Minimally invasive devascularization for variceal bleeding that could not be controlled with sclerotherapy

The appropriate therapy for continued bleeding despite sclerotherapy remains controversial. This study evaluates a devascularization procedure performed without the risks of major surgery and general anesthesia. Fifty consecutive patients, each with an endoscopically proven variceal hemorrhage that was uncontrollable with sclerotherapy, were treated with minimally invasive devascularization. The procedure was performed in three stages. First, the portal pressure was sharply reduced by angiographic embolization of the midsplenic artery. Then the esophagogastric variceal network was thrombosed by means of a catheter introduced during laparotomy, which created a portoazygos disconnection. Finally, the left gastric and left gastroepiploic arteries were embolized, which completed devascularization of the proximal stomach. According to the Child classification, 16 patients were in class B and 34 were in class C. All Child's class B patients (16/16) and 71% (24/34) of Child's class C patients survived hospitalization. One-year survival was 94% (15/16) for Child's class B and 62% (21/34) for Child's class C patients. Rebleeding occurred in 63% (25/40) of the discharged patients but caused the death of only seven. In conclusion, the 20% initial hospital mortality for these difficult patients was significantly better than that reported for emergency surgery, and the rate of rebleeding was comparable to that seen with other nonshunting therapies.