Recurrence Of Varices Research Articles

Prediction of Recurrence of Esophageal Varices Following Endoscopic Treatment Using Color Doppler Endoscopic Ultrasonography

Background:The time to recurrence of esophageal varices following endoscopic therapy varies greatly between patients, even when similar procedures are used. Although the reasons for this remain largely unknown, it may be partly dependent on the hemodynamics of the collaterals that connect with the varices. Aims: To identify high-risk varices for early recurrence by examining the hemodynamics of the left gastric vein (LGV) using color Doppler EUS (CD-EUS). Methods:We performed CD-EUS (FG36UX Pentax, GFUC30P Olympus) prior to treatment in patients with moderate to large esophageal varices. All patients then received endoscopic band ligation and combined sclerotherapy. Follow-up endoscopies were performed every 3 months following treatment, to evaluate rates of recurrence. Results: A total of 82 patients were examined. Hepatofugal flow velocity in the LGV ranged from 2 to 29.2 cm/sec. The LGV bifurcates into anterior and posterior branches, the former connecting with the esophageal varices, while the latter connects with paraesophageal collaterals. In the hazard model, flow velocity in the LGV and relative dominance of the branch diameter of the LGV were the only factors affecting the time to variceal recurrence. There were no significant factors among other parameters including age, sex, etiology of cirrhosis, coexistence of hepatocellular carcinoma, Child-pugh classification and endoscopic appearance of varices. The patients were classified into one of three groups, depending on a combination of the hepatofugal flow velocity and the dominance of the branches of the LGV: Group 1 (n = 20), anterior-branch-dominant and flow velocity ≥12 cm /sec; Group 2 (n = 22), anterior-branch-dominant and flow velocity <12cm/sec; Group 3 (n = 40), posterior-branch-dominant or non-dominant. The cumulative recurrence-free probability at 12 months (analyzed by the Kaplan-Meyer method and the log-rank test) was 11% in Group 1, 74% in Group 2 and 78 % in Group 3 (P < 0.0001). Conclusions: Esophageal varices appear to recur more easily in patients with anterior-branch-dominant systems and rapid hepatofugal flow in the LGV. CD-EUS may be useful in predicting recurrence of varices following endoscopic treatment and may assist in selecting the optimal treatment for each patient.

Comparison of Argon Plasma Coagulation and Paravariceal Injection Sclerotherapy of 1% Polidocanol in Mucosa-Fibrosing Therapy for Esophageal Varices

Background:Endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) are widely used for esophageal varices treatment. However, recurrence of esophageal varices have sometimes been observed after these treatments. In Japan, therefore, in addition to these treatment, a mucosa-fibrosing therapy by paravariceal injection sclerotherapy was performed for complete disappearance of esophageal varices.Aim:This study evaluated the efficacy, complication, recurrence of esophageal varices of mucosa-fibrosing therapy by argon plasma coagulation (APC) compared with those by paravariceal injection sclerotherapy using 1% polidocanol (1% PD). Patients and methods:Sixty-seven patients with F2 or F3 esophageal varices exhibiting the red color sign (high risk group, according to the criteria of the “Japan Society for Portal Hypertension and Esophago-Gastric varices”) were enrolled between March 1999 and March 2003. Twenty-two patients received the mucosa-fibrosing therapy by APC and 45 patients received the mucosa-fibrosing therapy by paravariceal injection sclerotherapy of 1% PD. Eighteen of the 22 patients in the APC group and 39 of the 45 patients in the 1% PD group received prophylactic treatment. All candidates for prophylactic treatment were regarded as being at the high-risk for variceal hemorrhage. Five patients in the APC group and 13 patients in the 1% PD group had concomitant hepatoma. Endoscopic APC (gas flow 1.6 L/min, power setting 50W) was used to promote fibrosis of the esophageal mucosa. We defined recurrence as being greater than F1 or the appearance of red color sign. Result:The number of treatment sessions to eradicate the varices in the APC group was significantly lower than those in the 1% PD group (total:2.3+/-0.7 vs. 2.8+/-0.8, mucosa-fibrosing therapy:1.2+/-0.4 vs. 1.7+/-0.6, p<0.05). According to Kaplan-Meier analysis, the one-and three-year cumulative recurrence-free rate in the APC group (85.2%, 77.5%) were not significantly higher than those in the 1% PD group (81.5%, 71.1%)(Wilcoxon test, p=0.64). Three patients (6.7%) in the 1% PD group developed stricture of esophagus, but there were no other complications detected in the two groups. Conclusions:We concluded that the mucosa-fibrosing therapy with APC is a useful new option for esophageal varices because it is safe and requires less invasion during esophageal varices treatment.

Endoscopic and Echoendoscopic Evaluation of Gastric Varices Eradication with Cianoacrilate

Endoscopic and Echoendoscopic Evaluation of Gastric Varices Eradication with Cianoacrilate Erika Macedo, Fernanda Thuler, Veruska Di Sena, Gustavo De Paulo, Frank Nakao, Jose Ardengh, Angelo P. Ferrari Jr. Introduction: bleeding from gastric varices rupture is more severe than from esophageal varices. Usual endoscopic techniques (sclerotherapy and banding) are not good choices for gastric varices eradication. Cianoacrilate endoscopic injection has been reported as the best choice for such patients. Aim: to asses the value of echoendoscopy in monitoring gastric varices eradication by cianoacrilate injection. Method: 17 patients with Sarin type GEV2 varices were submitted to endoscopic injection of a cianoacrilate and lipiodol solution (1 ml each). Patients younger than 18 years and/or with severe systemic disease were excluded from the study. All patients were submitted to EUS and endoscopy before and at 3, 6 and 12 months after index treatment. Doppler signal was used during EUS. After each 3-month interval the injection was repeated if there was endoscopic evidence of remaining or recurrent varices. Results: our study group consisted of 10 men and 7 women, mean age 50.6 years (range 22 76, median 51 years). Portal hypertension was secondary to cirrhosis due to schistosomiasis (4), chronic B or C viral hepatitis (3 and 8) and alcohol abuse (2). Endoscopic injection was successfully performed in the U turn position, with no immediate complications. Three patients are still waiting for the first 3-month re-evaluation and two patients died of hepatic insufficiency, unrelated to bleeding. Among the remaining 12 patients, 8 finished the study (1 year follow-up), 4 had their 3and 6month follow-up (2 in each group). In seven patients there was a need for additional injection sessions: a mean of 1.8 sessions/patient (range 1-3). Endoscopic follow up showed complete eradication of variceal novel in every patient. EUS follow up showed absence of variceal flow (negative Doppler signal) in every patient considered eradicated by conventional endoscopy. There were no complications. Conclusion: endoscopic injection of cianoacrilate plus lipiodol is a safe and effective method for gastric varices eradication. EUS evaluation allows detection of variceal flow andmay help in planning additional treatment as well as in monitoring the patient.

Clinicopathologic Study of Gastric Submucosal Tumor: Endosonographic and Immunohistochemical Findings of Gastrointestinal Stromal Tumors (GISTs) in Stomach

Clinicopathologic Study of Gastric Submucosal Tumor: Endosonographic and Immunohistochemical Findings of Gastrointestinal Stromal Tumors (GISTs) in Stomach Bong Min Ko, Su Jin Hong, Kye Won Kwon, Chang Beom Ryu, Joo Young Cho, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim BACKGROUND/AIM: The gastrointestinal stromal tumors (GIST) constitute the largest catergory of primary non-epithelial neoplasm of the gastrointestinal tract and include most tumors previously designated as leiomyomas/leiomyosarcomas. Clinically and pathologically, GIST represents a spectrum of tumors that include benign and malignant variants. A small proportion of tumors apparently lacking mitotic activity do metastasis. This study was performed to evaluate the need of follow up and treatment of GISTs. METHOD: This study was performed on 38 patients who had gastric submucosal tumor on endoscopy and endosonography (EUS) and confirmed by histologic examinations using immunohistochemistry between January 2001 and October 2003 at our hospital. We evaluated the clinical features, EUS findings (size, layer, echogenicity, cystic change, lobuation, marginal halo, echogenic foci) and immunohistochemical stain (CD117, CD34, SMA, S-100, Ki-67). RESULT: 1) 14 of the 38 patients in gastric submucosal tumors were diagnosed GIST. 2) The age of the patients with GIST ranged from 37 to 86 years old, with an average age of 58.3 years. 3) In GIST, lobulation on EUS findings was correlated with risk of aggressive behavior in GISTs significantly (<0.05). 4) Ki-67 was correlated with risk of aggressive behavior in GISTs significantly (<0.05). 5) GISTs appeared as hypoechoic mass arising from 2nd, 3rd and 4th layer. CONCLUSION: EUS and histologic diagnosis including immunohistochemical stain approach should be performed to differentiate diagnosis when showed gastric SMT. Although GISTs has low malignant potential, regular follow up or resection is needed. *T1650 Endoscopic and Echoendoscopic Evaluation of Gastric Varices Eradication with Cianoacrilate Erika Macedo, Fernanda Thuler, Veruska Di Sena, Gustavo De Paulo, Frank Nakao, Jose Ardengh, Angelo P. Ferrari Jr. Introduction: bleeding from gastric varices rupture is more severe than from esophageal varices. Usual endoscopic techniques (sclerotherapy and banding) are not good choices for gastric varices eradication. Cianoacrilate endoscopic injection has been reported as the best choice for such patients. Aim: to asses the value of echoendoscopy in monitoring gastric varices eradication by cianoacrilate injection. Method: 17 patients with Sarin type GEV2 varices were submitted to endoscopic injection of a cianoacrilate and lipiodol solution (1 ml each). Patients younger than 18 years and/or with severe systemic disease were excluded from the study. All patients were submitted to EUS and endoscopy before and at 3, 6 and 12 months after index treatment. Doppler signal was used during EUS. After each 3-month interval the injection was repeated if there was endoscopic evidence of remaining or recurrent varices. Results: our study group consisted of 10 men and 7 women, mean age 50.6 years (range 22 76, median 51 years). Portal hypertension was secondary to cirrhosis due to schistosomiasis (4), chronic B or C viral hepatitis (3 and 8) and alcohol abuse (2). Endoscopic injection was successfully performed in the U turn position, with no immediate complications. Three patients are still waiting for the first 3-month re-evaluation and two patients died of hepatic insufficiency, unrelated to bleeding. Among the remaining 12 patients, 8 finished the study (1 year follow-up), 4 had their 3and 6month follow-up (2 in each group). In seven patients there was a need for additional injection sessions: a mean of 1.8 sessions/patient (range 1-3). Endoscopic follow up showed complete eradication of variceal novel in every patient. EUS follow up showed absence of variceal flow (negative Doppler signal) in every patient considered eradicated by conventional endoscopy. There were no complications. Conclusion: endoscopic injection of cianoacrilate plus lipiodol is a safe and effective method for gastric varices eradication. EUS evaluation allows detection of variceal flow andmay help in planning additional treatment as well as in monitoring the patient.

Recurrent Varicose Veins after Surgery: A New Appraisal of a Common and Complex Problem in Vascular Surgery*1

Objective. To assess the true incidence, the reflux patterns and the mechanisms responsible for recurrent varicose vein disease according to current definitions and guidelines.Patients and methods. Ninety-three patients (69 female, 24 male, mean age: 48 years) were prospectively evaluated pre- and postoperatively (1 month and 5 years), using clinical and colour duplex examination of both lower limbs. The CEAP score and its modification for recurrence (REVAS) were used for classification.Results. In 113 operated lower limbs, 28 (25%) were found to have a recurrence, 20 of which were symptomatic (20/28, 72%). However, in this group, the mean severity score decreased significantly from 6.5 (SD 3.1) to 5.2 (SD 2.8) (p<0.001, paired t-test).The correlation between the type and cause of recurrence revealed: (1) true recurrent varices in eight limbs (8/28, 29%), primarily caused by neovascularisation, (2) new varicose veins as a consequence of disease progression in seven limbs (7/28, 25%), (3) residual veins in three limbs (3/28, 11%) mainly due to tactical errors (e.g. failure to strip the GSV), (4) complex patterns in 10 limbs (10/28, 36%).In the limbs with recurrence, 42 sources of venous reflux were identified: (1) 19 new sites of venous reflux were due to disease progression (15% of the operated limbs), (2) 13 were caused by neovascularisation (11.5% of the operated limbs), (3) six resulted from tactical failures (5.3% of the operated limbs) and (4) four were due to technical failures (3.5% of the operated limbs).Conclusions. This study shows that the recurrence of varicose veins after surgery is not uncommon. However, the clinical condition of most affected limbs remains improved. Progression of the disease and neovascularisation are responsible for more than half of the recurrences. Rigorous evaluation of patients and assiduous surgical technique might reduce recurrence due to technical and tactical failures.

Recurrent Varicose Veins after Surgery: A New Appraisal of a Common and Complex Problem in Vascular Surgery

Objective. To assess the true incidence, the reflux patterns and the mechanisms responsible for recurrent varicose vein disease according to current definitions and guidelines.Patients and methods. Ninety-three patients (69 female, 24 male, mean age: 48 years) were prospectively evaluated pre- and postoperatively (1 month and 5 years), using clinical and colour duplex examination of both lower limbs. The CEAP score and its modification for recurrence (REVAS) were used for classification.Results. In 113 operated lower limbs, 28 (25%) were found to have a recurrence, 20 of which were symptomatic (20/28, 72%). However, in this group, the mean severity score decreased significantly from 6.5 (SD 3.1) to 5.2 (SD 2.8) (p<0.001, paired t-test).The correlation between the type and cause of recurrence revealed: (1) true recurrent varices in eight limbs (8/28, 29%), primarily caused by neovascularisation, (2) new varicose veins as a consequence of disease progression in seven limbs (7/28, 25%), (3) residual veins in three limbs (3/28, 11%) mainly due to tactical errors (e.g. failure to strip the GSV), (4) complex patterns in 10 limbs (10/28, 36%).In the limbs with recurrence, 42 sources of venous reflux were identified: (1) 19 new sites of venous reflux were due to disease progression (15% of the operated limbs), (2) 13 were caused by neovascularisation (11.5% of the operated limbs), (3) six resulted from tactical failures (5.3% of the operated limbs) and (4) four were due to technical failures (3.5% of the operated limbs).Conclusions. This study shows that the recurrence of varicose veins after surgery is not uncommon. However, the clinical condition of most affected limbs remains improved. Progression of the disease and neovascularisation are responsible for more than half of the recurrences. Rigorous evaluation of patients and assiduous surgical technique might reduce recurrence due to technical and tactical failures.

Fifteen-year follow up of endoscopic injection sclerotherapy in children with extrahepatic portal venous obstruction.

Endoscopic sclerotherapy has emerged as an effective treatment for bleeding esophageal varices both in adults and children but the long-term outcome is poorly defined in children. The authors report a 15-year follow up of sclerotherapy in children with extrahepatic portal venous obstruction. Between June 1982 and February 1992, 69 children with bleeding esophageal varices underwent sclerotherapy; variceal eradication was achieved in 63 (91.3%) patients, with procedure-related morbidity of 28.9% and mortality of 1.4%. Fifty-nine patients with variceal eradication were followed for between 10.4 and 20.1 years (mean, 15.1 +/- 3.1 years). After a median period of 3 years (range, 1.2-12.8 years), seven (11.9%) patients presented with recurrent bleeding (esophageal varices, four; gastric varices, two; and duodenal ulcer, one). Recurrent bleeding occurred in six of seven (85.7%) patients within the first 4 years of initial variceal eradication. Esophageal varices recurred in eight (13.6%) patients. Five of the seven patients with recurrent bleeding and all eight with recurrent varices were effectively treated with further sclerotherapy. Two patients with gastric variceal bleeding unresponsive to sclerotherapy underwent shunt surgery. Elective surgery was required in eight additional patients for reasons other than recurrent varices or bleeding. The authors conclude that (i) sclerotherapy is the ideal, safe and effective treatment for bleeding esophageal varices, that it prevented bleeding in 88.1% patients after variceal eradication and hence, should be included in primary management strategies; (ii) follow-up endoscopy should be performed on a yearly basis for the first 4 years after variceal eradication; and (iii) surgery is required as a complementary technique for patients with uncontrolled bleeding, painful splenomegaly, growth retardation and symptomatic portal biliopathy.

Caroli’s syndrome and imaging: report of a case

A 21-year-old man was referred for assessment of a portal hypertension. He had been followed up from birth because of a “presumed” hepato-renal policystic disease. At the age of 8 years, a portal hypertension with hepatomegaly, splenomegaly and grade-II esophageal varices was detected, and beta-blockers were initiated for treatment. At the age of 14 different examinations were performed, which were consistent with a Caroli’s syndrome. Magnetic resonance (MRI) cholangiography showed a nodular liver with saccular cystic dilatations communicating with the biliary tree, and demonstrated the presence of policystic renal disease. A liver biopsy showed portal spaces with minimal duct proliferation and fibrosclerotic bands. At the age of 20, a vascular MRI scan showed severe signs of portal hypertension with giant variceal nodules around the splenic hilus, small gastric curvature, and esophagogastric junction. Upper gastrointestinal endoscopy showed a progression of esophageal varices to grade-IV varices, with ingurgitation and presence of “red spots”. Because of a substantial risk of hemorrhage, band ligation was performed as a primary prophylaxis for bleeding. One year later, a recurrence of esophageal varices developed in the upper esophagus. Laboratory tests showed impaired liver function tests (prothrombin activity 49.2%, bilirubin 3.15 mg/dl, albumin 4.7 g/dl). Given the evidence of severe portal hypertension, high risk of variceal bleeding, and impaired liver function tests, liver transplantation was considered. Caroli’s disease is characterized by the presence of cystic dilatations of the intrahepatic bile ducts. Two primary types of the disease have been identified ‐a “pure” type or Caroli’s disease (type 1) and a “complex” type associated with congenital hepatic fibrosis, also named Caroli’s syndrome. The significantly more frequent complex form is transmitted

Effect of spontaneous portosystemic shunts on hemorrhage from esophagogastric varices.

The role of a massive spontaneous portosystemic shunt (MSPSS) in cirrhotic patients with portal hypertension remains unclear. The aim of this study was to investigate clinical outcomes and portal hemodynamic changes following ligation of the MSPSS during devascularization surgery. Portography and gastroendoscopy were performed before and after surgery for hemodynamic and follow-up studies. Three types of MSPSS were demonstrated portographically: 22 portoumbilical shunts, 18 splenorenal shunts, and 2 inferior mesenteric-caval shunts. A total of 40 MSPSS patients with esophagogastric variceal (EGV) bleeding underwent surgery: 26 had ligation of the MSPSS, and the remaining 14 served as the nonligation group. Neither the preoperative mean portal pressure (MPP) nor the postoperative MPP were significantly different between the ligation and nonligation groups (p>0.1), and there was no significant difference regarding surgical mortality, recurrent varices, or cumulative survival rate for the two groups in the follow-up study. However, postoperative portography demonstrated persistent drainage of portal flow and decreased intrahepatic portal perfusion in the nonligation patients. Clinical signs of hepatic encephalopathy subsided after ligation of the MSPSS in three patients. Therefore ligation of the MSPSS, which may be responsible for the development of encephalopathy, is recommended during devascularization surgery for EGV in cirrhotic patients.

Clinical spectrum of recurrent postoperative varicose veins and efficacy of sclerotherapy management using the compass technique

Objectives: Tostudy the clinical spectrum of recurrent varices after surgery (REVAS) and the efficacy of sclerotherapy under the comprehensive objective mapping, precise image-guided injection, antireflux positioning and sequential sclerotherapy (COMPASS) technique in their management. Methods: Design: prospective open study with 1.5-5.7-year follow up. Patients: 253 legs of 168 consecutive patients who had received previous surgery for primary varicosity. Main outcome measures: obliteration, recanalization, residual reflux, neovascularization, venous dysfunction score and cumulative obliteration. Results: REVAS presents as a symptomatic chronic venous disease of women in their fifties, a decade later than primary varicosities are reported. Almost 75% of REVAS occurred at the groin, mostly with features of chronic venous disease. The COMPASS technique achieved sustained obliteration in 97% of the groin varices and in 100% of the thigh and isolated refluxes around the popliteal fossa. The cumulative obliteration rate was sustained at &gt;90% and obliteration of perforator reflux was sustained. There was a significant decrease in the venous dysfunction score. In the mean 3.1±1.7 years of follow up, only 3% possible neovascularization was seen. There were no serious adverse experiences reported. Conclusions: REVAS is a symptomatic chronic venous disease requiring skilled medical attention. The COMPASS technique appears to be more efficacious than the presently available surgical approaches to its long-term management.

Endoscopic ligation of esophageal varices for prophylaxis of first bleeding in children and adolescents with portal hypertension: preliminary results of a prospective study

Background/purpose Endoscopic variceal ligation (EVL) is effective in controlling rebleeding from esophageal varices in children, but there is no data on the use of EVL to prevent initial bleeding. The objective of this study was to prospectively evaluate the efficacy of EVL in preventing the first hemorrhage from esophageal varices in children. Methods Thirty-seven children with portal hypertension (22 liver cirrhosis, 15 portal vein thrombosis), aged 4 to 17 years (M = 9.5 ± 4.4 years) were included in the study. The criteria for inclusion were (1) no previous variceal bleeding; (2) the presence of esophageal varices classified grade II or more, and (3) their enlargement by at least I grade after 6 months of observation without endoscopic treatment or appearance of endoscopic signs of high bleeding risk. A Multi-Band Ligator was used, and 2 to 6 bands were fixed under general anesthesia during one procedure depending on the number and size of varices. Follow-up examinations were performed every 3 months, repeating the procedure if necessary. In total, 75 procedures of EVL were performed, from one to 5 in each patient Results Four patients underwent liver transplantation before eradication of varices. Two others were excluded from the observation because of lack of compliance to the protocol. Of the remaining 31 patients, eradication of varices was achieved in 28 children (90.3%) after 2.0 EVL sessions performed at 3-month intervals. The average time of follow-up after cessation of treatment is 16 months. No bleeding from varices occurred in any child during or after treatment. There were no differences in results between children with liver cirrhosis and portal vein thrombosis. Development of hypertensive gastropathy was observed in 2 children with one episode of bleeding. Recurrence of varices without bleeding occurred in 3 children after 12, 13, and 28 months from eradication. Conclusions The study results confirmed that endoscopic variceal ligation is a safe and highly effective procedure in children with portal hypertension, regardless of its etiology. Eradication of esophageal varices was followed by 16 months free of bleeding. Prolonged observation is mandatory to conclude if preventive EVL influences the natural history of disease and diminishes the risk of first bleeding onset.

Endoscopic blockade to prevent resurfacing of esophageal varices

Endoscopic blockade to prevent resurfacing of esophageal varices

Endoscopic color Doppler ultrasonographic evaluation of recurrent esophagogastric varices following endoscopic injection sclerotherapy

Background: Endoscopic injection sclerotherapy (EIS) for treatment of esophagogastric varices is well established in Japan. However, varices may still recur unpredictably following EIS. We studied this problem using endoscopic color Doppler ultrasonography (ECDUS) and specifically examined esophagogastric blood flows. Methods: Prophylactic EIS was performed by intravariceal injection of 5% ethanolamine oleate (EO) in 49 patients with esophageal varices secondary to liver cirrhosis. No patient had documented hepatocellular carcinoma (HCC) before EIS, and patients who developed HCC during follow-up were excluded. We performed ECDUS before EIS, and 2 weeks and 2 years later. The esophagogastric intra- and extramural venous blood flows, including flow in the azygos vein, were compared between these observations. Gastric intramural blood flow and changes in extramural gastric blood flow, including the azygos vein flow, were scored. Dynamic computer tomography (CT), ultrasonography (US), and color Doppler-ultrasonography (CDUS) were also performed before EIS and 1 month following the procedure. Thereafter, patients underwent CT and US examinations every 6 months for 2 years to detect any development of porto-systemic shunts or HCC. Results: The average number of EIS procedure per patient was 3.1±0.8 (mean±SD), and the total amount of sclerosant injected was approximately 33.5±6.5 ml. The overall recurrence rate over the 2-year follow-up was 36.7%. The gastric intra- and extramural blood flows did not differ between those patients with or without major shunts before EIS. In patients with recurrent variceal formation, the gastric intramural blood flow score following EIS (2.1±0.5) was significantly higher than that in patients without recurrence (0.8±0.6) ( P<0.01). In addition, gastric extramural blood flow score following EIS (0.8±0.6) was significantly lower in patients with recurrence than that in those without recurrence (1.7±0.5) ( P<0.01). The same differences held after exclusion of patients with major shunts. The gastric intramural blood flow score in patients with recurrent variceal formation (2.1±0.4) was significantly higher than that in patients without recurrence score ( P<0.01). Moreover, gastric extramural blood flow score in patients with recurrent variceal formation (1.0±0.7) was significantly lower than in patients without recurrence (1.6±0.5) ( P<0.01). Conclusions: Two characteristics were observed in patients with recurrent cases of esophageal varices 2 weeks following EIS. The first was the maintenance of gastric intramural blood flow. The second was the absence of dilation of the gastric extramural blood vessels. These observations may enable us to predict the recurrence of esophagogastric varices using ECDUS within 2 weeks following EIS.

Treatment of Variceal Bleeding.

Mortality due to variceal bleeding secondary to portal hypertension has decreased significantly in the past 2 decades. Endoscopic therapy has been the mainstay of treatment for acute variceal bleeding. Variceal banding ligation has superceded injection sclerotherapy as the most popular treatment modality for acute bleeding. Multiple banding ligators are widely used with high success in restoring hemostasis. The combination of banding and sclerotherapy may be useful in preventing the early recurrence of varices and rebleeding after initial obliteration of varices. Selective vasoactive agents such as somatostatin analogs also improve the outcome of patients. Radiologic shunting has proven to be an effective salvage procedure when endoscopic treatments fail and may be a good intermediate-stage therapy while the patient is waiting for liver transplantation.

A new technique of combined endoscopic sclerotherapy and ligation for variceal bleeding

To develop a technique of combined endoscopic sclerotherapy and ligation (ESL) in which both techniques of endoscopic sclerotherapy (ES) and endoscopic variceal ligation (EVL) can be optimally used. ESL was performed in 10 patients (age 46.4+/-7.9; 9 males, 1 female) with cirrhosis of liver using sclerotherapy needle and Speedband, Superview multiple band ligater (Boston Scientific, Microvasive, Watertown, MA). A single band was placed 5-10 cm proximal to the gastro-esophageal junction over each varix from proximal to distal margin, followed by intravariceal injection of 1.5 % ethoxysclerol (4 ml each) 2 to 3 cm proximal to the gastroesophageal junction on the ligated varices distal to deployed band. EVL was then performed at the injection site. Similarly other varices were also injected and ligated from distal to proximally. In the subsequent sessions, ES alone was performed to sclerose small varices at the gastroesophageal junction. ESL was successfully performed in all patients. A median of 3 (ESL 1, ES 2) sessions (ranged 1-4) were required to eradicate the varices in 9 (90 %) of 10 patients. Recurrence of varices without bleed was seen in 1 patient during a mean follow-up of 10.3 months (ranged 6-15). Two patients died of liver failure. None died of variceal bleeding. None of the patients had procedure related complications. ESL may be useful in the fast eradication of esophageal varices. However, randomised controlled trials are required to find out its relative efficacy and impact on variceal recurrence in comparison to ES or EVL.

288 Hepatic venous pressure gradient (HVPG) predicts early recurrence of varices and rebleeding after endoscopic band ligation (EBL)

288 Hepatic venous pressure gradient (HVPG) predicts early recurrence of varices and rebleeding after endoscopic band ligation (EBL)

Argon plasma coagulation prevents variceal recurrence after band ligation of esophageal varices: Preliminary results of a prospective randomized trial

Background: Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence in small uncontrolled series. The aim of this study was to determine whether argon plasma coagulation is effective in reducing variceal recurrence after endoscopic variceal ligation. Methods: Thirty patients with cirrhosis, a history of acute esophageal variceal bleeding, and eradication of varices by endoscopic variceal ligation were randomized to argon plasma coagulation (16 patients) or observation (14 patients). The 2 groups were similar with respect to all background variables including age, Child-Pugh score, presence of gastric varices, and degree of portal hypertensive gastropathy. In the argon plasma coagulation group, the entire esophageal mucosa 4 to 5 cm proximal to the esophagogastric junction was thermocoagulated circumferentially with argon plasma coagulation in 1 to 3 sessions performed at weekly intervals. Endoscopy was performed every 3 months to check for recurrence of varices in both groups. Results: During the course of the study, no serious complication was noted. After argon plasma coagulation, transient fever occurred in 13 patients and 8 complained of dysphagia or retrosternal pain/discomfort. Mean follow-up for all patients was 16 months (range 9-28 months). No recurrence of varices or variceal hemorrhage was observed in the argon plasma coagulation group, whereas varices recurred in 42.8% (6/14) of the patients in the control group ( p < 0.04) and bleeding recurred in 7.2% (1/14). Conclusions: Argon plasma coagulation of the distal esophageal mucosa after eradication of esophageal varices by endoscopic variceal ligation is safe and effective for reducing the rate of variceal recurrence. (Gastrointest Endosc 2002;56:467-71.)

Endoscopic ligation compared with sclerotherapy for bleeding esophageal varices in children with extrahepatic portal venous obstruction

Endoscopic sclerotherapy is an effective treatment for bleeding esophageal varices, but it is associated with significant complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, has been shown to be superior to sclerotherapy in adult patients with cirrhosis. To determine the efficacy and safety of endoscopic sclerotherapy and ligation, the 2 methods were compared in a randomized control trial in 49 children with extrahepatic portal venous obstruction who had proven bleeding from esophageal varices. Twenty-four patients were treated with sclerotherapy and 25 with band ligation. No significant differences were found between the sclerotherapy and ligation groups in arresting active index bleeding (100% each) and achieving variceal eradication (91.7% vs. 96%, P = .61). Band ligation eradicated varices in fewer endoscopic sessions than did sclerotherapy (3.9 ± 1.1 vs. 6.1 ± 1.7, respectively, P < .0001). The rebleeding rate was significantly higher in the sclerotherapy group (25% vs. 4%, P = .049), as was the rate of major complications (25% vs. 4%, P = .049). After eradication, esophageal variceal recurrence was not significantly different in patients treated by ligation than by sclerotherapy (17.4% vs. 10%, P = .67). In conclusion, variceal band ligation in children is a safe and effective technique that achieves variceal eradication more quickly, with a lower rebleeding rate and fewer complications compared with sclerotherapy. (H EPATOLOGY 2002;36:666-672.)

Results after Re-Operation in the Groin for Recurrent Varices of the Long Saphenous Vein

Objective: To evaluate the outcome of re-operation in the groin for recurrent varicose veins. Design: Retropective follow-up study Setting: Department of Vascular Surgery, Gentofte University Hospital, Copenhagen, Denmark. Methods and materials: Thirty-two patients with 43 operated legs. Operations were performed between January 1996 and the end of April 1997 and solely as a groin dissection; no stripping was done. Follow-up consisted of a clinical examination and duplex scanning with an ATL HDI 5000 scanner. Results: Sixteen cured legs, 17 with reflux beginning at mid-thigh, mainly a Hunter's perforating vein, and 10 with remaining reflux at the sapheno-femoral junction. Conclusion: Recurrence rate in the groin is acceptable. Stripping of the long saphenous vein is mandatory to bring down the recurrence rate from mid-thigh perforating veins. This is now standard procedure in our department.

Endoscopic Injection Sclerotherapy for the Treatment of Recurrent Esophageal Varices after Esophageal Transection

Background: We examined the hemodynamic changes associated with recurrent esophageal varices after esophageal transection (ET) and evaluated the effectiveness of endoscopic injection sclerotherapy (EIS) as the treatment for these varices. Methods: Nineteen patients with recurrent esophageal varices after ET were treated by EIS. Endoscopic varicealography during injection sclerotherapy, following oral blockage of flow by a balloon, identified three patterns: (i) type 1: common type, continuous filling by the feeder vessel of the varix; (ii) type 2: retrograde-disappearing type, confirmed hepatofugal flow; and (iii) type 3: immediate washout type, immediate washout of contrast medium. Results: Angiography revealed that the hepatofugal feeder vessel was the right gastric vein in all cases. Fourteen patients (73.7%) were classified as type 1, 4 patients (21.1%) as type 2, and 1 patient (5.3%) as type 3. Fewer treatment sessions were required in type 1 than in type 2 (P < 0.005). Recurrent varices were completely eradicated in all patients except the patient with type 3 disease. Cumulative re-recurrence rates at 5 and 10 years were similar for types 1 and 2 (28.6 and 71.4%vs 25 and 25%, respectively). The cumulative survival rates after EIS at 5 and 10 years were also similar for types 1 and 2 (77.1 and 66.1%vs 66.7 and 66.7%). Conclusion: Endoscopic injection sclerotherapy is an effective treatment for recurrent esophageal varices after ET, except in type 3 disease. Our classification based on endoscopic varicealography during injection sclerotherapy provides knowledge of blood flow within the varices that helps to inform the treatment strategy.