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Background: Laparoscopic gastric devascularization(Lap GDS) and splenectomy (SPL) for gastric varices is technically challenging because of highly developed collateral vessels and bleeding tendency. We investigated the feasibility of customization of Lap GDS and SPL based on CT vascular anatomy., Methods: We analyzed 61 cirrhotic patients with gastric varices who underwent Lap GDS and SPL between 2006 and 2014. Lap GDS was customized according to the afferent feeding veins (left gastric vein (LGV) and/or posterior gastric vein (PGV)/short gastric vein (SGV)) and efferent drainage veins (gastrorenal shunt and/or gastrophrenic shunt, or numerous retroperitoneal veins) based on CT imaging., Results: Thirty-four patients with efferent drainage veins suitable for balloon-occluded retrograde transvenous obliteration (B-RTO) underwent B-RTO instead of surgical GDS, with subsequent Lap SPL. Among 27 patients with gastric varices unsuitable for B-RTO, 15 patients with PGV/SGV underwent Lap GDS of the greater curvature and SPL, and 12 patients with LGV or LGV/PGV/SGV underwent Lap GDS of the greater and lesser curvature and SPL. The mean operation time was 294 min and mean blood loss was 198 g. There was no mortality or severe morbidity. Gastric varices were eradicated in all 61 patients, with no bleeding or recurrence during a mean follow-up of 55.9 months. The cumulative 3-, 5-, and 7-year survival rates were 92, 82, and 64%, respectively., Conclusions: Lap GDS and SPL customized based on CT vascular anatomy is a safe and effective procedure for treating gastric varices.

Introduction: Laparoscopic devascularization of the upper stomach and splenectomy (Dev+Sp), is technically difficult in patients with portal hypertension because of enlarged collateral vessels and spleen. This report presents the efficacy and safety of hand-assisted laparoscopic (HALS) Dev+Sp., Methods: Ten patients underwent HALS Dev+Sp as a treatment for esophagogastric varices between 2005 and 2012 (HALS group). A vessel-sealing system was used for devascularization of vessels. An autosuture device was applied to dissect the splenic hilum and the left gastric and enlarged short gastric vessels. The operative and postoperative data were compared between patients who previously underwent laparoscopic Dev+Sp (LAP group, n = 9) and conventional Dev+Sp (OP group, n = 10) between 2001 and 2008., Results: The mean operative time was 328, 336, and 245 min (P < 0.05) and the mean blood loss was 1786, 981, and 250 mL (P < 0.05) in the OP, LAP, and HALS groups, respectively. Laparoscopic surgery was converted to HALS in one patient and to open surgery in three patients. There were no conversions in the HALS group. There was no significant difference in the cumulative recurrence rate and bleeding rate in the groups., Conclusion: HALS Dev+Sp is a feasible and effective surgery in patients with portal hypertension., (© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

Purposes: The purpose of our study was to evaluate the efficacy of balloon-occluded retrograde transvenous obliteration (B-RTO) in patients after living donor liver transplantation (LDLT)., Methods: Five patients with gastric varices (GVx) and/or liver dysfunction who were treated with B-RTO from January 2001 to December 2007 were enrolled in this study (GVx, n = 2; liver dysfunction, n = 1; both, n = 2). The eradication rate of the GVx, portal vein hemodynamics and improvement of liver function were evaluated., Results: B-RTO was performed successfully, and the GVx disappeared or decreased markedly in all patients. Recurrence of GVx was not observed during the follow-up. Significantly increased portal vein inflow and improved liver function were observed in all patients., Conclusions: B-RTO may be an effective treatment for patients after LDLT to prevent bleeding from GVx or to modulate portal vein inflow that is reduced by prolonged large portosystemic shunts.

Background: Transient esophageal ulceration is a common finding after sclerotherapy of varices. These ulcers sometimes cause pain, ulcer bleeding, and stricture formation. Gastroesophageal reflux (GER) after Endoscopic injection sclerotherapy (EIS) is a known cause of worsening ulcer formation. Therefore, an efficient drug for GER is desirable to improve the quality of life of patients with esophageal varices., Methods: We randomized 18 Japanese cirrhotic patients who had risky esophageal varices. The patients were randomly allocated into two groups, and during EIS sessions, one group was administered proton pump inhibitor(PPI) (Rabeprazole 20 mg a person once a day), while the other received histamine H2 receptor antagonist (H2-blocker) (famotidine 20 mg a person, twice a day). Gastroesophageal reflux was monitored by a 24-h pH-monitoring catheter introduced into the distal esophagus. Ulcer formation was evaluated using an endoscopic examination. The subjective and objective symptoms were also compared between the two groups., Results: All patients in the H2-blocker group showed an increased percentage of time with pH < 4.0 after EIS sessions, but no patients in the PPI group showed an increased such symptoms. The H2-blocker group also experienced a significantly higher number of days of heartburn and dysphasia than did the PPI group (p = 0.017, p = 0.042). The rate of ulcer improvement was found to be faster in Rabeprazole group than in H2 blocker group (p = 0.008)., Conclusion: These results suggest that Rabeprazole treatment prevents EIS-associated gastroesophageal reflux and promotes ulcer healing. Rabeprazole also improve the subjective symptoms following EIS.

A 74-year-old noncirrhotic woman presented with abdominal distension and pain in the right hypochondrium. Contrast-enhanced computed tomography (CT) demonstrated multiple large simple liver cysts occupying the right lobe of the liver, the largest of which was 19 cm in diameter. Gastric varices were enhanced in the fundus of the stomach. The patient underwent surgery to deroof the hepatic cysts with ablation using argon beam coagulation. Esophagogastroduodenoscopy (EGD) showed that the portal hypertensive gastropathy was ameliorated after the operation; however, the fundal varices were only slightly decreased. After the operation, we observed that the hepatic vein waveform gradually changed from a gently curved pattern to a normal triphasic pattern. We treated the fundal varices with balloon-occluded retrograde transvenous obliteration 3 months after the initial operation. We describe our successful treatment of this rare case and discuss the utility of hepatic vein waveform analysis in the study of portal hypertension.

Background and Aim: Balloon-occluded retrograde transvenous obliteration (B-RTO) is a new alternative treatment for gastric varices (GVx), but the long-term efficacy is not known. We investigated the long-term effects of B-RTO on rebleeding, prevention of first bleeding, mortality and occurrence of risky esophageal varices (EVx)., Methods: B-RTO was performed in 68 cirrhotic patients with GVx. Twenty patients had recent bleeding, transiently treated by endoscopic Histoacryl injection or balloon tamponade. Forty-eight patients had varices likely to bleed, but no bleeding. After B-RTO, the recurrent bleeding, occurrence of EVx and mortality over the long-term were evaluated., Results: B-RTO was successfully performed in 63 of 68 patients (92.6%). Varices eradication was confirmed by endoscopy in 61 of 63 patients (96.6%). During follow up, GVx bleeding occurred in two patients (3.2%). The 8-year cumulative rebleeding rates of patients with bleeding and risky GVx were 14% and 0%, respectively. Risky EVx occurred in 10 patients (17%) and the cumulative occurrence rate was 22% in 8 years. The cumulative occurrence rate of risky EVx was higher in GVx with EVx (GOV2-GVx) compared to GVx without EVx (IGV1, P < 0.05). No ectopic variceal bleeding occurred. No patients died from variceal bleeding. Hepatocellular carcinoma was the only significant prognostic factor (P < 0.05)., Conclusion: B-RTO is beneficial over the long-term, despite worsening EVx in some patients, because of excellent treatment efficacy and improved mortality. We believe that B-RTO can become a first-choice radical treatment following hemostasis for gastric variceal bleeding and prophylactic treatment for risky GVx.

Background and Aims: Oesophageal varices are an important complication in primary biliary cirrhosis (PBC). However, there have yet to be any studies made on treatment of oesophageal varices in PBC. We therefore studied the efficacy and related complications of endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) as an initial treatment in primary biliary cirrhotic patients., Methods: From December 1985 to March 1999, 29 biliary cirrhotic Japanese patients with portal hypertension and oesophageal varices were treated in our clinics. Eleven patients were treated with EVL and EIS, and 18 patients underwent EIS only. The liver function, renal function and respiratory function were studied before and after endoscopic treatment and any complications were also examined., Results: In stages III and IV, significant differences were observed in the serum levels for total bilirubin and gamma-glutamic pyruvic transaminase only in the EIS group. Significant differences were observed in the rate of appearance of pyrexia, retrosternal pain and pleural effusion between the EIS and EVL groups., Conclusion: EVL significantly reduced the adverse effects associated with EIS at the initial session in primary biliary cirrhotic patients.

A Japanese woman, who had undergone a left gastric venous caval shunt operation for esophageal varices 17 years earlier, was admitted to our hospital because of bleeding from giant gastric varices. An angiographic examination revealed a stealing of the portal blood flow to the inferior vena cava through both a dilated right gastroepiploic vein and a right gastric vein via the left gastric venous caval shunt. The gastric varices disappeared after obliterating both the feeding and drainage vessels by means of intervention radiology. We thus, consider the occlusion of both the afferent and efferent vessels to be an effective treatment for gastric varices.

This report describes a 38-year-old man with massive gastrointestinal bleeding from jejunal varices. He had been previously diagnosed to have idiopathic portal hypertension and esophageal varices, and had undergone an esophageal transection 8 years earlier. The pre-operative diagnosis was a suspected hemorrhage from the small intestine as visualized by 99mTc-HSAD scintigraphy (technetium 99m-labeled human serum albumin D-type) and was not considered to be repeated massive lower GI tract bleeding. An exploratory laparotomy was performed, and intra-operative endoscopy revealed active bleeding from the jejunal varices. A partial resection of the small intestine resulted in a complete resolution of the bleeding. A review of the literature thereafter disclosed twelve previously reported cases of jejunal variceal bleeding.

Background/aims: The aim of this prospective randomized study is to investigate the safety, efficacy, complications and recurrence of varices after repeated endoscopic injection sclerotherapy (EIS), and combined therapy of endoscopic variceal ligation (EVL) and repeated EIS, for the treatment of esophageal varices., Material and Methods: Sixty-one consecutively treated cirrhotic patients were examined. Thirty patients were placed randomly in the EIS group and the other 31 in the EVL+EIS group. For the EIS group, EIS was repeated at weekly intervals using 5% ethanol- amine oleate (EO) until all the varices had been eradicated. In the EVL+EIS group, EVL was done at the initial session, then EIS was repeated at weekly intervals from one week after EVL., Results: There was no significant difference between the EIS and EVL+EIS groups with regard to the rate of eradication (80.0% vs 74.2%), the total number of treatment (4.1 +/- 0.8 sessions of EIS vs EVL and 3.0 +/- 0.5 sessions of EIS) and hospitalization time (4.9 +/- 1.6 vs 4.4 +/- 1.0 weeks). The total volume of EO used for the EVL+EIS group was significantly less than that for the EIS group (26.3 +/- 8.3 vs 47.1 +/- 11.6 ml, p < 0.01) and the incidence of minor complications at the initial treatment in the EVL+EIS group was significantly (p < 0.01) lower than that in the EIS group. Follow-up endoscopy showed that the rate of attaining circumferential ulceration and the following fibrotic scarring in the EVL+EIS group was significantly lower than that in the EIS group (21.7% vs 91.7%, p < 0.01) and that the incidence of variceal recurrence was significantly higher in the EVL+EIS group than in the EIS group (39.1% vs 8.3%, p < 0.05) over a median follow-up of 12.3 months., Conclusion: The combined therapy of EVL and repeated EIS seems favorable from the viewpoint of fewer complications, but repeated EIS is preferable to combined therapy to avoid recurrence of the esophageal varices.

Background/aims: The long-term results of a combination therapy of sclerotherapy with percutaneous transhepatic obliteration (PTO) was reviewed in 37 patients with large gastric varices. The study suggests that sclerotherapy combined with PTO can safely and effectively eradicate large gastric varices as an alternative approach to surgery. Complete eradication has also been shown to prevent the recurrence of gastric varices., Material and Methods: The long-term results of a combination therapy of sclerotherapy with PTO was reviewed in 37 patients with large gastric varices., Results: Complete eradication of the gastric varices was obtained in 26 patients (70.3%). There was no recurrence of the varices in whom complete eradication had been obtained, but in 11 patients with incomplete eradication gastric varices recurred during the mean follow-up period of 37.5 months. Bleeding occurred in 4 after the treatment and one patient died of massive bleeding from the recurrent gastric varices. There were no major complications with the procedure except for one who had a peripheral pulmonary arterial embolization as a result of a steel coil used for the PTO., Conclusion: This study suggests that sclerotherapy combined with PTO can effectively and safely eradicate large gastric varices and is an alternative approach to surgery for treating patients with gastric varices. It is also shown that complete eradication leads to a prevention of recurrence of gastric varices.

Two Japanese women with a solitary gastric varix were successfully and easily treated by obliterating the gastro-renal shunt with a balloon catheter in a transjugular venous approach without any major complications. The transjugular obliteration was thus found to be a bloodless and useful method for the treatment of a solitary gastric varix with a gastro-renal shunt.

Background/aims: The most common cause of failure of sclerotherapy is recurrent bleeding before eradication is complete. We investigated factors which would make feasible prediction of cases where esophageal varices would be more difficult to eradicate., Patients and Methods: Seven hundred and seventy patients underwent endoscopic injection sclerotherapy at Kyushu University Hospital from January, 1982 to June, 1989. For 580 of these patients we used the same sclerosant and a transparent overtube. For 19 of 580 patients over two months were needed to eradicate the varices (group 2), while eradication was complete in less than one month in 64 patients (group 1)., Results: There was a tendency toward a lower platelet count and a higher indocyanine green retention rate in group 2, but with no statistically significant difference. The number of sessions required for eradication of the varices was 8.1 +/- 2.5 and the total volume of sclerosant used was 98.2 +/- 62.3 ml in group 2, and 3.0 and 47.0 +/- 10.9 ml, respectively, in group 1 (p < 0.01). There was no significant difference in the number of sessions between the patients with large-sized and moderate-sized varices. Based on the extent of cephalad collateral vessels on the venous phase of celiac or superior mesenteric angiography, the vascular pattern could be classified into three types; Grade III, the most developed type was present in 100% and 57.1% on celiac and superior mesenteric angiography in group 2, while the rates were 11.1% and 5.6% in group 1 (p < 0.05)., Conclusions: This retrospective study shows that in patients with enormously enlarged cephalad collateral vessels it may be difficult to eradicate the varices, and in such cases, preoperative portography is most useful to predict whether or not esophageal varices can be eradicated.

Controversy exists as to the nature of gastric perfusion in portal-hypertensive gastropathy. To investigate portal hemodynamics and gastric mucosal perfusion in cirrhotic patients with and without portal-hypertensive gastropathy, we subjected 56 cirrhotic patients with portal hypertension to portal vein catheterization, pneumatic pressure sensor technique, duplex sonography and laser Doppler flowmetry. Thirteen patients had portal-hypertensive gastropathy: In 10 it was mild, and in 3 it was severe. The presence of portal-hypertensive gastropathy seemed to be independent of age, sex, cause of cirrhosis or grade of esophageal varices. Portal venous pressure, esophageal variceal pressure, portal venous flow and congestion index in patients with portal-hypertensive gastropathy were not significantly different from the values in those without portal-hypertensive gastropathy. However, portal-variceal pressure gradient (subtracting esophageal variceal pressure from portal venous pressure) (p < 0.01) and the incidence of palisading-type esophageal varices on portography (p < 0.05) was increased in patients with portal-hypertensive gastropathy significantly more than in those without portal-hypertensive gastropathy. In the fundus, gastric mucosal blood flow was significantly higher in patients with portal-hypertensive gastropathy than in those without portal-hypertensive gastropathy, whereas in the corpus and the antrum the values were not significantly different. We suggest that the mucosa of the upper stomach in patients with portal-hypertensive gastropathy is congestive and highly perfused. The pathogenesis of portal-hypertensive gastropathy may be related to both congestion and hyperemia in the upper stomach.