Between 1983 and 1992, endoscopic injection sclerotherapy (EIS) using 5% ethanolamine oleate according to the so-called traditional method was performed in 170 patients with esophageal varices. In 1993, we adopted a new method, tentatively called the “waiting method”, in which additional EIS was withheld (“waiting”) until variceal inflammatory swelling caused by the former EIS disappeared. Between 1993 and 1998, the waiting method was employed in 48 patients. The disappearance rate of esophageal varices by EIS in cases of no hepatocellular carcinoma treated by the waiting method was 93.9% (traditional method; 65.3%) and the recurrent rate was only 2.9% (traditional method; 8.0%). Compared to the traditional method, the amount of sclerosant (35.6 ± 15.4 vs 53.2 ±26.4 ml; p <0.01), frequency of EIS (3.0 ± 1.1 vs 4.8 ±2.3; p < 0.001), duration of hospitalization (89.6 ±33.2 vs 118.0 ± 42.0 days; p <0.001), and complications (2.1 vs 28.2%; p <0.001) decreased in patients treated with the waiting method. We propose that because EIS employing the waiting method has numerous merits compared to conventional EIS, it should be regarded as the first choice of treatment for esophageal varices.

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We performed eradicative endoscopic variceal ligation (eEVL) treatment for 38 patients with esophageal varices. An average of 38 O-rings were used not only for the eradication of esophageal varices but also for the devascularization of esophageal mucosa to improve the consolidation of therapeutic effects. After treatment, F factor became F₀, RC sign became negative, and blood flow decreased not only at the site of esophageal varices but also in their feeding vessels. The cumulative rate of non-recurrence in the observation period of 3 years and 1 month was 72.9% overall. That of Child A patients, Child B patients and Child C patients was 92.3% (longest observation period of 3 years and 1 month), 75% (2 years and 8 months) and 26.9% (2 years and 5 months), respectively. The difference between Child A and C was significant. Non-recurrence rate in patients whose cord vessels were imaged in post-treatment PTP was significantly lower than that in patients without cord vessel images. Cumulative non-bleeding rate was 97.1% during a period of 4 years in all patients. These results suggest that eEVL is a valuable alternative to endoscopic injection sclerotherapy.

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We investigated a series of patients who underwent endoscopic variceal ligation (EVL) in our hospital and evaluated the clinical usefulness of EVL in comparison with that of endoscopic injection sclerotherapy (EIS) and surgery. Seventy-two patients were treated with EVL alone and 30 patients were treated with combined therapy (EVL+EIS). A pneumo-active EVL device (Sumitomo Bakelite, Tokyo, Japan) was used for ligation. Another 226 patients were treated with EIS and 156 patients were treated with surgical methods. Recurrent varices were found in 41 (40%) patients during the follow-up period. Bleeding after the therapy occurred in 10 (9.8%) patients treated with EVL, 25 (11%) with EIS and 26 (17%) with surgery. Cumulative survival rates after 1, 3 and 5 years in the patients treated by EVL were 83%, 67% and 61%, respectively. These data were comparable to those of EIS (82, 60, 45%) and surgery (81, 69, 60%). Twenty-six patients treated with EVL died during the follow-up period, and major causes of death in EVL patients were liver failure and liver cancer. In conclusion, this study suggests that EVL can be an alternative to EIS and surgery in the treatment of esophageal varices.

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No treatment has been established for bleeding gastric fundal varices (FV), which are associated with a high mortality rate. We carried out a preliminary study to evaluate the short-term efficacy of prophylactic balloon endoscopic sclerotherapy for patients with high risk FV associated with gastrorenal shunt. Between May and November 1997, prophylactic balloon endoscopic sclerotherapy was performed in five cirrhotic patients judged as having high-risk FV. Variceal size was 14-21 mm (mean : 17.4 mm). The therapeutic effect of balloon endoscopic sclerotherapy on FV, complications, and patency of gastrorenal shunt were assessed. Blood flow in FV was well blocked with a balloon catheter inserted into gastrorenal shunt, and technical success was achieved in all patients after the procedure. FV disappeared in 3 patients or showed marked improvement in 2 patients. Subsequently FV did not recur. No local or systemic complications occurred and the gastrorenal shunt remained intact in all patients. No patient died or showed a change in Child-Pugh classification during the follow-up of period of 14-20 months (mean : 16.6 months). Development of esophageal varices did not occur in any patients. In conclusion, balloon endoscopic sclerotherapy may be useful because it is a safe and reliable treatment for high risk FV.

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We evaluated effect of prophylactic treatment on esophageal varices in 126 patients with hepatocellular carcinoma (HCC). A cumulative bleeding rate and a death rate were compared between 54 patients who underwent prophylactic therapy (prophylactic group) and 72 patients who did not undergo the treatment (non-prophylactic group). Cumulative bleeding rate in the prophylactic group was significantly lower than that in the non-prophylactic group (5.6% vs 23.5%, p <0.001). Death rate due to variceal bleeding and hepatic failure following variceal bleeding was significantly lower in the prophylactic group than in the non-prophylactic group (1 case, 2.9% vs 10 cases, 16.1%, p <0.05). A cumulative survival rate in the prophylactic group was significantly higher than that in the non-prophylactic group (p <0.0001). Nine patients with tumor thrombus in the main portal vein (Vp₃) had an extremely poor prognosis (survival periods of 66.7 days on average) and there was no statistical difference in the survival period between the cases of bleeding from esophageal varices and of non-bleeding. We conclude that prophylactic therapy for esophago-gastric varices in patients with HCC is valuable, because it decreases the rate of bleeding from esophageal varices and death caused by the bleeding, resulting in a prolonged survival period. The usefulness of prophylactic therapy for Vp₃ cases is, however, limited at present.

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[in Japanese]

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[in Japanese]

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To improve the treatment of recurrent esophageal varices following endoscopic injection sclerotherapy (EIS), we visualized collaterals that supply blood to the varices by endoscopic varicealography during EIS (EVIS). Of 40 patients who required additive EIS for recurrent esophageal varices, 24 shows “good” EVIS giving clear collateral images, whereas the remaining 16 showed “poor” EVIS producing unclear collateral images on EVIS performed before additive EIS. Therapeutic results were marked improvement in 20, moderate improvement in 2, and no improvement in 2 of the 24 cases of “good” EVIS images, whereas they were 4, 8 and 4 in the 16 “poor” image cases, respectively. These results indicate that the usefulness of additive EIS is dependent on clear visualization of collaterals on EVIS that enables complete EIS.

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Since 1992 we have used balloon occluded retrograde transvenous obliteration (B-RTO) for the primary treatment of solitary gastric varices. The selection criteria of patients include sufficiently prolonged filling of the contrast medium on varicography. Subjects were 22 patients admitted to our hospital for the treatment of gastric varices between March 1992 and February 1998. Therapeutic efficacy, recurrent rate, influence on coexisting esophagealvarices and adverse effects were evaluated during the observation period from 1 month to 6 years (average 2.2 years) after treatment. Gastric varices completely disappeared and no recurrence was observed in 21 of the 22 patients treated. Of these, collateral circulation seen as gastrorenal shunt disappeared in 16, but persisted in 2. The result was unclear in 3 patients. Treatment of coexisting esophageal varices was needed in 9, and the cumulative reappearance rates were 25.3% and 50.2% at 3 years and 5 years after treatment, respectively. Concerning adverse effects, fever higher than 38°C, pleural effusion chest pain and abdominal pain were observed in 70%, 50%, 35% and 30% of the patients, respectively. The levels of AST, ALT, BUN and creatinine showed negligible changes after the treatment. Levels of total bilirubin and LDH showed significant but temporary elevation after the treatment. These results indicate that B-RTO is a safe and reliable method for solitary gastric varices.

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To evaluate combined therapy of endoscopic ligation and sclerotherapy, we have treated 83 consecutive patients with large esophageal varices by the therapy. Seventy-eight of 83 patients were prophylactically treated. Endoscopic ligation was first repeated until esophageal varices were flattened and thereafter sclerotherapy was added to eradicate the varices. One point eight sessions of ligation and 2.4 sessions of sclerotherapy per a patient were performed and all varices were eradicated. No severe complication such as acute renal failure and esophageal perforation was experienced. The 5-yr cumulative rates of nonbleeding from esophageal varices and variceal recurrence were 92.5% and 54.4%, respectively. In prophylactic cases, we compared the combined therapy with sclerotherapy alone performed in our hospital previously. The sclerotherapy group had more complications during treatment than the combination group (7.8% vs. 0%, p <0.05). There was no significant difference in cumulative rates of nonbleeding from esophageal varices and variceal recurrence between the two groups. The combination therapy is effective and safe treatment for esophageal varices, and especially for poor risk patients, may be more useful than sclerotherapy alone.

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We retrospectively studied the hemodynamic characteristics of liver cirrhosis complicated by idiopathic pulmonary hypertension (PH), and compared the results with those of chronic hepatitis and liver cirrhosis without PH. Etiology of liver cirrhosis was excess alcohol intake in 2, hemochromatosis in 1, autoimmune hepatitis in 1 and hepatitis C in 1 case. The age of diagnosis ranged between 42 and 64 years. Prevalence of PH ascertained by right cardiac catheterization was 2% (5 cases) among 250 patients with liver cirrhosis. In these 5 patients, mean pressure of the pulmonary artery was 42.4±12.1 mmHg (mean±SD). Mean vascular resistance of the pulmonary artery was 832±400 dynes·sec·cm^-5/m² and the cardiac index (CI) was 3.13±0.66 l/ min/m² CI in 41 patients without PH was 4.26±0.90 l/min/m², and significantly higher than that of the patients with PH (p<0.01). Mean systemic vascular resistance was significantly higher, and circulating plasma volume was significantly smaller in patients with PH than patients without PH (2438±743 vs 757±228 dynes·sec·cm^-5/m², p<0.01 and 1.71±0.36 vs 2.07±0.29 l/min/m², p<0.05, respectively). These results suggest that hyperdynamic systemic circulation commonly seen in patients with cirrhosis is normalized by the complication of PH.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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