Recurrence Of Varices Research Articles

УСПЕШНАЯ ЛАПАРОСКОПИЧЕСКАЯ ЭЗОФАГОГАСТРАЛЬНАЯ ДЕВАСКУЛЯРИЗАЦИЯ С АППАРАТНОЙ ТРАНССЕКЦИЕЙ ПИЩЕВОДА

Background. Bleeding from esophageal varices is one of the leading causes of death in patients with liver cirrhosis. Purpose. The analysis of laparoscopic gastroesophageal devascularization with stapler transsection of the esophagus. Material and methods. The first successful laparoscopic gastroesophageal devascularization with stapler transsection of the esophagus in the Republic of Belarus was performed in Grodno Regional Clinical Hospital in December, 2014, in a female patient with liver cirrhosis, portal hypertension and recurrent bleeding from esophageal varices. Results and conclusions. The operation contributed to the persistent lack of variceal bleeding recurrence in the postoperative period. This operation is highly effective and minimally invasive.

Utility of endoscopic ultrasound in hemorrhage from recurrent duodenal varices.

Utility of endoscopic ultrasound in hemorrhage from recurrent duodenal varices.

Endoscopic Cyanoacrylate Glue Injection in Management of Gastric Variceal Bleeding: US Tertiary Care Center Experience

Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-line treatment for bleeding gastric varices (GV) there is still limited experience with this method in the US. Our aim was to analyze our 10-year experience of ECGI for treatment and prophylaxis of gastric variceal bleeding. Records of patients undergoing ECGI of GV at our US tertiary care center between 6/2005 and 5/2015 were reviewed. Assessed outcomes were primary hemostasis, early rebleeding during hospitalization, recurrent bleeding during follow-up, eradication and recurrence of GV. Prophylactic ECGI was performed in 16 patients with large GV. Eradication was achieved in 15 (94%). During the median follow-up of 27 (IQR 7-47) months, 4 patients (26.6%) had variceal bleeding; all were treated successfully with ECGI. Fifty-seven patients underwent ECGI for GV bleeding. Primary hemostasis was achieved in all. Early rebleeding occurred in 2 (3.5%) and durable hemostasis could not be achieved. Follow-up beyond initial hospitalization was available in 41 patients. Bleeding recurred in 8 (19.5%) patients during a median follow-up of 12 (IQR, 3-51) months. Eradication of GV was achieved in 92% of patients but recurrent varices were found in 44% during a median follow up period of 33 months. ECGI is effective in achieving hemostasis of bleeding GV and their eradication. Recurrent bleeding and recurrence of varices after complete obliteration however are not infrequent and continued surveillance is advisable.

Endoscopic variceal ligation combined with argon plasma coagulation versus ligation alone for the secondary prophylaxis of variceal bleeding: a systematic review and meta-analysis.

Endoscopic variceal ligation (EVL) is often recommended as an effective method for the treatment of esophageal varices, despite the important tendency of variceal recurrence. Recent studies indicate that combining EVL with argon plasma coagulation (APC) may be a more effective therapy than ligation alone. To investigate these findings, we carried out a systematic review and meta-analysis to compare the safety and efficacy of EVL combined with APC versus ligation alone for the secondary prophylaxis of esophageal variceal hemorrhage. All studies were searched through PubMed, the Cochrane Library, and Science Direct. The outcome measures were relative risk (RR) or risk difference with 95% confidence intervals (CIs) for dichotomous data and standardized mean difference for continuous data. Heterogeneity was calculated using the χ and the I-tests. Two investigators independently identified four randomized-controlled trials included in the research. The variceal recurrence rate was significantly lower in the combined therapy group (RR=0.19, 95% CI: 0.09-0.41, P=0.000). The bleeding recurrence and mortalities in the two groups showed no significant differences (RR=0.29, 95% CI: 0.08-1.04, P=0.058; risk difference=-0.02, 95% CI: -0.08-0.04, P=0.576, respectively). Although the pyrexia incidence rate was significantly higher in the combined group (RR=3.42, 95% CI: 1.56-7.48, P=0.002), there was intertrial heterogeneity (I=52.5%, P=0.097). EVL combined with APC is superior to ligation alone for endoscopic variceal recurrence without severe adverse events in secondary prophylaxis against esophageal variceal bleeding. More high-quality studies are needed to strengthen this conclusion.

A Meta-analysis on effectiveness of different surgical procedures in treating esophageal variceal bleeding in patients with portal hypertension

Objective To compare the effectiveness of surgical procedures (devascularization, shunt and combined shunt and devascularization) in treating recurrent variceal bleeding and other complications in patients with portal hypertension. Methods A systematic literature search was carried out on patients with portal hypertension, and a Meta-analysis was conducted using Revman 5.3 software to evaluate the effectiveness of different surgical procedures on recurrent esophageal variceal bleeding, hepatic encephalopathy, operative mortality and survival rates. Results A total of 24 trials were finally selected using pre-determined inclusion criteria. Meta-analysis showed there was no significant difference among the three ope-rations on operative mortality (P>0.05). The rebleeding rate of the combined group was significantly lower than the devascularization group (P 0.18). The 1-year and 3-year survival rates were not significantly different between the combined and the shunt groups (both P>0.05). Conclusions Combined shunt and devascularization had better therapeutic effectiveness than either devascularization alone or shunt alone in patients with portal hypertension with a high rebleeding risk. There were no significant difference among the three surgical procedures in operative mortality. The survival rates of combined surgery were significantly better than devascrlarization alone. Key words: Portal hypertension; Devascularization; Shunt; Rebleeding; Hepatic encephalopathy

Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices

Gastric varices develop in 5% to 33% of patients with portal hypertension. Their most common form is concomitant gastroesophageal varices. Scleroligation (combined sclerotherapy and band ligation) has been used successfully in management of esophageal varices but has not been evaluated previously in the management of gastroesophageal varices. The aim of this work was evaluation of a new scleroligation technique for management of bleeding gastroesophageal varices regarding efficacy, adverse events, variceal recurrence, and survival. This study was conducted on 120 cirrhotic patients with bleeding gastroesophageal varices, whom we divided randomly into 2 groups of 60 patients each-a band ligation group and a scleroligation group. The mean number of sessions was lower in the scleroligation group than in the band ligation group (2.22 ± 0.92 and 3.43 ± 0.67, respectively) (P< .001), as were the duration of treatment and total number of bands used. Cost and survival were comparable in the 2 groups. There was no significant difference between the 2 maneuvers regarding adverse events, recurrence rates, or rebleeding rates after obliteration. Recurrence was significantly higher in patients with larger varices, ulceration, and postprocedure pyrexia. Rebleeding was significantly higher among those who experienced postprocedure pyrexia and developed or had worsening of gastric antral vascular ectasia. Scleroligation appears to achieve a faster rate of eradication with fewer treatment sessions and total number of bands deployed to achieve variceal obliteration than band ligation and is comparable in cost and in adverse event and recurrence rates. (Clinical trial registration number: NCT02646202.).

Comparison of outcomes in patients at high risk for recurrent gastroesophageal variceal bleeding treated by endoscopic ultrasound-guided cyanoacrylate injection for secondary prophylaxis or conventional endoscopic cyanoacrylate injection for index bleeding alone

Background and Objectives:Patients with hepatocellular carcinoma (HCC) or other malignancies with portal vein thrombosis (PVT) are at high risk for recurrent variceal bleeding. Recent evidence suggested that secondary prophylaxis (SP) for variceal bleeding may improve clinical outcomes.Methods:From 2014 to 2016, consecutive patients with HCC ± PVT or non-HCC malignancy + PVT with gastroesophageal variceal bleeding within 12 weeks were recruited for endoscopic ultrasound-guided cyanoacrylate injection (EUS-CYA) for SP. Varices = 3 mm on EUS were treated by EUS-CYA. Patients were followed up for 6 months after EUS or till death. A historical control group of HCC patients who underwent esophagogastroduodenoscopy-CYA (EGD-CYA) for index gastroesophageal variceal bleeding alone was identified in a prospective gastrointestinal bleed database from 2009 to 2013 for comparison.Results:Twenty-three patients underwent EUS-CYA for SP, while 33 HCC patients who underwent EGD-CYA for index variceal bleeding alone were identified as historical controls. In the EUS-CYA group, twenty patients had HCC + cirrhosis (85.0% also with PVT), while the other three patients had non-HCC malignancy + PVT. Majority of the HCC patients in both groups had Barcelona clinic liver cancer Stage C disease (85.0% vs. 75.8%, P = 0.421) and Child-Pugh Class B cirrhosis (55.0% vs. 71.4%, P = 0.241). Both the 30- and 90-day death adjusted cumulative incidence of rebleeding was significantly lower in the EUS-CYA group when compared to EGD-CYA control group (13% vs. 42% at 30-day, P = 0.023 and 22% vs. 61% at 90-day, P = 0.005, respectively).Conclusion:EUS-CYA for SP significantly reduces both the 30-day and 90-day death adjusted cumulative incidence of rebleeding in patients at high risk for recurrent gastroesophageal variceal bleeding when compared to EGD-CYA for index bleeding alone.

Endoscopic Variceal Ligation followed by Argon Plasma Coagulation Against Endoscopic Variceal Ligation Alone: A Randomized Controlled Trial.

Our aim was to study the efficacy and the safety of argon plasma coagulation (APC) in secondary prophylaxis against esophageal varices in view of many contraindications and side effects to β-blockers in cirrhotic patients. Rebleeding rates from esophageal varices after endoscopic variceal ligation (EVL) are high; thus, the current recommendation is to combine nonselective β-blockers to it, but side effects and relative contraindications to nonselective β-blockers hinder their usage or require discontinuation in 15% to 20% of the cirrhotic patients. Thus, it is important to find another combination. This study included all patients admitted to the Alexandria Main University Hospital during the period between April 2012 and October 2012 with variceal bleeding. After exclusions, the total number of included patients was 40. All participants were subjected to EVL and eradication of varices, and then they were randomized to either APC (group 1) or just observation (group 2). Both groups were followed up by endoscopy every 3 months for 30 months. During the 2.5-year follow-up, 21% of the participants in group 1 experienced esophageal variceal recurrence, but no one needed rebanding. In group 2, 68.4% of the participants experienced esophageal variceal recurrence (P=0.003) and 63.2% underwent rebanding (P<0.001). APC after esophageal variceal eradication using EVL can decrease the risk of recurrence of esophageal varices and the need for rebanding. This technique may be recommended in secondary prophylaxis against esophageal variceal bleeding in those who have contraindications, are intolerant, or are noncompliant to nonselective β-blockers.

Recurrent varices after surgery

The aim - analysis of causes and treatment of recurrent varices after surgery. Results of the study. At receipt of chronic venous insufficiency (CVI) of C2 was noted in 22 (38.5 %%) C3 26 (45.6%), and C4 in 9 (15.7%) cases. The vast majority of patients (n = 45 (78.9%)) were operated under general surgery departments of district general surgeons. Neoangi-ogenesis groin noted in 7 (12.2%) cases. In 8 (14%) cases in patients with primary operations were removed only varicose tributaries of the great saphenous vein trunk. Of the 57 patients, 6 (10.5%) had not revealed the presence of a remote trunk great saphenous vein in the thigh, and 4 (7%) cases marked by recanalization of the great saphenous vein trunk at the hip after EVLT. In 3 (5.3%) cases were identified long stump of the small saphenous vein. In 6 (10.5%) cases not removed at the trunk BPV tibia. In 3 (5.3%) cases were identified long stump of the small saphenous vein. In the remaining 23 cases noted the presence of varicose veins changed hypodermic pools large and small saphenous veins (GSV, SSV) (they are recorded in 9 cases residual varicose veins). Of the 57 patients, surgical treatment performed in 54 observations, surgical tactics depended on the location and cause of relapse. In 10 cases, resection of the stump of GSV/SSV and ligation of its tributaries. Just 10 patients made stripping the GSV trunk at the hip. In 14 patients we performed EVLT of trunk of the great saphenous vein and miniphlebectomy of tributaries. Conclusions. RVD in most cases is caused by tactical and technical errors after the initial operation, as well as the progression of the varicose veins and requires a differentiated approach in the treatment based on the study of venous hemodynamics using duplex scanning.

Duodenal Hemangioma as a Complication of Portal Hypertension

Portal hypertensive duodenopathy (PHD) is an uncommon outcome of portal hypertension (PHTN) and can present wither as incidental finding or associated with anemia from gastrointestinal bleeding. A 75-year-old male with well controlled HIV presented with symptomatic anemia (Hb 5.2 mg/dL). He had a history of variceal bleeding one year prior for which he had a liver biopsy and was diagnosed with cryptogenic cirrhosis and obstructive portal venopathy. The esophageal varices were ligated and obliterated. Four months ago, MRI for hepatoma surveillance showed portal vein thrombosis, managed conservatively. On this admission, his medications were Atripla, Aspirin, Omeprazole and Nadolol. Panendoscopy and capsule endoscopy were non-diagnostic. Repeat endoscopy showed a nodule in the bulb and third portion of duodenum, one of which was oozing blood. This was treated with argon plasma coagulation (APC) and hemostatic clips. They were histologically confirmed as hemangioma. Surveillance endoscopy showed a new nodule in the duodenal bulb. Pathology showed mild chronic duodenitis with focal gastric metaplasia and duodenal mucosa with focally increased vessels, consistent with hemangioma. A third surveillance endoscopy also demonstrated a nodule in the bulb with actively oozing and was treated with APC. PHD presenting as erythema, telangiectasia, ulcers, or varices has been reported with a prevalence of up to 51.4%. Also, there have been two case reports of duodenal polyps, presenting as bleeding and as an incidental finding, respectively. Histologically, PHD has been associated with angiogenesis, congestion, edema, apoptosis, fibrosis and villous changes. Duodenal hemangiomas are very rare vascular malformations with only 22 reported cases. Our case is the first to describe PHD-associated recurrent duodenal hemangioma, presenting with bleeding and anemia, in a patient with portal vein thrombosis. The relapsing nature of this lesion, in absence of recurrence of esophageal varices, suggests upregulated angiogenesis. The possible hemodynamic changes associated with successful variceal ligation and portal vein thrombosis may also contribute to development of duodenal hemangioma. While endoscopic management is effective, repeat endoscopy may be required given recurrence. The definitive management of duodenal hemangioma would likely involve therapies beyond treatment of PHTN with B-blockers or Transjugular intrahepatic portosystemic shunt, such as liver transplantation.Figure 1Figure 2

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.

A Comparative Study of the Efficacy of the Modified Sugiura Procedure and the Hassab Procedure for Treatment of Rebleeding after Endoscopic Variceal Ligation Due to Portal Hypertension

Although the modified Sugiura procedure and Hassab procedure have been used for many years, it remains unclear as to which is more effective for the treatment of rebleeding due to portal hypertension (PHT) after endoscopic variceal ligation (EVL). Hence, we conducted a retrospective study to compare the efficacy of these two procedures for treatment of rebleeding due to PHT after EVL. Of 66 patients diagnosed with PHT and rebleeding after EVL in our institute from January 2007 to January 2014, 31 underwent the modified Sugiura procedure (Group S), whereas 35 underwent the Hassab procedure (Group H). The surgical duration, blood loss volume, blood transfusion rate, postoperative complication rate, postoperative rebleeding rate, postoperative hospital stay, and long-term complication rates were compared between groups. Greater blood loss volume (P = 0.036), higher blood transfusion rate (P = 0.002), and longer surgical duration (P < 0.001) were observed in Group S than in Group H. There was no significant difference in the rate of short-term postoperative rebleeding between the groups (P = 0.695), although the rate of long-term rebleeding was lower (P = 0.031) in Group S. Recurrence of esophageal varices in Group S was less frequent in Group H (P = 0.002), although there was no significant difference between the groups in the rates of recurrence of gastric varices and other long-term complications (P > 0.05). The modified Sugiura procedure is more effective than the Hassab procedure for the treatment of rebleeding after EVL.

Mo1171 Endoscopic Ultrasound Evaluation After Endoscopic Eradication of Esophageal Varices With Band Ligation: Does It Predict Variceal Recurrence?

Mo1171 Endoscopic Ultrasound Evaluation After Endoscopic Eradication of Esophageal Varices With Band Ligation: Does It Predict Variceal Recurrence?

The predictive value of endoscopic ultrasound for the recurrence of esophageal varices after endoscopic esophageal varix ligation

Objective To assess the relationship between the recurrence of esophageal varices following endoscopic esophageal varix ligation (EVL) and esophageal collateral veins(ECV)under endoscopic ultrasound (EUS), and analyze the predictive value of EUS for recurrence of esophageal varices. Methods Sixty patients with cirrhotic portal hypertension combined with esophageal varices underwent EVL for eradication of varices. Endoscopy and EUS were performed before ligation to detect and describe the type of esophageal varices, and grade, location, and the number of ECV. Over a 12-month period, variceal recurrence was examined. The statistical analyses were performed to assess the relationship between esophageal varices following EVL and ECV. Results Of the 60 patients, 29 (48.3%) had variceal recurrence within 12 months after EVL. Univariate logistic regression analysis showed that severe peri-ECV (OR=22.67; 95%CI: 4.37-117.47, P<0.001), severe para-ECV(OR=16.31; 95%CI: 0.84-108.14, P=0.018), multiple peri-ECV (OR=22.67; 95%CI: 4.37-117.47, P<0.001), and the presence of perforating veins (OR=6.67, 95%CI: 1.46-30.43, P=0.014) were significantly related to the variceal recurrence after EVL. Multivariate logistic regression model showed that severe peri-ECV (OR=24.39; 95%CI: 2.34-253.78, P=0.008) and multiple peri-ECV (OR=24.39; 95%CI: 2.34-253.78, P=0.008) severe para-ECV(OR=19.42; 95%CI: 4.84-148.54, P=0.012)remained independent prognostic factors for variceal recurrence. The sensitivity and specificity of multivariate logistic regression model in predicting variceal recurrence were 89.2% and 90.5%, respectively (prognostic value AUC=0.946). The sensitivity and specificity were 86.4% and 87.7% in predicting variceal recurrence(prognostic value AUC=0.871). Conclusion Recurrence rate of esophageal varices after EVL is high. EUS can clearly depict ECV. Severe peri-ECV and multiple peri-ECV are significant and independent prognostic factors associated with variceal recurrence risk. EUS before EVL will help predict variceal recurrence after EVL. Key words: Esophageal and gastric varices; Therapeutic endoscopy; Forecasting; Ultrasonic endoscope

Clinical efficacy of endoscopic esophageal variceal ligation in elderly patients with hepatic cirrhosis

Objective To evaluate the clinical efficacy of endoscopic esophageal variceal ligation (EVL) for esophageal variceal bleeding (EVB) in elderly patients with hepatic cirrhosis. Methods From July 2007 to July 2013, clinical data of 198 patients who had been diagnosed with liver cirrhosis presenting with EVB were retrospectively analyzed.Among them, 167 patients who had received EVL were divided into the elderly EVL group (n=97, age≥60 years) and the non-elderly EVL group (n=70, aged<60 years). The other 31 cases (aged≥ 60 years) had received propranolol therapy.Treatment effectiveness, adverse effects, complications and the one-year survival rate of each group were analyzed. Results The efficacy rates and variceal recurrences were 77.3% (75/97) and 78.6% (55/70) in the elderly EVL group and 19.6% (19/97) and 18.6% (13/70) in the non-elderly EVL group, respectively, with no significant difference between the two groups (each P>0.05). The re-bleeding rate was higher in the propranolol treatment group than in the elderly and non-elderly EVL groups 〔58.1%(18/31)vs.24.7%(24/97)vs, 22.9%(16/70), χ2=14.76, P=0.00〕. One-year survival rates in the elderly group, the non-elderly EVL group and the propranolol treatment group were 86.6 (84/97), 88.6% (62/70), 64.5% (20/31), respectively, with statistically significant differences between the three groups (χ2=10.24, P=0.01). Conclusions EVL is effective for the treatment of hepatic cirrhosis with EVB and can be used as a secondary prophylaxis measure for EVB in elderly patients with hepatic cirrhosis. Key words: Endoscopic and gastric variceas; Liver cirrhosis

Role of EUS evaluation after endoscopic eradication of esophageal varices with band ligation

Variceal recurrence after endoscopic band ligation (EBL) for secondary prophylaxis is a frequent event. Some studies have reported a correlation between variceal recurrence and variceal rebleeding with the EUS features of paraesophageal vessels. A prospective observational study was conducted to correlate EUS evaluation of paraesophageal varices, azygos vein, and thoracic duct with variceal recurrence after EBL variceal eradication in patients with cirrhosis. EUS was performed before and 1 month after EBL variceal eradication. Paraesophageal varices, azygos vein, and thoracic duct maximum diameters were evaluated in predetermined anatomic stations. After EBL variceal eradication, patients were submitted to endoscopic examinations every 3 months for 1 year. We looked for EUS features that could predict variceal recurrence. Thirty patients completed a 1-year endoscopic follow-up. Seventeen patients (57%) presented variceal recurrence. There was no correlation between azygos vein and thoracic duct diameter with variceal recurrence. Larger paraesophageal varices predicted variceal recurrence in both evaluation periods. Paraesophageal varices diameters that best correlated with variceal recurrence were 6.3mm before EBL (52.9% sensitivity, 92.3% specificity, and .749 area under the receiver operating characteristic curve [AUROC]) and 4mm after EBL (70.6% sensitivity, 84.6% specificity, and .801 AUROC). We conclude that paraesophageal varices diameter measured by EUS predicts variceal recurrence within 1 year after EBL variceal eradication. Paraesophageal diameter after variceal eradication is a better recurrence predictor, because it has a lower cut-off parameter, higher sensitivity, and higher AUROC.

Partial splenic embolization has beneficial effects for the management of gastroesophageal variceal hemorrhage.

Background/Aims:Partial splenic embolization (PSE) is used in the management of gastroesophageal variceal hemorrhage (GEVH). However, it is uncertain whether it has beneficial effects for GEVH patients in preventing variceal recurrence and variceal hemorrhage, as well as promoting overall survival (OS), when it is combined with conventional therapies.Materials and Methods:The databases including PubMed, EMBASE, Web of Science, Google scholar, and Cochrane Central Register of Controlled Trials were searched up to 11th of November, 2015. Meta-analyses were performed by using Review Manager 5.3 software for analyzing the risk of bias, Newcastle-Ottawa Scale for assessing the bias of cohort studies, and GRADEprofiler software for assessing outcomes obtained from the meta-analyses.Results:A total of 1505 articles were reviewed, and 1 randomized controlled trial and 5 cohort studies with 244 participants were eligible for inclusion. The pooled hazard ratio (HR) of variceal recurrence is 0.50 (95% confidence interval (CI) 0.37, 0.68; P< 0.00001; I2 = 0%). The pooled HR of variceal hemorrhage is 0.24 (95% CI 0.15, 0.39; P< 0.00001; I2 = 0%). The pooled HR of OS is 0.50 (95% CI 0.33, 0.67; P< 0.00001; I2 = 0%). Meta-analyses demonstrated statistically significant superiority of combinational therapies over conventional therapies in preventing variceal recurrence and variceal hemorrhage and prolonging OS. The complications related to PSE were mild or moderate and nonfatal.Conclusions:The results indicate that PSE has beneficial effects for GEVH patients, however, future investigation with a larger number of subjects in clinical trials is warranted.

Endoscopic band ligation combined with argon plasma coagulation versus band ligation alone for eradication of esophageal varices

Background and aim Bleeding esophageal varices are the gravest complications of liver cirrhosis, with a high mortality. Although band ligation is considered the gold standard in the eradication of varices, it is plagued by a high recurrence rate after variceal eradication. The aim of the study was to assess safety and efficacy of endoscopic band ligation plus argon plasma coagulation (APC) versus endoscopic band ligation alone for the prevention of variceal recurrence and rebleeding. Patients and methods This prospective randomized comparative study was carried out on 100 patients admitted to Tropical Medicine and Gastroenterology Department, Qena University Hospital, during the period from March 2012 to complete follow-up on March 2014. Patients were randomized into two groups: group 1 included 50 patients who were subjected to endoscopic band ligation plus APC, and group 2 included 50 patients who were subjected to variceal band ligation. Results On comparing the results of the two groups as regards the incidence of variceal recurrence during the follow-up period, combined treatment group with band ligation plus APC had a significant low recurrence rate in comparison with band ligation alone treated group. As regards post-treatment complications in the combined treated group, there was transient fever (≥38°C) in 36% of patients, retrosternal pain (5–7 days) was reported in 20% cases, and bleeding during argon application occurred in one patient 2%. The development of severe complications did not occur in any of the patients. Mortality was reported in 10 cases in group 1 (three cases died by causes not related to liver disease). Conclusion Combined band ligation plus APC is safe and effective in prevention of variceal recurrence and rebleeding. The reported side effects were mild and reported mainly in older patients with child class C.

下腿部の穿通枝，もしくは伏在静脈本幹に逆流源を有する再発性下肢静脈瘤に対する手術症例の検討

下肢静脈瘤の再発には初回手術の手技，戦略で避けられるものもある．再発をできるだけなくすため，今回下腿部の穿通枝か伏在静脈本幹に逆流源を有する再発性下肢静脈瘤（recurrent varices after surgery: REVAS）に対する再手術症例の再発機序や背景を検討し，治療についても言及した．2008 年1 月～2015 年7 月の下肢静脈瘤手術1519 肢中，REVAS に対する再手術は108 肢（7.1％）で，うち下腿に原因のあるものは59 例66 肢であった，既往手術は大伏在静脈高位結紮+ ストリッピングが多かった．再発の原因静脈では不全穿通枝が断然多かったが，前回ストリッピングされた大伏在静脈の末梢側伏在静脈本幹もみられた．逆流静脈に対する処置を全例に施行，皮膚病変下の不全穿通枝26 肢には内視鏡下筋膜下不全穿通枝切離術（SEPS）を施行した．全例良好に経過した．初回手術時に診断された逆流をすべて処理することが再発回避に重要であるが，残す場合にはフォローアップが重要であり，適宜追加治療を行うべきと考えられた．

下肢静脈瘤治療における非造影3DCT 静脈撮影の有用性─特に術後再発に関する形態学的危険因子の検討─

下肢静脈瘤の診療に際して非造影3DCT 静脈撮影を併用した場合の有用性について検討した．とくに術後再発の原因になりやすい①大伏在静脈大腿静脈接合部（saphenofemoral junction: SFJ）分枝，②血管新生，③重複大伏在静脈（duplicated great saphenous vein: D-GSV）の3 項目に関して症例を提示し報告する．対象はデュプレックス超音波検査に加えて非造影3DCT 静脈撮影を併用した59 症例（64 肢）とした．結果：① SFJ 分枝形態を3 タイプに分類した．SFJ 分枝再発の高リスク群としてタイプ2．高位分岐型（49.2％）とタイプ3．共通幹形成型（22.0％）が挙げられた．再発リスクの高い分枝は主に副伏在静脈（accessory saphenous vein: ASV）であった．②血管新生については，浅腹壁静脈（superficial epigastric vein: SEV），浅腸骨回旋静脈（superficial circumflex iliac vein: SCIV）および大伏在静脈（great saphenous vein: GSV）の切離断端から発生していることを確認した．③ D-GSV は，検討症例中30.5％に認めたが，D-GSV 術後に大腿部穿通枝が不全交通枝（incompetent perforating vein: IPV）となり術後再発源となった症例を提示する．症例を選択し非造影3DCT 静脈撮影を併用することは，術後再発防止や再発症例の治療戦略を立てるうえで有用と考えられた．