Recurrence Of Varices Research Articles

Percutaneous transhepatic variceal embolization combined with endoscopic ligation for the prevention of variceal rebleeding

To compare the efficiency of percutaneous transhepatic variceal embolization (PTVE) plus endoscopic variceal ligation (EVL) with EVL alone in the treatment of esophageal variceal bleeding. Cirrhotic patients with recent esophageal variceal bleeding from January 2007 to December 2011 were collected and assigned to PTVE + EVL (N = 41) or EVL (N = 47) groups. We performed chart reviews and prospective follow-up to determine variceal rebleeding, recurrence of varices and survival. During the follow-up period, recurrence of esophageal varices (EV) occurred in 8 patients (19.5%) in the PTVE + EVL group and 23 (48.9%) in the EVL group (P = 0.004). The time to recurrence of EV was 9.2 ± 2.7 months and 4.9 ± 2.1 months, respectively. Three patients (7.3%) in the PTVE + EVL group and 12 (25.5%) in the EVL group experienced rebleeding from all sources (P = 0.023). One patient (2.4%) in the PTVE + EVL group and 7 (14.9%) in the EVL group experienced rebleeding from EV (P = 0.024). Multivariate Cox analysis indicated that the treatment method was the only predictor of rebleeding. There was no significant difference in the survival rate between the two groups. With adequate and permanent obliteration of EV and their feeding veins, the combination of PTVE with cyanoacrylate and EVL is more effective than EVL alone in the prevention and treatment of EV recurrence and rebleeding.

Percutaneous transportal outflow‐vessel‐occluded sclerotherapy for gastric varices unmanageable by balloon‐occluded retrograde transvenous obliteration

In this report we introduce percutaneous transportal outflow-vessel-occluded sclerotherapy (PTOS) for gastric varices unmanageable by balloon-occluded retrograde transvenous obliteration (BRTO) in two cases and evaluate its safety and efficacy. The PTOS is a technique which could obstruct gastric varices subsequent to the occlusion of the outflow route, being based on the rationale of BRTO. In the PTOS procedure, coil embolization of the outflow vessel is first conducted through a microcatheter advanced beyond the gastric varices via the percutaneous transhepatic approach; sclerosing agent (5% ethanolamine oleate) is then injected into the gastric varices after confirmation of static blood flow in the varices. Two patients underwent initial BRTO that eventually failed because of the presence of numerous fine and abruptly angled outflow vessels (case 1), and the presence of a tortuous and elongated outflow vessel accompanied by numerous small collateral outflows that could not be occluded (case 2). Cases 1 and 2 received PTOS using 5% ethanolamine oleate (15 mL and 10 mL, respectively). Portal venous pressure following PTOS showed an increase from 29 to 34 mmHg in case 1 and remained at 24 mmHg in case 2. No major complication was encountered in either patient. One-year follow-up gastroendoscopy showed no recurrence of gastric varices in either patient. Although PTOS is slightly more invasive than BRTO, PTOS can be used as an alternative catheter treatment procedure for gastric varices that are unmanageable by BRTO.

Abstract No. 318 - Meta-analysis of balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices

Purpose Variceal bleeding is a major and potentially fatal complication of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding, but is associated with high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of gastric varices in Asia over the last 2 decades and has shown promising results. However, to the best of our knowledge, no meta-analyses of the BRTO literature have yet been published. Materials and Methods Systematic review and meta-analysis of BRTO literature were performed to estimate outcomes for BRTO for gastric varices. Separate metaanalyses were performed for technical success rate, survival, gastric variceal recurrence, esophageal variceal exacerbation, and complication rate. Institutional review board approval was not required for this retrospective analysis. Results An extensive literature review resulted in 20 suitable studies which were included. The inclusion/exclusion criteria, patient demographics, outcome measures, and complications will be summarized. Systematic review and meta-analysis was performed on results for BRTO for 734 patients from multiple centers. Cumulative rates of procedural technical success and gastric variceal recurrence were 83.8% (55.5-100%), 2.6% (0-7.2%), respectively. Exacerbation of esophageal varices was reported at a rate of 37.1% (10-67%). Major complication rates were reported at 3.8% (0-15.3%). Long-term preservation of hepatic function was noted. Patient 1-, 3-, and 5-year survival rates are 92.2% (83.1-100%), 82.6% (71-100%), and 67.9% (53.7-85%). The presence of hepatocellular carcinoma and Child-Pugh class C were factors significantly impacting patient survival. Conclusion BRTO is an effective and relatively safe procedure for the management of gastric varices. BRTO should be considered as a useful procedure in the toolbox of radiologists for the management of gastric varices in the presence of a gastrorenal shunt. BRTO is associated with long-term obliteration of gastric varices and preservation of hepatic function, thus patients with limited hepatic reserve should be considered for BRTO when possible.

Endovascular Treatment of Pelvic Congestion Syndrome: Visual Analog Scale (VAS) Long-Term Follow-up Clinical Evaluation in 202 Patients

This study was designed to evaluate the clinical outcome and patients' satisfaction after a 5 year follow-up period for pelvic congestion syndrome (PCS) coil embolization in patients who suffered from chronic pelvic pain that initially consulted for lower limb venous insufficiency. A total of 202 patients suffering from chronic pelvic pain were recruited prospectively in a single center (mean age 43.5 years; range 27-57) where they were being treated for lower limb varices. Inclusion criteria were: lower limb varices and chronic pelvic pain (>6 months), >6 mm pelvic venous caliber in ultrasonography, and venous reflux or presence of communicating veins. Both ovarian and hypogastric veins were targeted for embolization. Pain level was assessed before and after embolotherapy and during follow-up using a visual analog scale (VAS). Technical and clinical success and recurrence of leg varices were studied. Patients completed a quality questionnaire. Clinical follow-up was performed at 1, 3, and 6 months and every year for 5 years. Technical success was 100%. Clinical success was achieved in 168 patients (93.85%), with complete disappearance of symptoms in 60 patients (33.52%). Pain score (VAS) was 7.34 ± 0.7 preprocedural versus 0.78 ± 1.2 at the end of follow-up (P < 0.0001). Complications were: groin hematoma (n = 6), coil migration (n = 4), and reaction to contrast media (n = 1). Twenty-three cases presented abdominal pain after procedure. In 24 patients (12.5%), there was recurrence of their leg varices within the follow-up. The mean degree of patients' satisfaction was 7.4/9. Coil embolization of PCS is an effective and safe procedure, with high clinical success rate and degree of satisfaction.

“Downhill” Esophageal Varices in Congenital Heart Disease

“Downhill” Esophageal Varices in Congenital Heart Disease

Esophageal variceal ligation in the secondary prevention of variceal bleeding: result of long term follow-up

IntroductionLong-term outcome of patients after band ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation in patients with portal hypertension in the Hassan II university hospital, Fes, Morocco.MethodsOver 118 months patients treated by endoscopic variceal ligation were received regular follow- up and detailed clinical assessment of at least 24 months.ResultsOne hundred twenty five patients were followed up for a mean of 31 months (range 12-107 months). Obliteration of the varices was achieved in 89.6 % (N = 112) of patients, with 3 +/-1.99 (range 1-8) endoscopy sessions over a period of 14 + /-6.8 weeks (range 3-28). The percentage of variceal recurrence during follow-up after ligation was 20.5 % (N = 23). Recurrence were observed in a mean of 22 months +/- 7.3 (range 3-48). Bleeding rate from recurrent varices was 30.4 % (7/23). Rebleeding from esophageal ulcers occurred in 5.6 % (7/125) of patients. Portal hypertensive gastropathy before and after eradication of varices was 17.6% (N = 22) and 44.6% (N = 50) respectively; p< 0.05. Fundal gastric varices was 30.4% (N = 38) and 35.7% (N = 40) before and after eradication of varices respectively; p> 0.05. The overall mortality was 4 % (N = 5).ConclusionBand ligation was an effective technical approach for variceal obliteration with low rates of variceal recurrence, rebleeding and development of gastric varices. Furthermore, it was associated with frequent development of portal hypertensive gastropathy.

Long-term Outcomes of Endoscopic Variceal Ligation to Prevent Rebleeding in Children with Esophageal Varices

After an episode of acute bleeding from esophageal varices, patients are at a high risk for recurrent bleeding and death. However, there are few reports regarding the long-term results of secondary prophylaxis using endoscopic variceal ligation (EVL) against variceal rebleeding in pediatrics. Thirty-seven, who were followed for over 3 yr post-eradication, were included in the study. The mean duration of follow up after esophageal variceal eradication was 6.4±1.9 yr. The mean time required to achieve the eradication of varices was 3.25 months. The mean number of sessions and O-bands needed to eradicate varices was 1.9±1.2 and 3.8±1.5, respectively. During the period before the first EVL treatment, 145 episodes of bleedings developed in 37 children. Over the 3 yr of follow-up after variceal eradication, only 4 episodes of rebleeding developed in 4 of 37 patients. The four rebleeding episodes consisted of an esophageal variceal bleed, a gastric variceal bleed, a duodenal ulcer bleed, and a bleed caused by hemorrhagic gastritis. There was no mortality during long-term follow up after variceal eradication. During long-term follow up after esophageal variceal eradication using solely EVL in children with esophageal variceal bleeds, rebleeding episodes and recurrence of esophageal varices were rare. EVL is a safe and highly effective method for the long-term prophylaxis of variceal rebleeding in children with portal hypertension.

Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices

To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration (BRTO) for ruptured gastric varices. Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool. The gastric varices were confirmed by endoscopy, and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography (CE-CT). A 6-Fr balloon catheter (Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein, or into the gastrocaval shunt via the right femoral vein, depending on the varices drainage route. The sclerosant, 5% ethanolamine oleate iopamidol, was injected into the gastric varices through the catheter during balloon occlusion. In patients with incomplete thrombosis of the varices after the first BRTO, a second BRTO was performed the following day. Patients were followed up by endoscopy and CE-CT at 1 d, 1 wk, and 1, 3 and 6 mo after the procedure, and every 6 mo thereafter. Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices. These patients underwent a second BRTO on the next day, and additional sclerosant was injected through the catheter. Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients, while the remaining patient had incomplete thrombosis of the varices. None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d (range 8-2739 d). No major complications occurred after the procedure. However, esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo. Emergency BRTO is an effective and safe treatment for ruptured gastric varices.

Usefulness of Transnasal Argon Plasma Coagulation for Esophageal Varices Compared with the Peroral Method: A Randomized and Prospective Clinical Study

Background: Argon plasma coagulation (APC) is very useful as a consolidation treatment for reducing the recurrence of esophageal varices (EVs). However, repeated sedation in endoscopic treatment has the risk of prolonging hepatic encephalopathy and affects the respiratory state of liver cirrhosis (LC) patients, in whom pulmonary arteriovenous shunts are observed. We evaluated prospectively whether transnasal endoscopic APC without sedation is more effective than peroral endoscopic APC with sedation. Patients and Methods: LC patients (n = 101), treated by endoscopic injection sclerotherapy to eradicate EVs, were randomly divided into a transnasal APC group (n = 50) and a peroral APC group (n = 51). The primary efficacy endpoint was the cumulative recurrence rate of EVs. The secondary endpoints were blood pressure (BP), heart rate, oxygen saturation during APC and complications. Results: There was no significant difference in the cumulative recurrence rate of EVs at 36 months between the transnasal APC and peroral APC groups (35.0 vs. 40.8%, p = 0.39, log-rank test), indicating that transnasal APC is not inferior to peroral APC. The transnasal APC group showed more stable intraoperative BP and oxygen saturation values, and a lower incidence of epigastralgia (56.0 vs. 74.5%, p = 0.04). Conclusion: The efficacy of reducing the recurrence of EVs in the transnasal APC group was not significantly different from that in the peroral APC group. Transnasal APC caused less distress and required no sedation. Therefore, this method was more advantageous for LC patients at risk of suffering from prolongation of hepatic encephalopathy.

Endoscopic and Pharmacological Secondary Prophylaxis in Children and Adolescents With Esophageal Varices

The aim of this study was to describe the results of endoscopic secondary prophylaxis, alone or in combination with propranolol, used to prevent upper gastrointestinal bleeding (UGIB) in children and adolescents with esophageal varices. This observational study followed 43 patients younger than 18 years who received secondary prophylaxis between August 2001 and December 2009. Sclerotherapy and/or band ligation were performed, and propranolol was used when no contraindications were present. The rebleeding rate, number of endoscopic sessions required for variceal eradication, rate of varix recurrence, the occurrence of varices at the gastric fundus, and the occurrence of portal hypertensive gastropathy were evaluated. Endoscopic prophylaxis in combination with propranolol was performed in 25 patients (58.1%) and endoscopic prophylaxis alone was performed in 18 patients (41.9%). Esophageal varices were eradicated in all of the patients after a median of 3 sessions. Varices recurred in 22 patients (51.2%). Rebleeding occurred in 13 patients (30.2%). Fundal varices and portal hypertensive gastropathy developed in 31% and 61.9% of patients, respectively. No deaths related to the endoscopic procedure or UGIB occurred. No statistically significant differences in any of the studied variables were observed when comparing endoscopic prophylaxis with propranolol and endoscopic prophylaxis alone. No significant differences were observed between sclerotherapy and band ligation. Secondary prophylaxis was effective in eradicating esophageal varices. The use of propranolol did not affect the results of the endoscopic prophylaxis. Furthermore, randomized studies will be necessary to assess the best form of prevention during childhood.

Endoscopic variceal ligation as a safe and effective alternative to endoscopic sclerotherapy in bleeding ectopic duodenal varix—report of a rare case

Sir, Upper gastrointestinal bleeding (UGIB) following devascularization procedures for portal hypertension is rare. Ectopic varices (EVs), outside the esophagogastric region, pose significant diagnostic and therapeutic challenges and bleeding can bemassive and life-threatening. Endoscopic sclerotherapy (EST) has been used to eradicate EV. Endoscopic variceal ligation (EVL) is often not practised because of higher chances of recurrence and increased chances of rebleeding as reported in the literature. A 25-year-old lady presented with massive UGIB. She was known to be cirrhotic with portal hypertension (PHT) who underwent emergency devascularization with splenectomy, after failed endoscopic sclerotherapy 2 years earlier. She was on regular beta-blocker prophylaxis but had episodes of upper gastrointestinal bleeding after devascularization. The residual esophageal varices were obliterated with endoscopic sclerotherapy. She was conscious, oriented and hemodynamically stable. Esophagogastroduodenoscopy revealed varices in the first part of the duodenum. There were no residual esophageal or gastric varices or portal hypertensive gastropathy. A single band was applied over the duodenal varix (Fig. 1). She had no further episodes of UGIB and was discharged after a week of observation. She is on regular follow up for the past 18 months with no recurrence of varices. We report this case to highlight the successful use of EVL for duodenal EV. EVs account for 1 % to 5 % of all variceal bleeding [1–3] and need a high index of suspicion for diagnosis. They occur predominantly in the duodenum, jejunum, ileum, colon, rectum and enterostomy sites. Bleeding from these EVs is rare in patients with portal hypertension. The duodenum is a common site of EV hemorrhage in patients with PHT. Duodenal variceal bleeding is generally massive and life-threatening with mortality as high as 40 % from the initial bleeding [3–5]. The most common cause of duodenal variceal bleeding is extrahepatic PHT, less commonly intrahepatic PHT [6, 7]. Duodenal varices develop from collateral veins originating from the portal vein trunk or superior mesenteric vein, which empty into the inferior vena cava [1]. Diagnosis of ruptured duodenal varices and control of bleeding are difficult [1]. EST has been reported to be successful in the control of duodenal variceal bleeding [8, 9], but there are reports of rebleeding after EST [5]. Literature discussing the role of banding in patients with ectopic varices is limited. EVL for bleeding duodenal varices is challenging because of the difficulty in maintaining the field of vision. EVL has been tried for EV, but those patients received EST also. Hence, it was not clear as to which modality controlled the bleeding. EVL can be risky if the band applied does not completely encircle a characteristically large ectopic varix which can slough off causing a S. C. Sistla :D. Ram : S. M. Ali :N. Rajkumar Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605 006, India

Variceal recurrence, rebleeding rates and alterations in clinical and laboratory parameters following post‐variceal obliteration using endoscopic sclerotherapy

To study the rates of variceal recurrence and rebleeding following sclerotherapy and its effect on clinical and laboratory parameters in patients with portal hypertension. A total of 237 patients with portal hypertension together with esophageal variceal bleeding were included in the study. There were 138 patients with cirrhosis (group I), 42 with non-cirrhotic portal fibrosis (group II), and 57 with extrahepatic portal vein obstruction (group III). Baseline data and post-obliteration follow-up for rebleeding rates and changes in clinical and laboratory parameters were recorded. In all, 106 patients in group I, 31 in group II and 43 in group III experienced obliteration of varices. The recurrence of grade II varices occurred in 17 patients (9.4%) during a mean period of 9 months. Rebleeding from varices was observed in 4 patients (3.8%) in group I and 1 (3.2%) in group II, while none in group III experienced rebleeding. There was a significant improvement in ascites, jaundice, liver status, international normalized ratio and platelet count in group I patients after variceal eradication (P < 0.05). The main cause of death in the cirrhotic patients was active liver disease but not rebleeding. Following obliterative endoscopic sclerotherapy, rates of recurrence and rebleeding were significantly low when patients are kept under close observation. Disappearance of varices or reduction of variceal size improves the liver status in surviving cirrhotic patients.

How Do We Select an Endoscopic Treatment for Esophageal Varices on the Basis of Hemodynamic Analysis Using Color Doppler Endoscopic Ultrasonography

We investigated the hemodynamics of the left gastric vein (LGV) and its association with variceal recurrence using color Doppler endoscopic ultrasonography (CD-EUS). The long-term results of our technique known as combined ligation and sclerotherapy showed that the risk of variceal recurrence decreased after long-term follow-up with timely repeated therapies. On the basis of the hemodynamic background of these results, it was suggested that the posterior branch of the LGV could have developed as an extravariceal shunt, whereas the anterior branch, which directly feeds varices, seemed to disappear through long-term follow-up with repeated treatments. In the study comparing CD-EUS findings between patients with and without variceal recurrence, dominance between anterior and posterior branches and the hepatofugal flow velocity of the LGV were suggested to be important factors contributing to variceal recurrence. We consider that these patients may require more intense therapy, such as the mucofibrosing technique or a technique to obliterate both the varices and their donor vessels.

The initial experience of safety and efficacy of argon plasma coagulation (APC) in the primary prevention of variceal bleeding

Background and study aimsThe well-known complications of variceal bleeding together with the high mortality rate mandate effective prophylaxis. Because of the intolerance, failure of response and lack of compliance related to B blockers and because of the high incidence of variceal recurrence after endoscopic variceal ligation (EVL), other alternatives should be investigated. As APC provides coagulation at a shallow depth, it has been considered an ideal procedure to promote mucosal fibrosis for oesophageal varices. This study aims to investigate the safety and effectiveness of APC application to the oesophagus post-variceal obliteration in an attempt to decrease variceal recurrence and bleeding, as compared to EVL. Patients and methodsThis study included 60 patients with chronic liver disease and portal hypertension referred to the Gastrointestinal Endoscopy Unit, Kasr Al-Aini Hospital, Cairo University, during the period from August 2008 till January 2010. Patients had to have large-sized varices (F3), without history of bleeding, portal hypotensive drugs or intervention.Patients were allocated into either group I that included 30 patients for whom EVL was performed and sequentially followed by one session of APC or group II that included 30 patients for whom EVL alone was done. Patients underwent surveillance endoscopy at 3 and 6months to evaluate variceal recurrence (F1 or more). ResultsBoth groups were comparable in terms of the demographic features, hepatic functional reserve and endoscopic findings. Post-APC, fever was reported in 6.7%, dysphagia in 3.3%, procedure-related bleeding in 0% and stricture in 3.3%. At 3 and 6months follow-up, both groups were comparable in terms of variceal recurrence and none of the patients in both groups developed variceal bleeding. ConclusionAlthough, APC application to the oesophageal mucosa is a safe technique, its additive benefit in terms of variceal recurrence and re-bleeding is comparable to EVL alone. This is encountered when only a single session of APC is applied. A more beneficial effect of multiple sessions of APC awaits further studies.

Recurrence of esophageal varices after endoscopic band ligation: single centre experience

Background and objective. Endoscopic band ligation is the main endoscopic treatment for esophageal varices, but the main problem after endoscopic treatment is variceal recurrence. The aim of this study was to evaluate and determine the esophageal varices recurrence rate and the time interval after endoscopic band ligation and to investigate possible risk factors affecting recurrence. Material and methods. The retrospective analysis of endoscopic band ligation procedures, performed in Vilnius University Hospital Santariskiu Clinics during the period 2006–2010, was made. 133 endoscopic band ligation procedures were included in the study. Results. After endoscopic band ligation, esophageal varices recurred in 45% of cases. The early recurrence of esophageal varices occurred in 46.7% of cases. Extrahepatic portal hypertension and a greater size of varices lead to the statistically significant early recurrence of esophageal varices after endoscopic band ligation. Conclusions. Endoscopic band ligation is associated with a high recurrence rate of esophageal varices and half of these cases were indentified as early variceal recurrence.

Emergency anticoagulation treatment for cirrhosis patients with portal vein thrombosis and acute variceal bleeding

Objective. To determine the safety and efficacy of anticoagulation treatment for portal vein thrombosis in cirrhosis patients with acute variceal bleeding, with patient eligibility determined by contrast ultrasonography findings. Materials and methods. This prospective study included 23 consecutive cirrhosis patients (63.8 ± 11.8 years old, 12 males and 11 females) with emergency admission for acute variceal bleeding with or without portal vein thrombus. Eligibility for anticoagulation treatment was determined by positive intra-thrombus enhancement on contrast ultrasonography (perflubutane microbubble agent, 0.0075 mL/kg) performed before endoscopy. Low-molecular-weight heparin was administered after hemostasis was achieved by band ligation. Repeated band ligation or injection sclerotherapy combined with argon plasma coagulation was performed for variceal disappearance. Results. Hemostasis was achieved in all 10 patients with active bleeding. Five of these patients had portal vein thrombus, and all showed positive intra-thrombus enhancement on contrast ultrasonography. Anticoagulation treatment of these five patients resulted in complete recanalization of the portal vein within 2–11 days. There were no significant differences in the number of endoscopic treatment sessions or the length of hospital stay between the groups with and without thrombosis, and no complications including rebleeding were reported. Long term, none of the patients who continued oral anticoagulation treatment had recurrence of thrombosis (4/5). Variceal recurrence occurred only in the non-thrombosis group (2/18) during the follow-up period (median: 351 days). Conclusions. Early anticoagulation treatment in cirrhosis patients with portal vein thrombosis and acute variceal bleeding may be safe, tolerated, and effective in cases with positive intra-thrombus enhancement on contrast ultrasonography.

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.

Nodules in antrum after variceal eradication a new finding in patients with portal hypertension

Portal hypertension is known to cause esophageal varices, gastric varices and portal hypertensive gastropathy (PHG). The prevalence of gastric varices and PHG is known to increase after eradication of esophageal varices. PHG includes the presence of a mucosal mosaic pattern, cherry red spots, and/or black-brown spots and gastric vascular ectasia (GAVE). Patients with portal hypertension in whom esophageal varices were eradicated were on follow up endoscopy for detection of recurrence of esophageal varices. Their status of PHG was assessed and patients antral nodules were enrolled. Twenty patients with antral nodules were identified over one year. Fifteen out of 20 patients had cirrhosis as etiology of portal hypertension, three had non-cirrhotic portal hypertension and two had extra-hepatic portal vein thrombosis. GAVE was seen more commonly (n=8, 40%) in patients with PHG with nodules. PHG with antral nodules is a novel endoscopic finding present both in cirrhotic and non-cirrhotic portal hypertension with unknown pathogenesis, and is seen more commonly in patients with eradicated varices who are on long-term follow up.

Laparoscope and endoscope for portal hypertension

To determine the therapeutic effect of laparoscopic splenectomy, perisoph-agogastric devascularization, and endoscopic variceal ligation (EVL) on patients with portal hypertension. We randomly divided 105 patients into 3 groups: 40 had endoscopic band ligation (the ligation group), 35 had splenectomy and perisoph-agogastric devascularization (the laparotomy group), and the other 30 had laparoscopic splenectomy, perisoph-agogastric devascularization and endoscopic variceal ligation (the combination group). Blood samples were analyzed preoperatively and postoperatively on day 1,3,and 7,including alanine aminotransferase(ALT),aspartate aminotransferase(AST),total bilirubin(TBIL),and directed bilirubin(DBIL). The length of stay, blood loss, operation time, anal exhaust time, azygos vein diameter, blood flow velocity and blood flow, recurrence of esophageal varices and rehaemorrhagia were compared. Between the combination group and the laparotomy group, the serum levels of TbIL and Dbil had difference on 1st postoperative day(P<0.05). AST had difference on 7th postoperative day(P<0.05). The length of stay, blood loss, operation time, and anal exhaust time had significant difference(P<0.05). Among the combination group, the laparotomy group and the ligation group, the azygos vein blood flow before and after the treatment, recurrence of esophageal varices and rehaemorrhagia had no difference(P<0.05). Laparoscopic splenectomy, perisoph-agogastric devascularization and endoscopic variceal ligation have less trauma, lower recurrence rate, fewer complications and rapid recovery, and may reduce the azygous vein blood flow. It can be used safely for portal hypertension.

Technical Feasibility and Early Results of Radiologically Guided Foam Sclerotherapy for Treatment of Varicose Veins

Duplex ultrasound guidance of foam sclerotherapy has been established as a routine and standard treatment of varicose veins, but duplex-guided technique is not perfect because of its inherent shortcomings, and correlative complications have been reported. Moreover, not every country or region of the world can use duplex ultrasound guidance for foam sclerotherapy. To describe an original technique of using radiologically guided foam sclerotherapy for the treatment of leg varicose veins and to evaluate the technical feasibility and early results. Fifty-nine legs of 41 patients (23 male, 18 female; median age 47, range 25-75) with leg varicose veins treated using radiologically guided foam sclerotherapy were assessed. Polidocanol 1% was foamed 1:4 with air using the Tessari method. Foam sclerotherapy of the superficial varicosities and the great saphenous veins (GSVs) were performed using the filling-defects technique under radiologic guidance. Postoperative compression was maintained for 15 days. Clinical outcome was assessed according to clinical criteria. The procedure was technically successful in all 59 legs. At a median 9.0 months (range 6-12 months) of follow-up, the clinical outcome was full success in 53 legs (89.8%), and partial success in six legs (10.2%). There was no evidence of recurrence of varices or GSV reflux during follow-up. Minor complications included skin pigmentation in 27 legs (45.8%), and superficial thrombophlebitis in 18 legs (30.5%). No major complications or systemic events occurred. Radiologically guided foam sclerotherapy could be a safe, effective, and technically feasible treatment for varicose veins.