[in Japanese]

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Peritoneo-venous shunt (P-V shunt) has been known to be an excellent method of treatment of refractory ascites. However, it is sometimes difficult to decide the timing of its commencement because of its serous complications such as volume overload and disseminated intravasealor coagulation (DIC). We present a series of patients who underwent P-V shunt operations resulting in various outcomes.
Method : We performed P-V shunt in a series of thirteen patients with refractory ascites admitted to our institute from 1993 to 2005 using Denver or Le Veen shunt system. The background of these patients included liver cirrhosis with or without hepatocellular carcinoma (6 cases), carcinomatous peritonitis from advanced pancreatic cancer, primary biliary cirrhosis (one case), poor nutrition after pancreatoduodenectomy (one case), and liver metastasis from advanced colon cancer (3 cases; one after hepatic resection). The efficacy and potency of the shunt and the outcomes after shunt operation were analyzed.
Result : Body weight and abdominal circumference were reduced after shunting in 12 patients, and 10 were discharged. Complications were observed in 4 cases. Three cases died within 7 days after operation due to liver failure and cachexia due to carcinoma. All 3 patients had suffered from unstable status of respiratory and circulating system before operation. The average survival period of all the patients was 559 days.
Conclusion : Although P-V shunt is excellent treatment for intractable ascites, the timing of its commencement should be decided taking various complications into consideration.

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Based on the ability to induce vascular leakage and promote the accumulation of ascites, vascular endothelial growth factor (VEGF) -A is considered as a vascular permeability factor. VEGF-C and VEGF-D drive lymphangiogenesis, which can provide conduits for fluid to extravasate from leaky blood vessels. In order to evaluate whether these VEGF family members play a role in refractory ascites (RA), VEGF-A, VEGF-C, and VEGF-D levels were measured in the ascitic fluid of cirrhotic patients using enzyme-linked immunosorbent assay. We studied 24 cirrhotic patients; 12 had RA (group 1) and 12 had non-RA (group 2). Ascitic VEGF-A levels were significantly higher in group 1 than in group 2. Thus, the VEGF-A levels is useful in the discrimination between patients with and without RA. Moreover, a significant correlation was observed between ascitic fluid VEGF-C levels and urinary sodium excretions, a predictor of RA. These results suggest that ascitic VEGF-A levels may be helpful in the diagnosis of RA in cirrhotic patients. In addition, ascitic VEGF-C levels, in association with decreased urinary sodium excretion, may contribute to the prediction of development of RA.

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The assessment of hemodynamism is important for determining the best strategy for treatment of esophageal varices. We have been using invasive angiography for this purpose. We, however, recently introduce less invasive methods including endoscopic ultrasonography (EUS), magnetic resonance angiography (MRA), and multidetector-row CT (MD-CT). While three-dimensional CT (3D-CT) has been shown to be useful in the assessment of portal hemodynamics, particularly of gastric varices, hemodynamics of esophageal varices cannot be clearly imaged by this method because of potential overlapping of lung and heart images. We describe herein the improved construction of 3D-CT images of esophageal varices in 2 cases by volume rendering (VR) after analyzing detailed hemodynamics using MD-CT with the maximum intensity projection (MIP). We first highlight images of esophageal varices, then accentuate those of extraesophago-gastric collateral veins, and lastly superimpose these images on VR images. These procedures clearly visualize both esophageal varices feeding veins and perforating veins. Thus, innovated 3D-CT of esophageal varices is useful for evaluating portal hemodynamics.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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