Esophageal procedures to control bleeding from varices

Portal-systemic shunting of all types has failed to improve long-term survival in patients with bleeding esophageal varices and carries a high morbidity and prohibitive mortality in the emergency setting. Direct esophageal approaches are receiving renewed attention. Sclerotherapy promises to be the simplest, safest, and most effective treatment for acute bleeding. Rebleeding is frequent with this technique unless all the varices are subsequently obliterated. Even then, rebleeding may be a recurring hazard, albeit with reduced frequency and increasing interval. For the nonalcoholic patient with a significant life expectancy or in the young patient with cirrhosis, this can be a significant factor. Simple esophageal resection-transection using stapling devices is a rapidly accomplished, simple, and effective operative approach if combined with coronary vein ligation. This procedure deserves a trial earlier in such patients and in those who are failures of repeated sclerotherapy. Extensive esophagogastric devascularization preserving the paraesophageal veins--the Sugiura procedure--is a more extensive undertaking that is probably unnecessary for most and too dangerous for some. At present, it should be reserved for failures of other techniques. It shows promise of long-term effectiveness if performed safely on only certain patients.