الفهرس 
Introduction
Pathological anatomy of gastric varicesOnly 14 pages are availabe for public view
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Abstract
Bleeding from ruptured esophagogastric varices is one of the most serious complications in patients with liver cirrhosis and is the cause of death for about one third of such patients. Although the prevalence and bleeding frequency of GV are less than those of Es.V, the bleeding is more profuse, and the outcome is worse in bleeding GV than with bleeding Es.V. Different techniques have been used for the treatment of GV including pharmacological, endoscopic, percutaneous, and surgical approaches. Each treatment method has its own advantages and drawbacks, and the drawbacks of each treatment method have made it especially difficult for one of these methods to become the standard method. Recently, an endovascular treatment option termed as “Balloon occluded retrograde transvenous obliteration” (BRTO) was introduced and widely used in Japan for GV obliteration with favourable outcomes. This is a retrospective study including 68 patients (28 females (41.2%) and 40 males (58.8%) with median 68 years old ranging between 24 to 90 years old) with either bleeding GV controlled with upper endoscopic measures or high risk GV for rupture underwent BRTO between May 2007 and May 2018 at radiology department of Oita university hospital, Oita , Japan to assess safety, efficacy, and short and long term outcomes of the BRTO technique. All patients underwent Pre- and post-procedural CE-CT assessment of GV and other comorbid conditions, and pre- and post-procedure upper endoscopic evaluation of GV and Es.V. 78 BRTO sessions were performed in 68 patients with technical success rate of 97.4% (n=76/78 sessions). Conventional BRTO was done in 51 sessions (65.4%), selective BRTO in 13 sessions (16.7%), and ultraselective BRTO in 14 sessions (17.9%). Correlation of BRTV efferent anatomy with CT based efferent anatomy revealed that sensitivity of the CE-CT for detection of type A, B and C were 69.2%, 61.4%, and 100%, respectively. Specificity of CE-CT for detection of type A, B and C were 69.1%, 83.3%, 100%, respectively. While its positive predictive value for type A, B, and C were 34.6%, 87.1% and 100%, respectively and its negative predictive value for type A, B, and C were 90.5%, 54.1%, 100%.Overall intent-to-treat complete GV obliteration rate 1-week after last BRTO session was 91.2% (n=62/68). In technically successful cases only; the overall complete gastric varices obliteration rate 1- week after last BRTO was 92.5% (n=62/67). Ultraselective technique had signifcantly lower complete GV thrombosis rate than conventional (50% Vs 84.3%, p=0.01) and selective techniques (50% vs 100%, p=0.006). However, there was no statistically signifcant difference in complete GV obliteration rate between conventional and selective BRTO techniques (84.3% Vs 100%, p=0.2). The cummulative GV recurrence-free rates 6-month, 1-, 3- and 5-year after BRTO were 98%, 96%,96%, 96%, respectively. The cummulative GV rebleeding-free rates after all BRTO sessions at 6-month, 1-,3-,and 5- year were 98%, 98%, 96%, and 96% respectively. Minor adverse effects were developed after 55 sessions (70.5%) including; mild fever after 39 sessions (50%), macroscopic hematuria after 12 sessions (15.3%); microscopic hematuria after 15 sessions (19.2%), abdominal pain or discomfort after 15 sessions (19.2%); vomiting after 6 sessions (7.7%); back pain after 5 sessions (6.4%); chest pain after 1 session (1.3%); oliguria after 5 sessions (6.4%). Major adverse effects was developed after 7 sessions (8.9 %) including cardiogenic shock after 1 session (1.3%), renal dysfunction after 5 session (6.4%) and hepatic failure after 3 sessions (3.8%).BRTO related portal/splenic vein thrombosis was noted in 6 patients (7.7% of sessions, 8.8% of patients). Partial left renal vein thrombosis was developed in 2 patients (2.6% of sessions, 2.9% of patients). Procedure-related mortality rate was 3.8% of total sessions and 4.4% of patients (n=3). Bilirubin and hepatic enzymes levels were stationary or even improved except for lactate dehydrogenase enzyme level which shows significant rise in 1-week , 3- and 6-month levels, however, its mean level was within the normal range not exceeding 280 U/L during all follow up periods. Mean albumin level 1-week after BRTO was significantly lower than baseline albumin level with mean difference of 0.2±0.4 g/dl (p<0.0001). Then, mean albumin level improves and increases at 1-, 3-and 24-month after BRTO significantly than baseline albumin (p=0.003, 0.001, and 0.01, respectively). The median Child score 1-week after BRTO was significantly higher than baseline Child score (6 Vs 7) (p=0.01); However median Child score 1-, 3-, 6-, 12- and 24-months after BRTO returned to the baseline Child score i.e. no statistical difference from baseline Child score (p= 0.6, 0.7 , 0.8, 0.5, and 0.7, respectively). The mean serum ammonia level was lower at all follow up intervals after BRTO than baseline level, however it was only significantly lower 1-week , 1-month, and 6-month after BRTO (p=0.001, 0.03, .001, respectively). The cummulative rate of ascites exacerbation 1-, 3-, 6-, 12-, and 24-month after BRTO sessions were 5%, 25%, 28%, 36%, and 40%, respectively. Ascites exacrebation rate was signicantly higher after conventional BRTO technique than after non-conventional BRTO techniques (i.e. selective and ultraselective techniques) during the first 12 months (p=0.03; Breslow test). The cummulative rate of Es.V aggravation 1-, 3-, 6-, 12-, and 24-month after BRTO sessions were 6%, 29%, 40%, 48%, and 58%, respectively. Es.V aggravation was significantly higher after conventional BRTO techniques than non-conventional BRTO techniques especially during the first 12 months (p= 0.002).