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PubMed1999

Endoscopic management of gastric varices using a detachable snare and simultaneous endoscopic sclerotherapy and O-ring ligation.

BACKGROUND: Cyanoacrylate injection is highly effective and is regarded as the treatment of choice in bleeding gastric varices in Europe, but intravenous injection of cyanoacrylate is not allowed in the USA and Japan because it may cause embolisms in other organs. Accordingly, we developed a new endoscopic combined treatment of endoscopic management of gastric varices using a detachable snare (EVLs) and simultaneous endoscopic sclerotherapy and O-ring ligation (EISL) (i.e. EVLs + EISL), and we prospectively evaluated its efficacy and safety. METHODS: Gastric varices were ligated with the loop of a detachable snare that opened to a diameter of 4 cm (EVLs). Then the residual varices around the ligated portion were sclerosed by ethanolamine oleate and the injected vessel was ligated using a pneumo-activated EVL device (EISL). The EVLs + EISL was performed in 35 patients: on an emergency basis in eight patients, on an elective basis in six patients and as primary prophylaxis in 21 patients. Liver function was classified as Child-Pugh class A in 12 patients, class B in 12 patients and class C in 11 patients. RESULTS: Endoscopic disappearance of gastric varices was obtained in 97.1% of the patients and they regressed in all patients. Haemostasis was achieved in all eight emergency cases. The 2-year cumulative non-recurrence rate was 85%, the 2-year cumulative non-bleeding rate was 92% and the 2-year cumulative survival was 80%. No patients died of bleeding from gastric varices. There were no serious short-term complications, such as haemorrhage, gastro-oesophageal perforation, ileus, or renal impairment. CONCLUSION: Combined EVLs + EISL appears to be a useful treatment for gastric varices due to its safety and good clinical outcome.

Endoscopy↗
PubMed2000

Mallory-Weiss syndrome with severe bleeding: treatment by endoscopic ligation.

There is no consensus as to the best treatment for Mallory-Weiss tears with severe bleeding. Endoscopic ligation is an inexpensive, readily available, and easily learned technique, in contrast to conventional thermocoagulation or hemoclipping. To evaluate the utility of endoscopic ligation, we performed this technique during emergency endoscopy to treat severe bleeding from Mallory-Weiss tears in four patients in our hospital with continuous active bleeding from Mallory-Weiss tears. The patients were all male with an average age of 40.5 years. Symptoms associated with increased intra-abdominal pressure, including retching and vomiting were reported by all patients. The bleeding points were aspirated and controlled by endoscopic ligation, and complete hemostasis was achieved in all cases. We conclude that endoscopic ligation is easy to perform and may provide an alternative treatment for severe bleeding from Mallory-Weiss tears.

Adult↗
PubMed2000

Outcome after ligation of infected false femoral aneurysms in intravenous drug abusers.

OBJECTIVES: to determine the outcome of a policy of ligation with observation of infected false femoral aneurysms (IFFA) in intravenous drug abusers (IVDA), particularly with respect to the issue of limb preservation. DESIGN: a retrospective study. MATERIALS AND METHODS: thirty-seven consecutive cases of IFFA in 34 patients accrued over nine years were studied by case note review and by clinical or telephone interview. RESULTS: in 34 cases of ligation of primary IFFA there were no amputations, with patients describing claudication only in follow-up. In three cases of second IFFA in the same limb, repeat ligation resulted in two viable limbs with claudication only, and one above-knee amputation. At the nine year follow-up, all patients were still drug-dependent and considered unsuitable for late revascularisation. There were three deaths and all were drug-related. CONCLUSIONS: in our experience, ligation of IFFA is effective, safe and simple, and is the most appropriate method of dealing with these challenging cases.

Adult↗
PubMed2002

Can interposition of a silicone implant after sapheno-femoral ligation prevent recurrent varicose veins?

OBJECTIVES: To investigate whether a silicone implant at the sapheno-femoral ligation site could prevent recurrent varicosities. MATERIALS AND METHODS: Two non-randomised groups of patients were studied prospectively. In group A 173 patients and 212 limbs had sapheno-femoral ligation, while 172 patients and 210 limbs additionally had a piece (2x3cm) of silicone sheet sutured to the saphenous stump to cover the anterior half of the common femoral vein. The implant was fixed in apposition to the deep vein by carefully closing the cribriform fascia. Colour duplex scanning was performed after 2 and 12 months. RESULTS: In the no implant group neovascularisation was observed in 35 (17%) after 12 months, but only in 13 (6%) limbs treated with a silicone implant (p<0.05). CONCLUSIONS: Interposition of a partition of silicone implant seems to lower the incidence of neovascularisation one year after saphenofemoral ligation. This technique may constitute an efficient method to prevent recurrence at the correctly ligated saphenous stump.

Adult↗
PubMed2002

Ursodeoxycholic acid aggravates bile infarcts in bile duct-ligated and Mdr2 knockout mice via disruption of cholangioles.

BACKGROUND & AIMS: The effects of ursodeoxycholic acid (UDCA) in biliary obstruction are unclear. We aimed to determine the effects of UDCA in bile duct-ligated and in Mdr2 knockout (Mdr2(-/-)) mice with biliary strictures. METHODS: Mice fed UDCA (0.5% wt/wt) or a control diet were subjected to common bile duct ligation (CBDL), selective bile duct ligation (SBDL), or sham operation. UDCA was also fed to 2-month-old Mdr2(-/-) mice. Serum biochemistry, liver histology, and mortality rates were investigated. The biliary tract was studied by plastination, India ink injection, and electron microscopy. The effects of UDCA on biliary pressure were determined by cholangiomanometry. RESULTS: UDCA feeding in CBDL mice increased biliary pressure, with subsequent rupture of cholangioles and aggravation of hepatocyte necroses, resulting in significantly increased mortality. UDCA feeding in SBDL mice aggravated liver injury exclusively in the ligated lobe. Mdr2(-/-) mice developed liver lesions resembling sclerosing cholangitis characterized by biliary strictures and dilatations. UDCA induced bile infarcts in these animals. CONCLUSIONS: UDCA aggravates bile infarcts and hepatocyte necroses in mice with biliary obstruction via disruption of cholangioles as a result of increased biliary pressure caused by its choleretic action.

ATP Binding Cassette Transporter, Subfamily B↗
PubMed2002

Up-regulation of components of the renin-angiotensin system in the bile duct-ligated rat liver.

BACKGROUND & AIMS: Angiotensin II (ANG II) has profibrotic actions in the heart and kidney, whereas blockade of the renin angiotensin system (RAS) attenuates injury. This study examines whether the RAS is present in the liver and examines its regulation in the bile duct-ligation model of hepatic fibrogenesis. METHODS: Sham-operated and bile duct-ligated (BDL) Sprague-Dawley rats were studied. Gene and protein expression of hepatic renin, angiotensinogen, angiotensin-converting enzyme (ACE), and the angiotensin receptors AT1 and AT2 were assessed using real-time reverse-transcription polymerase chain reaction, in vitro autoradiography, and immunohistochemistry. RESULTS: Angiotensinogen and renin messenger RNA were detected in sham liver but were not increased following BDL. Angiotensinogen protein was widely distributed in hepatocytes in both normal and injured livers, but in BDL livers, it was also expressed within areas of active fibrogenesis. Both ACE and AT1 receptor genes were up-regulated following BDL. The low level of ACE activity in sham animals was significantly increased in areas of active fibrogenesis in BDL livers. The AT1 receptor was present in both normal and diseased liver parenchyma, with increased AT1 receptor binding seen in fibrotic areas in the diseased liver. The AT2 receptor gene was not detected in normal or diseased liver. CONCLUSIONS: Key elements of the RAS are present in normal liver tissue, and there is major up-regulation of the system in the bile duct-ligated liver. These findings are in keeping with recent experimental studies that have demonstrated antifibrotic effects of RAS blockade in the bile duct-ligated liver.

Animals↗
PubMed2001

A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices.

Gastric variceal bleeding is a catastrophic event. Both cyanoacrylate injection and banding ligation have been proven to be effective in the management of bleeding gastric varices. This study was performed to compare the efficacy and complications of both the modalities. Cirrhotic patients with a history of gastric variceal bleeding were randomized to 2 groups. The group receiving endoscopic obturation (group A) comprised 31 patients and the group receiving band ligation (group B) comprised 29 patients. Butyl cyanoacrylate and pneumatic-driven ligator were applied, respectively. Treatment was repeated regularly until obliteration of gastric varices. Active bleeding occurred in 15 patients in group A and 11 patients in group B. Initial hemostatic rate (defined as no bleeding for 72 hours after treatment) was 87% in group A and 45% in group B (P = .03). The sessions required to achieve variceal obliteration and obliteration rates were similar in both the groups. However, rebleeding rates were significantly higher in group B (54%) than group A (31%) (P = .0005). Treatment-induced ulcer bleeding occurred in 2 patients (7%) in group A and 8 patients (28%) in group B (P = .03). The amount of blood transfusions required were also higher in group B than group A (4.2 +/- 1.3 vs. 2.6 +/- 0.9 units, respectively) (P < .01). Nine patients of group A and 14 patients of group B died (P = .05). In conclusion, endoscopic obturation using cyanoacrylate proved more effective and safer than band ligation in the management of bleeding gastric varices.

Adult↗
PubMed2001

Chronology of histological changes after band ligation of esophageal varices in humans.

BACKGROUND AND STUDY AIMS: While the histological effects of endoscopic sclerotherapy in humans have been extensively described, the effects of endoscopic ligation have been reported in only two cases. The purpose of this study was to reconstruct the chronological sequence of histological changes after ligation of esophageal varices. PATIENTS AND METHODS: Autopsy specimens from six patients who received ligation of varices from nine hours to 22 months ante-mortem were evaluated for gross and microscopic changes. RESULTS: Early after ligation, the appearance was that of a polyp with its base compressed by the band. Variceal thrombosis was seen on day 2. Varying degrees of ischemic necrosis of the polyp were present on days 0-5. If the bands did not remain in situ for two days (premature loss), necrosis of the polyp and dilated variceal vessels were seen. On day 22, superficial ulcers were observed. After complete healing, fibrosis was seen in the submucosa. CONCLUSIONS: The changes seen in the present study are similar to those described in animals. The delay in ulcer healing, compared with the gross changes reported during follow-up endoscopic examinations, may be related to the severity of the underlying illness and the compromised immune status of patients in the present series.

Adult↗
PubMed2003

Clinical evaluation of combined endoscopic variceal ligation and sclerotherapy of gastric varices in liver cirrhosis.

BACKGROUND AND STUDY AIMS: Endoscopic injection sclerotherapy (EIS) using cyanoacrylate and balloon-occluded retrograde transvenous obliteration (B-RTO) are the main procedures used to treat gastric varices. However, neither technique is free of problems. EIS for gastric varices may cause embolism in other organs; B-RTO requires a gastrorenal shunt and may aggravate esophageal varices. We have developed a combined form of endoscopic therapy involving band ligation and sclerotherapy which is an effective and safe procedure for treating gastric varices. PATIENTS AND METHODS: Fifty-six patients with gastric varices and liver cirrhosis were treated at Almeida Memorial Hospital from June 1997 to May 2002 using the combined procedure. Each gastric varix was tightly ligated with O-rings, and 1 % polidocanol was injected into the submucosa around the ligated varix. If necessary, additional sclerotherapy was carried out after the initial treatment. RESULTS: The rate of hemostasis for variceal bleeding was 100 %, and no critical complications were noted. Complete disappearance of the gastric varices was observed endoscopically in all cases. Computed tomography showed that collateral vessels outside the gastric wall were not occluded by the treatment. Endoscopic follow-up examinations were carried out, and gastric varices recurred in seven patients (12.5 %). Only two of the patients (3.6 %) had a small amount of oozing bleeding. Additional endoscopic variceal ligation (EVL) and/or EIS were performed in these seven cases, and none of the patients died as a result of a bleeding gastric varix. CONCLUSIONS: The combined procedure was easily performed immediately after endoscopic examination, and required no special apparatus. It was found to be a safe and effective method of treating gastric varices.

Adult↗
PubMed2006

Submucosal plexus of dilatated gut disappears after ligation in chicken embryos: preliminary results.

INTRODUCTION: Dilatation and impaired function of the gut is a condition often seen in newborns with bowel obstruction caused by intestinal atresia. In a previous experimental study in chicken embryos, we established a model to study ultrastructural changes during the development of the enteric nervous system after small bowel ligation. The aim of this study is to investigate the changes of the enteric nervous system (ENS) after gut ligation. METHODS: 56 chicken embryos were investigated. In the operation group fertilized eggs and the allantoic membrane were opened and the small bowel was ligated on embryonal day (ED) 11. The controls were sham-operated. The gut was prepared and harvested for analysis on ED 11, 12, 13, 14, 15, 16, 17 and 18. Silver staining or staining of the specimens for acetylcholinesterase (AchE) was performed. RESULTS: A marked dilatation of the bowel was observed three days after operation (ED 14). The submucosal (PSM) and myenteric plexus (PM) appeared normal at this time, however silver staining showed rarification of the neuronal axonal network between the myenteric and submucosal plexus. Later, on ED 16 an additional rarification of the submucosal plexus was also seen in the operation group using AchE staining, compared to the controls. DISCUSSION: The data suggest that distension of the gut hinders normal development of the ENS in the gut ligation model of chicken embryos. The changes were observed sequentially, starting with rarification of the axonal network between the PM and PSM. Future studies will be required to show whether the changes of the ENS are reversible.

Animals↗
PubMed1997

Endoscopic variceal ligation using a clipping apparatus in children with portal hypertension.

BACKGROUND AND STUDY AIMS: Endoscopic variceal sclerotherapy (EVS) is a procedure frequently used to control bleeding from esophageal varices in adults. The use of EVS has been restricted in children due to the associated risks. The present paper describes the safety and efficacy of a new apparatus for endoscopic variceal ligation with clipping (EVLC). PATIENTS AND METHODS: Endoscopic variceal ligation using a clipping apparatus (HX-3 L, Olympus, Tokyo, Japan), was carried out in 12 children with portal hypertension (four with extrahepatic portal vein obstruction and eight with congenital biliary atresia; four boys and eight girls, age range 2-14 years). A total of 417 variceal clipping procedures were carried out in 56 separate EVLC sessions; 118 esophageal varices and 65 gastric fundic varices were ligated using 417 clips. Initially, the EVLC sessions were repeated at approximately monthly intervals until the varices were eradicated, but the interval was gradually extended to twice a year or once a year. RESULTS: Varices were successfully ligated at the first attempt in 414 (99.3%) of the 417 clipping procedures. The esophageal varices were initially eradicated in all patients. The follow-up period ranged from nine to 48 months, and complete variceal eradication or reduction of the grade of the varices was obtained in 11 of the 12 patients after initial eradication during this period. CONCLUSIONS: These data indicate that EVLC offers advantages in the treatment of patients with esophageal varices combined with gastric fundic varices.

Adolescent↗
PubMed2001

The effects of endoscopic variceal ligation and propranolol on portal hypertensive gastropathy: a prospective, controlled trial.

BACKGROUND: Endoscopic treatment of esophageal varices may accentuate portal hypertensive gastropathy. The impact of the combination of band ligation and propranolol on this condition remains unknown. METHODS: Patients with history of variceal bleeding were randomized to receive band ligation alone (control group, 40 patients) or a combination of band ligation and propranolol (propranolol group, 37 patients). Serial endoscopic evaluation of gastropathy was performed. Gastropathy was classified into 3 grades and scored as 0, 1, or 2. RESULTS: Before endoscopic treatment, 17% of the control group and 22% of the propranolol group had gastropathy (p = 0.78). The occurrence of gastropathy after endoscopic treatment was significantly higher in the control group than in the propranolol group (p = 0.002). Serial endoscopic follow-up revealed that the mean gastropathy score was significantly higher in the control group than in the propranolol group (p < 0.05). In patients with gastropathy the gastropathy score reached a peak at 6 months after endoscopic treatment in both the control and propranolol groups (85% vs. 48%, respectively). After variceal obliteration, accentuation of gastropathy was significant in the control group (p < 0.01) but not in the propranolol group. Gastropathy was less likely to develop in patients who developed gastric varices. Esophageal variceal recurrence was not related to the development of gastropathy after variceal obliteration with banding. Only one patient in the control group bled from gastropathy. CONCLUSION: Band ligation of esophageal varices may accentuate gastropathy, which in this study was partly relieved by propranolol.

Adult↗
PubMed2001

Thromboembolus from a ligated left atrial appendage.

The left atrial appendage of patients with mitral valve disease is commonly a source of thromboembolus and is often ligated during mitral valve surgery to diminish this risk. However, ligation is often incomplete. We describe a patient with a stroke whose only source of embolus was an incompletely ligated left atrial appendage. Attempts to exclude the left atrial appendage from the arterial circulation by suture ligation may not decrease the risk of thromboemboli and instead may increase such risk.

Aged↗
PubMed2003

The effect of ligation method on friction in sliding mechanics.

During orthodontic tooth movement with the preadjusted edgewise system, friction generated at the bracket/archwire interface tends to impede the desired movement. The method of ligation is an important contributor to this frictional force. This in vitro study investigated the effect of ligation method on friction and evaluated the efficacy of the new slick elastomeric modules from TP Orthodontics (La Porte, Ind), which are claimed to reduce friction at the module/wire interface. Slick modules were compared with regular nonslick modules, stainless steel ligatures, and the SPEED self-ligating bracket system (Strite Industries, Cambridge, Ontario, Canada). The effect of using slick modules with metal-reinforced ceramic (Clarity, 3M Unitek, Monrovia, Calif) and miniature brackets (Minitwin, 3M Unitek) was also examined. Results showed that, when considering tooth movement along a 0.019 x 0.025-in stainless steel archwire, saliva-lubricated slick modules can reduce static friction at the module/archwire interface by up to 60%, regardless of the bracket system. The SPEED brackets produced the lowest friction compared with the 3 other tested bracket systems when regular modules were used. The use of slick modules, however, with all of the ligated bracket types tested significantly reduced friction to below the values recorded in the SPEED groups. Loosely tied stainless steel ligatures were found to generate the least friction.

Analysis of Variance↗
PubMed2001

Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein.

OBJECTIVE: This study was done to determine the long-term incidence of refluxing epifascial-to-deep vein reconnections in the area of the former saphenofemoral junction after ligation of the true junction, along with all proximal tributaries, and resection of the greater saphenous vein. PATIENTS AND METHODS: A total of 125 limbs in 77 patients, representing 66% of 117 survivors among 602 patients who underwent operation between 1960 and 1967, were evaluated clinically and with duplex sonography for possible superficial-to-deep vein reconnections and clinical recurrence of thigh varicosities at a mean follow-up of 34 years. RESULTS: Clinical examination suggested saphenofemoral recurrence in 59 limbs (47%). In 11 instances these were actually varices associated with isolated superficial system reflux or reflux originating from a distally located perforating vein. Color-coded duplex ultrasonography demonstrated saphenofemoral reflux in 75 limbs (60%), versus the 48 identified on clinical examination (P <.001), and documented that the junction ligation had not been performed incorrectly by absence of the terminal valve or any patent proximal saphenous remnant. The reflux originated at the site of the ligated saphenofemoral junction in 53 limbs (71%) and from a nearby circumjunctional deep vein in the other 22 (29%). Of the real junctional recurrences, 22 appeared as a tangled cluster, and 31 involved a single-lumen varix. Only 27 recurrences were sufficiently symptomatic to warrant consideration of additional treatment; 25 of these were clinically evident, single-lumen, true junctional recurrences. CONCLUSIONS: This 34-year clinical follow-up study shows a 60% incidence of junctional and circumjunctional reconnections after ligation of the true saphenofemoral junction and its related tributaries. Color-coded duplex sonography is a necessary concomitant to clinical examination, detecting more recurrences and defining the pathologic anatomy to direct clinically indicated additional treatments.

Aged↗
PubMed1998

Incidence and pattern of varicocele recurrence after laparoscopic ligation of the internal spermatic vein with preservation of the testicular artery.

OBJECTIVES: To determine the incidence and pattern of recurrence of varicocele after laparoscopic internal spermatic vein ligation with testicular artery preservation. METHODS: In a prospective study, 16 patients who underwent 20 laparoscopic varix ligation were evaluated postoperatively for recurrence by clinical physical examination and percutaneous spermatic venography. RESULTS: No significant complications were encountered with the surgical or radiological procedure. Clinical recurrence was detected by physical examination in 20% of cases, while percutaneous spermatic venography detected recurrence in 45% of cases. The sensitivity and specificity of clinical physical examination for detecting varicocele recurrence was 33% and 90.9%, respectively with an accuracy rate of 65%. Recurrences were through parallel collaterals or medial transverse collaterals in 88.8% and 11.2%, respectively. Parallel collaterals joined the spermatic vein in mid or high retroperitoneum in seven patients while it joined the renal vein in one patient. There were no low retroperitoneal parallel collaterals. CONCLUSIONS: Laparoscopic ligation of internal spermatic vein with preservation of testicular artery is a procedure that is associated with low morbidity and quick recovery. It is able to achieve its surgical objective in only 55% of cases, however. Such information should be taken into consideration during patient counselling when selecting the operative technique of choice for varicocele ligation.

Adult↗
PubMed1998

Intestinal handling of mercury in the rat: implications of intestinal secretion of inorganic mercury following biliary ligation or cannulation.

Three sets of experiments were carried out to determine if there is an intestinal secretory component in the fecal excretion of administered inorganic mercury. In the first set of experiments the disposition of a nontoxic 0.5-micromol/kg intravenous dose of inorganic mercury was evaluated in control rats and rats whose bile duct had been ligated. Data collected 24 h after the administration of mercuric chloride indicated that some inorganic mercury had moved from the blood across the epithelium into the lumen of the stomach, small intestine, and large intestine. This secretory movement of mercury was most prominent in the small intestine. Interestingly, the renal uptake and accumulation of mercury were diminished significantly in the rats whose bile duct had been ligated. A time-course experiment showed that the maximum amount of secretory movement of mercury into the lumen of the small intestine occurred during the initial 12 h after the injection of mercuric chloride. By the end of 24 h after the injection of mercuric chloride, much of the inorganic mercury secreted in the small intestine appeared to have moved down into the large intestine. In a third experiment, the disposition of mercury was evaluated in control rats and rats who had their bile duct cannulated. The rationale for this third experiment was to study the disposition of mercury under conditions where obstruction of biliary outflow from the liver would not be as much of an issue as with ligation of the bile duct. Evidence for movement of mercury into the lumen of the intestines was also obtained from the rats whose bile duct had been ligated. Eighteen hours after the injection of mercuric chloride the amount of mercury in the luminal compartment of the small intestine was not statistically different between the two groups of rats. Approximately 1.7-2.1% of the administered dose was present in the luminal contents of the small intestine. Decreased renal uptake of mercury was also detected in the rats whose bile duct had been cannulated. The findings from the present study show that when bile flow is obstructed or diverted, clear evidence for secretory movement of mercury into the lumen of the gastrointestinal (GI) tract can be demonstrated. These findings also indicate that the secretory movement of mercury into the lumen of the GI tract is a mechanism that contributes significantly to the pool of mercury that is excreted in the feces.

Animals↗
PubMedDate not supplied

Chronic portal hypertension in the rat by triple-portal stenosing ligation.

A surgical technique based on the development of a triple stenosing ligation is used to worsen the complications inherent to the prehepatic chronic portal hypertension. The results have been compared with those obtained in rats with a single-portal stenosing ligation. An increase (p <.05) in the body, liver, spleen, and kidney weights as well as a decrease (p <.001) in the testes weight to body weight ratio were produced in both groups of animals. In addition, the variability in the obtained weights, particularly in the liver weight, stands out. The incidence of portosystemic and portohepatic collateral circulation and of the mesenteric venous vasculopathy increases in the animals with triple-portal stenosing ligation. The new proposed technique is a valid alternative to the classic one that used single portal stenosing ligation.

Animals↗