Efficacy and safety of oral sulfate solution for bowel preparation in Japanese patients undergoing colonoscopy: Noninferiority-based, randomized, controlled study.

OBJECTIVES: To compare the efficacy and safety of oral sulfate solution administered using the same-day dose and the split-dose regimens with those of polyethylene glycol plus ascorbate solution, used for bowel preparation in Japanese patients undergoing colonoscopy. METHODS: This multicenter (n = 13), randomized, active-controlled, colonoscopist- and image evaluator-blinded, noninferiority study with parallel-group comparison recruited 632 patients from December 2018 to June 2019. Of these, 602 patients were divided into the oral sulfate solution same-day dose group (n = 200); oral sulfate solution split-dose group (n = 202); and polyethylene glycol plus ascorbate same-day dose group (n = 200). Differences in the efficacy rates between the polyethylene glycol plus ascorbate group and each oral sulfate solution group were calculated using the asymptotic method. The safety of the oral sulfate solution was evaluated, based on the occurrence of adverse events and reactions. RESULTS: Both oral sulfate solution protocols were confirmed as noninferior to the polyethylene glycol plus ascorbate protocol for bowel-cleansing. The occurrence of adverse reactions was significantly lower in the oral sulfate solution same-day dose group than in the polyethylene glycol plus ascorbate group (P = 0.010). The occurrence of adverse reactions was not significantly different between the oral sulfate solution split-dose and the polyethylene glycol plus ascorbate group. CONCLUSIONS: Oral sulfate solution is not only safe and efficacious but also not inferior to polyethylene glycol plus ascorbate solution (active control). It could be used for bowel preparation in Japanese patients scheduled for colonoscopy (Clinical trial registration number: NCT03794310).

Relationships between splenorenal shunt/portal vein diameter ratio and systemic hemodynamics in patients with liver cirrhosis.

OBJECTIVES: The purpose of this study was to investigate the relationships between the splenorenal shunt (SRS)/portal vein (PV) diameter ratio (SRS/PV ratio) and systemic hemodynamics in patients with liver cirrhosis. PATIENTS AND METHODS: Thirty-seven patients with SRS due to liver cirrhosis were included in this study. SRS was evaluated in the retropancreatic space on contrast-enhanced CT and the diameter was measured at the maximum point. Systemic hemodynamics was studied using a thermodilution catheter. RESULTS: The SRS/PV ratio showed a significant correlation with the cardiac index (p < 0.01), and showed an inverse correlation with the systemic vascular resistance index and the arteriovenous oxygen content difference [C(a-v)O2] (p < 0.01). The Child-Pugh score showed a correlation with the SRS/PV ratio (p < 0.01). The SRS/PV ratio was 0.89 ± 0.52, 1.02 ± 0.51, and 1.74 ± 0.50 in the Child-Pugh A, B, and C classes, respectively. The SRS/PV ratio in the Child-Pugh C class was significantly higher than those in classes A and B (p < 0.01). The plasma ammonia level was 75.3 ± 23.2 in the group with an SRS/PV ratio <1.0 (n = 19) versus 102.6 ± 34.8 in the group with an SRS/PV ratio ≥1.0 (n = 18), and the ratio of encephalopathy was 5% (1/19) in the group with an SRS/PV ratio <1.0 (n = 19) versus 50% (9/18) in the group with an SRS/PV ratio ≥1.0 (n = 18), respectively. The differences between the two groups were statistically significant (p < 0.01). CONCLUSIONS: We conclude that the increase in the SRS/PV ratio is accompanied by deteriorated liver function, hyperdynamic status, and narrowed C(a-v)O2.

Relationships between types of esophagogastric varices and systemic hemodynamics in patients with liver cirrhosis.

BACKGROUND/AIMS: To investigate the relationships between the types of esophagogastric varices and systemic hemodynamics in patients with liver cirrhosis. METHODOLOGY: Fifty-three patients with esophagogastric varices were included in this study and divided into 4 groups according esophagogastric varices type. Groups 1 and 2 were medium-size (F2-EV) and large-size esophageal varices (F3-EV), respectively. Groups 3 and 4 were medium-size (F2-GV) and large-size isolated gastric varices (F3-GV), respectively. RESULTS: The cardiac indexes (CI) were 3.61 +/- 0.76, 4.65 +/- 1.11, 3.78 +/- 0.69 and 4.65 +/- 0.75 in groups 1 to 4, respectively. CI in patients with F3 varices (groups 2 and 4) were significantly higher than those in patients with F2 varices (groups 1 and 3) (p<0.01). The systemic vascular resistances (SVRI) were 2140 +/- 623, 1463 +/- 473, 1916 +/- 420 and 1504 +/- 250 in groups 1 to 4, respectively. SVRI in patients with F3 varices were significantly lower than those in patients with F2 varices (p<0.01). Plasma ammonia levels (NH3) were 78 +/- 27, 162 +/- 153, 80 +/- 27 and 138 +/- 71 in groups 1 to 4, respectively. NH3 in patients with F3 varices were significantly higher than those in patients with F2 varices (p<0.01). The arterio-venous oxygen content differences (Ca-vO2) were 2.93 +/- 0.60, 2.53 +/- 0.55, 2.67 +/- 0.54 and 2.32 +/- 0.64 in groups 1 to 4, respectively. CONCLUSIONS: We conclude that the development of esophagogastric varices is accompanied by deteriorated liver function, hyperdynamic status, increased NH3 and narrowed Ca-vO2.

Hemodynamic effects of combined therapy using partial splenic embolization and transjugular retrograde obliteration for gastric varices with gastrorenal shunt.

BACKGROUND: The purpose of the present study was to investigate the short-term effects of combined therapy using partial splenic embolization (PSE) and transjugular retrograde obliteration (TJO) on the portal hemodynamics of gastric varices with a gastrorenal shunt. PATIENTS AND METHODS: Sixteen patients with gastric varices and a gastrorenal shunt were included in this study. Partial splenic embolization was applied 2 weeks before TJO. The portal blood flow was measured by an ultrasonic duplex Doppler system, and the wedged hepatic venous pressure (WHVP) was measured by hepatic venous catheterization, before and after the combined therapy. RESULTS: The complete obliteration of the gastrorenal shunt and gastric varices was revealed by retrograde shuntography and computed tomography after TJO in all cases. The WHVP before and just after PSE was 23 +/- 7 and 19 +/- 7 mmHg, respectively, showing a significant change (P < 0.01). The WHVP before and the day after TJO was 20 +/- 5 mmHg and 22 +/- 6 mmHg, respectively, showing a significant change (P < 0.01). There was no significant difference between the WHVP before and after the combined therapy. The portal venous flow volume before and after the combined therapy were 514 +/- 146 and 512 +/- 161 ml/min, respectively, showing no significant change. However, the splenic venous flow volume before and after the combined therapy was 319 +/- 131 and 179 +/- 113 ml/min, respectively, showing a significant change (P < 0.05). CONCLUSIONS: The WHVP did not change after the combined therapy of PSE and TJO. Partial splenic embolization contributed to protecting portal congestion after TJO. We conclude that the combined therapy using PSE and TJO is an effective treatment for gastric varices from the portal hemodynamic point of view.

Gastric varices with gastrorenal shunt: combined therapy using transjugular retrograde obliteration and partial splenic embolization.

OBJECTIVE: This study was prospectively conducted to evaluate the effectiveness of the combination of transjugular retrograde obliteration and partial splenic embolization in the treatment of gastric varices with gastrorenal shunt. SUBJECTS AND METHODS: Between November 2002 and December 2006, 14 patients with gastric varices and gastrorenal shunt were treated by combining transjugular retrograde obliteration and partial splenic embolization (group 1). These patients were compared with 19 patients with gastric varices and gastrorenal shunt treated by only transjugular retrograde obliteration (group 2) for the disappearance rate of gastric varices, the cumulative survival rate, and the occurrence rate of esophageal varices after transjugular retrograde obliteration. Partial splenic embolization was performed 7-14 days before transjugular retrograde obliteration. No significant differences were seen between the two groups in terms of demographic data, including age, sex, and Child-Pugh classification. RESULTS: The disappearance rate of gastric varices after transjugular retrograde obliteration was 100% in both groups. The 3-year cumulative survival rate after transjugular retrograde obliteration was 92% in group 1 and 95% in group 2. The 3-year cumulative occurrence rate of esophageal varices after transjugular retrograde obliteration was 9% in group 1 and 45% in group 2, a significant difference (p < 0.05). CONCLUSION: The findings of this study indicate that partial splenic embolization contributed to preventing portal congestion after transjugular retrograde obliteration. We conclude that the combination of transjugular retrograde obliteration and partial splenic embolization for gastric varices is more effective than transjugular retrograde obliteration only in the long-term prevention of esophageal varices after transjugular retrograde obliteration.

Short-term portal hemodynamic effects of partial splenic embolization for hypersplenism.

BACKGROUND/AIMS: The purpose of this study was to investigate the short-term effects of partial splenic embolization (PSE) for hypersplenism on portal hemodynamics and liver function. METHODOLOGY: Thirty-seven patients with hypersplenism were included in this study. RESULTS: The wedged hepatic venous pressure before and after PSE were 39 +/- 10 and 33 +/- 8 cmH2O, respectively, showing significant change (p < 0.01). The flow volumes of the splenic vein before and after PSE were 477 +/- 200 and 319 +/-187 mL/min, respectively, also showing significant change (p < 0.05). However, the flow volumes of the portal vein before and after PSE were 713 +/- 284 and 684 +/- 152 mL/min, respectively, showing no significant change. The blood laboratory parameters showed no significant change after PSE. PSE damaged neither the portal blood flow volume nor the liver function, although it improved the local hyperdynamic state in the splenic area and thrombocytopenia. CONCLUSIONS: In conclusion, PSE is a safe and effective treatment for hypersplenism from the portal hemodynamic point of view.

Hyperamylasemia induced by percutaneous papillary balloon dilatation for symptomatic choledocholithiasis.

BACKGROUND/AIMS: We investigated the relationship between percutaneous papillary balloon dilatation (PPBD) and hyperamylasemia after PPBD. METHODOLOGY: We studied the rate of pancreatitis and asymptomatic hyperamylasemia after PPBD for choledocholithiasis in 64 symptomatic patients. Pancreatitis was defined as epigastric pain combined with at least a 3-fold rise in serum amylase at 24 hours after PPBD. Asymptomatic hyperamylasemia was defined as a rise in serum amylase (normal range, 50 to 160 IU/L) without epigastric pain. RESULTS: The stones were successfully pushed out into the duodenum in all patients. Three patients developed post-PPBD pancreatitis, graded moderate in one and mild in two. Serum amylase values were elevated over the normal upper limit in 21 patients, 33%, over 3-fold in 10, 16% over 1000 IU/L in 6, 9%. Asymptomatic hyperamylasemia was observed in 18 patients. The amylase value after PPBD was elevated to more than 160 IU/L in 44% (17/39) of patients 80 years old or under vs. 16% (4/25) of patients older than 80 and in 23% (10/44) of patients with intrahepatic bile duct dilatation on admission vs. 55% (11/20) of patients without it, with a significant difference, respectively (p<0.05). The amylase value after PPBD was elevated to more than 1000 IU/L in 15% (6/39) of patients 80 years old or under vs. 0% (0/25) of patients older than 80 and in 29% (4/14) of patients with bile duct stones having a horizontal diameter of 8mm or smaller and 4% (2/50) of patients with stones larger than 8mm (p < 0.05 and p<0.01, respectively). CONCLUSIONS: We believe that postoperative continuous decompression of the bile duct by PPBD is reliable and that it contributed to the prevention of severe pancreatitis. We conclude that PPBD can be performed more safely in symptomatic patients older than 80 with choledocholithiasis with intrahepatic bile duct dilatation at the time of admission.

New transjugular retrograde obliteration without the use of ethanolamine oleate for gastric varices.

OBJECTIVES: The purpose of this study was to investigate the short-term effects of new transjugular retrograde obliteration (TJO) without the use of ethanolamine oleate for gastric varices with a gastrorenal shunt. PATIENTS AND METHODS: Ten patients with gastric varices and a gastrorenal shunt were included in this study. Through the right internal jugular vein, a 5- or 6-Fr angiographic catheter with an occlusive balloon was inserted into the gastrorenal shunt. The balloon was inflated to occlude the gastrorenal shunt blood flow. Microcoils were used to obliterate the main blood drainage routes of gastric vein, such as inferior phrenic and and/or retroperitoneal veins. Continuous injection of 0.5 to 1.0 mL of absolute ethanol and 2 to 15 mL of 50% glucose solution into the gastrorenal shunt was carried out under fluoroscopy. This procedure was repeated at 5-minute intervals until gastric varices were clearly visualized. 5% ethanolamine oleate with iopamidol (5% EOI) was not used as a sclerosant. RESULTS: TJO without 5% EOI technically succeeded in all cases. Total volumes of absolute ethanol and 50% glucose solution for the variceal obliteration were 6±4 and 56±46 mL, respectively. To produce thrombi in the gastric varices, the catheter had to be retained for 24 hours in 7 patients and for 48 hours in 3. The volumes of absolute ethanol and 50% glucose solution were 4±2 and 37±20 in the former 7 patients and 11±4 and 100±64 mL in the latter 3 patients, respectively. Only minor complications were observed, which were as follows: fever >38°C in 6 patients, epigastric pain in 8 patients, and temporary hypertension in 2 patients. Computed tomography scan and endoscopic examination 3 months after TJO revealed complete eradication of gastric varices in all cases. CONCLUSIONS: We conclude that new TJO without the use of 5% EOI is an effective and safe method for gastric varices.

Combination treatment of transjugular retrograde obliteration and endoscopic embolization for portosystemic encephalopathy with esophageal varices.

The treatment of chronic portosystemic encephalopathy with esophageal varices has not yet been established. We were able to control a case of chronic portosystemic encephalopathy with esophageal varices using a combination treatment of transjugular retrograde obliteration and endoscopic embolization. A 57-year-old man came to our hospital in a confused, apathetic and tremulous state. The grade of encephalopathy was II. The plasma ammonia level was abnormally elevated to 119 microg/dL, and the ICGR15 was 59%. Endoscopic examination revealed nodular esophageal varices with cherry-red spots. There were no gastric varices. Ultrasonography and CT revealed liver cirrhosis with a splenorenal shunt. We first applied endoscopic embolization for the esophageal varices before transjugular retrograde obliteration. We injected 5% ethanolamine oleate with iopamidol retrogradely into the esophageal varices and their associated blood routes under fluoroscopy and obliterated the palisade vein, the cardiac venous plexus and left gastric vein. Transjugular retrograde obliteration was performed 14 days after endoscopic embolization. Retrograde shunt venography visualized the splenorenal shunt and communicating route to the retroperitoneal vein. There was no communicating route to the azygos vein. After obliteration of the communicating route to the retroperitoneal vein with absolute ethanol, 5% ethanolamine oleate with iopamidol was injected into the splenorenal shunt as far as the root of the posterior gastric vein. After transjugular retrograde obliteration, the encephalopathy improved to grade 0 even without the administration of lactulose and branched-chain amino acid. The plasma ammonia level and ICGR15 were reduced to 62 microg/dL and 26%. We conclude that combination treatment of transjugular retrograde obliteration and endoscopic embolization is a rational, effective and safe treatment for chronic portosystemic encephalopathy complicated with esophageal varices.

Perioperative music therapy with a key-lighting keyboard system in elderly patients undergoing digestive tract surgery.

BACKGROUND/AIMS: It is important to minimize the perioperative mental dysfunction of elderly patients undergoing surgery and to avoid lowering their coping skills postoperatively. Music therapy for digestive tract surgery has yet not been explored. METHODOLOGY: We evaluated perioperative music therapy using a simple key-lighting keyboard system in 37 elderly patients who underwent digestive tract surgery (Group A) compared with 13 patients who were not applied music therapy (Group B). RESULTS: On the first day after surgery there were no general hemodynamic changes after music therapy. There were no significant changes in the Philadelphia Geriatric Center morale scale and the Yesavage depression scale between the day before surgery and 7 POD in both groups. The self-assessed visual analogue health scale and the number connection test worsened significantly from 58.9+/-14.6 and 159+/-47 to 42.3+/-14.6 and 199+/-51 (p<0.05), respectively, over this time in Group B, but it did not worsen significantly in Group A. The happiness score increased significantly from 3.9+/-1.1 to 4.6+/-1.2 (P<0.05) over this time in Group A, but it did not increase significantly in Group B. CONCLUSIONS: We conclude that the music therapy with a key-lighting keyboard system in elderly patients does not change postoperative hemodynamics and helps to maintain perioperative mental functioning.

Combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration for complicated gastroesophageal varices.

The treatment of complicated gastroesophageal varices with a gastrorenal shunt and portal hypertensive gastropathy has not yet been established. We were able to control a case of complicated large gastroesophageal varices with gastrorenal shunt and portal hypertensive gastropathy using a combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration. We first applied partial splenic embolization to reduce the hyperdynamic cycle of portal hypertension and to treat thrombocytopenia. We secondarily applied endoscopic embolization for the esophageal varices. Transjugular retrograde obliteration was performed for the gastric varices 14 days after endoscopic embolization. The wedged hepatic venous pressure had not changed after transjugular retrograde obliteration. After the combination treatment, the gastroesophageal varices were successfully obliterated, but portal hypertensive gastropathy did not worsen. The platelets count, arterial ketone body ratio and ICGR15 were improved. Partial splenic embolization was useful to protect side effects of endoscopic embolization and transjugular retrograde obliteration. We conclude that the combination treatment of partial splenic embolization, endoscopic embolization and transjugular retrograde obliteration is a rational, effective and safe treatment for complicated gastroesophageal varices with gastrorenal shunt and portal hypertensive gastropathy.

Transjugular Retrograde Obliteration prior to Liver Resection for Hepatocellular Carcinoma Associated with Hyperammonemia due to Spontaneous Portosystemic Shunt.

A 67-year-old woman had hepatocellular carcinoma (HCC) measuring 3.7 cm at S8 of the liver with hyperammonemia due to a spontaneous giant mesocaval shunt. Admission laboratory data revealed albumin, 2.9 g/dL; total bilirubin, 1.3 mg/dL; plasma ammonia level (NH3), 152 g/dL; total bile acid (TBA) 108.5 µmoL/L; indocyanine green retention rate at 15 min (ICG15), 63%. Superior mesenteric arterial portography revealed a hepatofugal giant mesocaval shunt, and the portal vein was not visualized. Before surgery, transjugular retrograde obliteration (TJO) for the mesocaval shunt was attempted to normalize the portal blood flow. Via the right internal jugular vein, a 6 F occlusive balloon catheter was inserted superselectively into the mesocaval shunt. The mesocaval shunt was successfully embolized using absolute ethanol and a 50% glucose solution. Eleven days after TJO, NH3, TBA, and ICG15 decreased to 56, 44, and 33, respectively. Superior mesenteric arterial portography after TJO revealed a hepatopetal portal flow. Partial hepatectomy of S8 was performed 25 days after TJO. The subsequent clinical course showed no complications, and the woman was discharged on postoperative day 14. We conclude that the combined therapy of surgery and TJO is an effective means of treating HCC with hyperammonemia due to a spontaneous portosystemic shunt.

Effects of combined therapy using partial splenic embolization and transjugular retrograde obliteration on systemic hemodynamics in patients with gastric varices and a splenorenal shunt.

OBJECTIVES: The purpose of this study was to investigate the effects of combined therapy using partial splenic embolization (PSE) and transjugular retrograde obliteration (TJO) on the systemic hemodynamics of gastric varices with a splenorenal shunt. PATIENTS AND METHODS: Eleven patients having gastric varices with a splenorenal shunt were included in this study. PSE was applied 2 weeks before TJO. Systemic hemodynamic studies were performed before and 22 ± 12 months after the combined therapy. RESULTS: Complete obliteration of the splenorenal shunt and gastric varices was revealed by retrograde shuntography and computed tomography after TJO in all cases. The cardiac index (1/min/m2) before and after the combined therapy was 3.98 ± 0.85 and 4.05 ± 0.78, respectively. The systemic vascular resistance index (dynes s/cm5/m2) before and after the combined therapy was 1887 ± 450 and 1837 ± 4621, respectively. They showed no significant change. The arterio-venous oxygen content difference (vol%) before and after the combined therapy was 2.55 ± 0.55 and 3.21 ± 0.90, respectively, showing a significant change (P<0.05). The splenic venous flow volume before and after the combined therapy was 307 ± 158 and 166 ± 78 mL/min, respectively, showing a significant change (P<0.05). CONCLUSIONS: : We conclude that the combined therapy using PSE and TJO reduces the splenic venous flow and stops the splenorenal shunt flow, which improves the arterio-venous oxygen content difference.

A case of a gastric submucosal tumor treated with combined therapy using superselective TAE and endoscopic local resection.

The case was a 76-year-old female, who was noted to have a gastric submucosal tumor 25 mm in size located at the lesser curvature of the gastric body. Computed tomography revealed that the tumor was located near the coronary loop between the left and right gastric arteries. On the day before endoscopic local resection, abdominal angiography was performed and it revealed that the tumor was supplied by the left and right gastric arteries. Superselective transarterial embolization of the left and right gastric arteries around the tumor was performed to prevent accidental bleeding during the endoscopic procedure. Endoscopic local resection using full-thickness resection and submucosal dissection techniques was performed under general anesthesia. The tumor was completely resected without accidental bleeding. A gastric wall defect was closed using metallic clips and loop snares. Histologic examination revealed that the tumor was a low-risk gastrointestinal stromal tumor. We suggest that the combined therapy using superselective transarterial embolization and endoscopic local resection is an optional safe method for the treatment of gastric submucosal tumors.

Simultaneous laparoscopic cholecystectomy and percutaneous papillary balloon dilatation for cholecystocholedocholithiasis.

AIM: We evaluated the effectiveness of simultaneous laparoscopic cholecystectomy (LC) and percutaneous papillary balloon dilatation (PPBD) under general anesthesia in the treatment of cholecystocholedocholithiasis in elderly patients in poor general condition. PATIENTS AND METHODS: We treated 17 patients (group 1) with LC and PPBD as separate procedures and 21 patients (group 2) with simultaneous LC and PPBD under general anesthesia. We compared the success rates, complications, durations of percutaneous transhepatic biliary drainage (PTBD) and hospital stays of the 2 groups. RESULTS: The stones were successfully pushed out into the duodenum in all patients in both groups. All patients in group 1 complained of transient pain caused by balloon dilatation of the papilla. In group 2, PPBD was performed comfortably in all patients because of the general anesthesia. The mean postoperative stay of patients in both groups was 9 days. The overall duration of the hospital stay and the duration of PTBD were 28 +/- 5 and 25 +/- 9 days, respectively, in group 1, and 18 +/- 7 and 15 +/- 8 days in group 2 (significant difference: p < 0.01 and p < 0.01, respectively). There were no deaths or major complications, although transient hyperamylasemia occurred in both groups. CONCLUSIONS: Cholecystocholedocholithiasis can be treated by simultaneous LC and PPBD under general anesthesia without laparotomy, sphincterotomy, choledochotomy or the discomfort arising from papillary dilatation.

Appendiceal stump abscess as an early complication of laparoscopic appendectomy: report of a case.

We report the case of an appendiceal stump abscess that was treated by relaparoscopy 4 days after a laparoscopic appendectomy (LA). Surgeons should be aware of the possibility of appendiceal stump abscess occurring as an early complication of LA. When performing LA, the appendiceal stump should be as short as possible, and the ligation of the root of the appendix should be only moderately tight, so as not to cause ischemic change of the stump, indicated by discoloration or edema. The insertion of a drain for monitoring exudate, as well as sonography, and relaparoscopy are helpful for diagnosing and treating this complication.