Complications of percutaneous transhepatic catheterization of the portal venous system in patients with portal hypertension

We report here complications of percutaneous transhepatic catheterization of the portal venous system in 170 Japanese patients with portal hypertension. All patients underwent percutaneous transhepatic portography and percutaneous transhepatic obliteration of oesophagogastric varices was also performed in 29 patients. After retraction of the catheter, the puncture canal was plugged with gelatin sponge in 150 subjects and with one steel coil in 20 others. The overall complication rate was 16.5%. Intraperitoneal bleeding occurred in 10.6% of patients and 2.9% required blood transfusion. In these patients with intraperitoneal bleeding, the gelatin sponge was used for plugging after retraction of the catheter, while in the 20 patients with a steel coil plug, haemoperitoneum never occurred. Right pleural effusion was recognized in 3.5% of patients, intraperitoneal bile leakage in 1.8% and deterioration of liver function due to arteriovenous fistula in 0.6%. By univariate and multivariate analyses, female gender was the only risk factor for intraperitoneal bleeding among 150 patients investigated by percutaneous transhepatic catheterization of the portal venous system with gelatin sponge plugging. Intraperitoneal bleeding is the most important complication in patients with portal hypertension; it is difficult to predict intraperitoneal bleeding before retraction of the catheter in patients for whom gelatin sponge is used. Thus, for patients undergoing percutaneous transhepatic catheterization of the portal venous system, close follow up is recommended.

Orthostatic hypotension caused by a localised dorsal medullary tumour

Images

The treatment of gastric varices by a balloon-occluded retrograde transvenous obliteration; a transjugular venous approach

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.

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura: comparison of laparoscopic surgery and conventional open surgery

In chronic idiopathic thrombocytopenic purpura (ITP), the two main therapeutic choices are steroid treatment or splenectomy. The adult form of ITP is described as a disease found primarily in young adults, with a female predominance. Treatment with steroids effects a complete response in less than 30% of patients, whereas splenectomy is successful in more than 60% of patients who undergo it. The minimal access afforded by laparoscopic splenectomy is considered highly desirable for these patients. The purpose of this study was to compare the clinical benefits of a laparoscopic splenectomy with those of conventional open surgery for patients with ITP. From 1968 to 1993, splenectomy was performed on 51 patients: 10 operations done laparoscopically and 41 performed conventionally. Complications, postoperative pain, recovery, and hospital charges were then compared. Laparoscopic splenectomy involved minimal incisions, and a significantly lower frequency of analgesia was required for postoperative abdominal pain (1.3 vs. 3.3); hospital stay was shorter (8.2 vs. 20.1 days) (p < 0.005). Operative time was significantly longer for the laparoscopic surgery (249.2 vs. 99.8 min) (p < 0.0001), but blood loss was less (176.0 vs. 511.7 g) (p < 0.01). No intraoperative or postoperative major complications occurred with the laparoscopic procedures, compared with 46.3% with conventional surgery. Finally, the total hospital costs were lower with laparoscopic splenectomy, especially for postoperative care (p < 0.05). A laparoscopic splenectomy may well be considered the surgical treatment of choice for patients requiring a splenectomy in view of both quality of life and economy.

Periventricular leukomalacia associated with hypocarbia

We here report a case of periventricular leukomalacia (PVL) associated with hypocarbia which remained even after extubation. The patient had no risk factors affecting PVL development other than hypocarbia. We consider that the irregular tachypnea, which remained after extubation might be attributable to overdriving of ventilation of central neurogenic origin. Our patient's clinical course suggests that sodium bicarbonate drip infusion is a very effective way to alter the set point of respiratory neuronal drive of the patient with central neurogenic hyperventilation.

Extreme hyperbilirubinemia induced by endoscopic injection sclerotherapy in a patient with esophageal varices and thalassemia: report of a case

We describe herein the case of a 57-year-old man with thalassemia who developed acute liver failure after undergoing endoscopic injection sclerotherapy (EIS) to control hemorrhage from a ruptured esophageal varix. The patient, who had been confirmed as having liver cirrhosis due to chronic hepatitis C with thalassemia in 1989, was admitted to our department to undergo EIS for esophageal varices, at which time his serum total bilirubin level was 5.5 mg/dl. As a small amount of hematemesis occurred just after a percutaneous transhepatic portography was performed, emergency EIS was carried out, following which the serum total bilirubin level markedly increased, mainly with a direct fraction, until it reached 70 mg/dl. The patient eventually died from acute liver failure with extreme hyperbilirubinemia on the 27th day after experiencing hematemesis despite all treatment. This unfortunate case demonstrates that sclerotherapy could be an inappropriate method of treatment for patients with hemolytic disease.

Effect of teprenone on portal hypertensive gastric mucosa

Teprenone (geranylgeranylacetone) is a gastric mucosal protective drug used clinically in Japan for treatment of gastric ulcers and gastritis. Its effect on portal hypertensive (PHT) gastric mucosa which has impaired defensive mechanisms is not known. In 20 PHT and 20 sham-operated rats, we studied the effects of teprenone or placebo on: (1) portal pressure; (2) gastric pH; (3) gastric mucosal blood flow using laser doppler flowmetry, and (4) hexosamine content in gastric mucosa. The gastric mucosal blood flow was significantly higher in the PHT + teprenone group than in the PHT + placebo group (463 +/- 75 and 381 +/- 82 perfusion units, respectively; p < 0.05). The hexosamine content was significantly lower in PHT rats than in sham-operated controls (12.6 +/- 2.3 vs. 14.3 +/- 2.2 micrograms/mg, respectively). Teprenone treatment significantly increased the gastric mucosal hexosamine concentration in both sham-operated and PHT rats (17.2 +/- 3.1 and 15.6 +/- 3.6 micrograms/mg, respectively). These effects of teprenone, combined with its known prostaglandin-stimulating action, suggest a potential role for this agent in the treatment of PHT gastric mucosal abnormalities.

The role of the spleen, platelets, and plasma hepatocyte growth factor activity on hepatic regeneration in rats

BACKGROUND

Hepatocyte growth factor (HGF) is a humoral factor that may act as a trigger for hepatic regeneration. In this study, changes in the plasma HGF activity on hepatic regeneration in a splenectomized condition were measured for the first time, while the role of the spleen and platelets on hepatic regeneration were also carefully evaluated.

STUDY DESIGN

Seventy-five male Wistar rats were classified into three groups: group A consisted of rats who underwent a sham operation and a partial hepatectomy; group B consisted of those who underwent a splenectomy and partial hepatectomy; and group C consisted of those who underwent a splenectomy, partial hepatectomy, and were administered an antiplatelet agent.

RESULTS

At 24 hours after partial hepatectomy, the weights of the livers of the rats in groups B and C were significantly greater than those of group A, while the labeling index of group C was significantly higher than that of group A and also tended to be higher than that of group B. Regarding the number of platelets, the transient increase in group A occurred earlier than that of either group B or C. The plasma HGF activities also showed a transient increase and the maximum levels were reached at 24 hours in group A, six hours in group B, and 12 hours in group C.

CONCLUSIONS

It is suggested that the spleen plays an inhibitory role in hepatic regeneration. In the early stage of hepatic regeneration, platelets possibly control HGF induction, while in the following stage, a possible feedback mechanism is also postulated to exist.

Noninvasive variceal pressure measurement may be useful for predicting effect of sclerotherapy for esophageal varices

This study assessed the relationship between variceal pressure and morphological findings and hemodynamics of esophageal varices as well as the effect of sclerotherapy. Esophageal variceal pressure was measured in 40 patients with portal hypertension, using a noninvasive method. Esophageal variceal pressures were significantly higher in moderate or large varices than they were in small varices. Variceal pressures were significantly higher in patients with red color signs on the varices than in those without. According to the percutaneous transhepatic portography, the structure of the esophageal varices was classified into two types: the bar type and the palisading type. The maximum variceal pressure was significantly higher in the bar type than in the palisading type. In patients who underwent more than five sessions of sclerotherapy, the variceal pressure was significantly higher than in those receiving less than four sessions. These results suggest that variceal pressure may well reflect the vascular pattern and be useful for predicting the effect of sclerotherapy.

Laparoscopic hepatic resection for hepatocellular carcinoma

Despite recent progress in diagnostics for hepatocellular carcinoma, the rate of resectability remains low, mainly because of the advancement of the underlying liver disease. We report a case of a 54-year-old man with a hepatocellular carcinoma and poor liver function that was treated successfully with a laparoscopic hepatic resection. Laparoscopic hepatic resection is considered to be feasible with the aid of an ultrasonic dissector and a microwave coagulator; however, close attention should be paid to the development of air embolism and hepatic vein injury.

Development of early squamous cell carcinoma of the esophagus after endoscopic injection sclerotherapy for esophageal varices

A 56-year-old Japanese man with liver cirrhosis was admitted to Kyushu University Hospital in September, 1986 for the treatment of large esophageal varices. Endoscopy revealed four tortuous folds of large esophageal varices, extending proximally from the esophagocardial junction to 34 cm from the dental arch. Endoscopic injection sclerotherapy was performed on the lower esophagus using 5% ethanolamine oleate, and esophageal varices were completely eradicated in 5 sessions with a total of 70 ml of sclerosant. In March 1991, 4 years and 6 months after the treatment, endoscopy revealed a mild redness and an irregular surface 33 cm from the dental arch. The histologic diagnosis was squamous cell carcinoma. The possible relationship between sclerotherapy and the development of esophageal carcinoma should be considered.

Hemodynamic analysis of findings in patients with portal hypertension: multicenter analysis in Japan. Japan Portal Hypertension Study Group

BACKGROUND/AIMS

A multicenter study was done to assess the pathophysiology of malcirculation with portal hypertension.

PATIENTS AND METHODS

Patients were admitted to 48 different institutes from 1990 to 1992.

RESULTS

Portal venous pressure was 345.9 +/- 72.1 mmH2O in patients with portal hypertension. In patients with liver cirrhosis, the diameter of the splenic artery, of the proper hepatic artery, of the left gastric artery and of the splenic vein was significantly larger (p<0.05) than seen in the controls without portal hypertension. In patients with idiopathic portal hypertension, the diameter of the splenic artery and of the vein was significantly larger (p<0.05) and that of the proper hepatic artery was significantly smaller (p<0.05) than seen in the cirrhotic patients. In the cirrhotic patients, blood flow volume was significantly larger (p<0.05) in the splenic vein. In patient with idiopathic portal hypertension, blood flow volume in the portal vein and splenic vein were significantly larger (p<0.05) and that of superior mesenteric vein showed an increasing tendency to enlarge.

CONCLUSION

This study shows that a hyperdynamic state is present in patient with portal hypertension.

Prognostic significance of hepatic vein waveform by Doppler ultrasonography in cirrhotic patients with portal hypertension

OBJECTIVE

We prospectively evaluated the prognostic value of the flat hepatic vein waveform, measured by Doppler ultrasound, in cirrhotic patients with portal hypertension.

METHODS

The Doppler pattern of right and left hepatic veins in a series of 120 consecutive cirrhotic patients with portal hypertension but without hepatocellular carcinoma was examined, together with clinical and biochemical parameters.

RESULTS

Flat waveform of the right hepatic vein was recognized in nine patients and that of the left hepatic vein was seen in 13. After a mean follow-up of 13.6 +/- 9.7 months, 17 patients died, all from liver failure. In the univariate analysis, variable significantly associated with the duration of survival were age, etiology of the liver cirrhosis, upper gastrointestinal bleeding after start of the study, Child-Pugh score, ascites, encephalopathy, prothrombin index, bilirubin, albumin, and flat Doppler waveform in the right and left hepatic veins. Multivariate analysis showed that flat Doppler waveform in the right hepatic vein, bilirubin, and prothrombin index were independently related to survival.

CONCLUSIONS

The prognostic accuracy in cases of cirrhosis with portal hypertension is significantly improved with acquisition of information obtained from hepatic vein waveform by Doppler ultrasound.

Recurrent rectal bleeding from portal hypertensive colopathy in a patient with hemorrhoids

In a 62-yr-old woman who complained of recurrent rectal bleeding, hemorrhoids with mucosal prolapse were found. Virus-related cirrhosis also was present. Colonoscopy revealed spontaneous bleeding from two rectal ectasias (portal hypertensive colopathy) located 9 cm from the anus. Endoscopic hemostasis was achieved with a heater probe, and there has been no recurrent hemorrhage. Colonoscopy is important in ruling out hemorrhage from portal hypertensive colopathy when rectal bleeding occurs in the presence of portal hypertension.

Sclerotherapy-resistant esophageal varices with enormously enlarged cephalad collateral vessels predictable using portography

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.

Development of esophageal cancer after endoscopic injection sclerotherapy for esophageal varices: three case reports

We report here three cases of squamous-cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. All three patients were men and cigarette smokers, with a mean age of 58.3 +/- 5.0 years. Hepatitis B and C virus infection tests were negative, and alcoholic cirrhosis was present in each patient. The interval between sclerotherapy and the development of carcinoma was 9, 10, and 33 months, in the respective cases. The sclerosant used was 5% ethanolamine oleate with a mean total volume of 51.0 +/- 18.9 ml. While we have no evidence of a direct relationship between sclerotherapy and esophageal cancer, in patients with alcoholic cirrhosis who have risk factors for esophageal cancer there may be an acceleration of the potential malignancy, as a result of the chronic inflammation related to sclerotherapy. Such patients should be closely followed, using endoscopy.

Increased prostacyclin content in gastric mucosa of cirrhotic patients with portal hypertensive gastropathy

Plasma levels and gastric mucosal contents of prostaglandin (PG) E2 and prostacyclin were determined in cirrhotic patients with portal hypertensive gastropathy (PHG), in cirrhotic patients without PHG and in healthy controls. PGE2 and 6-keto-PGF1 alpha (a stable metabolite of prostacyclin) levels were measured in 30 cirrhotic patients and 10 controls, using radioimmunoassay. Of 30 cirrhotics, 13 had PHG of the fundus and the corpus. Plasma concentrations of 6-keto-PGF1 alpha in the cirrhotic patients were significantly higher than in the controls (p < 0.01), but there was no significant difference between cirrhotics and controls with regard to plasma levels of PGE2. The gastric mucosal contents of 6-keto-PGF1 alpha in the fundus was significantly higher in cirrhotics with PHG than those without PHG (p < 0.05) and controls (p < 0.01). However, the gastric mucosal contents of PGE2 in the fundus were not significantly different in cirrhotics with and without PHG. The gastric mucosal contents of 6-keto-PGF1 alpha significantly correlated to the plasma levels (r = 0.37, p < 0.05), but there was no significant correlation between plasma levels and gastric mucosal contents of PGE2. Since prostacyclin has vasodilator and gastric acid inhibitory effects, we speculate that high contents of prostacyclin in the gastric mucosa may have some role in the pathogenesis of PHG.

Portal venous blood flow unaltered in cirrhotic patients given metoclopramide injections

The effects of metoclopramide on blood flow in portal and left gastric veins and cardiovascular haemodynamic variables were studied in 30 patients with both liver cirrhosis and oesophageal varices. Measurements were made under baseline conditions and after the intravenous administration of saline, metoclopramide 10 mg, and metoclopramide 20 mg. Portal haemodynamics, including portal and left gastric veins were studied using pulsed Doppler ultrasound. In all groups, the blood flow and the maximal diameter of portal and left gastric veins, and heart rate remained unchanged. However, metoclopramide 10 mg significantly decreased the mean arterial pressure 15 minutes after administration while metoclopramide 20 mg decreased it 30, 45 and 60 minutes after administration. Therefore, metoclopramide apparently does not alter the blood flow of the portal venous system in these patients.

Endoscopic injection sclerotherapy for esophageal varices associated with concomitant portal venous thrombus of hepatocellular carcinoma

Between 1983 and 1994, we treated 51 patients with esophageal varices and portal trunk and main branch invasion of hepatocellular carcinoma, using endoscopic injection sclerotherapy. Variceal bleeding was controlled in 28 of 29 patients (96.6%), esophageal varices were completely eradicated in 28 (54.9%), and only 2 of 28 (7.1%) bled from small, dilated, venous vessels after eradication. The cumulative nonbleeding rate at 3 years was 87.5%. Death caused by hepatocellular carcinoma accounted for 89.4% of the patients, whereas the rate of bleeding from esophageal varices was 4.3%. Variables significantly associated with the duration of survival were Okuda's clinical stage, alpha-fetoprotein, eradication of esophageal varices by sclerotherapy, and treatment of hepatocellular carcinoma, as determined in a univariate analysis. Multivariate analysis showed that eradication of esophageal varices by sclerotherapy, Okuda's clinical stage, and age were independent factors which significantly influenced survival time. We propose that complete eradication of esophageal varices and close follow-up using endoscopy may lead to a reduction in bleeding from esophageal varices, and hence may reduce mortality rates related to this bleeding.

Modulation of extraluminally induced vasoconstrictions by endothelium-derived nitric oxide in the canine basilar artery

The present study was undertaken to investigate the role of endothelium in extraluminally induced vasospasm of the cerebral artery using isolated perfused canine basilar arteries. The extraluminal applications of high K+ and prostaglandin F2 alpha (PGF2 alpha) induced concentration-dependent vasoconstriction. Both constrictive responses were significantly enhanced by denuding endothelium. Additionally, the responses in the endothelium-intact arteries were markedly augmented by intraluminal perfusion with NG-monomethyl-L-arginine (L-NMMA). These results suggest that the inhibition of nitric oxide (NO) synthase in endothelium enhances increase in transmembrane Ca(2+)-influx which is a common constrictive mechanism to the vasoconstrictors. The augmentative action induced by L-NMMA was inhibited by intraluminal perfusion of L-arginine, but not by D-arginine. Furthermore, the augmentation was not observed in the arteries without endothelium. These results suggest that the endothelium may have a great significance on responsiveness to extraluminal vasoactive substances and that endothelium-derived NO may modulate the extraluminally induced vasoconstriction which is responsible for cerebral vasospasm after subarachnoid hemorrhage.

Classification of gastric lesions associated with portal hypertension

There are two gastric mucosal lesions which commonly occur in patients with portal hypertension; one is portal hypertensive gastropathy and the other is gastric varices. These lesions occasionally cause fatal haemorrhage. Several classifications for these lesions have been proposed, but none of them have been evaluated prospectively. We consider it better to classify portal hypertensive gastropathy into three stages including non-specific redness, specific mosaic pattern and red spots. Gastric varices may be classified according to form, location and mucosal lesions. Prospective trials are needed to obtain more practical evidence for the accurate classification of these gastric lesions.

Feasibility of laparoscopic cholecystectomy for patients with a nonvisualized gallbladder on drip infusion cholangiography

We report here the operative findings, the incidence of successful laparoscopic treatment, and the perioperative complications in patients with nonvisualized gallbladder on drip infusion cholangiography (DIC). Eighty-five patients with a nonvisualized gallbladder on DIC were entered into the study. None of the patients had a minimal adhesive gallbladder; 51 to 85 patients (60.0%) had moderate adhesive gallbladders, and 34 (40.0%) had severely adhesive ones. The rate of successful laparoscopic treatment, including laparoscopy-assisted abdominal surgery, was 97.6% (83 of 85 patients). Perioperative complications occurred in only three patients (3.5%), and there were no deaths related to the operation. Thus, when patients with a nonvisualized gallbladder on DIC undergo laparoscopic cholecystectomy, meticulous procedures must be carried out; however, as the rate of successful laparoscopic treatment is high, cholecystectomy under laparoscopy is feasible for experienced surgeons.