for gastric varices is more effective than transjugular retrograde obliteration only in the long-term prevention of esophageal varices after transjugular retrograde obliteration.

Huge submucosal hematoma of the stomach after accidental removal of the PErcutaneous endoscopic gastrostomy tube

We report a case of massive hemorrhage and aspiration pneumonia as complications of percutaneous endoscopic gastrostomy (PEG). Three months after insertion of a PEG tube, the patient accidentally pulled out the tube by himself. After the accident, the patient experienced hematemesis, which caused aspiration pneumonia. The button‐type tube was reinserted into the PEG fistula for hemostasis. The bleeding stopped temporarily; however, 21 days later, the patient relapsed into a condition of massive PEG site bleeding and hematemesis. He was transferred to our hospital, Kuniyoshi Hospital, to control the bleeding and aspiration pneumonia. Endoscopy revealed a sliding type of large hiatal hernia and a huge submucosal hematoma with an ulceration at the lower part of the gastric body. Emergency surgery including local gastrectomy, gastrostomy, jejunostomy and tracheostomy were helpful to treat these complications. Endoscopists should be aware how to treat these complications. One should not hesitate to perform open surgery when other treatments fail.

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.

Technique of laparoscopic cholecystectomy combined with percutaneous papillary balloon dilatation under general anesthesia for cholecystocholedocholithiasis

Since the introduction of laparoscopic cholecystectomy (LC), the treatment of cholecystocholedocholithiasis has become a controversial issue among surgeons and endoscopists all over the world. We evaluated the effectiveness of LC combined with percutaneous papillary balloon dilatation (PPBD) under general anesthesia in the treatment of cholecystocholedocholithiasis in 22 patients. All stones in the bile duct were successfully evacuated into the duodenum in all patients. The PPBD was feasible in all patients under general anesthesia. The mean postoperative stay was 9 days. The overall length hospital stay and the duration of PTBD were 19 ± 7 days and 16 ± 8 days, respectively. There were no deaths nor major complications, although a transient hyperamylasemia was found in 10 patients (45%). Cholecystocholedocholithiasis was able to be treated by means of LC combined with PPBD under general anesthesia without laparotomy, sphincterotomy or choledochotomy. This technique can be a choice for the treatment that enables a patient to avoid any discomfort arisen as a result of papillary dilatation.

An Improved Endoscopic Variceal Ligator for Esophagogastric Varix.: – Three-O-Band-Shooter–

Abstract: We recently reported a 16.0 mm in length new type of instrument with an inner cylinder of 10.3 mm for endoscopic variceal ligation (EVL). This device is capable of shooting three elastic O bands consecutively in rapid succession without removing the endoscope. The aspirated volume of variceal tissue with the new instrument is larger than that obtained with the Stiegmann ligator. We performed EVL in 16 cases with esophageal varices and seven with solitary gastric varices. EVL was performed for prophylaxis in all cases. The esophageal varices disappeared in all 16 cases after ulcer formation. The procedure was performed once in 14 cases and twice in the remaining two. Three patients died of hepatic failure during the follow‐up period which ranged from four to 16 months. Six and 12 month cumulative recurrence rates were 30% and 48%, respectively. All gastric varices disappeared after a single EVL session. There was one variceal recurrence during the follow‐up period. Computed tomography and/ or arterioportography performed previously had shown patent gastro‐renal shunt in five cases. No changes in the shunts were observed after treatment. No serious complications attributable to EVL were encountered in this series. Therefore, this method is potentially useful for the treatment of not only esophageal varices but also gastric varices.