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The general rules made in 1980 for recording endoscopic findings of esophageal varices have widely been used in Japan and in other countries. However, since the development of endoscopic sclerotherapy and other modalities of endoscopic treatment, these 1980 rules were found to be insufficient for recording mucosal changes after treatment. The general rules as revised in 1991 recognize mucosal changes such as erosion, ulcer, scar, thrombosed varices, and bleeding signs. These new 1991 rules, which seem useful for recording initial evaluation of gastroesophageal varices and for describing mucosal changes after sclerotherapy as well, are described here.

Background: We studied new prognostic factors of esophageal variceal rupture by analyzing electronic video images of esophageal varices in 30 patients with portal hypertension., Methods: Fifteen of the patients were emergency or elective cases (bleeders), and the remaining 15 were prophylactic cases (nonbleeders). A comparison was made between the bleeders and nonbleeders in terms of endoscopic findings and the image processing data, especially variceal color tone and red color sign., Results: Endoscopic findings based on the general rules prepared by the Japanese Research Society for Portal Hypertension showed no significant difference between the two groups. However, with regard to the image processing data, both the ratio of red signal and the ratio of value were significantly lower in bleeders than in nonbleeders. In addition, the area ratio of red color sign was significantly higher in the former than in the latter. A follow-up study of nonbleeders also indicated that image processing data were more reliable than traditional endoscopic rules., Conclusions: By adding these image processing data to the traditional general rules for recording endoscopic findings, it is possible to select patients with varices that have a higher risk of rupture.

During the last three decades the Sugiura procedure and other nonshunting operations have been widely performed as the operations of choice for bleeding esophageal varices in Japan. The Sugiura procedure (University of Tokyo method), a transthoracoabdominal esophageal transection, consists in paraesophageal devascularization, esophageal transection and reanastomosis, splenectomy, and pyloroplasty. The results have been satisfactory with low operative mortality and low rebleeding rate. The prognosis of the patients after this operation depended on the liver function at the time of operation but not on whether operation was done as an emergency, elective, or prophylactic measure. Although the Sugiura procedure has recently been performed in more selected cases with an advance in endoscopic injection sclerotherapy, this procedure remains the ultimate direct operation for portal hypertension in Japan.

Transection and devascularization procedures (Sugiura procedure and transabdominal transection of oesophagus and devascularization) had been the most popular modality of treatment for oesophagogastric varices until the 1970s but the trends of treatment for varices have changed drastically during the last decade. This is partly due to the recent development of endoscopic sclerotherapy and partly due to the patient's increasing demand for less invasive treatment. Recently most patients with oesophagogastric varices are treated initially by endoscopic sclerotherapy and surgical treatment is only called for after sclerotherapy has failed.

Thirty-six patients with oesophageal varices underwent a non-shunting operation including oesophageal transection. Of these, 16 had an emergency or elective operation (bleeders) and the remaining 20 had prophylactic surgery (non-bleeders). A comparative study was performed between the bleeders and non-bleeders in terms of preoperative endoscopic findings and histopathology of the oesophagus. The severity of red colour sign showed no significant difference between the two groups. The venous dilatation in each of the three layers of the oesophageal mucosa was demonstrated histologically to be of the same degree in bleeders and non-bleeders. In addition, the hepatic venous pressure gradient in cirrhotic patients did not differ between the two groups; for bleeders this was a mean(s.d.) of 15.2(6.1) mmHg and for non-bleeders 14.4(2.9) mmHg. We were unable to find any factors differentiating bleeders from non-bleeders, although these results do not justify prophylactic surgery for oesophageal varices.

The results of a total of 523 nonshunting operations performed at our institution from 1964 to 1990 were analyzed and compared to those of chronic sclerotherapy. Although the overall operative mortality rate of nonshunting operations was low (26/523:5.0%), it was relatively high in Child's C cirrhotic patients (22/129:17%) and in those who underwent surgery on an emergency basis (14/60:23%). Cumulative survival rates of Child's C cirrhotic patients at 5 and 10 years (37.4%, 13.0%) following nonshunting operations were much lower than those of Child's A (76.6%, 54.9%) or Child's B (71.6%, 35.5%). One- and three-year survival rates for patients treated with sclerotherapy were 90%, 72% in Child's A (22 patients), 82%, 49% in Child's B (47), and 56%, 30% in Child's C (50), while cumulative rebleeding rates at one and three years following sclerotherapy were 12%, 12% in Child's A, 18%, 27% in Child's B, and 35%, 55% in Child's C respectively. Our data indicated that nonshunting operations can be safely performed with a good long-term outcome in Child's A or B cases on an elective basis, and sclerotherapy may be the treatment of choice for emergency cases or for Child's C cases although the risk of rebleeding is high following sclerotherapy.

We report two cases of squamous cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. The interval between sclerotherapy and the development of carcinoma was 24 months in case 1 and 21 months in case 2. The sclerosant was 5% sodium morrhuate in case 1 (total dose, 10 ml) and 5% ethanolamine oleate in case 2 (45.5 ml). Although no recurrent variceal bleeding occurred after sclerotherapy, we could not perform any curative surgical treatment for esophageal cancer because of the advanced stage of the cancer and the severity of the accompanying liver dysfunction. It is difficult to determine the relationship between sclerotherapy and carcinoma; however, long-term surveillance is essential to avoid overlooking a neoplasm in the esophagus after endoscopic injection sclerotherapy.

The endoscopic tamponade method, using a new transparent balloon tube, has been developed for the emergency control of bleeding esophageal varices. The introduction of the tube is performed while observing the esophagus utlizing a fiberoptic endoscope, which is inserted within the lumen of the tube so that the accidental injury to the mucosa can be avoided. The accurate diagnosis of the cause of bleeding is possible so that the most suitable form of treatment can be initiated without delay. Hemostasis is achieved with minimum balloon pressure, and the examination of the varices may be repeated, whenever desired, so that damage to the esophageal mucosa can be avoided. Deflation of the balloons and termination of the tamponade can be selected and planned so that the recurrence of bleeding immediately after the removal of the tube can be avoided. This method has so far been used successfully without any complications in 5 patients.