Tetsuya Iwanaga

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.

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.

Morphological and Hemodynamic Changes of the Lung after Injection of 5% Ethanolamine Oleate into Dogs

We examined the pulmonary hemodynamics and morphology after injection of a sclerosing solution of 5% ethanolamine oleate (EO) into 24 normal dogs. EO of 0.5 ml/kg (n = 5), 1.0 ml/kg (n = 6), and 3.0 ml/kg (n = 7) was injected through the jugular vein into the right atrium for pathological examination and gravimetric study of the lung, while monitoring the pulmonary hemodynamics for 12 h. Normal saline of 3.0 ml/kg was injected into the remaining 6 control dogs, using the same method. Cardiac output significantly decreased immediately after injection of the sclerosant in all dogs given 0.5 ml/kg, 1.0 ml/kg and 3.0 ml/kg injections of EO; however, there was a tendency toward recovery from 6 h after injection in dogs given 0.5 ml/kg and from 9 h in dogs given 1.0 ml/kg. Pulmonary hypertension just after injection and hypoxia at 9-12 h occurred only when 3.0 ml/kg was injected. Irreversible pulmonary hemorrhage was present in the excised lungs in 4 of 7 dogs given 3.0 ml/kg, while there were no significant lesions in the other dogs. The lung water content in cases of 1.0 and 3.0 ml/kg injections was significantly higher than that in the controls, while there was no significant difference between those given 0.5 ml/kg and of the controls. The findings obtained in this study suggest that EO less than 0.5 ml/kg used for sclerosing esophageal varices seems to have little untoward influence on pulmonary hemodynamics and morphology.

Esophageal transection may well be the approach of choice for patients with portal venous obstruction and esophageal varices

Thirty patients with esophageal varices, portal venous obstruction and a histologically proven normal liver underwent either one of 2 different types of surgery. Shunt surgery was performed on 20 patients: 9 had a mesocaval shunt, 3, a splenorenal shunt, 4, a left gastric venacaval shunt, and 4, a distal splenorenal shunt. Conversely, direct interruption was performed on the other 10 patients: 6 underwent an esophageal transection, and 4 underwent a resection of the proximal stomach. Re-hemorrhage occurred in 7 of the former 20 patients but not in any of the 10 on whom the direct interruption method was used. In 6 of these 7 patients who experienced rebleeding, subsequent direct interruption surgery led to control of the bleeding. One patient died of a variceal hemorrhage one month postoperatively. The total 10 year cumulative survival rate was 86.3 per cent. In the light of these findings, we believe that methods of direct interruption, such as esophageal transection, may well be the approach of choice for patients with esophageal varices caused by extrahepatic portal venous obstruction.

A transparent over-tube for endoscopic injection sclerotherapy and results in patients with esophageal varices

This report describes our data regarding repeated injection sclerotherapy using a newly designed over-tube. We treated 17 consecutive patients with esophageal varices, (3 acute, 6 elective and 8 prophylactic). An intravariceal injection of 5 per cent ethanolamine oleate was administered, using a newly designed transparent over-tube containing a second lumen for a flexible injection needle. This over-tube provides an easier, safer, shorter-in-time method of sclerosing esophageal varices. One of the 17 patients died as a result of liver failure associated with advanced cirrhosis and a concomitant hepatoma. Eradication of esophageal varices was attained in the remaining 16 patients, after an average of 5.0 injections over an average period of 5.8 weeks (range: 3–7 injections during 3–11 weeks). No complications, such as esophageal perforation or aspiration pneumonia were encountered. Recurrent variceal bleeding has not occurred during the 9 months follow-up.

Ultrasonic Duplex System to Facilitate Assessment of Portal Blood Flow Velocity

The usefulness of an ultrasonic duplex system to assess portal blood flow was investigated. In a model involving a steady flow through a vinyl tube in agar, there was a significant linear correlation between the maximum blood flow velocity measured by this system (V-max) and the mean blood flow velocity calculated from the actually measured blood flow volume (V-mean), that is, V-mean = 0.53 X V-max was obtained (r = 0.994; n = 47). This equation was used to calculate the mean portal blood flow velocity by this system (V-dopp) in 10 patients with liver disease, and the findings were compared with data simultaneously obtained by cineangiographic mapping of Lipiodol droplets released into the portal vein through a catheter placed in situ at the time of surgery (V-cine). A linear correlation between V-dopp and V-cine was statistically significant (r = 0.970; n = 13), and the regression line was V-cine = 1.29 X V-dopp -2.11. The ultrasonic duplex system proved reliable for a quantitative assessment of portal hemodynamics.

Validity of ultrasonic duplex system for measurement of the portal blood flow in patients with liver disease.

The validity of an ultrasonic duplex system for assessment of portal blood flow was clinically investigated. The maximum portal blood flow velocity was measured using this system (X) in ten patients with liver disease, and data obtained were compared on patients simultaneously undergoing cineangiographic mapping of Lipiodol droplets released into the portal vein through an indwelling catheter (Y). A linear correlation between X and Y was statistically significant (r=0.970, n=13). The ultrasonic duplex system proved reliable for a quantitative assessment of portal hemodynamics.