We evaluated treatment of esophageal varices complicated by gastric cancer in total of 97 cases including 13 cases we experienced and 84 cases reported in our country. In our class, the rate of recurrence of varices is 22.2% (2/9) in total gastrectomy with splenectomy, but 100% (2/2) in distal gastrectomy without splenectomy. For the selection of an adequate treatment method we should precisely assess the advance of gastric cancer, the severity of liver dysfunction and the degree of esophagogastric varices. Generally total gastrectomy with splenectomy and paraesophageal devascularization is most effective. However, because this procedure is hard to tolerate for patients with poor liver function reserve, distal gastrectomy without splenectomy and additional endoscopic injection sclerotherapy is more adequate for such cases.

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To determine current role of surgery when endoscopic treatment of patients with esophagogastric varices is preferred, we retrospectively studied the clinical outcomes of patients who received endoscopic and/or surgical treatment. Between May/1982 and March/2000, we performed endoscopic treatment as the first choice in 288 patients with esophagogastric varices. Thirteen of the 288 (4.5%) had previously undergone varices-related surgery or required subsequent additional surgery. Upon review of the patients' medical records, nine patients (3.1%) were found to have undergone surgical treatment, such as esophageal transection or Hassab's operation, prior to endoscopic treatment. In contrast, only four (1.6%) patients required varices-related surgery after endoscopic treatment, including one for paraesophageal hematoma, and three for bleeding from gastric varices. Endoscopic treatment was ineffective in these latter three cases, which included a patient with left side portal hypertension who had required Hassab's operation. Nine patients died of variceal hemorrhage after endoscopic treatment who didn't surgery. Our findings show that endoscopic treatment alone effectively controlled esophagogastric varices in most patients (95.5%). However, intractable gastric varices should be treated by early surgery, and clinicians should be aware of the possible presence of local portal hypertension as it is a contra-indication for endoscopic treatment.

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We observed duodenal erosion in 45 (10.8%) of 418 patients who underwent endoscopic therapy for gastroesophageal varices. Duodenal erosion in patients with portal hypertension was likely to be located in ringed fashion around circular Kerckring's folds, while ordinary duodenitis causes spotty erosive lesions mainly observed in the bulbus. Examination by endoscopic ultrasonography revealed edematous duodenal walls and the structure of proliferated vessels both in and around the duodenal walls. Histological characteristics were dilatation of vessels and edema in the mucosal and submucosal layers. We assume that the decrease in mucosal resistance caused by the congestion associated with portal hypertension is one factor that induce the characteristic erosions in the duodenum. Duodenal erosion in patients with portal hypertension is regarded as one of the lesions accompanying portal hypertensive duodenopathy.

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Portal hemodynamics was studied using digital subtraction angiography in 302 patients with esophageal varices. 1) Left gastric vein was depicted in 47% of F₁ cases, 66% of F₂cases, 84% of F₃ cases, and short gastric veins were depicted in 13%, 21% and 24% respectively, by superior mesenteric arteriography and splenic arteriography. Esophageal varices were demonstrated in 97%, 100% and 100%, respectively by left gastric arteriography. 2) The direction of left gastric vein was hepatopetal in 47%, to and fro in 23%, hepatofugal in 23%, and undetermined in 7% of F₁ cases. As the degree of esophageal varices increased, the incidence of hepatopetal cases and to and fro cases were decreased, and that of hepatofugal cases was increased. 3) According to their hemodynamics, esophageal varices were classified into two groups, “left gastric artery dependent esophageal varices”, which were mainly supplied with the blood flow of upper gastric area, and “mixed type esophageal varices”, which were supplied with portal blood flow and the blood flow of upper gastric area. The former filled about a half of F₁ cases, one third of F₂ cases, and one sixth of F₃ cases. The latter filled about a half of F₁ cases, two thirds of F₂ cases, and five sixths of F₃ cases.

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Endoscopic variceal ligation (EVL) without additional therapy is reported to show high recurrence rate in early period afte treatment. To reduce this high recurrence rate, we introduced the combination therapy of EVL and microwave coagulation (MWC) for esophageal varices in 1994. At first, EVL is performed for eradication of esophageal varices. After disappearance of variceal forms, MWC is added for mucosa-fibrosing therapy. MWC is conducted with an output of 40 Watt and a duration of 5 s. Endpoint of EVL-MWC combination therapy is until we confirm endoscopically the complete disappearance of variceal forms by EVL and the circular ulceration of lower esophageal wall by MWC. Since March 1994 to December 1999 we have performed EVL-MWC combination therapy in 126 patients with liver cirrhosis in our medical center. In this study, to evaluate the efficacy of EVL-MWC combination therapy, we investigated shortand long-term results, incidence of complications, and prognosis of the patients who had undergone this combination therapy. Till achievement of endpoint, the average sessions of EVL-MWC combination therapy was 2.9 times and the average days of treatment was 25.6 days. No major complications and no severe side effects were found during and/or after EVL and MWC treatments. Over all the RC sign recurrences were recognized in 27 patients (21.4%) during 6 years following up period after EVL-MWC combination therapy. The average period of recurrence was 462.7 days. Recurrent bleeding occurred in 5 patients (4%). We concluded that EVL-MWC combination therapy was easy and safe, and had long-term efficacy for esophageal varices.

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We newly devised emergency varicoembolization for ruptured gastro-esophageal varices by modifying transjugular intrahepatic portosystemic shunt (TIPS) treatment. We propose the term “varicoembolization via the intrahepatic portal vein root (VEIP)” for this procedure. We performed VEIP in patients with ruptured gastro-esophageal varices who were suspected of developing complications such as bleeding, hepatic coma, and renal and/or heart failure after conventional therapies. In the present study, we evaluated its advantages in comparison with conventional therapies. The results obtained demonstrated that our technique was effective in treating the patients who were unable to be treated with conventional therapies because of various reasons such as ascites, bleeding tendency. Moreover, it could treat endoscopically uncontrollable ruptured varices. It is suggested that this procedure is of valuable as a novel alternative in the treatment of gastro-esophageal varices.

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[in Japanese]

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