Highly selective portal decompression for bleeding esophageal varices

Since 1974, 112 patients with ruptured esophageal varices, have undergone resection-anastomosis of the supracardial esophagus using the circular suture stapler. Recently, preliminary splenic artery ligature has also been associated, if possible, with systematic ligature of the gastric coronary vein and followed by cardioplasty, to prevent gastro-esophageal reflux and block subcardial venous flow. This highly selective portal decompression (HSPD) procedure provides lasting reduction in blood pressure (confirmed by manometric recordings) in the esophago-cardial region, without any reduction in the distal hepatic flow (no portocaval shunt) or increase in the proximal flow (raised portal pressure). Results were compared with those of the initial, already encouraging, protocol, and demonstrated a tangible improvement after more than one year follow-up. In 50 cases (Child A:16, B:29 and C:5), postoperative mortality was 10% (5 cases) during the first month and 7.5% (3 cases/40) during the first year. There was no specific morbidity due to the additional procedure nor cases of portocaval encephalopathy. During the first postoperative year, the frequency of hemorrhagic complications was one tenth of that during the year before surgery. These very encouraging results suggest the possibility of extending the indications for HSPD in the treatment of recurrent digestive hemorrhages from ruptured esophago-cardial varices, replacing porto-systemic shunts which are sometimes well tolerated but always anti-physiological.