Percutaneous transhepatic obliteration for isolated gastric varices with gastropericardiac shunt: case report

Management of isolated gastric varices with a gastropericardiac shunt (GPS) has not yet been established. We were able to control a case of isolated gastric varices with a GPS by percutaneous transhepatic obliteration (PTO) using a microcatheter. In this case, the main blood drainage route was not a gastrorenal shunt, so transvenous retrograde obliteration could not be performed and PTO using the microcatheter was applied. Percutaneous transhepatic splenic venography revealed that the gastric varices came from the posterior gastric vein and the main drainage route was a GPS. Gastric varices and their blood supply were superselectively embolized using platinum microcoils and absolute ethanol. Portal venous pressure did not change after PTO because the route from the left gastric vein to the azygos venous system was preserved. Computed tomography 7 days after PTO revealed that the gastric varices were completely obliterated by the thrombi. Plasma ammonia level, arterial ketone body ratio, and indocyanine green retention rate at 15 min were improved. We conclude that PTO using a microcatheter is a rational, effective, and safe therapy for isolated gastric varices with a GPS.

Role of percutaneous transhepatic obliteration for special types of varices with portal hypertension

The treatment of special types of varices with portal hypertension has not yet been established. We were able to control 13 cases of special types of varices by percutaneous transhepatic obliteration (PTO). These 13 cases consisted of 2 esophagojejunal varices after total gastrectomy for gastric cancer, 1 stoma varices after abdominoperineal excision for rectal cancer, 2 mesenteric varices with encephalopathy, 1 gastric variceal rupture, 1 gastrorenal and gastroazygos shunt with encephalopathy, 3 giant bar-type esophageal varices, 2 isolated gastric varices with gastropericardiac shunts, and 1 isolated gastric varices with gastrophrenic shunt. The special types of varices were successfully embolized in all cases and there were no complications. We conclude that the PTO is still an effective and safe treatment for special types of varices with portal hypertension.

Intussusception due to intestinal anisakiasis: a case report

This report describes our experience of intussusception due to intestinal anisakiasis which was treated by laparoscopy-assisted surgery. The unique sonographic findings of this complication were a pseudokidney sign and a target sign with an edema of Kerckring's folds in the intussusceptum. Surgeons should know about intussusception as a rare complication of intestinal anisakiasis. Sonography, computed tomography and laparoscopy are helpful in diagnosing and treating this complication.

Early scheduled laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for patients with acute cholecystitis

AIM

The present study was conducted to evaluate the effectiveness of early scheduled laparoscopic cholecystectomy (LC) following percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute cholecystitis.

PATIENTS AND METHODS

31 patients with acute cholecystitis were treated by early scheduled LC following PTGBD (group 1). These patients were compared with 9 patients treated by early LC without PTGBD (group 2) and with 12 patients treated by delayed LC following conservative therapy (group 3) for the success rate of intraoperative cholangiography, the conversion rate to open cholecystectomy, operative time, and hospital stay. Early scheduled LC following PTGBD was defined as scheduled LC when the patient's condition recovered and it was performed 1-7 days (mean: 4 days) after admission. The patients' age in group 1, 2, and 3 was 66 +/- 13, 65 +/- 10, and 64 +/- 9 years, respectively, without significant difference. Most of the patients had additional diseases.

RESULTS

The success rate of intraoperative cholangiography was 97% (30/31) in group 1, 67% (6/9) in group 2, and 67% (8/12) in group 3. The conversion rate to open cholecystectomy was 3% (1/31) in group 1, 33% (3/9) in group 2, and 33% (4/12) in group 3. The operative time for LC was 89 +/- 33 min in group 1, 116 +/- 24 min in group 2, and 135 +/- 30 min in group 3. The mean hospital stay after LC was 9 +/- 4 days in group 1, 9 +/- 3 days in group 2, and 17 +/- 7 days in group 3. In group 1, the success rate of intraoperative cholangiography was higher, the conversion rate to open cholecystectomy was lower, and operative time was shorter than in groups 2 and 3 with significant difference (p <0.05, p <0.05, and p <0.01, respectively).

CONCLUSION

The findings of this study indicate that early scheduled LC following PTGBD is a safe and effective therapeutic option for patients with acute cholecystitis especially in elderly and complicated patients.

Laparoscopic appendectomy with the help of a wire snare

This report describes the performance of a laparoscopic appendectomy (LA), a new technique using a "wire snare" without any specific complications. The snare consisted of an 18-gauge injection needle and folded fine wire, measuring 0.28 mm in diameter. LA was performed in 95 patients with acute appendicitis using a cheap and simple wire snare to catch the ligation thread of #0 silk. A good view of the appendix and mesoappendix was obtained in all cases by traction of the #0 silk. The operative time needed to perform LA using a wire snare for nongangrenous appendicitis in 77 cases overall, the first 10 cases, and the last 10 cases was 54+/-17, 64+/-5, and 33+/-4 min, respectively. Two of the 95 patients required conversion to an open appendectomy because of technical difficulties due to the formation of an inflammatory mass. There were no complications associated with insertion of the snare. The wire snare is an innovative technique and does not increase the costs significantly, and should help reduce the number of trocar sites and the operative time, while also making an LA easier to perform.

Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices

BACKGROUND/AIM

The correlation between angiographic vascular patterns and endoscopic findings in portal hypertension is not sufficiently known, and knowledge of the vascular anatomy may contribute to an improvement in endoscopic embolization and transjugular retrograde obliteration procedures. We propose a new vascular map that should prove useful for this purpose.

METHODS

Between April 1985 and December 1997 we performed percutaneous transhepatic portography in a selected group of 75 patients (16 women and 59 men), aged 43-71 years, from whom informed consent was obtained. All patients had been diagnosed endoscopically as having either esophageal or isolated gastric varices. According to the Child-Pugh classification, class A, B, and C cirrhosis was seen in 19, 40, and 16 patients, respectively. We created a vascular map of esophageal and isolated gastric varices, based on the opacification of the portal venous collaterals on percutaneous transhepatic portography. We compared the patients in both variceal groups in terms of portal venous pressure, main blood supply, and drainage routes.

RESULTS

We found that the portal collateral system was divided into two systems: the portoazygos venous system and the portophrenic venous system. The former contributed to the formation of esophageal and cardiac varices and the latter to the formation of isolated gastric varices located at the fundus or at both the cardia and fundus. The left gastric vein participated as blood supply in 70% of the isolated gastric varices and in 100% of the esophageal varices (p < 0.01). The posterior gastric vein participated as blood supply in 70% of the isolated gastric varices and in 24% of the esophageal varices (p < 0.01). We classified the main blood drainage routes of isolated gastric varices functionally into three types: gastrorenal shunt (85%), gastrophrenic shunt (10%), and gastropericardiac shunt (5%). The portal venous pressure in patients with esophageal varices was 358 +/- 66 mm H(2)O, whereas in patients with isolated gastric varices it was 262 +/- 44 mm H(2)O (p < 0.01).

CONCLUSION

We suggest that this new vascular map will be useful in endoscopic embolization and transjugular retrograde obliteration procedures for esophageal and isolated gastric varices.

Eight years of experience with transjugular retrograde obliteration for gastric varices with gastrorenal shunts

BACKGROUND AND OBJECTIVES

There is no standard treatment for gastric varices. Transjugular retrograde obliteration (TJO) is one way of obliterating gastric varices with gastrorenal shunts, in which blood flow is abundant. Our aim was to examine our experience with TJO during an 8-year period and to determine the long-term effects of this treatment.

METHODS

We performed TJO procedures in 52 patients to obliterate gastric varices. All the patients had liver cirrhosis. Sixteen had hepatocellular carcinoma (HCC) without vascular invasion. We inserted an angiographic catheter with an occlusive balloon through the right internal jugular vein into the gastrorenal shunt or the gastric varices. After controlling the other blood-draining routes with a microcoil or absolute ethanol, or both, we injected 5% ethanolamine oleate with iopamidol into the gastric varices under fluoroscopy.

RESULTS

The gastric varices were successfully obliterated by TJO in all cases. The complications were all minor and transient. The mortality rate for TJO was 0%. There was no recurrence and no bleeding of gastric varices at all after TJO. Patient survival differed depending on the presence or absence of HCC (P <.05). The development of HCC in the cirrhotic liver was the most common cause of late death. Gastrointestinal bleeding was not a cause of death. The occurrence rate of esophageal varices after TJO was high, but these varices could be treated easily by endoscopic injection sclerotherapy before they bled.

CONCLUSIONS

Portal blood flow through the gastrorenal shunt is diverted to the porto-azygos venous system after the gastrorenal shunt is obliterated by TJO. TJO is a safe option that we recommend for treating gastric varices with gastrorenal shunts, provided that the TJO is followed by endoscopic injection sclerotherapy.

Short-term portal hemodynamic effects of endoscopic embolization for esophageal varices

BACKGROUND/AIM

Endoscopic embolization (EE) is a specialized treatment that obliterates esophageal varices along with their associated blood supply. The purpose of this study was to investigate the short-term effects of EE for esophageal varices on portal hemodynamics and liver function.

METHODS

Thirty patients with esophageal varices were included in this study. The portal blood flow was measured by an ultrasonic duplex Doppler system before and after EE. EE was performed by freehand intravariceal injection of 5% ethanolamine oleate with iopamidol with the aid of a balloon attached to the tip of an endoscope under fluoroscopy.

RESULTS

For the blood supply system, endoscopic varicography at the time of EE was able to show the vessels of the cardiac branch of the left gastric vein in 93% of the cases, the cardiac venous plexus in 90%, the trunk of the left gastric vein in 27%, the lesser curvature branch of the left gastric vein in 10%, the fundic branch of the short gastric vein in 13%, and the posterior gastric vein in 13%. For the blood drainage system, endoscopic varicography was able to show the paraesophageal vein in 39% of the cases, the inferior phrenic vein in 17%, and the mediastinal vein in 13%. No clotting was detected after EE in the intra- and extraportal veins in any of the cases. The flow velocities in the main portal vein before and after EE were 14.2+/-3.2 and 15.5+/-3.5 cm/s, respectively, showing no significant change. The cross-sectional area of the portal vein before and after EE was 0.96+/-0.21 and 1.04+/-0.23 cm(2), and the flow volume of the portal vein was 817+/-288 and 930+/-189 ml/min, both also showing no significant change. The blood laboratory parameters showed no significant change after EE.

CONCLUSIONS

We conclude that neither portal blood flow nor liver function were damaged by EE, although both the varices and their associated blood supply were obliterated.

Short-term hemodynamic effects of transjugular retrograde obliteration of gastric varices with gastrorenal shunt

OBJECTIVES

The purpose of this study was to investigate the short-term effects on portal hemodynamics of transjugular retrograde obliteration (TJO) of gastric varices with gastrorenal shunt.

METHODS

Thirty patients with gastric varices and a gastrorenal shunt were included in this study. The patients ranged in age from 42 to 75 years (16 men and 14 women), and according to Child's classification, class A, B and C cirrhosis was seen in 1, 13 and 16 patients, respectively. The portal blood flow was measured by an ultrasonic duplex Doppler system, and the wedged hepatic venous pressure was measured by hepatic venous catheterization, before and after TJO.

RESULTS

Complete obliteration of the gastrorenal shunt and gastric varices was revealed by retrograde inferior phrenic venography and computed tomography after TJO in all cases. The wedged hepatic venous pressure was significantly increased the day after TJO compared with that before therapy (257 +/- 71 vs. 307 +/- 73 mm H(2)O, p < 0.01). The portal venous flow was significantly increased 1 week after TJO compared with that before therapy (744 +/- 190 vs. 946 +/- 166 ml/min, p < 0.01). The serum albumin levels before and after TJO were 3.0 +/- 0.4 and 3.1 +/- 0.5 g/dl, respectively, and the total bilirubin levels were 1.5 +/- 0.7 and 1. 5 +/- 0.8 mg/dl, respectively, neither of these parameters changing significantly. The plasma ammonia levels before and after TJO were 109 +/- 62 and 67 +/- 31 microg/dl, and the indocyanine green retention rates at 15 min were 31 +/- 13 and 24 +/- 13%, both showing a significant change (p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

We conclude that TJO increases portal blood flow which contributes to the decrease in plasma ammonia levels and the indocyanine green retention rate, although increasing the wedged hepatic venous pressure.

Laparoscopic cholecystofistulectomy for preoperatively diagnosed cholecystoduodenal fistula

The presence of cholecystoduodenal fistula, a rare condition, has been one of the reasons for conversion from laparoscopic cholecystectomy to open cholecystectomy. Here we report a patient with cholecystocholedocholithiasis complicated by cholecystoduodenal fistula, diagnosed preoperatively and treated by combined endoscopic sphincterotomy and laparoscopic cholecystofistulectomy. After the removal of multiple bile-duct stones by endoscopic sphincterotomy, the patient underwent laparoscopic cholecystofistulectomy. We were able to resect the fistula without cleavage, using an endoscopic linear stapling device, because we had been able to confirm the site of the fistula preoperatively. The patient's postoperative course was uneventful. We conclude that laparoscopic cholecystofistulectomy by skilled laparoscopic surgeons can be adopted as a first-choice treatment for cholecystoduodenal fistula.

Transjugular retrograde obliteration for chronic portosystemic encephalopathy

Chronic portosystemic encephalopathy (CPSE) is uncommon, and its management has yet to be determined. We have been able to control five cases of CPSE using transjugular retrograde obliteration (TJO), and we report our clinical results with this technique. All of the five patients were suffering from cirrhosis and had gastric varices and large gastrorenal shunts. According to Sherlock's classification, the grade of encephalopathy was II in two patients, III in two, and IV in one. According to Child's classification, one had class B and four had class C cirrhosis. TJO was performed using a 6-F angiographic catheter with an occlusive balloon 20 mm in diameter. Absolute ethanol and 5% ethanolamine oleate with iopamidol were used to obliterate the gastrorenal shunt. The gastrorenal shunt was successfully obliterated, and the encephalopathy improved to grade 0 after TJO in all cases. The portal flow volume increased significantly from 542 +/- 189 to 992 +/- 139 mL/min (p < 0.01). The plasma ammonia levels before and after TJO were 189 +/- 40 and 51 +/- 23 microg/dL, and the indocyanine green retention rates at 15 min were 44 +/- 13% and 27 +/- 12%, with both changes being significant (p < 0.01). Minor complications observed were fever of over 38 degrees C and tarry stools due to hemorrhagic gastritis in one patient, which was being controlled conservatively. One patient died of hepatocellular carcinoma 27 months after TJO. The other four patients survived without recurrence of CPSE 17-74 months (44 +/- 24 months) after TJO. We conclude that TJO can be adopted as a safe and effective treatment for CPSE.

Blood supply routes of recurrent esophageal varices following endoscopic embolization

BACKGROUND/AIM

The blood supply routes of recurrent esophageal varices following complete endoscopic embolization (EE) are not yet known. The purpose of this study is to identify these blood supply routes by comparing endoscopic varicography and percutaneous transhepatic portography (PTP).

METHODS

Eleven cases of recurrent esophageal varices following EE are included in this study. The blood supply routes of primary and recurrent varices were analyzed by comparing the varicography obtained at the initial and repeat EE with PTPs before and after the initial EE.

RESULTS

Endoscopic varicography at the time of initial EE could show the vessels of the left gastric vein (LGV) system, such as the cardiac branch of the LGV, and the cardiac venous plexus (CP) in 100% of cases, and the trunk of the LGV in 73% (8/11) of cases, whereas the posterior gastric vein was seen in only 18% (2/11) of cases. PTP performed 2 weeks after the initial EE confirmed that the routes visualized by endoscopic varicography could be obliterated in 10 of 11 cases. The blood supply routes of recurrent varices, demonstrated by varicography, were the vessels of the short gastric vein (SGV) system, such as the fundic branch of the SGV or the posterior gastric vein in 82% (9/11) of cases, and the partially reformed fine CP in 27% (3/11) of cases. Varicography revealed the remnant vessels of the LGV in only 1 case.

CONCLUSIONS

The primary esophageal varices are supplied with blood mainly from the cardiac branch of the LGV through the CP. However, the blood supplies of recurrent varices following EE come from the fundic branch of the SGV or the posterior gastric vein. We conclude that three-dimensional obliteration of esophageal varices and their feeders, the LGV and SGV systems, is completed by initial and repeat EEs.

Urgent transjugular retrograde obliteration for prophylaxis of rebleeding from gastric varices in patients with a spontaneous portosplenorenal shunt

BACKGROUND

Bleeding isolated gastric varices with a spontaneous portosplenorenal shunt are difficult to control. The urgent use of transjugular retrograde obliteration (TJO) to prevent early rebleeding and to improve early mortality has not yet been demonstrated. We report our experience with this technique in patients with isolated gastric varices after treatment of acute bleeding.

METHODS

We reviewed our experience of 6 patients with isolated gastric varices with a spontaneous portosplenoral shunt treated with TJO after treatment of acute bleeding. We basically applied endoscopic glue embolization using cyanoacrylate monomer for treatment of acute bleeding. TJO was a method using an occlusive balloon catheter to control a spontaneous portosplenorenal shunt flow while injecting sclerosant retrograde into the gastric varices.

RESULTS

Treatment of acute bleeding was achieved immediately by endoscopic glue embolization, endoscopic variceal ligation, and ligating the varices with sutures following anterior gastrotomy in 4, 1 and 1 patients, respectively, and then TJO was performed. Permanent hemostasis and variceal eradication was achieved in these 6, and they all survived. They were alive for 6-66 months without gastric variceal recurrence.

CONCLUSIONS

We conclude that urgent TJO is effective in the prophylaxis of early and late rebleeding from isolated gastric varices in patients with a spontaneous portosplenorenal shunt.

A multiple gastric ulcer case caused by cytomegalovirus infection

The patient was a 31 year old male complaining discomfort in the epigastrium. Endoscopy of the upper gastrointestinal tract indicated multiple gastric ulcers. Biopsy specimen taken from the ulcerous region indicated giant cells accompanying intranuclear inclusion bodies in the gastric mucosa. Since the patient tested positive to cytomegalovirus (CMV)-IgM antibody, he was assumed to have gastric ulcers caused by CMV infection. However, the patient was cured without the administration of antiviral agent because no definite immunodeficiency status was observed. The result of present study indicated that endoscopic biopsy is useful for diagnosing gastrointestinal lesion attributable to CMW infection.

[Permeability to horseradish peroxidase of the ciliary muscle vessels of squirrel monkeys]

The morphology and permeability to horseradish peroxidase (HRP) of the ciliary muscle capillaries of squirrel monkeys were studied. The endothelial cells of the capillaries were of the continuous type and the interendothelial clefts were closed by a zonula occludens. Many vesicles were present in the cytoplasm of the endothelial cells. In addition to these vesicles, large vacuole-like structures, 100-500 nm in diameter, were observed in the cytoplasm of capillary endothelium, especially in the circular and radial ciliary muscles. When HRP was perfused into the anterior chamber, the 3,3'-diaminobenzidine reaction product was observed in the lumen of the ciliary muscle vessels after 30 minutes. When HRP was administered intravenously, the reaction product was observed among the muscle fiber bundles after 15 minutes. In both cases, the reaction products were also present in the cytoplasmic vesicles and vacuole-like structures, suggesting that these structures are involved in the bidirectional transport of HRP between interstitium and blood.

[Relation of intragastric pH with the response of gastrin and somatostatin secretion to electrical vagal stimulation]

The association of gastrin and somatostatin secretion with intragastric pH was investigated in the in vitro experimental system that provides concurrent isolated rat stomach perfusion and vagal stimulation. As a result, it was found that the gastric cavity must be neutral or alkaline for gastrin secretion to respond to electrical vagal stimulation. For somatostatin secretion to respond to the same stimulus the gastric cavity must be acidic. It was further suggested that gastrin secretion may be regulated by non-cholinergic neurons which are in turn regulated by non-nicotinic preganglionic fibers, while somatostatin secretion may be regulated by non-cholinergic excitatory neurons as well as by cholinergic inhibitory neurons which are regulated by nicotinic preganglionic fibers.

[Scanning electron microscopic study of rat lungs in experimental chronic paraquat poisoning]

It is well known that Paraquat (1,1'-dimethyl-4,4'-bipyridylium dichloride), used widely as a herbicide, causes a primary toxic effect in the lungs of humans and laboratory animals. This paper describes the pulmonary changes of chronic paraquat poisoning in rats, comparing scanning electron microscopic findings. Twenty-four rats were given repeated injections of 10/kg body weight paraquat intraperitoneally for 6 consecutive months, and six control rats were given 0.9% NaCl solution. The animals exposed to paraquat showed thickening of alveolar septum, inflammatory cell infiltration, interstitial fibrosis, and marked proliferation of alveolar macrophages. Among them four rats (21%) showed the typical findings of diffuse pulmonary fibrosis. Lesions were more severe at the subpleural region of the lung. The desquamation of alveolar epithelial cells and subsequent exposure of the basement membranes were observed in places. Although alveolar epithelial cells both in the type I and the type II were prolific, the type II cells showed partial loss of microvilli and projections. These findings may indicate the lowering of the type II cell function and subsequent decrease of surfactant excretion which causes respiratory insufficiency. Furthermore, alveolar macrophages showed a tendency to increase in number with progressive development of fibrosis. This tendency may support the hypothesis by Schoenberger et al., in which alveolar macrophages release both fibronectin and a growth factor for fibroblast after paraquat exposure.

High incidence of urinary JC virus excretion in nonimmunosuppressed older patients

Urine specimens from 120 patients attending urologic clinics were screened by blot hybridization for the presence of a polyomavirus DNA. Detected viral DNA was then identified as BK or JC by fine restriction enzyme analysis. BK and JC viral DNA was found in 5 (4%) and 35 (29%) patients, respectively. Detection rates were compared among three age groups: 0-29, 30-59, and 60-89 years. Detection of JC viral DNA increased with age and reached the highest value (45%) in the group aged 60-89 years. For BK viral DNA a correlation between detection and age was not clear because the rate of detection was low, although the highest rate (9%) occurred in the oldest group. To confirm the active urinary excretion of polyomavirus DNA in older patients, urine specimens from 23 patients (60-90 years) treated at an internal medicine clinic were examined for viral DNA. BK and JC viral DNA were in 2 (9%) and 12 patients (52%), respectively. These results suggest that JC virus is frequently reactivated in older individuals.

[A case of malakoplakia of the testis and epididymis]

A forty-two year-old man with left epididymo-testicular malakoplakia was reported. Thirty-two cases of testicular malakoplakia with (5 cases) and without (27 cases) epididymal malakoplakia were reviewed. The mean age was 48. 2 year-old. Two-thirds of the cases suffered from right side involvement. All cases except a few cases received orchiectomy within 2.6 months on average from the onset of the symptoms. Diabetes mellitus, malignant diseases, or chronic renal failure seem to have a causal relation to the development of testicular malakoplakia. Six cases of epididymal malakoplakia were also reviewed.

[Detection and prognosis of alimentary tract cancers--mass screening]

The limitation of detectability and curability in terms of current techniques (screening and details) were sought in otherwise healthy examinees. Not a few cancers were present in the alimentary tract, except for the stomach, in these otherwise healthy examinees who voluntarily underwent gastric cancer mass screening. The prognosis of alimentary tract cancers deteriorates in the descending, following order: colon cancer, stomach cancer, and esophageal cancer. The survival rate of primary liver cancer, cholecyst cancer, and pancreas cancer is extremely low. Unless new techniques are developed in these diagnoses, no improvement in the survival rate can be anticipated.