Since August 1990, we treated 80 cases with gastric varices by balloon-occluded retrograde transvenous obliteration (B-RTO) and evaluated their long-term prognosis. Survival rates one and five years after B-RTO were 93.3% and 55.3%, respectively. Cumulative relapse rates of fundal varices one and five years after B-RTO were 1.4% and 4.4%, respectively. Cause of death after a long-term survival was development of hepatoma in half of cases. Thus, it was revealed by the present study that a significant prognostic factor after B-RTO was accompanying hepatoma.

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To clarify the effects of prophylactic treatment for large gastric fundic varices, therapeutic efficacy, change in liver function and portal hemodynamics were studied in 27 patients who underwent Hassab's operation or balloon-occluded retrograde transvenous obliteration (B-RTO). Results are as following : 1) All gastric fundic varices were found to disappear by endoscopic examination, and they didn't recur throughout the period of observation ranging from 12 months to 126 months. 2) Refractory ascites was encountered in one of 8 patients who underwent Hassab's operation, but severe complications were not observed in 19 patients who underwent B-RTO. 3) Serum albumin level was significantly increased (p < 0.05) and ICGR, 5 value was significantly lowered (p < 0.05) one year after the treatment in patients whose portal flow was judged to be hepatofugal by superior mesenteric arterial venography before the treatment, and a diameter of gastric-renal shunt (GRS) or gastric-inferior phrenic vein shunt (GIS) were wider than 10 mm. 4) Cumulative detection rate of red color sign positive esophageal varices were significantly higher (p < 0.01) in patients with collaterals other than GRS or GIS before treatment (42.9% at before treatment, 84.1% at 4-years after) than that in patients without other collaterals (0% at 2-years, 16.7% at 4-years). We conclude that, by selecting appropriate cases, prophylactic treatment for large gastric fundic varices with Hassab's operation or B-RTO brings about beneficial results.

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We conducted a retrospective study to determine the indication of preventive endoscopic injection sclerotherapy (EIS) for isolated gastric varices (i-GV). For this purpose, endoscopic findings of patients with hemorrhagic i-GV were compared with those of patients with non-hemorrhagic i-GV. We investigated risk factors for variceal bleeding based on endoscopic findings and sought vascular factors relating to recurrence i-GV using endoscopic ultrasonography. Findings to predict recurrence of i-GV and rebleeding from the i-GV after EIS were selected. Largeness in size, a positive red color sign and erosions on i-GV were characteristically found in patients with hemorrhagic i-GV. Comparison of findings on endoscopic ultrasonography between patients with recurrence of i-GV and those without recurrence of i-GV revealed that aechoic lumens corresponding to perforating veins and peri-gastric collateral veins around the gastric serosa were significantly more often found in patients with hemorrhagic i-GV than in patients without recurrence of i-GV. Since massive hemorrhage from i-GV results in a poor prognosis. Thus, additional EIS is necessary to prevent recurrence and re-bleeding from i-GV when these risk factors were found after initial EIS.

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We studied efficacy of Hassab's operation in 28 cases with solitary gastric varices. Operative death was observed in one case with the Child C liver dysfunction. In remaining all cases varices disappeared irrespective of their location or types of collateral vessels, and no recurrence was observed by endoscopic examination performed one month after the operation. In 2 cases, esophageal varices occurred postoperatively, but their varices were low in degree. No bleeding occurred in either case, although one case was retreated by EIS. Improvement of hypersplenism, hepatic encephalopathy and liver function were observed in some cases. Compared with esophageal varices, development and bleeding of gastric varices are low in frequency. However, once rupture occurs, bleeding is more massive than that in esophageal varices. Therefore, appropriate treatment methods should be selected in consideration of their location and the types of collateral vessels flown into the varices. However, no treatment has yet gained unanimousity regarding safety or reliability for acute bleeding. We propose that Hassab's operation is effective as prophylactic therapy for solitary gastric varices, either residual or newly developed varices seen after EIS, for cases with a high risk of bleeding in near future.

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In this communication, we report the results of 27 patients who underwent non-shunting operation for gastric varices (including esophago-gastric varices) in our department during the past 9 years and 7 months. Causes of portal hypertension were liver cirrhosis in 21, extrahepatic portal vein obstruction in three, and idiopathic portal hypertension in three. Six of the 27 patients experienced bleeding from gastric varices. Operative methods were esophageal transections in 18, Hassab operations in five and Hassab operations with endoscopic injection sclerotherapy or endoscopic variceal ligation in four. Hassab operation was mainly indicated for patients without esophageal varices. The mean observation period of all patients was 977.7 days. Postoperative complications were observed in 11.1% of patients. Gastric varices completely disappeared in all patients and no recurrence was experienced during mean observation period of 978 days. We concluded that advantage of the non-shunting operation for gastric varices was good therapeutic results, while disadvantage was a relative high rate of complications.

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In 91 patients with fundic gastric varices, we analyzed a relationship between variceal bleeding and portal hemodynamics. Portal pressure in 25 bleeders who underwent percutaneous transhepatic portography was 318 mmH₂O (mean) and it was significantly higher than that in 12 non-bleeders (p < 0.05). Feeding veins to fundic gastric varices were located near the splenic hilum in 60% of the patients. Blood flow velocity in the feeding vein to fundic gastric varices in 18 bleeders who underwent Doppler US was higher than that in 29 non-bleeders (p = 0.053). In 32.3% of 31 bleeders, reversed flow was observed in the splenic vein, and the incidence was significantly higher than that in 40 non-bleeders (p < 0.05). A cumulative bleeding rate in patients with reversed flow in the splenic vein was higher than that in patients with forward flow (p < 0.05). These results suggest that evaluation of hemodynamic state in the varices is useful to decide the indication of prophylactic treatment of fundic gastric varices.

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To evaluate efficacy of prophylactic endoscopic injection sclerotherapy (EIS) for gastric varices, we examined prognosis of patients with gastric varices treated with and without prophylactic EIS. The EIS group was consisted of 31 patients and non-EIS group was consisted of 30 patients. Presence of F₂ or F₃ gastric varices was endoscopically confirmed in all patients, although they did not have episodes of variceal bleeding. EIS was performed under fluoroscopy by injecting 5% ethanolamine oleate mixed with iopamidol directly into gastric varices. Prognosis was estimated by comparing cumulative bleeding rates, mortality from bleeding and whole mortality between the EIS and non-EIS groups. Regulatory factors for the prognosis were further examined by multivariate analyses. Cumulative bleeding rates, mortality from bleeding and whole mortality in the EIS group were be significantly lower than those of the non-EIS group. Furthermore, prophylactic EIS was shown to be one of significant a regulatory factors for bleeding rates and mortality by using a proportional hazard model. These prognostic analyses suggest that prophylactic EIS is extremely useful for the treatment of F₂ and F₃ gastric varices.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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Portal hemodynamic response to oral intake of glucose was investigated in twenty-eight patients with liver cirrhosis and nine patients with non liver diseases by Doppler ultrasound. In a fasting state, splenic and superior mesenteric venous flow volume increased significantly in patients with liver cirrhosis compared with that in patients with non liver diseases, whereas blood flow volume in the portal trunk was almost equal in these two groups. After glucose intake, percentage changes of blood flow volume in the splenic vein, the superior mesenteric vein, and the portal trunk in patients with liver cirrhosis were significantly smaller than those in patients with non liver diseases. In conclusion, it is suggested that splenic and mesenteric circulation is hyper-dynamic, although hyporesponsive after oral feeding in liver cirrhosis.

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The influence of partial splenic embolization (PSE) on the liver function was examined by measuring changes of hepatic hemodynamics and serum cytokines after PSE in 17 patients with liver cirrhosis. Portal blood flows at the splenic vein and portal trunk measured by pulsed Doppler ultrasongraphy decreased after PSE. Indocyanin green retention rate showed no significant change. Hepatic uptake calculated by blood disappearance ratio and Rmax both measured by ^99mTc-galactosyl human serum albumin (^99mTc-GSA) liver scintigraphy increased significantly three days and decreased 30 days after PSE. Liver volume assayed by single proton emission computed tomography and hepatic blood flow (HBF) measured by ^99mTc-GSA liver scintigraphy showed no significant change. Human hepatocyte growth factor increased one and three days after PSE, while transforming growth factor-A increased 14 days after PSE. We conclude that PSE causes changes in the liver function, which are not accompanied by any morphological change of the liver and the change of HBF.

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Purpose of this study is to determine short term hemodynamic changes of portal vein following non-shunt operations in 6 patients with esophageal varices. Non-shunt operations were the Hassab's operation in 5, and transabdominal esophageal transection in I. We measured portal vein pressure and blood flow of the left and short gastric vein before and during the operations. A portal vein flow volume was measured before and after the operations using MRI in 2 patients. There was a parallelism between pressure of radial artery and that of portal vein. After ligation of splenic artery, blood flow of the left gastric vein was decreased, suggesting blood flow was hepatofugal in the left gastric vein. Portal vein pressure was maintained without any changes during this operation, while portal flow volume was decreased after operation. These observations suggest that non-shunt operations for esophageal varices induce a decrease in portal blood flow.

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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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This study was undertaken to evaluate the usefulness of color Doppler with that of power Doppler in detecting gastric varices. The gastric varices were categorized as follows : F₂ type in 15 an F₃ type varices in four. Among 19 cases, seven had fundic varices, 12 cardiofornical varices. Vessel images of gastric varices and gastro-renal shunt were clearly delineated by color Doppler in 17 of 19 (89.5%) and at the same rate, respectively. Power Doppler was performed in 10 patients, and the vessel images of gastric varices were visualized in all 10 patients. The gastro-renal shunt were found in nine of the 10 cases (90.0%). In six (60.0%), power Doppler visualized short gastric vein which color Doppler was unable to detect. We conclude that power Doppler is more useful than color Doppler in the assessment of hemodynamics of gastric varices.

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We evaluated the efficacy of endoscopic injection sclerotherapy (EIS) using cyanoacrylate in 17 cases with gastric varices, including the cases treated with high concentration of cyanoacrylate (67 or 75% Histoacryl (HA)). In all 8 cases with hemorrhagic gastric varices, we succeeded in hemostasis with this procedure. And the dose of cyanoacrylate needed was 2.0-4.0 ml in one session of EIS. The series of additional sclerotherapy using cyanoacrylate, ethanol, or ethanolamine oleate was performed to reduce the size of gastric varices in 11 cases. The results were complete disappearance of varices in 4 cases, marked reduction in 9 cases, and no change in 4 cases. Especially of 7 cases using the highest concentration of cyanoacrylate (75%HA), no additional sclerotherapy was needed in 5 cases, and 3 cases reached complete disappearance with one injection of 75%HA. In this procedure, the dose of cyanoacrylate needed was 2.5-8.0 ml in one session of EIS. In 4 cases inflow of cyanoacrylate polymer into subclavian vein or portal vein was noted. But no serious complication occurred. In conclusion, our procedure is considered to be a useful, convenient and safe in the therapy of gastric varices.

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In order to investigate the hemostatic effects of oral side balloon used for endoscopic injection sclerotherapy and its relation to existence of penetrating veins, we studied 29 patients with esophageal varices due to portal hypertension using color Doppler-endoscopic ultrasonography (CD-EUS). Blood flow in intramural esophageal varices disappeared in 27.6% (a disappearance group), reduced in 34.5% (a reduction group), and did not change in 37.9% (a no-change group) after inflation of the balloon. Penetrating veins were not detected in the disappearance group, but detected in 72.2% of the reduction and no change groups. The flow in penetrating veins directed from intramural to extramural varices in 54% after the balloon inflation. There was a significant difference in the extramural esophageal blood flow scores (defined using CD-EUS) between the disappearance group and the other two groups. There were no correlations in the intramural esophageal blood flow scores, endoscopic variceal findings, Child-Pugh grades of liver function and the existence of other collateral veins among three groups. It suggested that hemostatic effect of the balloon on intramural esophageal blood flow depends on the existence of penetrating veins and the amount of extramural esophageal variceal flow.

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Since 1973 we have treated 152 patients with gastroesophageal varices. Those who died within a hospital stay and who developed hepatoma during the postoperative observation period were excluded from the present study. Postoperative varices greater than CbF₂ or RC (+) in endo-scopic findings were defined as recurrent varices. A cumulative rate of recurrence and hemorrhage in postoperative 5 years were 35% and 18%, respectively. Operative procedures were terminal esophago-proximal gastrectomy with splenectomy between 1973 and 1983 (group A), and esophageal transection using an automatic anasto-moser since 1984 (group B). A 5 year recurrence rate of varices in group B was significantly higher (42%) than that in group A. A hemorrhage rate was, however, not increased. Furthermore, since endoscopic variceal ligation in combination with endoscopic injection sclerotherapy has been introduced in our hospital in 1989, 5 year hemorrhage rate is kept at 0%. These findings suggest that early and aggressive treatment of recurrent varices are of prime importance for the prevention of postoperative variceal hemorrhage and the improvement of quality of life.

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