The current treatment of bleeding esophageal varices.

The urgent treatment of acute, massive hemorrhage from rupturedesophageal varices is greatly enhanced by the active, early involvementof a team, composed of surgeons, gastroenterologists and interventionalradiologists. The team members should be used towork harmoniously within the framework of a well established therapeuticprotocol. In order to satisfy these conditions, we have est ablishedthe following approach: A Swan-Ganz right cardiac catheteris placed soon after the patient’s arrival in the hospital, in an effortto assess the degree of hyperdynamic circulation and thus defineeach patient’s potential morbidity and mortality. Esophagoscopywith sclerosis of the varices follows immediately. If the hemorrhageis not arrested, the treatment is continued with the embolisation ofthe splenic artery via angiography. In order to prevent recurrenceof bleeding, we add a porto-azygos disconnection to the treatmentprogram. This procedure consists in ligating the coronary vein andthrombosing the short gastric veins with alcohol or stents, injectedthrough catheters advanced under fluoroscopy via the mesentericvein. If after both of these therapeutic maneuvers the gradient of thehepato-portal pressures remains above 30 cm of water, we completethe treatment program with the placement of a TIPS, introducedthrough a combined mesenteric and femoral approach. In 192 patientstreated in this fashion, we have been able to place the TIPS inall instances. There has been no operative mortality; 23% of patientsdied within 30 days and the long term mortality has been19%. In this group of patients there occurred one intraoperativecomplication and complete control of bleeding was obtained in 90%of patients.