Hassab's Operation Research Articles

Efficacy of endoscopic therapy combined with partial splenic embolization versus Hassab's operation for patients with liver cirrhosis with esophageal variceal bleeding and hypersplenism: a multicenter cohort study based on propensity score matching.

The prognosis comparison between endoscopic therapy + partial splenic embolization (PSE) and Hassab's operation is unclear in the treatment of esophageal variceal bleeding in patients with liver cirrhosis. This study aimed to compare the outcome of endoscopic therapy + PSE (EP) with a combination of splenectomy + pericardial devascularization procedure, known as Hassab's operation (SH) for esophageal variceal bleeding in patients with liver cirrhosis with hypersplenism. We enrolled 328 patients, including 125 and 203 patients who underwent EP and SH, respectively. Each group consisted of 110 patients after propensity score matching (PSM). Subsequently, we recorded and analyzed bleeding episodes and mortality in 6months and 1, 2, and 5years after therapies. The median follow-up time in the EP and SH groups was 53 and 64months, respectively. Bleeding incidence 6months after therapies in the EP group was lower than that in the SH group (1.8% vs. 10.0%, P = 0.010). Additionally, complications in the perioperative period were not significantly different (0% vs. 3.6%, P = 0.008). However, the bleeding rate between the two groups was not significantly different at 1, 2, and 5years after therapies (7.3% vs. 12.7%, P = 0.157; 10.9% vs. 16.4%, P = 0.205; 30.6% vs. 31.8%, P = 0.801), as well as mortality rate (4.5% vs 7.3%, P = 0.571). Compared with SH therapy, the bleeding rate 6months after EP therapy was lower, but the long-term bleeding rate was similar.

Esophagogastric varix caused by extrahepatic portal vein obstruction with essential thrombocythemia: A case report.

Extrahepatic portal vein obstruction (EHPVO) is a very rare disease-causing portal hypertension. Myeloproliferative neoplasm (MPN) including essential thrombocythemia (ET) is reported as a risk factor for EHPVO due to underlying persistent thrombophilia.A Japanese woman in her 40s was referred to our hospital with a one-month history of gastric variceal bleeding due to EHPVO. Laboratory investigation demonstrated thrombocytosis despite portal hypertension. She had a mutation of clonal marker JAK2V617F with EHPVO, which prompted us to consult a hematologist. Bone marrow biopsy revealed megakaryocyte lineage proliferation, leading to a diagnosis of ET.Esophagogastroduodenoscopy indicated esophagogastric varices (LsF2CbRC2, Lg-cF1RC1). Abdominal Computed Tomography and angiography revealed splenomegaly and portal vein thrombosis with cavernous transformation. These radiologic findings suggested EHPVO.The patient had a history of ruptured esophagogastric varices and required prophylaxis against further variceal bleeding prior to anti-thrombotic therapy for EHPVO with ET. We performed laparoscopic Hassab's operation followed by endoscopic variceal ligation (EVL) and hematological cytoreduction therapy.Laparoscopic Hassab's operation and three bi-monthly EVL improved the esophagogastric varix (LmF0RC0, Lg-f F0RC0) at 6 months after surgery. Platelet count decreased to 60.1 x104 /uL by cytoreduction therapy. She was very healthy at 7 months after surgery.Patients with EHPVO are traditionally referred to the gastroenterologist for abdominal pain, intestinal bleeding, or refractory ascites; however, hypercoagulative disease may be occult in such patients and require the attention of a hematologist. When encountering the patients with splanchnic thrombosis caused by EHPVO, the gastroenterologists should screen for hematological disease, including MPN.

КЛИНИЧЕСКИЙ СЛУЧАЙ ЛЕЧЕНИЯ ПАЦИЕНТА С ПОРТАЛЬНОЙ ГИПЕРТЕНЗИЕЙ, РАЗВИВШЕЙСЯ НА ФОНЕ ТРОМБОЗА ВОРОТНОЙ ВЕНЫ

Non-cirrhotic causes of the development of portal hypertension make up about 10%. The factors leading to its development are the development of thrombosis in the portal vein system, occlusion due to pancreatitis, pancreatic tumors, and other causes. Acute bleeding from esophageal varices is a formidable complication of portal hypertension, regardless of its etiology. The tactics of treatment and prevention of bleeding from esophageal varices in patients with portal vein thrombosis generally corresponds to that for intrahepatic portal hypertension in liver cirrhosis with some additions. Aim. Presentation of the results of clinical observation of an open Hassab operation (esophagogastric devascularization without esophageal transection + splenectomy) in a patient with portal vein thrombosis complicated by portal hypertension and esophageal varices, as well as a short literary excursion on this issue. Materials and methods. The patient was admitted to the surgical department with thrombosis of the portal, splenic and superior mesenteric veins complicated by subhepatic portal hypertension with splenomegaly, varicose veins of the esophagus and stomach of the 2nd-3rd degrees, left-sided hydrothorax, moderate anemia. Direct anticoagulants, antibiotics, non-steroidal anti-inflammatory drugs, proton pump inhibitors were used. Given the risk of bleeding from varicose veins of the esophagus and stomach, as well as existing necrosis in the spleen, Hassab operation (esophagogastric devascularization in combination with splenectomy) was performed at the fourth level of surgical management. Results. Despite ongoing therapy with antiplatelet agents, in 2 months after the operation the patient developed thrombosis of the left subclavian and internal jugular veins as well as recurrent left-sided hydrothorax. Conservative therapy has been successful. Relapse of esophageal varices bleeding was diagnosed in a patient 4 years after surgery, conservative and endoscopic hemostasis being successful. Acute thrombophlebitis of the saphenous veins of the right lower leg was diagnosed in the patient 9 years after surgery, it having been treated conservatively. Acute adhesive intestinal obstruction developed 11 years after surgery, conservative therapy was successful. Currently, the patient is being followed at the outpatient department, his condition being satisfactory and hydroxycarbamide, antiplatelet agents and non-selective betablockers being taken by him on a regular basis takes. Based on this clinical observation, it seems difficult to judge the effect of Hassab operation on the course of the disease in the described patient. However, it is worth noting a persistent increase in the level of platelets in the general blood test in the postoperative period, which could contribute to the recurrence of venous thrombosis in the patient. Conclusions. According to the current scientifically based recommendations in the treatment of these patients priority should be given to conservative and minimally invasive endoscopic and interventional X-ray endovascular techniques.

Long-Term Outcome of Hassab Operation in Children With Portal Hypertension

Long-Term Outcome of Hassab Operation in Children With Portal Hypertension

Clinical efficacy of re-modified Sugiura procedure for portal hypertension

Objective To investigate the clinical efficacy of re-modified Sugiura procedure for the treatment of portal hypertension. Methods The retrospective cohort study was adopted. The clinical data of 119 patients with portal hypertension who were admitted to Second People's Hospital of Yichang from June 2006 to October 2014 were collected. Seventy-two patients who underwent pericardial devascularization were allocated into the Hassab group, and the other 47 patients who underwent the re-modified Sugiura procedure were allocated into the R-M Sugiura group. All the patients firstly underwent splenectomy. The patients of the Hassab group received the classical surgery of pericardial devascularization, and the operation in the R-M Sugiura group was improved on the modified Sugiura procedure in several aspects: (1) the cardia was transected obliquely. (2) Paraesophageal vessels were preserved by selective pericardial devascularization. (3) The pedicled omentum covered the anterior anastomosis and was sutured to the posterior abdominal wall. Observed indices included (1) intraoperative and postoperative situations: operation time, volume of intraoperative blood loss, postoperative anal exhaust time and duration of postoperative hospital stay. (2) Postoperative complications: postoperative pleural effusion, peri-operative digestive tract re-bleeding, difficult swallowing, portal vein thrombosis and gastric dynamic dysfunction. (3) Situation of follow-up. The follow-up was performed by telephone interview and outpatient examination to observe the grading of the esophageal varices at postoperative month 6 and 18 using gastroscope till February 2016. Measurement data with normal distribution were presented as ±s, and comparison between groups was done by the t test. Count data were analyzed by the chi-square test. Ranked data were analyzed by Wilcoxon rank test. Results (1) Intraoperative and postoperative situations: operation time of the Hassab group and the R-M Sugiura group was (201±27)minutes and (255±32)minutes, respectively, with a statistically significant difference between the 2 groups (t=9.67, P 0.05). (2) Postoperative complica-tions: dysphagia was detected in 3 patients of the Hassab group and in 10 patients of the R-M Sugiura group at the postoperative day 10, with a statistically significant difference between the 2 groups (χ2=0.86, P 0.05). The number of postoperative pleural effusion, perioperative digestive tract rebleeding, portal vein thrombosis and gastric dynamic dysfunction of the Hassab group and the R-M Sugiura group were 23, 6, 10, 8 cases and 20, 1, 6, 6 cases, respectively, showing no statistically significant difference (χ2=1.39, 1.02, 0.03, 0.08, P>0.05). (3) Situation of follow-up: all the patients were reexamined using gastroscope to observe the grading of esophageal varices. There were 0, 7, 56, 9 patients of G0, GⅠ, GⅡ, GⅢ grading of varices in the Hassab group and 35, 12, 0, 0 patients in the R-M Sugiura group at postoperative month 6, showing a statistically significant difference between the 2 groups (Z=-9.64, P<0.05). There were 0, 0, 48, 24 patients of G0, GⅠ, GⅡ, GⅢ grading of varices in the Hassab group and 24, 20, 3, 0 patients in the R-M Sugiura group at postoperative month 18, showing a statistically significant difference between the 2 groups (Z=-9.28, P<0.05). Conclusion The re-modified Sugiura procedure is more effective than the Hassab operation in curing portal hypertension, and it could also reduce the rate of rehemorrhage and improve the short-term and long-term prognosis. Key words: Portal hypertension; Modified Sugiura; Surgical procedures, operative; Improvement measure

The use experience of thrombomodulin alfa to prevent portal thrombosis after Hassab's operation

The use experience of thrombomodulin alfa to prevent portal thrombosis after Hassab's operation

Laparoscope-assisted Hassab's Operation for Esophagogastric Varices After Living Donor Liver Transplantation: A Case Report

This is the first successful report of a laparoscope-assisted Hassab's operation for esophagogastric varices after living donor liver transplantation (LDLT). A 35-year-old man underwent LDLT using a right lobe graft as an aid for primary sclerosing cholangitis (PSC) in 2005. Follow-up endoscopic and computed tomography (CT) examinations showed esophagogastric varices with splenomegaly in 2009 that increased (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2]; gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderator enlarged, beady varices [F2], absent red color signs [RC0]). A portal venous flow to the esophagogastric varices through a large left gastric vein was also confirmed. Preoperative Child-Pugh was grade B and score was 9. Because these esophagogastric varices had a high risk of variceal bleeding, we proceeded with a laparoscope-assisted Hassab's operation. Operative time was 464 minutes. Blood loss was 1660 mL. A graft liver biopsy was also performed and recurrence of PSC was confirmed histologically. It was suggested that portal hypertension and esophagogastric varices were caused by recurrence of PSC. Postoperative complications were massive ascites and enteritis. Both of them were treated successfully. This patient was discharged on postoperative day 43. Follow-up endoscopic study showed improvement in the esophagogastric varices (esophageal varices [EV]: locus superior [Ls], no varicose appearance [F0], absent red color signs [RC0], gastric varices [GV]: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) at 6 months after the operation. We also confirmed the improvement of esophagogastric varices by serial examinations of CT.

Laparoscopic splenectomy plus preoperative endoscopic variceal ligation versus splenectomy with pericardial devascularization (Hassab’s operation) for control of severe varices due to portal hypertension

Our research was conducted to introduce a new, compound surgical method for laparoscopic splenectomy (LS) with preoperative endoscopic variceal ligation (EVL) and compare the new method's efficiency with that of Hassab's operation in patients with severe esophageal varices due to portal hypertension. Between March 2009 and March 2012, 47 patients with liver cirrhosis, portal hypertension, and severe esophageal varices were retrospectively analyzed. Of these patients, 19 received the combined preoperative EVL and LS (minimally invasive surgery, MIS group), and 28 patients received splenectomy with pericardial devascularization (Hassab's operation, H group). Before surgery, there were no differences in the patient characteristics of the two groups. There were no significant differences in operating time, but significantly less intraoperative blood loss and shorter postoperative hospital stay were found in the MIS group compared with the H group. The mean follow-up periods of the MIS and H groups were 12.1 and 13.6 months, respectively. No deaths were documented during the follow-up period. Generally, hematological parameters and liver function variables eventually revealed considerable improvement in both groups. In the MIS group, the patients with varices improved significantly from severe to mild, and in some cases, the varices disappeared after treatment. Three patients in the H group suffered rebleeding and were treated with repeated EVL. No bleeding or rebleeding occurred in the MIS group. The final results suggest that LS with preoperative EVL provides a restorative efficacy equivalent to that of Hassab's operation. Based on the recurrence rate and the rebleeding rate of severe esophageal varices, our surgical strategy (EVL and LS) is a safe and minimally invasive technique that appears satisfactory in comparison to other open procedures.

A modified Hassab’s operation for portal hypertension: experience with 562 cases

BackgroundMany patients with portal hypertension require surgical treatment each year, and Hassab’s operation, or esophagogastric devascularization and splenectomy, is an elective procedure. However, it is difficult to devascularize all the vessels of the upper half of the stomach and distal esophagus when hyperblastosis, edema, extensive vein conglobation, and conglutination are present during the operation. These increase the postoperative risk of repeat bleeding. Patients and methodsWe modified Hassab’s operation to address the difficulties associated with devascularization in these cases. All consecutive Chinese patients with liver cirrhosis and portal hypertension who underwent the modified Hassab operation in the Second Affiliated Hospital of Xi’an Jiaotong University from September 1995 to December 2010 were included in the present retrospective study. ResultsA total of 562 modified Hassab’s operations were performed, and all the emergency operations performed because of bleeding obtained hemostasis. Although the pressure and blood flow of the portal vein decreased slightly after surgery, it was still maintained at a high level. Overall, 21.8% of the patients had complications, and 4.6% of these patients died during the hospitalization period. Within the 12-month follow-up period, the overall improvement rate of varices was 98.5% and the variceal bleeding rate was 1%. The 5-year bleeding rate was 9.7%. ConclusionsThe modified Hassab operation is an effective procedure for the treatment of portal hypertension. Few early or late complications were observed among the patients.

Recent role of Hassab's operation for cirrhotic patients: Combination with endoscopic procedure for varices

Recently, endoscopic and radiological procedures for various symptoms related to cirrhosis have improved. Thus, the role of Hassab's operation (gastroesophageal decongestion and splenectomy) has changed for cirrhotic patients. Hassab's operation was performed on patients who had gastroesophageal varices that were difficult to control with balloon occluded retrograde transvenous obliteration or an endoscopic procedure, or had hypersplenism. Thirteen consecutive patients underwent this operation, and the outcomes of all patients were reviewed retrospectively. There was no operative morbidity or rebleeding varices. In the preoperative endoscopic injection sclerotherapy treated group (n=6), only one patient (16.7%) developed recurrent varices. Mean platelet counts were significantly higher 6 months after surgery (201 ± 65 × 10(3)/mm(3)) than preoperatively (64 ± 54 × 10(3)/mm(3)). In patients with hepatocellular carcinoma, percutaneous therapies, such as radio frequency ablation, were safely performed with adequate therapeutic effect. Interferon therapy was given to patients with hepatitis C virus (HCV)-related cirrhosis without interruption. Hassab's operation is a satisfactory approach to controlling varices, especially when combined with preoperative endoscopic treatment. Platelet counts were significantly higher after surgery. This therapy was important for cirrhotic patients contraindicated for liver transplantation in that they could continue their therapy for hepatocellular carcinoma (HCC) and HCV as needed.

Surgical treatment of hepatocellular carcinoma with severe intratumoral arterioportal shunt

We report a case of hepatocellular carcinoma (HCC) that caused a severe arterioportal shunt (APS). A 49-year-old man was admitted to hospital due to esophagogastric variceal hemorrhage and HCC, and underwent endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). He was then referred to our hospital. Abdominal computed tomography revealed a low-density lesion in the posterior segment of the liver and an intratumoral APS, which caused portal hypertension. Although the patient underwent EVL, EIS, Hassab's operation, and transcatheter arterial embolization for APS, he vomited blood due to rupture of esophagogastric varices. Right hepatectomy was performed for the treatment of HCC and APS, although the indocyanine green retention value at 15 min after intravenous injection was poor (30%). The patient's postoperative course was uneventful. Eventually, APS disappeared and the esophagogastric varices improved.

Hand-assisted laparoscopic splenectomy and devascularization of the upper stomach in the management of gastric varices.

BackgroundBleeding from esophagogastric varices is the major cause of death in patients with portal hypertension. Although esophageal varices can be treated with endoscopic procedures, the treatment for gastric varices is still controversial. The aim of this study was to describe a surgical technique and our preliminary results of hand-assisted laparoscopic Hassab’s procedure.MethodsBetween February 2002 and May 2005, we performed 7 cases of gastric varices with this type of operation. The patients included 4 men and 3 women who ranged in age from 23 to 74 years (underlying liver disease: 5 case of liver cirrhosis, 1 case of polycystic disease, 1 case of extrahepatic portal vein obstruction). After splenctomy was performed, we devascularized the vessels of the upper stomach and the esophagus 5 cm away from the esophago-cardia junction.ResultsThe operative time ranged from 132 to 290 minutes. Intraoperative blood loss was estimated to be from 50 ml to 475 ml. The weight of removed spleen ranged from 110 g to 800 g. During the follow-up period, all gastric varices disappeared and no bleeding from varicose veins was observed. All patients had hypersplenism with thrombocytopenia before surgery (mean: 11.1 ± 7.4 × 104/ml), which was improved postoperatively (mean: 30.8 ±19.0 × 104/ml). This data were statistically significant (P = 0.033). One patient died of aspiration pneumonia related to postoperative pyloric stricture.ConclusionsAlthough there is no agreement concerning the best treatment of gastric varices, the hand-assisted laparoscopic Hassab’s operation is a safe, moderately invasive method, and its outcome appears to be equal to that of other open procedures.

Splenectomy with endoscopic variceal ligation is superior to splenectomy with pericardial devascularization in treatment of portal hypertension

To investigate the therapeutic efficacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassab's operation) in patients with portal hypertension. A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n = 53, group A) or Hassab's operation (n = 50, group B). The portal blood flow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 mo with an average of 45 mo, and the Dagradi classification of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade II or less in both groups. There was little difference in the recurrence rate of esophageal varices (11.9% vs 13.2%) and the re-bleeding rate (7.1% vs 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were significantly higher in group B (60.0% and 52.0%) than in group A (32.1% and 20.8%, P < 0.05). No patients died of operation-related complications. There was no significant difference in gastric emptying time, FPP and portal blood flow volume between the two groups. The results suggest that splenectomy with EVL achieves similar therapeutic efficacy to that of Hassab's operation in terms of the recurrence rate of esophageal varices and the re-bleeding rate, but the former results in fewer and milder complications.

Formation, hemodynamics and new management options for gastric varices

Abstract Gastric varices develop in patients with portal hypertension, including liver cirrhosis, idiopathic portal hypertension as well as left sided‐local portal hypertension such as splenic vein thrombosis or splenic AV malformation. The inflow vein is the left gastric vein, posterior vein, or short gastric vein, while the outflow vein is the gastro‐renal shunt in most of the patients with gastric varices. The form of the gastric varices is classified into three types of venous dilatation; tortuous type, notched type and tumor type according to the shape and size of the varices. The location is classified into five sites; the posterior site, anterior site, greater curvature site and lesser curvature site of the cardiac area, and the fundic area. The risk of the rupture depends on the mucosal factor of the varices as well as the location and the form. The hemostasis rate has been improved to 94–97% with the usage of the endoscopic occlusive agent such as Histoacryl. It is absolutely necessary to eradicate the gastric varices within a few weeks after rupture of the gastric varices. There are new management options such as laparoscopic Hassab's operation or balloon‐occluded retrograde transvenous obliteration of the varices (B‐RTO). The 5‐year cumulative rate of the non‐variceal bleeding is more than 90% after the B‐RTO as well as after surgery. Further prospective clinical trials are to be investigated for an evidence‐based medicine.

Gallbladder motility in patients with hepatic cirrhosis before and after portal azygous disconnection.

To determine and compare the effect of vagus nerve on gallbladder motility in patients with hepatic cirrhosis before and after portal azygous disconnection (PAD). PAD operation (or Hassab's operation) was performed on 18 patients with portal hypertension, and anterior and posterior vagal trunks were cut. On d 3 before operation and d 10 after operation, (99m)Tc-EHIDA 185 MBq was administered intravenously to the patients, and scintigraphy was performed at 0.25 min/frame. A standard fat meal was administered 30 min after scintigraphy, and dynamic imaging was performed 60 min after the fat meal. Following appearance of the region of interest (ROI) in gallbladder, the time-activity curve of ROI was established. The following seven parameters were used: radioactivity at 30 min after injection of (99m)Tc-EHIDA (RC 30 min), bile emptying fraction (EF), bile emptying period (EP), emptying rate (ER), latent period (LP), latent period radiocounting increment (LI), and latent period radiocounting increment rate (LR). The RC 30 min decreased significantly after operation, compared with that before operation (2 693.6+/- 2 406.9 vs 5 606.8+/-2 625.4, P<0.05). The radiocounting of gallbladder increased gradually during LP. LP after operation was significantly longer than that before operation (13.36+/-5.92 vs 2.24+/-1.48, P<0.01). LI and LR after operation were significantly higher than those before operation (2 861.62+/-028.3 vs 331.21+/-421.02, and 113.42+/-49.52 vs 7.57+/-10.75, respectively, both P<0.01). EP after operation was significantly shorter than that before operation (18.5+/-6.3 vs 24.1+/-6.4, P<0.05). EF and ER after operation were significantly lower than those before operation (13.1+/-5.4 vs 32.3+/-16.3, and 0.7+/-0.3 vs 1.4+/-0.8, respectively, both P<0.01). PAD operation is a good clinical model in studying the effect of vagus on gallbladder motility. The gallbladder tension after PAD operation decreases significantly during the interdigestive phase. The latent period of gallbladder contraction prolongs and the motility weakens apparently after a standard fat meal. Human vagus influences the gallbladder motility, and cutting of the nerve inhibits the gallbladder motility.

門脈圧亢進症例に対するHassab手術後のサイトカイン, 肝線維化マーカーの変動とその意義

門脈圧亢進症例に対するHassab手術後のサイトカイン, 肝線維化マーカーの変動とその意義

Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Combination with Recanalization of Portal and Superior Mesenteric Vein Thrombosis Ensured Hassab's Operation for High-Risk Esophago-Gastric Varices

Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Combination with Recanalization of Portal and Superior Mesenteric Vein Thrombosis Ensured Hassab's Operation for High-Risk Esophago-Gastric Varices

Indication and Outcome of Hassab's Operation for Patients with Liver Cirrhosis

Indication and Outcome of Hassab's Operation for Patients with Liver Cirrhosis

Evaluation of a non-shunting operation by measurement of the blood flow velocity using transendoscopic microvascular Doppler sonography for esophageal and gastric varices

The purpose of this study was to evaluate whether transendoscopic microvascular Doppler sonography (EMDS) is useful to analyze Hassab's operation and esophageal transection (non-shunting operation) which are effective for patients with esophagogastric varices. Twenty patients with esophagogastric varices were examined. Before the operation, we examined the conditions of the esophagogastric varices and measured the velocity of the varices with EMDS. The blood flow velocity in the largest varices (F3) was significantly higher than that in the straight varices (F1). After the operation, the esophageal and gastric variceal blood flow velocities were markedly decreased in 15 patients. In five of the patients who received Hassab's operation, the esophageal variceal form and blood flow velocity still remained. After endoscopic injection sclerotherapy, the velocity and form were completely resolved. The non-shunting operation is effective therapy in the esophageal and gastric varices. It is concluded that EMDS is a non-invasive method and it appears to be very useful for the evaluation of the non-shunting operation.

A case of a hemodialysis patient treated with Hassab operation and EVL for the esophagogastric varices

A case of a hemodialysis patient treated with Hassab operation and EVL for the esophagogastric varices