Portal Hypertension: Surgical Therapy

Acute esophageal variceal or fundal variceal hemorrhage

The following measures can be considered to stop acute esophageal variceal or fundus variceal hemorrhage:

  • Rubber band ligation (GBL) – This is performed endoscopically and is considered the method of choice. It is associated with significantly fewer complications than variceal sclerotherapy.
  • Variceal sclerotherapy (variceal sclerotherapy) – This involves injecting a sclerosant (hardening agent), such as polidocanol, which leads to sclerosis due to an inflammatory stimulus. Possible complications include perforation (piercing), strictures (high-grade narrowing), pleural effusion (pathological (abnormal) accumulation of fluid between the pleura parietalis (pleura of the chest) and pleura visceralis (pleura of the lungs)), pericardial effusion (accumulation of fluid in the pericardium), fever, and bacteremia (presence of bacteria in the blood). The complication rate is 10%.
  • Histoacryl – Treatment with plastic adhesives is indicated for gastric fundal varices (varicose veins of the base of the stomach) if they cannot be safely treated by ligation.
  • Sondent tamponade – for persistent (ongoing) bleeding to compress the varices; Balloon probe: inflation of a balloon that compresses the blood vessels. The Sengstaken-Blakemore probe (for varices of the terminal esophagus and cardiac region (transition area from the esophagus to the stomach)) or the Linton Nachlas probe (for varices of the gastric fundus) are recommended for this purpose. This is followed by endoscopic therapy.The use of a compression probe is associated with the following risks and should therefore only be used in the short term (complication rate 10-20%):
    • Esophagitis (inflammation of the esophagus).
    • Esophageal necrosis (death of the esophageal mucosa).
    • Esophageal rupture (rupture of the esophagus)
    • Pneumonia (pneumonia) due to the passage of gastric juice into the lungs.
  • Self-expanding metal stent (with plastic coating) – e.g., Ella stent; placed in the distal esophagus (part of the esophagus that lies in the abdominal cavity) for 1-2 weeks; considered a back-up procedure

Secondary prophylaxis – recurrence prophylaxis

The risk of recurrent bleeding (bleeding again after the first bleeding) is high. Within the first 10 days after the first hemorrhage, it is 35%, and within one year after the first hemorrhage, the recurrence rate is 70%. Consequently, secondary prophylaxis is mandatory. It is most effective by a combination therapy of rubber band ligation and drug therapy (nonselective beta-blockers).