Endoscopic injection sclerotherapy was given to 155 patients with esophageal varices mainly related to non-alcoholic liver cirrhosis. The formation of a superficial ulcer in the lower esophagus was achieved in 141 (91.0%) of the 155 patients, with an average of 4.1 sessions of endoscopic injection sclerotherapy during an average time of 4.9 weeks. The average volume of 5% ethanolamine oleate sclerosant used was 24.8, 19.2, 12.3 and 6.5 ml for the initial to fourth sessions of endoscopic injection sclerotherapy, respectively. For 14 patients, a sufficient number of sessions of endoscopic injection sclerotherapy could not be given: 10 early deaths (5 hepatoma, 4 liver failure and 1 gastric bleeding), and 4 refused further sessions. When the esophageal mucosa had been eliminated and a superficial ulcer had formed, episodes of recurrent bleeding or recurrence of esophageal varices were nil over a median follow-up of 14.6 months, with a range of 1 to 27 months. In seven patients, bleeding recurred before elimination of the mucosa could be achieved, but these bleeding episodes were well controlled with an additional session of endoscopic injection sclerotherapy. At the time of analysis, there were 36 deaths (20 hepatoma, 14 liver failure and 2 gastric bleeding) among these 155 patients. Thus, the mean follow-up was 16.3 months (range: 7 to 27 months) in the 119 survivors, with no recurrence of the varices. We propose that removal of the esophageal mucosa may well be the endpoint of repeated endoscopic injection sclerotherapy in the management of patients on injection sclerotherapy.

Endoscopy↗

PubMedDate not supplied

Three-dimensional view of the vascular structure of the lower esophagus in clinical portal hypertension.

The venous anatomy of the lower esophagus and upper stomach was studied in nine patients with portal hypertension and in five without, following infusion of a silicon rubber compound into vessels of the excised organs within whole tissues made transparent with methyl salicylate. Four venous channels were identified in normal tissues: intraepithelial, subepithelial superficial, deep submucosal and adventitial veins. In portal hypertensive patients, giant esophageal varices formed 2 to 3 cm above the esophagogastric junction fused with numerous superficial and deep submucosal veins. Gastric varices were present in the submucosa where the left gastric venous branch penetrated the gastric wall 2 cm below the esophagogastric junction. The lower esophageal varices were classified into two types of vascular structure: palisading type in five and bar type in four. The palisading type had dilated intraepithelial channels and numerous small superficial collateral veins extending in a longitudinal arrangement. The bar type had triply dilated subepithelial superficial veins and deep submucosal veins which eroded the epithelium, and the gastric varices were present in the latter type. Our study provides evidence of the three-dimensional vascular structure of the lower esophageal varices without the necessity for tissue dissection.

Aged↗

PubMedDate not supplied

Optimal dose of hepatobiliary contrast agent for MR cholangiography: experimental study in rats.

The purpose of this study is to clarify the optimal dose of gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) for cholangiography in conventional T1-weighted imaging. We divided 30 rats into three dose groups (3, 10, and 30 micromol/kg). For the in vitro study, we collected bile and measured the concentration of gadolinium in bile after Gd-EOB-DTPA injection. T1-weighted images of the collected bile were obtained for measurement of signal intensity. For the in vivo study, we obtained T1-weighted images before and after injection and evaluated bile duct/liver contrast by the signal intensity ratio and visual assessment of the images. The gadolinium concentration had an early peak; however, the signal intensity of the bile had a later peak because of the high gadolinium concentration during the early phase, which induced a T2-shortening effect. Optimal bile duct/liver contrast was obtained in the 10-micromol/kg groups at all time points. We conclude that the optimal dose of Gd-EOB-DTPA for MR cholangiography in rats is 10 micromol/kg, one-third of the dose used in liver imaging.

Animals↗

PubMedDate not supplied

Endoscopic injection sclerotherapy for esophageal varices in the elderly.

A group of 1127 patients who underwent sclerotherapy for esophageal varices were compared for outcome in terms of age: over and under age 70 years. Esophageal varices were completely eradicated in 81 of 110 patients > 70 years (73.6%) and in 791 of 1017 patients < 70 years (77.8%). Gastrointestinal bleeding after sclerotherapy occurred in 9 patients > 70 years (8.2%) and in 84 of those < 70 years (8.3%). Complications occurred in 16 patients > 70 years (14.5%) and in 141 < 70 years (13.9%). Liver failure and hepatoma accounted for more than 80% of the causes of death in both groups (80.3% versus 83.8%). The 5-year cumulative survival rates in patients with bleeding esophageal varices (bleeders) without hepatoma were 21.8% in those > 70 years and 58.7% in those < 70 years (p < 0.01), the relative survivals being 25.3% versus 66.6%. Patients without hepatoma and treated by prophylactic sclerotherapy accounted for 66.2% of patients > 70 years and 61.7% of those < 70 years, the relative survivals being 75.9% versus 71.9%. As analyzed by the Cox proportional-hazards model, age > 70 years was a prognostic factor in the bleeders (p < 0.01) but not in the nonbleeders. We recommend that elderly patients with esophageal varices be given prophylactic sclerotherapy, as the outcome for these patients is poor once bleeding has occurred.

Aged↗

PubMedDate not supplied

Laparoscopic oversewing of a bleeding Mallory-Weiss tear under endoscopic guidance.

Continuous bleeding from a Mallory-Weiss tear required laparoscopic surgery to halt the bleeding. The oversewing of the laceration at the esophagogastric junction was readily performed under video control with endoscopic guidance and the bleeding ceased. To stop bleeding from such a tear, we prefer to use this modern approach.

Hemostasis, Endoscopic↗

PubMedDate not supplied

A rapid and simple technique for insertion of a T-tube into the minimally incised common bile duct at laparoscopic surgery.

We fabricated a stainless-steel over-tube for rapid and simple insertion of a T-tube following common bile duct exploration during laparoscopic surgery. With this over-tube, operating time is greatly shortened because minimal incision and only two sutures are needed to prevent bile leakage.

Cholecystectomy, Laparoscopic↗

PubMedDate not supplied

A prospective randomized trial comparing pneumoperitoneum and U-shaped retractor elevation for laparoscopic cholecystectomy.

Between April and August 1991, 83 Japanese patients with symptomatic gallstones underwent laparoscopic cholecystectomy in our clinics. A prospective randomized trial was carried out to examine the safety, efficacy, and complications of the two techniques, pneumoperitoneum vs an elevating method using a U-shaped retractor. Forty-two patients were randomly allocated to the pneumoperitoneum (P) group and 41 to the U-shaped retractor (U) group. These two groups were well matched with respect to age, sex, etiology, and the severity of the chronic cholecystitis. Laparoscopic resection was successful for 88.1% (37/42) in the P group and 100% (41/41) in the U group. In patients with a severe fibrotic gallbladder, the rate of success was significantly higher (P < 0.05) in the U group (100%, 6/6) than in the P group (11.8%, 1/6). In the moderately inflamed group, the operation time (mean +/- SD) was significantly (P < 0.01) less in the U group (58.7 +/- 22.7) than in the P group (87.3 +/- 18.3). With the U-shaped retractor the usual surgical instruments can be used, and a rapid and safer laparoscopic cholecystectomy can be carried out. We prefer this approach to a pneumoperitoneum for patients with an inflamed gallbladder as hospital stay and pain are minimal.

Cholecystectomy, Laparoscopic↗