Residual Varices Research Articles

Downhill Esophageal Varices: A Rare and Potentially Correctable Cause of Serious Gastrointestinal Bleeding

Instances of downhill esophageal varices are rare in the literature, and the optimal management strategy when they are found is not well known. In the reported cases, a catheter-associated thrombus of the upper venous system is often implicated as the cause of the varices, which then form due to collateral flow. We present the hospital course of a patient found to have downhill varices. A 65 year old female with history of stage IIIB colorectal cancer (status post right hemicolectomy with end ileostomy formation and curative chemotherapy; still with chest port) presented to our institution with several episodes of melena through her ostomy over the preceding day. She was hemodynamically stable on admission, and hemoglobin was 10.8 gm/dL (baseline 12.8 gm/dL). A CT of the chest with intravenous contrast was performed due to shortness of breath, and a large thrombus was seen involving the right innominate vein, superior vena cava, and azygos vein. The patient's chest port had retracted and now terminated in the superior vena cava. An esophagogastroduodenoscopy (EGD) was performed, and innumerable grade III varices (one with a white nipple sign; no active bleeding) were found in the proximal and mid esophagus; it was otherwise normal. Banding was not performed. Ileoscopy showed melena only. Three days later, interventional radiology performed a thrombectomy of the large venous clot and placed a superior vena cava stent to ensure continued flow. The chest port was removed. The patient was placed on therapeutic anticoagulation due to the stenting. Repeat EGD was performed due to a continued slow drift downward in hemoglobin. The EGD revealed only one small varix in the proximal esophagus (no high risk stigmata; no banding performed). The patient's hemoglobin stabilized, and patient had no further melena. She was discharged on a therapeutic dose of enoxaparin. The outcome in this case reinforces the notion that prompt revascularization should be a high priority in patients with downhill varices. Even though this patient received a procedure that required therapeutic anticoagulation only days after a variceal bleed, she is now at low risk for further bleeding, as her varices almost completely collapsed within one day of the intervention. This case highlights a rare but serious cause of upper gastrointestinal bleeding, and how prompt intervention can be a lasting solution.Figure: Esophagoscopy of the proximal esophagus demonstrating grade III varices with white nipple sign (arrow).Figure: Esophagoscopy after interventional radiology guided thrombectomy and stenting of the superior vena cava; no residual varices seen.

BRTO assisted endoscopic Histoacryl injection in treating gastric varices with gastrorenal shunt

Aims: We evaluated the feasibility, efficacy and safety of a novel technique of balloon-occluded retrograde transvenous obliteration (BRTO) assisted endoscopic Histoacryl (N-buthyl-2-cyanoacrylate) injection.Material and methods: A total with 11 patients were enrolled and analyzed in this single center, open-label, prospective study. Patients with high-risk gastric varices (defined as fundal varices, large GV (>5 mm), presence of a red spot, and Child-Pugh score C) and concurrent gastrorenal shunt underwent endoscopic Histoacryl injection while the gastrorenal shunt was temporarily occluded with an occlusion balloon. Feasibility, hemostatic effect, intra- and postoperative complications, and varices recurrence were evaluated.Results: All procedures were successfully done per protocol. Except for one patient who underwent rescue Histoacryl injection due to residual varices, single therapy was sufficient to eliminate gastric varices in ten patients. Intra-operative hemorrhage occurred in one case and was stopped after additional Histoacryl injection. One patient was confirmed to have treatment-related fungemia. No death or major complications occurred, including ectopic embolism, worsening of hepatic and renal function, etc. No recurrence of the varices was found during a median follow-up time (mean ± SD) of 228 ± 153 days.Conclusions: BRTO assisted endoscopic Histoacryl injection is effective and safe for patients with high-risk gastric varices and concurrent gastrorenal shunt.

Natural History of Recurrent Varices Undergoing Reintervention: A Retrospective Study

Recurrent varices after surgery are a complex problem. Many studies regarding the causes of recurrence and the best procedures that can be used to study them have been conducted but few studies on the natural history of the operations performed for recurrence. To evaluate the efficiency of reintervention in controlling the varicose disease, its symptoms, and patient satisfaction. Of 71 patients operated on for surgical recurrence related to an inguinal cavernoma between 1996 and 2004, 51 were reassessed in May 2006 with a clinical and Duplex examination. Surgical and anesthesiological data were collected. The average follow-up after reintervention for the 51 of the 71 treated patients who came to the examination was 5.8 years; 38 (74.5%) of the patients were very satisfied, and one patient (2%) was dissatisfied. Thirty-five (68.6%) of the patients still had varices, but only 17 of these had real varices at the original site; 18 patients showed persistent or residual varices (3 patients, 5.8%) or a progression (15 patients, 29.9%) of the varicose disease. Surgical intervention on an outpatient basis may have a significant role in controlling the varicose disease with few complications.

Transabdominal Modified Devascularization Procedure with or without Esophageal Stapler Transection—An Operation Adequate for Effective Control of a Variceal Bleed. Is Esophageal Stapler Transection Necessary?

In Japan, the original Sugiura procedure reported favorable results in non-cirrhotic patients but in the West, the modified Sugiura procedure is not widely accepted because of high rebleeding, morbidity, and mortality in cirrhotics. We retrospectively analyzed the efficacy of our modified Sugiura procedure i.e., devascularization with/without esophageal transection combined with salvage endotherapy and pharmacotherapy for control of a variceal bleed. Between January 1999 and December 2004, 912 patients with variceal bleeding were treated. Of these, 66 (7.2%) patients were subjected to surgery after failed endotherapy/propranolol. Among these 66 patients, 52 had transabdominal devascularization (16 emergency, 36 elective); 14 patients underwent devascularization with esophageal stapler transection (group I), and 38 patients had devascularization without esophageal stapler transection (group II). Another 14 patients underwent elective end-to-side proximal splenorenal shunt surgery. Postoperative mortality was 7.1% in group I, 10.5% in group II (P>0.05). Mortality for emergency surgery was 31.2% (5/16) but there were no deaths in the elective surgery group. Overall morbidity was 57.1% in group I and 21.0% in group II (P<0.05). The rates of variceal rebleeding were 7.1% and 7.8%; residual varices were 30.7% and 32.3%; recurrent varices were 7.6% and 5.8% following the group I and group II procedures, respectively, over a mean follow-up period of 39.9 (7-2) months. Esophageal transection-related morbidity (leak, stricture, and bleeding) was 21.4% (3/14) in group I. Devascularization without esophageal stapler transection is a safe and effective procedure for adequate (urgent and long-term) control of variceal bleeding with similar results and less morbidity when compared to devascularization with esophageal transection in cirrhotic patients, as well as non-cirrhotic patients.

Leg Ulcer Recurrence and its Risk Factors: A Duplex Ultrasound Study before and after Vein Surgery

Assessment of risk factors for ulcer recurrence in chronic leg ulcer patients treated by varicose vein surgery. Retrospective follow-up study. 62 patients, 43 women and 19 men (Median=56.5 years, range 24-77) with the CEAP classifications of C(5)-C(6) and E(P) (primary venous insufficiency). Patients underwent colour duplex ultrasound (CDU) investigation before varicose vein surgery. Post-operatively CDU, ambulatory venous pressure (AVP) and an interview were performed. The median clinical follow-up was 5.5 years (range 2-11 years). The estimated 5-year ulcer recurrence rate was 19% in all patients. The risk of ulcer recurrence was significantly lower (p<0.05) in legs without residual varices or recurrence. The five year risk of ulcer recurrence depended on the time interval between ulcer appearance and the surgical intervention (index operation), post-operative venous axial reflux and AVP (mmHg). More than 50% of the patients had a calculated probability of ulcer recurrence of less than 3%, but 13% had a probability of more than 23% based on our analysis. A long history of venous ulcer is a pre- and post-operative risk factor for recurrent ulceration. Total elimination of incompetent superficial and perforator veins lowers the risk of ulcer recurrence, whereas residual axial reflux increases the risk. Postoperative CDU is effective in identifying patients at risk of ulcer recurrence.

Radiofrequency Endovenous Obliteration versus Stripping of the Long Saphenous Vein in the Management of Primary Varicose Veins: 3-Year Outcome of a Randomized Study

We evaluated the 3-year outcome of a series of patients with primary varicose veins who were randomized to radiofrequency endovenous obliteration vs. stripping of the long saphenous vein (LSV). Twenty-eight patients were included in the study: 15 were randomized to the radiofrequency endovenous obliteration procedure and 13 to LSV stripping. At 3-year follow-up, five patients (33.3%) of the endovenous group had recurrent or residual varices and in three of them a reflux in the thigh veins was detected. None of the primarily occluded LSV segments was recanalized. In the stripping group, three patients (23.1%, p = 0.68) showed varicosities at clinical and duplex examinations. In one patient, a patent duplicate LSV trunk was detected. In the remaining two patients, no reflux in the thigh region was detected. According to the present results, radiofrequency endovenous obliteration of the LSV is associated with somewhat poorer short-term results compared with the stripping operation.

Hook phlebectomy versus transilluminated powered phlebectomy for varicose vein surgery: Early results

Objectives: to compare Transilluminated Powered Phlebectomy (TIPP) (TriVexTM System) with Muller's hook phlebectomy. Materials and Methods: between January and April 2001, 40 patients (group 1) undergoing TIPP were non-randomly compared to 40 patients undergoing Muller's hook phlebectomy (group 2) in the course of conventional vein stripping and perforator ligation. All patients had at least C2 CEAP disease. Results: hospital stay averaged 2 days (range 1-3 days; median 2 days) and was similar for the two groups. TIPP took significantly longer (56 ± 12 vs 45 ± 10 min, p < 0.001) but was associated with significantly fewer incisions (6 [2-8] vs 8 [4-21], p < 0.001). The mean pain score (out of 10) at 2 and 7 days and 6 weeks was 5, 2 and zero after TIPP and 4, 2 and zero after hook phlebectomy. The incidence of postoperative haematoma formation was significantly higher after TIPP (45 vs 25%, p = 0.06), especially in the calf region (25 vs 2.5%, p = 0.003). Conclusion: TIPP was slower (although speed increased with practice) associated with more haematoma (although this reduced with practice) and fewer incisions. In other respects (pain, cosmetic satisfaction, other complications, residual varices) it was not significantly different from hook phlebectomy. Greater clinical experience with the technique and randomized studies are required to determine whether TIPP is a valuable addition to our armamentarium.Eur J Vasc Endovasc Surg 25, 473-475 (2003)

The Role of Sclerotherapy in Children

Introduction : Endoscopic sclerotherapy to control variceal bleeding in adults has been proven to be useful. Complications from this procedure that have been reported include esophageal stricture, perforation, mediastinitis and recurrent bleeding. This procedure has increasingly been used in pediatric patients, thus increasing the incidence of its complications. The purpose of this study: To report the effect of sclerotherapy in variceal bleeding Method : All patients that underwent sclerotherapy since 1989 were included in the study and were followed up until December 1999. We recorded the frequency of injections, recurrent bleeding, and gastropathy. Results : During the last ten years, we have used sclerotherapy in 26 patients. The varices were secondary to intrahepatic portal hypertension. The average age at initial sclerotherapy was 7 years (ranging from 1-12 years). Two patients died following initial sclerotherapy. Nine patients could not be followed up and 17 patients were under monitoring for 2-10 years. Four patients died after 2-8 years of follow up due to the underlying diseases. Complete obliteration of all varices was obtained in 12 cases, minimal residual varices in four and 1 case was unfavorable for injection. Six patients (35.3%) suffered from recurrent bleeding; 4 patients had minimal residual varices (1 year follow up), and 2 patients had complete obliteration (3 years follow up). Gastropathy was found in 6 patients after 12 to 32 sessions of injection. Complications such as perforation or stricture were not found. Conclusions : Sclerotherapy is a very useful technique to control variceal bleeding in children. We found recurrent bleeding and gastropathy in 35.3% patients. Other complications were not found. Keywords : Sclerotherapy, children, endoscopy varices esophagus

How I Do Long Saphenous Vein Surgery

Objective: To describe the author's own technique for treating long saphenous vein incompetence. Method: The long saphenous vein is stripped using a disposable stripper with the patient under general anaesthesia. Saphenous varices are managed by hook phlebectomy. Conclusions: The author's technique is effective in the management of large saphenous varices associated with long saphenous incompetence. The result is cosmetically satisfactory. Any residual varices are dealt with by sclerotherapy.

3558 Argon plasma coagulation for eradication of esophageal varices after treatment with endoscopic variceal banding ligation or sclerotherapy.

Background: Endoscopic variceal banding ligation (EVL) and sclerotherapy (EVS) have been used to prevent variceal hemorrhage. However, the rate of recurrence of esophageal varices after EVL or EVS is considerably high. Argon plasma coagulation (APC) is a new modality of electrosurgery to apply high frequency electric current into tissue to cause defined thermal effects. This study was conducted to determine whether APC is beneficial for eradication of residual esophageal varices after EVL or EIS. Methods: Cirrhotic patients with endoscopically assessed high-risk esophageal varices but no history of bleeding underwent EVL or EIS to reduce the risk of hemorrhage. When the size of varices was reduced 1 week later, the entire esophageal mucosae 4-5 cm proximal to the esophagogastric junction was coagulated with one session of APC in a total of 15 patients.APC was performed with the use of argon source APC300 and high frequency generator ICC 200 (ERBE, Germany). Follow-up endoscopy was performed 7 days and 1 month after the initial procedure and thereafter every 3 months, to check for recurrent/residual esophageal varices and its complications. Results: Ten to 14 days after APC, ulcerations with white coating were noted in all cases, whereas varices were completely eradicated. One month after APC, while the varices remained eradicated, coagulated esophageal mucosae became whitish and the ulcerations were nearly completely healed. During the course, no patients complained of dysphagia or retrosternal pain. Furthermore, neither development of gastric varices nor aggravation of portal hypertensive gastropathy was observed endoscopically. No serious complication such as bleeding necessitating endoscopic therapy and perforation or stricture of the esophagus was encountered. Over a maximum follow-up period of 5 months, neither recurrence of nor hemorrhage from esophageal varices was observed. Conclusions: APC ablation of residual esophageal varices in patients who have undergone prior EVL or EIS is safe and may be a novel approach to eradicate esophageal varices. It requires a long term follow-up of the eradicated varices to further evaluate its efficacy.

Role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in pediatric patients.

Role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in pediatric patients.

Four Years' Follow-up Results of Three Different Percutaneous Treatments for Male Varicocele

Objective: To evaluate the efficacy of three different interventional radiological procedures for the treatment of venous reflux in symptomatic male varicocele. Design: Prospective study with a 48-month colour duplex ultrasound (CD) follow-up. Setting: Department of Radiology, Tor Vergata University of Rome. Patients: From January 1991 to December 1993, 45 symptomatic patients with third- to fourth-degree varicocele, according to Sarteschi's CD classification, were randomly divided into three equal groups (15 patients each). Interventions: The first group received sclerotherapy (Athoxysclerol), the second underwent embolisation (Gianturco coils), while the third group received combined sclero–embolisation therapy (Athoxysclerol and Gianturco coils). Main outcomes measures: The frequency of recurrence for each procedure. Results: Two recurrences (13%) after 1 and 2 years occurred in patients who underwent sclerotherapy. In the embolisation group, two patients showed residual varices (13%). Neither recurrence nor residue was seen in the third group, who received combined therapy. Conclusions: Sclerotherapy provides good immediate results but drug dilution may cause a relapse shortly after treatment. Embolisation has a lower immediate success but better long-term success. Combined treatment provides the highest long-term success rate.

Four Years’ Follow-up Results of Three Different Percutaneous Treatments for Male Varicocele

Objective: To evaluate the efficacy of three different interventional radiological procedures for the treatment of venous reflux in symptomatic male varicocele. Design: Prospective study with a 48-month colour duplex ultrasound (CD) follow-up. Setting: Department of Radiology, Tor Vergata University of Pome. Patients: From January 1991 to December 1993, 45 symptomatic patients with third- to fourth-degree varicocele, according to Sarteschi's CD classification, were randomly divided into three equal groups (15 patients each). Interventions: The first group received sclerotherapy (Athoxysclerol), the second underwent embolisation (Gianturco coils), while the third group received combined sclero-embolisation therapy (Athoxysclerol and Gianturco coils). Main outcomes measures: The frequency of recurrence for each procedure. Results: Two recurrences (13%) after 1 and 2 years occurred in patients who underwent sclerotherapy. In the embolisation group, two patients showed residual varices (13%). Neither recurrence nor-residue was seen in the third group, who received combined therapy. Conclusions: Sclerotherapy provides good immediate results but drug dilution may cause a relapse shortly after treatment. Embolisation has a lower immediate success but better long-term success. Combined treatment provides the highest long-term success-rate.

Is thigh saphenectomy a necessary adjunct to high ligation and stab avulsion phlebectomy?

Background: Controversy still exists as to whether the thigh saphenous vein should be stripped concomitant with high ligation and phlebectomy. Method: A total of 218 procedures were retrospectively grouped into three groups: group 1, 10 limbs with visible, duplex scan-confirmed varicose veins of the thigh saphenous vein; group 2, 13 saphenous veins with varices that were not clinically evident; group 3, 195 limbs with incompetent saphenous veins without thigh saphenous varices. Results: Five limbs in group 1 were treated by high ligation, phlebectomy, and thigh saphenectomy. All did well. Five had high ligation and phlebectomy only. Two developed painful phlebitis, and two had residual varices in the saphenous vein. Group 2 and group 3 were treated by high ligation and phlebectomy. One group 2 limb developed saphenous phlebitis. Five limbs in group 3 developed recurrent veins that were removed in the office. Conclusion: Thigh saphenectomy is only required when there are visible, duplex scan-confirmed varices of the thigh saphenous itself, or when the procedure is performed for severely symptomatic patients or those with advanced stasis changes.

Transabdominal extensive oesophagogastric devascularization with gastro-oesophageal stapling in the management of acute variceal bleeding

Operation is required for patients with portal hypertension who have failed to respond to emergency sclerotherapy for control of acute variceal bleeding. This study evaluates the role of transabdominal extensive oesophagogastric devascularization combined with gastro-oesophageal stapling for control of acute variceal bleeding in patients with portal hypertension of different aetiologies. Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling was performed in 65 patients (28 with cirrhosis, 17 with non-cirrhotic portal fibrosis and 20 with extrahepatic portal venous obstruction) in whom emergency endoscopic sclerotherapy, and/or pharmacotherapy and balloon tamponade had failed. The Sugiura procedure was modified to minimize operating time and to reduce the operative difficulties due to oesophageal wall necrosis after sclerotherapy. The operative mortality rate was higher in patients with cirrhosis (P = 0.0003); sepsis was the leading cause of death (in nine of 18). A high mortality rate (12 of 15) was seen in patients with Child grade C cirrhosis. Control of bleeding was achieved in all patients. The procedure-related complication rate was 17 per cent with a 6 per cent oesophageal leak rate; four of 47 surviving patients developed oesophageal stricture. During a mean follow-up of 33 months, residual varices, recurrent varices and rebleeding were seen in three, two and three of 47 survivors. Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling is an effective and safe procedure for control of acute variceal haemorrhage with satisfactory long-term control, especially in patients without cirrhosis and low-risk patients with cirrhosis.

Bleeding gastroesophageal varices: gastric vein embolization after partial portal decompression.

Shunts that decompress the portal vein are effective in the treatment of bleeding esophageal varices. Use of large-caliber portacaval shunts, however, results in the complete decompression of the portal system and the risk of subsequent development of hepatic encephalopathy. Use of small-caliber portacaval shunts results in mild portal hypertension and less frequent hepatic encephalopathy but may increase the risk of recurrent bleeding. Thirty-three patients underwent angiography after partial decompression portacaval shunting (median trans-shunt pressures, 8 mm Hg). Embolization of residual varices, noted in 13 patients, was performed. Results included one complication with no sequelae and no bleeding a mean of 13 months after the procedure was performed. Trans-shunt embolization of esophageal varices effectively prevents bleeding varices after partial portal decompression.

What happens to esophageal varices after transection and devascularization?

In 14 patients who underwent endoscopic examination after esophageal transection and proximal gastric devascularization, varices disappeared in seven patients, were reduced in diameter or number in six patients, and were unchanged in one patient. No varices were present in any patient within 1 cm of the stapled anastomosis, and Doppler studies showed no flow in residual varices. During a mean follow-up of 20 months (range: 6 to 44 months), varices recurred in three patients and enlarged in five others. This study suggests that variceal obliteration, a reduction in variceal diameter, the removal of the bleeding zone in the esophagus, and undetectable blood flow in residual varices all contribute to the prevention of variceal rebleeding; although these changes are not always permanent, the return to the preoperative state may take many years.

Endoscopic sclerotherapy: lessons from a necropsy study

A retrospective necropsy survey of 13 patients who had received endoscopic injection sclerotherapy was carried out to study tissue changes induced and to determine the causes of death. These results were compared with autopsy findings in nine patients with portal hypertension, comparable for age, sex, and nature and severity of underlying liver disease, who had not received sclerotherapy. Although all treated patients had variceal thrombosis with an associated vasculitis, residual varices were usually present, probably reflecting the brief duration of treatment (median, 12 days). The major complications of sclerotherapy resulted from necrosis, with resultant mucosal ulceration and abscess formation. These features were not present in the control group. Complications contributing to death were hemorrhage in three patients, and in one sepsis with deep necrosis and periesophageal abscess formation.

Eradication of esophageal varices with repeated injection sclerotherapy in inoperable patients.

Esophageal varices in 50 cirrhotic patients were treated with repeated injection sclerotherapy. Eradication of varices was achieved in 27 patients (54.0%) with a mean of 4.5 injections (range 2-12) after a mean period of 3.1 months (range 1-11). There was no variceal bleeding in these 27 patients once eradication had been achieved, with a mean follow up period of 5.6 months, although bleeding occurred in 5 of the same group before eradication of the varices had been achieved, during an average of 3.1 months, and in 6 of the remaining 23 patients (10 episodes) with residual varices after a mean of 4.7 injections (range 2-12) in a mean period of 12.2 months (range 1-33). Esophageal varices can thus be eradicated with repeated injections and bleeding from recurrent esophageal varices can be prevented in many patients after eradication has been achieved.

Simplified oesophageal transection for bleeding varices.

Thirty patients with bleeding oesophageal varices were treated by oesophageal transection using the SPTU gun. Any form of shunt was contraindicated in all the patients. Twelve operations were done as urgent procedures within 36 hours of haemorrhage. The overall operative mortality rate was 10%, and there were two late deaths during follow-up, which has so far extended from two months to two years. Three of the patients had recurrent bleeding, and residual varices were probably the source in two. There were no cases of portal systemic encephalopathy. Although the follow-up is too short to allow any definite conclusions, these early results suggest that oesophageal transection with the SPTU gun may be useful in the large proportion of patients in whom injection sclerotherapy, shunt surgery, or conservative treatment is inappropriate.