Sclerotherapy resistant oesophageal varices: what are their clinical significance in prophylactic sclerotherapy?

Effectiveness of gastric devascularization and splenectomy for patients with gastric varices

BACKGROUND

Bleeding from gastric varices is difficult to control and has a high mortality rate. Recently, newly developed treatments for this serious lesion have been used, but surgical intervention is still advocated by several studies. We report our experience with gastric devascularization and splenectomy and its effectiveness for patients with gastric varices.

STUDY DESIGN

Gastric devascularization and splenectomy was successfully performed to treat patients with isolated gastric varices (n = 42). The patients included 27 men and 15 women who ranged from 29 to 73 years of age (average 53.7 years). We analyzed the findings of gastric varices using endoscopy, the results of gastric devascularization and splenectomy, and survival after the operation.

RESULTS

No patient had tortuous varices (F1). Twenty-seven patients (64.3%) had nodular varices (F2) and 15 (35.7%) had tumorous varices (F3). Twenty-five patients (59.5%) had large varices that occupied two or more areas. Twenty-nine patients (69.0%) had varices with a positive red color sign. No major complications during or after the operation were observed, and peri-operative death did not occur. Gastric varices were eradicated in all 42 patients. Survival rates were 97.6% after 1 year, 88.1% after 3 years, 76.2% after 5 years (mean followup period, 46 months).

CONCLUSIONS

This study showed that gastric devascularization and splenectomy provides satisfactory results for patients with gastric varices that are likely to bleed and that it can be performed even on patients who have had other treatments.

Transvenous sclerotherapy for huge oesophagogastric varices using open injection sclerotherapy

BACKGROUND

The optimum procedure for long-term management of oesophagogastric varices when endoscopic sclerotherapy or ligation fails is yet to be established. This report describes a new procedure for treating huge oesophagogastric varices by open injection sclerotherapy.

METHODS

Twenty-three patients with huge oesophagogastric varices underwent laparotomy and devascularization of the upper stomach with splenectomy. The left gastric vein was catheterized for repeated injection of 5 per cent ethanolamine oleate during the postoperative period.

RESULTS

In all patients, the varices were eradicated after a mean of 3 sessions of sclerotherapy. There were no deaths or major complications during the mean follow-up period of 41 months. Small recurring varices in two patients were treated successfully by endoscopic sclerotherapy and interventional radiology.

CONCLUSION

Open injection sclerotherapy is an effective and safe procedure for the treatment of huge oesophagogastric varices.

Dysphagia after prophylactic endoscopic injection sclerotherapy for oesophageal varices: not fatal but a distressing complication

BACKGROUND

Although dysphagia resulting from oesophageal strictures induced by endoscopic injection sclerotherapy (EIS) is not a fatal complication, it is often quite distressing for the patients. The aim of the current study was to clarify the relationship between dysphagia resulting from oesophageal stricture following prophylactic EIS and the volume of sclerosant consumed in the EIS series.

METHODS

Fifty-two patients with oesophageal varices, who had been treated by prophylactic EIS, were selected as the subjects.

RESULTS

Seventeen (32.7%) patients developed dysphagia following prophylactic EIS, and five patients with a severe stricture required bougie dilatation to take meals. The volume of sclerosant used in the initial session of EIS for patients with subsequent dysphagia (24.9 +/- 4.0 mL) was significantly larger than that for patients without dysphagia (18.4 +/- 5.1 mL; P < 0.001). The mean volume of sclerosant consumed per session during the EIS series for patients with dysphagia (16.5 +/- 3.0 mL) was also significantly larger than that for patients without dysphagia (13.1 +/- 3.8 mL; P < 0.01).

CONCLUSIONS

The injection of a superfluous amount of sclerosant in prophylactic EIS brings about distressing dysphagia with oesophageal stricture in the patients with oesophageal varices who had no such complaint or symptoms before the therapy.

Laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices with hypersplenism

BACKGROUND

The combination of sclerotherapy with surgical salvage for sclerotherapy-resistant esophagogastric varices has recently received much attention, however, the longterm results after such an operation have yet to be reported. This is a preliminary report of a laparoscopic adaptation of a previously described surgical procedure for the treatment of refractory esophagogastric varices.

STUDY DESIGN

Laparoscopic gastric devascularization and splenectomy (Hassab's operation) was successfully performed to treat recurrent sclerotherapy-resistant giant esophageal varices (n=4) and recurrent rebleeding gastric varices (n=6). The patients included 8 men and 2 women who ranged in age from 35 to 67 years (average, 54.2 years). The procedure and clinical results were evaluated from various viewpoints.

RESULTS

The duration of the operation ranged from 200 to 400 minutes (mean+/-standard deviation; 287.5+/-66.0 minutes) and blood loss from 10 to 1,500 mL (average, 515.5+/-507.9 mL). The weight of the spleen ranged from 500 to 850 g (average 608.0+/-126.6 g). Conversion to minimal open operation with a gasless lifting method was done in 1 patient because of uncontrolled bleeding from the splenic vein. There were no other major complications either intraoperatively or postoperatively. All patients had hypersplenism; preoperative platelet counts ranged from 1.6 to 6.8 x 10(4)/microL (average, 4.5+/-2.7 x 10(4) microL) and the postoperative count was from 5.9 to 36.0 x 10(4)/microL (average, 21.7+/-11.5 x 10(4) microL). Postoperative endoscopy revealed that varices disappeared, and no patient had recurrence of the varices after operation during the mean followup period of 12.8+/-4.1 months (average, 8 to 20 months).

CONCLUSIONS

The combination of laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices is considered a feasible and relatively safe surgical method for patients with hypersplenism.