The creation of transjugular intrahepatic portosystemic shunt (TIPS) is a widely performed technique to relieve portal hypertension, and to manage recurrent variceal bleeding and refractory ascites in patients where medical and/or endoscopic treatments have failed. However, portosystemic shunt creation can be challenging in the presence of chronic portal vein occlusion. In this case report, we describe a minimally invasive endovascular mesocaval shunt creation with transsplenic approach for the management of recurrent variceal bleeding in a portal hypertension patient with intra- and extrahepatic portal vein occlusion.
Adolescent ; Chronic Disease ; Esophageal and Gastric Varices/complications ; Esophageal and Gastric Varices/diagnostic imaging ; Esophageal and Gastric Varices/therapy ; Female ; Gastrointestinal Hemorrhage/complications ; Gastrointestinal Hemorrhage/diagnostic imaging ; Gastrointestinal Hemorrhage/therapy ; Humans ; Jejunum/pathology ; Portacaval Shunt, Surgical ; Portal Vein/diagnostic imaging ; Portal Vein/pathology ; Portal Vein/surgery ; Tomography, X-Ray Computed ; Treatment Outcome ; Venous Thrombosis/complications ; Venous Thrombosis/diagnostic imaging ; Venous Thrombosis/therapy

OBJECTIVETo investigate the clinical effect of fast-track surgery combined with Chinese medicine treatment in devascularization operation for cirrhotic esophageal varices.

METHODSSeventy-two patients with cirrhotic esophageal varices were selected from January 2009 to June 2013, and randomly assigned to a conventional group and a fast-track group (fast-track surgery combined with Chinese medicine treatment) using a randomized digital table, 36 cases in each group. Operation and anesthesia recovery time, postoperative hospitalization and quality of life were recorded and compared between groups during the perioperative period.

RESULTSCompared with the conventional group, the fast-track group had longer operation time (253.6±46.4 min vs. 220.6±51.0 min) and anesthesia recovery time (50.5±15.9 min vs. 23.5±9.6 min; P<0.01); less bleeding (311.3±46.8 mL vs. 356.2±57.5 mL; P<0.01) and less transfusion (1932.3±106.9 mL vs. 2045.6±115.4 mL; P<0.01); as well as faster recovery of gastrointestinal function, shorter postoperative hospitalization and higher quality of life. There were no serious postoperative complications and no further bleeding occurred.

CONCLUSIONFast-track surgery combined with Chinese medicine treatment is a safe and feasible approach to accelerate the recovery of patients with cirrhotic portal hypertension in perioperative period of devascularization operation.

Adult ; Aged ; Anesthesia Recovery Period ; Blood Loss, Surgical ; Blood Transfusion ; Chronic Disease ; Esophageal and Gastric Varices ; surgery ; therapy ; Female ; Humans ; Length of Stay ; Liver Cirrhosis ; complications ; Male ; Medicine, Chinese Traditional ; Middle Aged ; Operative Time ; Postoperative Complications ; Postoperative Period ; Quality of Life ; Splenectomy

In North Korea, the prevalence of hepatitis B is high due to natural factors, gaps in vaccination, and the lack of antiviral treatment. Aid projects are urgently needed, however impeded by North Korea's political and economical situation and isolation. The feasibility of a joint North Korean and German humanitarian hepatitis B prevention program was assessed. Part 1: Hepatitis B vaccination catch-up campaign. Part 2: Implementation of endoscopic ligation of esophageal varices (EVL) by trainings in Germany and North Korea. By vaccinating 7 million children between 2010 and 2012, the hepatitis B vaccination gap was closed. Coverage of 99.23% was reached. A total of 11 hepatitis B-induced liver cirrhosis patients (mean age 41.1 yr) with severe esophageal varices and previous bleedings were successfully treated by EVL without major complications. A clinical standard operating procedure, a feedback system and a follow-up plan were developed. The bi-modal preventive strategy was implemented successfully. Parts of the project can serve as an example for other low-income countries, however its general transferability is limited due to the special circumstances in North Korea.
Adult ; Combined Modality Therapy/methods/statistics & numerical data ; Democratic People's Republic of Korea/epidemiology ; Esophageal and Gastric Varices/*embryology/*surgery ; Esophagoscopy/statistics & numerical data ; Feasibility Studies ; Female ; Hepatitis B/*epidemiology/*prevention & control ; Hepatitis B Vaccines/*administration & dosage ; Humans ; Male ; Mass Vaccination/*statistics & numerical data ; Middle Aged ; Prevalence ; Retrospective Studies ; Risk Factors ; Secondary Prevention/methods/statistics & numerical data ; Treatment Outcome

This report describes two non-cirrhotic patients with portal vein thrombosis who underwent successful balloon occlusion retrograde transvenous obliteration (BRTO) of gastric varices with a satisfactory response and no complications. One patient was a 35-year-old female with a history of Crohn's disease, status post-total abdominal colectomy, and portal vein and mesenteric vein thrombosis. The other patient was a 51-year-old female with necrotizing pancreatitis, portal vein thrombosis, and gastric varices. The BRTO procedure was a useful treatment for gastric varices in non-cirrhotic patients with portal vein thrombosis in the presence of a gastrorenal shunt.
Adult ; Balloon Occlusion/*methods ; Crohn Disease/surgery ; Esophageal and Gastric Varices/*therapy ; Female ; Humans ; *Mesenteric Veins ; Middle Aged ; Pancreatitis, Acute Necrotizing/complications ; *Portal Vein ; Venous Thrombosis/*complications

BACKGROUND/AIMS: To investigate the efficacy and longterm outcome of esophageal variceal ligation (EVL) plus propranolol in comparison with propranolol alone for the primary prophylaxis of esophageal variceal bleeding. METHODS: A total of 504 patients were retrospectively enrolled in this study. 330 patients were in propranolol group (Gr1) and 174 patients were in EVL plus propranolol group (Gr2). The endpoints of this study were esophageal variceal bleeding and mortality. Association analyses were performed to evaluate bleeding and mortality between Gr1 and Gr2. RESULTS: EVL was more applied in patients with high risk, such as large-sized varices (F2 or F3) or positive red color signs. Total 38 patients had bleeds, 32 in Gr1 and 6 in Gr2. The cumulative probability of bleeding at 120 months was 13% in Gr1 versus 4% in Gr2 (P=0.04). The predictive factors of variceal bleeding were red color signs (OR 2.962, P=0.007) and the method of propranolol plus EVL (OR 0.160, P=0.000). 20 patients died in Gr1 and 12 in Gr2. Mortality rates are similar in the two groups compared, 6.7% in Gr1 and 6.9% in Gr2. The cumulative probability of mortality at 120 months was not significantly different in the two groups (7% in Gr1, 12% in Gr2, P=0.798). The prognostic factors for mortality were age over 50 (OR 5.496, P=0.002), Child-Pugh class B (OR 3.979, P=0.001), and Child-Pugh class C (OR 10.861, P=0.000). CONCLUSIONS: EVL plus propranolol is more effective than propranolol alone in the prevention of the first variceal bleeding in patients with liver cirrhosis.
Adrenergic beta-Antagonists/*therapeutic use ; Adult ; Aged ; Esophageal and Gastric Varices/*pathology ; Female ; Follow-Up Studies ; Gastrointestinal Hemorrhage/*drug therapy/mortality/surgery ; Humans ; Ligation ; Liver Cirrhosis/etiology ; Logistic Models ; Male ; Middle Aged ; Odds Ratio ; Proportional Hazards Models ; Propranolol/*therapeutic use ; Retrospective Studies ; Severity of Illness Index ; Survival Rate

OBJECTIVE: To evaluate the feasibility of percutaneous access via the recanalized paraumbilical vein for varix embolization. MATERIALS AND METHODS: Between July 2008 and Jan 2014, percutaneous access via the recanalized paraumbilical vein for varix embolization was attempted in seven patients with variceal bleeding. Paraumbilical vein puncture was performed under ultrasonographic guidance, followed by introduction of a 5-Fr sheath. We retrospectively evaluated the technical feasibility, procedure-related complications, and clinical outcomes of each patient. RESULTS: Recanalized paraumbilical vein catheterization was performed successfully in all patients. Gastroesophageal varix embolization was performed in six patients, and umbilical varix embolization was performed in one patient. Embolic materials used are N-butyl cyanoacrylate (n = 6) and coil with N-butyl cyanoacrylate (n = 1). There were no procedure-related complications. One patient underwent repeated variceal embolization 6 hours after initial procedure via recanalized paraumbilical vein, due to rebleeding from gastric varix. CONCLUSION: Percutaneous access via the paraumbilical vein for varix embolization is a simple alternative in patients with portal hypertension.
Adult ; Child ; Embolization, Therapeutic ; Enbucrilate/therapeutic use ; Esophageal and Gastric Varices/radiography/*therapy ; Female ; Humans ; Intracranial Hemorrhages/etiology ; Male ; Middle Aged ; Retrospective Studies ; Tomography, X-Ray Computed ; Treatment Outcome ; Umbilical Veins/surgery/ultrasonography

We present a case of a patient with rapid deterioration of esophageal varices caused by portal hypertension accompanied by a large arterioportal shunt that developed after radiofrequency ablation of hepatocellular carcinoma. We used n-butyl cyanoacrylate (NBCA) as an embolic material to achieve pinpoint embolization of the shunt, because the microcatheter tip was 2 cm away from the shunt site. Under hepatic arterial flow control using a balloon catheter, the arterioportal shunt was successfully embolized with NBCA, which caused an improvement in the esophageal varices.
Aged ; Arteriovenous Fistula/etiology/radiography/*therapy ; Carcinoma, Hepatocellular/*surgery ; Catheter Ablation/*adverse effects ; Embolization, Therapeutic/*methods ; Enbucrilate/*therapeutic use ; Esophageal and Gastric Varices/etiology/*therapy ; Hepatic Artery/*abnormalities/radiography ; Humans ; Liver Neoplasms/*surgery ; Male ; Portal Vein/*abnormalities/radiography

OBJECTIVE: To compare endoscopic variceal ligation (EVL) with propranolol for prophylaxis of first variceal bleeding. METHODS: We chose 168 patients with cirrhosis and esophageal varices in our hospital and allocated them to EVL and propranolol groups. Treatment effectiveness and safety in the 2 groups were observed. RESULTS: he parameters of two groups were similar before therapy. Follow-up period was 8-36 months. Variceal bleeding occurred in 24 (28.6%) of the EVL group and in 20 (23.9%) of the propranolol group (P>0.05). Overall mortality and death related to bleeding were similar (21.4% vs 17.9%; 7.1% vs 6.0%, P>0.05). Adverse events related to EVL were 43 (3 of them life-threatening) compared to 16 in the propranolol group (51.19% vs 19.05%, P<0.05). CONCLUSION Propranolol may be the better choice in prophylaxis of variceal bleeding with similar effects and lower adverse events than with EVL.
Aged ; Endoscopy, Gastrointestinal ; methods ; Esophageal and Gastric Varices ; complications ; drug therapy ; surgery ; therapy ; Female ; Gastrointestinal Hemorrhage ; etiology ; prevention & control ; Humans ; Ligation ; methods ; Liver Cirrhosis ; complications ; Male ; Middle Aged ; Propranolol ; therapeutic use

Intravariceal injection of N-butyl-2-cyanoacrylate is widely used for the hemostasis of bleeding gastric varices, but not routinely for esophageal variceal hemorrhage because of various complications such as pyrexia, bacteremia, deep ulceration, and pulmonary embolization. We report a rare case of esophageal sinus formation after cyanoacrylate obliteration therapy for uncontrolled bleeding from post-endoscopic variceal ligation (EVL) ulcer. A 50-year-old man with alcoholic liver cirrhosis presented with hematemesis. Emergent esophagogastroscopy revealed bleeding from large esophageal varices with ruptured erosion, and bleeding was initially controlled by EVL, but rebleeding from the post-EVL ulcer occurred at 17th day later. Although we tried again EVL and the injections of 5% ethanolamine oleate at paraesophageal varices, bleeding was not controlled. Therefore, we administered 1 mL cyanoacrylate diluted with lipiodol and bleeding was controlled. Three months after the endoscopic therapy, follow-up endoscopy showed medium to large-sized esophageal varices and sinus at lower esophagus. Barium esophagography revealed an outpouching in esophageal wall and endoscopic ultrasonography demonstrated an ostium with sinus. It is noteworthy that esophageal sinus can be developed as a rare late complication of endoscopic cyanoacrylate obliteration therapy.
Cyanoacrylates/administration & dosage/*adverse effects ; *Embolization, Therapeutic ; Endoscopy, Digestive System ; Esophageal and Gastric Varices/complications/*diagnosis/therapy ; Esophagus/radiography/ultrasonography ; Ethiodized Oil/therapeutic use ; Gastrointestinal Hemorrhage/surgery/*therapy ; Humans ; Ligation ; Liver Cirrhosis, Alcoholic/*complications/diagnosis ; Male ; Middle Aged ; Tissue Adhesives/administration & dosage/*adverse effects ; Ulcer/*complications

We report herein a case of 35-years-old woman in whom portal hypertension (esophageal varix and splenomegaly) developed after 12 cycles of oxaliplatin based adjuvant chemotherapy for rectal cancer. She was transferred for the evaluation of etiology of new-onset portal hypertension. The esophageal varix and splenomegaly were absent before the oxaliplatin based adjuvant chemotherapy. Thorough history taking and serological exam revealed no evidence of chronic liver disease. Liver biopsy was done and there was no cirrhotic nodule formation. Instead, perivenular fibrosis was noted. Considering new development of esophageal varices and splenomegaly after 12 cycles of oxaliplatin-based adjuvant chemotherapy, we could conclude that portal hypertension in this patient were due to sinusoidal injury by oxaliplatin. Finally, we recommend regular follow-up with endoscopy and radiologic examination for checking the development of varices and for screening of varices and splenomegaly in patients with colo-rectal cancer who receive oxaliplatin-based chemotherapy.
Adult ; Antineoplastic Agents/*adverse effects/therapeutic use ; Chemotherapy, Adjuvant ; Esophageal and Gastric Varices/chemically induced ; Female ; Fibrosis ; Humans ; Hypertension, Portal/chemically induced/*diagnosis ; Liver/pathology ; Organoplatinum Compounds/*adverse effects/therapeutic use ; Positron-Emission Tomography ; Rectal Neoplasms/*drug therapy/surgery ; Splenomegaly/chemically induced ; Tomography, X-Ray Computed