An aggressive, nonshunting approach for control of bleeding esophageal varices

Morbidity and mortality from variceal hemorrhage can be significantly reduced. A well-defined treatment protocol which obviates delay, procrastination and excessive blood loss is essential. Early aggressive endoscopic sclerotherapy is extremely safe and effective in controlling the acute hemorrhagic event. However, technical details remain to be standardized; rebleeding can be significant and sclerosing until roentgenologic obliteration is essential. Stapled esophageal transection and coronary vein ligation are a reasonable and effective surgical approach when necessary; however, the exact timing and place of this procedure in the therapeutic schema are not yet defined. It requires further phase one studies and not more randomized control trials! It can be difficult after recent sclerotherapy and would appear to require upper gastric devascularization or perhaps percutaneous embolization if gastric varices are venographically prominent. We have recently attempted to modify the procedure in such patients by stapling across the anterior and posterior gastric walls as an alternative or addition to complete esophageal transection. This is accomplished through a small gastrotomy adjacent to the gastroesophageal junction. Shunting procedures or more extensive surgical intervention does not appear necessary, desirable or warranted at this time; however, longer follow-up study is essential.