Elastic band ligation for bleeding esophagogastric varices.

Experimental studies have shown ligation results in replacement of submucosal structures, including varices, with scar tissue resulting in eradication of varices. Elastic band ligation is equal in efficacy to sclerotherapy for control of active bleeding from esophageal varices. Ligation appears superior to sclerotherapy for long-term prevention of recurrent variceal bleeding, requires fewer treatment sessions to eradicate varices, is associated with fewer bleeding and non-bleeding complications of treatment, and results in improved survival. Results from the synchronous combination of elastic band ligation with sclerotherapy do not appear to be superior to those obtainable with those from endoscopic ligation used alone.

Laparoscopic ultrasonography. Has it extended the horizon?

Laparoscopic ultrasonography complements conventional radiologic evaluation of the biliary system at cholecystectomy. Addition of laparoscopic ultrasonography for staging patients with hepatic and pancreatic cancer improves accuracy and minimizes futile laparotomy. Dedicated laparoscopic ultrasound-guided biopsy devices facilitate tissue sampling. Ultrasonography will play an increasingly important role in laparoscopic diagnosis and treatment.

Approaches to the endoscopic treatment of esophageal varices.

Endoscopic therapy is commonly employed for both initial and subsequent definitive treatment of variceal bleeding. Sclerotherapy performed with a flexible endoscope is currently the most widespread technique. Available data suggests that such treatment does not improve outcome in the acute treatment of variceal bleeding (first 30 days) but appears superior to conventional medical management in the long term. Sclerotherapy does not appear better or worse than pharmacological therapy or surgical therapy when these treatments are compared in the elective setting. Although effective, endoscopic sclerotherapy is recognized to be associated with many major and minor treatment-related complications and a significant incidence of recurrent hemorrhage. In response to these shortcomings newer forms of endoscopic therapy such as polymer injection and endoscopic ligation have been developed. Polymer injection appears well suited for patients with active bleeding and for those with gastric varices but does not have advantages for chronic treatment aimed at variceal eradication. Endoscopic ligation appears at least as effective as conventional sclerotherapy for control of acute bleeding and prevention of rebleeding and is associated with few treatment induced complications. While endoscopic therapy will likely continue as the most commonly employed treatment for patients with hemorrhage from esophageal varices, newer methods with wider margins of safety and efficacy seem destined to supplement or replace conventional endoscopic sclerotherapy.

Decision for surgical management of perforation following endoscopic sphincterotomy.

Duodenal perforation resulting from endoscopic sphincterotomy (ES) is a serious complication with a high mortality. Diagnosis is often problematic and the optimum treatment is controversial. Eight proven perforations occurred following 441 ES at University of Colorado Hospital, a rate of 1.8 per cent. Physical and laboratory findings were of little diagnostic value, whereas plain abdominal radiographs showed evidence of perforation in 86 per cent. All patients were operated on promptly after diagnosis of perforation. Delay in diagnosis of perforation beyond 24 hours in six patients was associated with a high morbidity and two deaths. Analysis of published series confirmed that delay in diagnosis and delay in operation after perforation were associated with a higher mortality rate than early diagnosis with or without operation. We recommend operative intervention in all patients with clinical evidence of perforation following ES.

Techniques for endoscopic obliteration of esophageal varices.

Endoscopic treatment is widely accepted for both initial and subsequent definitive therapy in patients with hemorrhage from esophageal varices. Endoscopic sclerotherapy, once performed with rigid endoscopes in anesthetized patients, is now performed with flexible endoscopes in awake patients, who frequently return home immediately after the procedure. Such treatment does not confer a survival advantage in the early period after variceal hemorrhage, but serial treatment does result in a lower risk of recurrent hemorrhage and probably prolongs life. Primary treatment by endoscopic sclerotherapy appears to be equal or more effective than primary shunt therapy, even with a sclerotherapy failure rate of from 10 to 30 percent. In spite of such results, the incidence of rebleeding and treatment-related complications and the mortality among sclerotherapy-treated patients remain high. Newer forms of endoscopic treatment such as polymer injection and mechanical ligation have emerged in attempts to better the results obtained with sclerotherapy. Refinement of the technique for conventional sclerotherapy and the potential for increased effectiveness of the new techniques may yet result in improved and safer endoscopic therapy for bleeding esophageal varices.

Direct catheterization of the mesenteric vein: combined surgical and radiologic approach to the treatment of variceal hemorrhage.

Minilaparotomy and direct catheterization of the mesenteric vein for variceal embolization was attempted in 15 patients in whom medical and endoscopic treatment of variceal hemorrhage had failed. Hemorrhage was controlled immediately after the procedure in 11 patients. The 30-day survival rate was 60% (n = 9). The cause of death in six patients was variceal bleeding (n = 2), liver failure (n = 3), and respiratory failure (n = 1). The 6-month survival rate was 33% (n = 5), and the 1-year survival rate was 27% (n = 4). Bleeding recurred in 67% of surviving patients; however, fatal variceal bleeding occurred in only 22% (n = 2). Direct mesenteric vein catheterization allows simplified entry into the portal vein for embolization of bleeding esophageal or gastric varices. Early experience suggests that the results are similar to those of percutaneous transhepatic embolization, without the complications and technical demands of a transhepatic approach.

Increased secondary bile acids in a choledochal cyst. Possible role in biliary metaplasia and carcinoma.

Choledochal cysts are uncommon congenital or acquired lesions of the biliary tree. The incidence of biliary tract carcinoma in patients with choledochal cysts is 5-35 times greater than that of the general population. Factors responsible for the increased risk of carcinoma are unknown. The case of a young woman who underwent excision of a choledochal cyst 16 years after initial diagnosis and treatment by choledochocystduodenostomy is reported. Metaplasia of the epithelial lining of the cyst was found in the resected specimen. The relative composition of bile acids in cyst contents was as follows: lithocholate, 2%; deoxycholate, 88%; chenodeoxycholate, 5%; and cholate, 5%. Virtually all bile acids were recovered in unconjugated form. In contrast, the bile acid composition of hepatic bile was as follows: lithocholate, 0%; deoxycholate, 34%; chenodeoxycholate, 43%; and cholate, 23%. Bile acids were fully conjugated. These data suggest that stasis of bile within choledochal cysts contributes to bacterial overgrowth and generation of unconjugated secondary bile acids.

Spontaneous bile duct rupture in pregnancy.

Spontaneous bile duct rupture occurred in a 23-year-old who required emergency Cesarean section for fetal distress. This condition has not been reported in association with pregnancy. Only forty cases of spontaneous bile duct perforation in adults have been previously reported. Seventy percent of these perforations were related to biliary calculi. Sites of perforation were evenly distributed between common hepatic duct and common bile duct. Recommended treatment includes cholecystectomy, common bile duct exploration, T-tube placement, and Roux-En-Y ductal anastomosis if disruption is extensive.

Dieulafoy disease: arteriographic findings and treatment.

Dieulafoy disease is an unusual cause of massive and frequently fatal gastrointestinal tract hemorrhage that results from the erosion of a submucosal artery. Although the lesion has been found throughout the gastrointestinal tract, it most commonly occurs in the proximal stomach. Nine patients with this condition have been treated at the authors' institution during the past 5 years. The bleeding lesion was located before surgery with selective visceral arteriography in three patients. Rapid extravasation was demonstrated from an eroded but otherwise normal-appearing artery in all three cases. Hemorrhage was controlled successfully in one patient with selective embolization of the involved left gastric artery branch. The remaining eight patients were treated with surgical ligation.

Endoscopic ligation of esophageal varices.

One hundred consecutive patients with bleeding esophageal varices were treated with a new endoscopic ligating device that effects strangulation of varices using small elastic "O" rings. Treatments were continued after initial hospitalization to achieve variceal eradication. Follow-up ranged from 6 to 26 (mean: 15) months. Bleeding was controlled until discharge from hospital or death in 18 of 21 patients who were actively bleeding at index endoscopy. Overall, 26 patients died during the study, 12 during the index hospitalization. Cause of death was organ failure in 21, exsanguination in 3, and cancer in 2. Forty-one of 88 initial survivors experienced 72 episodes of recurrent bleeding (1 to 4 per patient). All but five rebleeds occurred before eradication. Sixty of 88 patients (68%) who survived index hospitalization had their varices eradicated. A median of 5 (1 to 12) treatments was required. Nine patients eventually had other forms of treatment for recurrent bleeding. Only 3 non-bleeding complications resulted from 462 endoscopic treatment sessions. We conclude that endoscopic ligation controls active variceal bleeding and eradicates varices with efficacy similar to that of sclerotherapy and with minimal risk of complications.

Endoscopic cholangiography and stone removal prior to cholecystectomy. A more cost-effective approach than operative duct exploration?

Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85,526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration.

Endoscopic sclerotherapy versus endoscopic variceal ligation: esophageal symptoms, complications, and motility.

Endoscopic sclerotherapy is an effective method for treating bleeding esophageal varices. However, a number of complications may limit its usefulness. A newly developed method for treating bleeding varices, endoscopic variceal ligation, that uses small rubber bands to occlude and eradicate the varices, may cause less damage to the esophagus. Twenty-eight patients (seven with no prior treatment, eight undergoing sclerotherapy, and 12 undergoing variceal ligation) were evaluated with a symptom questionnaire and esophageal manometry. The lower esophageal sphincter (LES) pressures in the three groups did not differ. The percent LES relaxation was significantly (p = 0.04) less in the sclerotherapy group than in the untreated group. Contraction waves in the esophageal body were not different in amplitude, duration, and propagation speed in the three groups. There was no increase in the amount of heartburn after either form of treatment. Eight of the nine sclerotherapy patients had a stricture after treatment that required dilatation, whereas none of the ligation patients had strictures. We conclude from this that early in the course of sclerotherapy, stricture formation is common, but any long-lasting adverse effect on esophageal function is minimal. We also conclude variceal ligation therapy causes less esophageal dysfunction and has fewer local complications. Thus, endoscopic variceal ligation may be a safer and more easily tolerated alternative to endoscopic sclerotherapy.

Endoscopic esophageal varix ligation: preliminary clinical experience.

Endoscopic variceal ligation (EVL) was performed in 14 consecutive patients who had recently bled from esophageal varices. None was actively bleeding at initial treatment. Ligations were accomplished using an endoscopic ligating device and an overtube. There were no procedural complications. 132 varix ligations were performed during 44 separate EVL sessions. Two patients were lost to follow-up and two died; neither death resulted from hemorrhage or treatment complications. Variceal rebleeding occurred in 2 noncompliant patients (14.3%) and was successfully controlled with emergent EVL. Ten patients achieved complete variceal eradication with from 1 to 6 (mean, 3.9) EVL sessions. No major complications (perforation, secondary bleeding, deep ulceration) resulted and there were no treatment failures. Follow-up of 10 surviving patients ranged from 240 to 370 (mean, 280) days. Endoscopic observation suggested that varices were obliterated by a process of mechanical strangulation, ischemia, superficial ulceration, and scar formation. Preliminary data indicate that EVL is a safe and effective treatment for esophageal varices.