Chronology of histological changes after band ligation of esophageal varices in humans.

BACKGROUND AND STUDY AIMS: While the histological effects of endoscopic sclerotherapy in humans have been extensively described, the effects of endoscopic ligation have been reported in only two cases. The purpose of this study was to reconstruct the chronological sequence of histological changes after ligation of esophageal varices. PATIENTS AND METHODS: Autopsy specimens from six patients who received ligation of varices from nine hours to 22 months ante-mortem were evaluated for gross and microscopic changes. RESULTS: Early after ligation, the appearance was that of a polyp with its base compressed by the band. Variceal thrombosis was seen on day 2. Varying degrees of ischemic necrosis of the polyp were present on days 0-5. If the bands did not remain in situ for two days (premature loss), necrosis of the polyp and dilated variceal vessels were seen. On day 22, superficial ulcers were observed. After complete healing, fibrosis was seen in the submucosa. CONCLUSIONS: The changes seen in the present study are similar to those described in animals. The delay in ulcer healing, compared with the gross changes reported during follow-up endoscopic examinations, may be related to the severity of the underlying illness and the compromised immune status of patients in the present series.

Management of esophageal varices.

Of the consequences of portal hypertension, varices carry the most sinister implications. During life, the risk of hemorrhage from varices hangs like a "sword of Damocles" over a cirrhotic's head. Hemorrhage, when it occurs, expedites the patient's demise, or often itself proves to be the terminal event. Compared with other causes of gastrointestinal bleeding, hemorrhage from varices is most severe, and the available therapies, over the long-term, are the least definitive.

A randomized comparison of dilatation alone versus dilatation plus laser in patients receiving chemotherapy and external beam radiation for esophageal carcinoma.

Most patients with carcinoma of the esophagus have advanced disease at presentation. Since cure is usually not possible, the goal of treatment is the palliation of dysphagia. Palliative modalities include bougies, balloons, stents, tumor probe, laser, surgery, chemotherapy, and radiation. In recent years, combined chemotherapy and radiation has shown promising results. However, the relief of dysphagia is slow and frequently incomplete. We compared the effectiveness of dilatation alone versus dilatation plus Nd-YAG laser therapy for the relief of dysphagia while assessing the role of chemotherapy and radiation as an adjunct to surgery. Fifteen patients with squamous cell carcinoma of esophagus who were deemed fit for intensive chemotherapy and radiation were randomized to receive either dilatation alone (N = 7) or dilatation plus laser (N = 8); the end-point for initial success was the passage of a 45 French Savary dilator, and the relief of dysphagia. At entry, 13 of these 15 patients were judged potentially resectable. However, after chemotherapy and radiation, only 3 of 13 (20%) patients could be offered surgery; the remainder were considered too poor a surgical risk. Follow-up was for 30 months, or until death. Further dilatations were performed as needed for relief of dysphagia. No difference was observed between the laser plus dilatation and the dilatation alone group with respect to the degree of dysphagia, weight record, quality of life index (Karnofsky score), or mortality rate. Our results indicate that in patients undergoing chemotherapy and radiation for esophageal carcinoma, dilatation alone provides adequate palliation of dysphagia, and in these patients, chemotherapy and radiation is a poor adjunct to surgical treatment.

An objective end point for dilation improves outcome of peptic esophageal strictures: a prospective randomized trial.

BACKGROUND: The usual end point for defining success of dilation is subjective (relief of dysphagia). In most patents thus managed strictures recur. We asked whether an objective end point would improve outcome. METHODS: After dilation to 15 mm, patients were randomized into subjective and objective groups. In subjective group patients, end point for dilation was alleviation of dysphagia; in objective group patients, passing the 12 mm barium pill test. Objective group patients who failed underwent redilation until they passed the pill or failed three times. During Part 1 of the study, patients received ranitidine, during Part 2 they received omeprazole. RESULTS: In part 1, dysphagia was alleviated in 7 of 8 subjective group patients. Only 2 of 10 objective group patients passed the pill test and no additional patients passed after 3 sessions, although most had no dysphagia. In Part 2, 19 subjective groups and 15 objective group patients were studied. End point was not achieved in 3 objective group patients. Over long-term follow-up, objective group patients had less recurrent dysphagia (p = 0.02) and required fewer redilation sessions (p < 0.05). Overall, the pill test correlated with the presence or absence of dysphagia (P < 0.001). Predictive value of passing the pill 1 week after dilation for the absence of dysphagia was 100%, but of failing the pill test and the presence of dysphagia was only 18%. CONCLUSIONS: Achieving an objective end point reduces stricture recurrence and the need for subsequent dilation. Initial subjective improvement does not predict long-term success.

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: a multicenter prospective randomized trial.

Patients who have bled from varices remain at risk for rebleeding. There is interest in methods that would enable rapid eradication of varices. The present trial was designed to study whether combining ligation with sclerotherapy will allow quicker eradication of varices than either modality alone. Patients with bleeding esophageal varices were randomized into ligation or combination therapy groups. Patients in the ligation group were treated with endoscopic rubber band ligation alone. In combination group patients, each variceal column was ligated distally and 1 mL of ethanolamine was injected proximal to each ligated site. Subsequent treatment sessions were at 7- to 14-day intervals until varices were eradicated. The clinical and endoscopic characteristics of 25 patients in the ligation group were similar to those of 22 patients in the combination group. Follow-up was up to 30 months. Active bleeding was controlled in 100% of patients in the ligation group and 75% of those in combination group (P = NS). It took 3.3 +/- .4 (range, 1-7) sessions to eradicate varices with ligation and 4.1 +/- .6 (1-7) with combination therapy (P = NS). Survival (four deaths in ligation group, 8 in combination group), rebleeding rate (25% vs. 36%), and varix recurrence (16% vs. 23%) also were similar. There were more complications with combination therapy, including deep ulcers (65% vs. 20%; P < .05); dysphagia (30% vs. 0%; P < .05), with three strictures requiring dilation; and pain (30% vs. 10%; P = NS). Our results show that sclerotherapy combined with ligation offers no benefit over ligation alone. The higher complication rate with combination therapy does not warrant this approach.

The Saeed Six-Shooter: a prospective study of a new endoscopic multiple rubber-band ligator for the treatment of varices.

BACKGROUND AND STUDY AIMS: Rubber-band ligation is superior to sclerotherapy, and is considered to be the endoscopic treatment of choice for bleeding varices. The single-shot mechanism of the ligation device generally used is inherently inefficient, and makes the procedure tedious. It also requires overtube placement, associated with discomfort and complications. This study describes the Saeed Six-Shooter, a multiple ligation device. PATIENTS AND METHODS: Twenty-seven consecutive patients with variceal bleeding were prospectively studied. After initial endoscopic ligation, subsequent sessions were every 7-10 days. The parameters studied were the ease of use, the ability to control active bleeding and eradicate varices, survival, and complications. RESULTS: Active bleeding was controlled in all seven (100%) patients. Esophageal varices were eradicated in 70% (3.2 +/- 1.2 sessions), and gastric varices in 88% of patients (2 +/- 1.2 sessions). Five patients re-bled, two from esophageal varices, two from gastric varices, and one from treatment-induced ulcer. There were four deaths, none due to exsanguination. A single complication, esophageal stricture, resolved with balloon dilation. Intubation was no more difficult with the endoscope loaded with the Six-Shooter than with the endoscope alone (P > 0.3). Six ligations were performed in 39% of cases within 60 seconds, and in 74% of cases within 90 seconds. For gastric varices, the device was effectively used with the endoscope retroflexed. CONCLUSIONS: The Saeed Six-Shooter is a safe and efficient instrument for the endoscopic ligation of varices, and has overcome the limitations of the single-shot ligator.

Hepatosplenic candidiasis in non-neutropenic patients: a case report and literature survey.

Hepatosplenic candidiasis is an increasingly recognized infectious complication in patients who have an underlying malignancy and/or have chemotherapy-induced neutropenia. Only six cases of hepatosplenic candidiasis in non-neutropenic patients have been described to date, to which we add a seventh. Our patient had many of the classically described manifestations of hepatosplenic candidiasis, and responded well to therapy with amphotericin B. Retrospective comparative analysis of cases of hepatosplenic candidiasis reveals that non-neutropenic patients seem to respond well to medical therapy that is less intensive than that given to neutropenic subjects (total dosage of amphotericin B 0.84 g vs. 2.70 g, respectively) and tend to have a better prognosis (mortality rate 33% vs. 44%, respectively).

Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: a prospective randomized trial.

BACKGROUND AND STUDY AIMS: Rebleeding after initial endoscopic hemostasis remains an important determinant of poor prognosis in patients with ulcer hemorrhage. Prospective identification of patients who are at high risk for rebleeding, and directing further therapeutic measures in these patients, would be expected to improve the prognosis. PATIENTS AND METHODS: We used our previously described scoring system (the Baylor Bleeding Score) to identify patients at increased risk for rebleeding after initially successful endoscopic hemostasis, and randomized them into retreatment and no-retreatment groups. Patients in the retreatment group received additional endoscopic heat probe therapy at 24 hours, the follow-up was otherwise similar. Forty men with major ulcer hemorrhage were randomized, 19 to the retreatment group and 21 to the no-retreatment group. Patients in the two groups had similar Baylor Bleeding Scores, blood transfusion needs (median three vs. two units), ulcer sites (duodenal 57% vs. 43%), stigmata of hemorrhage (actively bleeding 68% vs 67%), and received similar initial endoscopic therapy (heat probe 240 J vs. 300 J). Patients in the retreatment group received additional heat probe therapy (median 165 J) at 24 hours. RESULTS: Rebleeding, requiring significantly more blood transfusion, occurred in 24% of the no-retreatment group patients compared to none of the retreatment group patients (p < 0.05). CONCLUSIONS: Endoscopic retreatment after successful initial endoscopic hemostasis prevents rebleeding in highrisk patients with ulcer bleeding.

Technology assessment status evaluation: balloon dilation of gastrointestinal tract strictures. American Society for Gastrointestinal Endoscopy.

Balloon dilation is an acceptable modality for the dilation of stenoses at various sites in the gastrointestinal tract. In the esophagus its reported efficacy and safety is similar to bougienage; in other sites it offers an alternative to surgical treatment, in most cases as the definitive therapy.

Technology assessment status evaluation: monitoring equipment for endoscopy. American Society for Gastrointestinal Endoscopy.

An understanding of the principles and limitations of monitoring devices is valuable for their appropriate use and interpretation. Reliable monitoring de available as an adjunct to skilled personnel to detect changes in patient condition during endoscopy. Combination units that provide pulse oximetry, automated sphygmomanometry and ECG monitoring appear to be the most convenient and cost effective products.

Technology assessment status evaluation: disposable endoscopic accessories. American Society for Gastrointestinal Endoscopy.

Data supporting the preferential use of disposable endoscopic accessories is limited. These devices have been widely disseminated without careful evaluation of their impact on the environment and medical costs. In addition, current facility reimbursement for endoscopic procedures does not adequately cover the costs of these accessories. Re-use of accessories labelled "for single use only" as a potential means to reduce costs has not been carefully evaluated. More prospective data comparing the efficacy, safety, and cost effectiveness of disposable versus reusable accessories is needed.

Prospective validation of the Baylor bleeding score for predicting the likelihood of rebleeding after endoscopic hemostasis of peptic ulcers.

Endoscopic therapy is effective in securing hemostasis for bleeding ulcers, but bleeding recurs in 10% to 30% of patients. Prospective identification of patients at increased risk for rebleeding is requisite to reducing rebleeding rates. We previously developed a three-component scoring system that identifies patients at increased risk for rebleeding. In the present study, we prospectively validated our scoring system. Forty-seven men ranging in age from 23 to 95 years in whom endoscopic therapy for bleeding ulcers was successful were studied. Patients with pre-endoscopy scores greater than 5 or postendoscopy scores greater than 10 were stratified as high-risk, and patients with pre-endoscopy scores of 5 or less and post-endoscopy scores of 10 or less as low-risk. Twenty-six patients were categorized as high-risk and 19 as low-risk. All patients were followed until discharged from the hospital. The rebleeding rate for high-risk patients was 31% (8 of 26), compared with 0 for low-risk patients (p < .05). We conclude that our scoring system accurately predicts patients at increased risk for rebleeding after successful endoscopic therapy of bleeding ulcers.

Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus.

We prospectively compared the efficacy of polyvinyl bougies (Savary type) passed over a guide wire and through-the-scope balloons for the dilation of peptic esophageal strictures in a randomized study. Thirty-four patients, 17 in each treatment arm, were studied. At entry, dysphagia was assessed according to a six-point scale (0, unable to swallow; 5, normal). The end-point for dilation was to size 45F or 15 mm. Discomfort during the procedure was graded on a four-point scale (0, no discomfort; 1, mild; 2, moderate; 3, severe discomfort). Follow-up visits were at 1 week, 1 month, 3 months, and every 3 months thereafter for 2 years. At the 1-week visit, the size of esophageal lumen was measured by 8-, 10-, and 12-mm pills. Both devices effectively relieved dysphagia. By life-table analysis, stricture recurrence during the first year of follow-up was similar in both groups, but during the second year, the risk of recurrence was significantly lower in patients whose strictures were dilated with balloons. Other advantages of balloons included the need for fewer treatment sessions to achieve the defined end-diameter for dilation (1.1 + 0.1 versus 1.7 + 0.2, p < .05), and less procedural discomfort (p < .05). The differences in luminal size after dilation, measured by the barium pill test, were not significant. Ability to pass the 12-mm pill and absence of dysphagia were correlated. Our results indicate that both devices are effective in relieving dysphagia, but balloons may have a long-term advantage.