Variceal rebleeding and recurrence after endoscopic injection sclerotherapy: a prospective evaluation in 204 patients

HYPOTHESIS: Eradication of esophageal varices by repeated injection sclerotherapy and maintenance of eradication using continued surveillance endoscopy may reduce recurrent variceal bleeding and death from esophageal varices. DESIGN: A prospective study of consecutive adult patients with endoscopically proved esophageal variceal bleeding. SETTING: A tertiary care university hospital in a metropolitan area. PATIENTS: Two hundred four patients (127 men and 77 women; mean age, 50.1 years; age range, 16-82 years) underwent 993 emergency and elective variceal endoscopic injection treatments with 5% ethanolamine oleate during 1992 endoscopy sessions. Most (166 [81.4%]) had cirrhosis, mainly due to alcohol abuse (131 [78. 9%]). The number of patients with each modified Pugh-Child risk grade was as follows: A, 30; B, 91; and C, 83. (The modified Pugh-Child classification comprises ascites, encephalopathy, serum albumin and bilirubin levels, and prothrombin time. Each variable is given a value of 1 to 3 with increasing impairment of liver function. Addition of the values leads to the Pugh-Child risk grades for each patient, with 5 and 6 giving grade A; 7 through 9, grade B; and 10 through 15, grade C, respectively.) RESULTS: Ninety-five patients (46.6%) rebled at a median of 17 days (range, 0-2583 days). Seventy-four patients (36.3%) had a total of 112 further bleeding episodes before eradication of varices. Varices were eradicated in 99 (87.6%) of 113 patients who survived longer than 3 months after a median of 5 injections and remained eradicated in 43 (mean follow-up after eradication, 38 months; range, 4-125 months). Rebleeding was markedly reduced after eradication of varices. Varices recurred in 56 patients, of whom only 10 rebled from recurrent esophageal varices. Cumulative survival by life table analysis was 55%, 41%, and 30% at 1, 3, and 5 years, respectively. One hundred thirty-seven patients (67.2%) died during follow-up. Liver failure was the most common cause of death. Minor complications (mucosal ulceration) occurred in 105 patients. Major complications, including a localized injection site leak (n = 9), esophageal stenosis (n = 25), and esophageal perforation (n = 5), occurred in 39 patients. CONCLUSIONS: Repeated injection sclerotherapy eradicated esophageal varices in most long-term patients. Complications related to injection sclerotherapy were mostly minor. Complete eradication of varices reduced rebleeding and death from esophageal varices.     

Endoscopic sclerotherapy in the management of esophageal varices in 61 children with biliary atresia

Sixty-one children who have survived 2.5 years or more after corrective surgery for biliary atresia were prospectively followed by endoscopy. Esophageal varices were detected in 41 patients (67%), 17 of whom (28%) had experienced episodes of variceal hemorrhage. Control of variceal bleeding was achieved by endoscopic injection sclerotherapy in all but one child who died from hemorrhage before the completion of treatment. Complications of the technique comprised episodes of bleeding before variceal obliteration (7), esophageal ulceration (5), and stricture (3). These resolved with conservative management and without long-term sequelae. During a mean follow-up period of 2.8 years after variceal obliteration, rebleeding from recurrent esophageal varices developed in only one child and responded to further sclerotherapy. These results are better than those following surgical procedures for portal hypertension in biliary atresia, and therefore endoscopic sclerotherapy is recommended as the treatment of choice.     

A 15-year experience of injection sclerotherapy in adult patients with extrahepatic portal venous obstruction.

OBJECTIVE: The authors report a 15-year experience with injection sclerotherapy in the management of adult and teenage patients with esophageal varices due to extrahepatic portal venous obstruction (EHPVO). SUMMARY BACKGROUND DATA: Extrahepatic portal venous obstruction is an uncommon cause of esophageal varices and is associated with normal liver function. Effective control of variceal bleeding is the major factor influencing survival. The results of surgery have been unsatisfactory, and therefore, more conservative management policies have been adopted. METHODS: Fifty-five patients with proven EHPVO underwent repeated injection sclerotherapy via either a modified rigid esophagoscope under general anaesthesia or a fiber-optic endoscope under light sedation, using ethanolamine oleate as the sclerosant. RESULTS: Esophageal varices were eradicated in 44 patients after a median number 6 injections (range 1-17) over a mean of 12.5 months (range 1-48). The mean follow-up was 6.8 years (range 1.1-14.6 years). Eleven patients were admitted on eighteen occasions with bleeding from esophageal varices before eradication and there were seven bleeding episodes in six patients from recurrent varices after initial eradication. Complications related to sclerotherapy included injection site leak (6), stenosis (11) and mucosal ulceration (32) during 362 injection sclerotherapy episodes. Four patients died during the study period. CONCLUSIONS: Injection scelotherapy is the treatment of choice in most patients with EHPVO.     

Long-term injection sclerotherapy treatment for esophageal varices. A 10-year prospective evaluation.

Long-term injection sclerotherapy after proved variceal bleeding was assessed in 245 patients. The majority had alcoholic cirrhosis and the patients were equally distributed between modified Pugh-Child's risk grades A, B, and C. Esophageal varices were eradicated in 88% of the 140 patients who survived long enough for analysis, and remained eradicated for a mean of 19.4 months. The incidence of recurrent variceal bleeding after the first hospital admission was 0.02 bleeding episodes per patient month of follow-up study and was markedly reduced after eradication of varices. The overall cumulative survival rates at 1, 5, and 10 years were 54%, 39%, and 29%, respectively. The prognosis was influenced by the risk grade and the number of variceal bleeds before entering the study and to a lesser extent by the etiology of the cirrhosis. Fifty-two per cent of the patients died during the 10-year period. Liver failure was the major cause of death. Complications were mostly of a minor nature but they became cumulative with time. Minor complications included mucosal slough and injection-site leak, although the latter had an associated mortality risk. Significant esophageal stenosis and esophageal rupture were rare. As a result of this study a more radical surgical policy is proposed for sclerotherapy failures. These are defined as patients in whom varices are difficult to eradicate or who continue to have major variceal bleeds. Such patients should be subjected to either a portosystemic shunt or a devascularization and transection procedure.     

Endoscopic ligation of esophageal varices

One hundred consecutive patients with bleeding esophageal varices were treated with a new endoscopic ligating device that effects strangulation of varices using small elastic "O" rings. Treatments were continued after initial hospitalization to achieve variceal eradication. Follow-up ranged from 6 to 26 (mean: 15) months. Bleeding was controlled until discharge from hospital or death in 18 of 21 patients who were actively bleeding at index endoscopy. Overall, 26 patients died during the study, 12 during the index hospitalization. Cause of death was organ failure in 21, exsanguination in 3, and cancer in 2. Forty-one of 88 initial survivors experienced 72 episodes of recurrent bleeding (1 to 4 per patient). All but five rebleeds occurred before eradication. Sixty of 88 patients (68%) who survived index hospitalization had their varices eradicated. A median of 5 (1 to 12) treatments was required. Nine patients eventually had other forms of treatment for recurrent bleeding. Only 3 non-bleeding complications resulted from 462 endoscopic treatment sessions. We conclude that endoscopic ligation controls active variceal bleeding and eradicates varices with efficacy similar to that of sclerotherapy and with minimal risk of complications.     

The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices

The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.     

Endoscopic band ligation of oesophageal varices

BACKGROUND: For 25 years the optimal management of bleeding oesophageal varices has included endoscopic injection sclerotherapy (EIS) both to arrest bleeding and to prevent rebleeding. However, the recent innovation of endoscopic variceal ligation (EVL) may be a more effective treatment; this paper reviews its efficacy. METHODS: All Medline (National Library of Medicine, Washington DC, USA) articles containing the text words 'oesophageal varices', 'sclerotherapy' or 'band ligation' were reviewed. Prospective randomized studies comparing sclerotherapy with band ligation, or combinations thereof, were included. RESULTS: After an acute variceal bleed EVL is as effective as EIS for control and eradication of oesophageal varices. Initial control of bleeding is similar, but eradication is achieved in fewer sessions with EVL. EVL is associated with lower rebleeding rates and fewer procedure-related complications; it is also more effective for control of active bleeding at initial endoscopy. Combination therapy (EIS plus EVL) confers no advantage over EVL alone. CONCLUSION: EVL is similar to EIS for control of bleeding varices, but the former has less associated morbidity, lower rebleeding rates and achieves more rapid variceal eradication. EVL should be considered the endoscopic treatment of choice in the management of variceal haemorrhage.     

Markers of potential esophageal variceal rebleeding in cirrhotic patients undergoing endoscopic injection sclerotherapy

Endoscopic injection sclerotherapy has proven to be effective in reducing the severity of bleeding from esophageal varices in cirrhotic patients. However, rebleeding occurs in certain patients, and this can affect their long-term survival. Therefore, to evaluate varices that were likely to rebleed, the relationship between esophageal variceal re-bleeding and endoscopic variceal findings at the time of the initial injection scierotherapy were investigated, in cirrhotic patients. Sixty-three patients were investigated; they were assigned to three groups according to their Child's classification: A, B, and C. After the initial scierotherapy, rebleeding occurred in 14 patients (22%), specifically in 5% of those in group A, in 16% of those in group B, and in 47% of those in group C. The endoscopie findings at the time of the initial scierotherapy revealed that redness of the varices was most intense in the group C patients. Patients in whom the varices were intensely red and/or were located up to the level of the tracheal bifurcation were found to be the most likely to rebleed. Therefore, to prevent rebleeding in patients manifesting these signs, careful monitoring and repeated endoscopie injection scierotherapy is recommended.     

Endoscopic clipping versus band ligation in the management of bleeding esophageal varices

BACKGROUND: The effectiveness of endoscopic clipping in the hemostasis of bleeding esophageal varices and the eventual variceal eradication was compared with that of band ligation. METHODS: Forty patients were enrolled in the study in a prospective manner, 19 of whom received endoscopic clipping (group I) and the remaining (n = 21 patients) received endoscopic band ligation (group II). All patients in this study presented with bleeding from esophageal varices. The patient characteristics (age, sex, Child-Pugh score, variceal grade) were comparable in the two groups. After initial hemostasis, the patients were assigned one of the two forms of endoscopic therapy which was continued in the follow-up sessions until varices were eradicated. Early and late results were compared. RESULTS: Initial hemostasis was achieved in all patients in group I but two patients in group II required clip ligation for initial hemostasis because of the failure in band ligation. Those two were treated with band ligation in the follow-up sessions. A total of 224 clips in 53 treatment sessions and 296 bands in 82 treatment sessions were placed in group I and group II, respectively. The rates of complete variceal eradication were 89% and 76% in group I and group II, respectively (p > 0.05). The median number of required treatment sessions for complete eradication of the varices was significantly lower in group I than group II (3 versus 4, p = 0.013). Three patients from group I (15%) and seven patients from group II (33%) were readmitted for variceal bleeding during the follow-up period (p > 0.05). CONCLUSIONS: With the advantages of high initial hemostasis rate, decreased risk of rebleeding, and fewer treatment sessions needed for variceal eradication, endoscopic clipping is as effective as band ligation, or perhaps more effective in the treatment of bleeding esophageal varices.     

Prophylactic Sclerotherapy: Yes or No!

Controlled trials of endoscopic sclerotherapy for the prevention of the first variceal hemorrhage have given controversial results. We continued a previously reported study and randomly assigned 141 patients with esophageal varics and no prior gastrointestinal bleeding to either prophylactic sclerotherapy (n=70) or no treatment (n=71). Sclerotherapy was performed until complete eradication of the varices was achieved; recurrent varics were treated with repeat sclerotherapy. The groups were well balanced in terms of demographic and clinical characteristics. Patients in both groups who bled from varices received sclerotherapy whenever possible.During a median follow-up of 56 months, variceal bleeding occurred in 7% in sclerotherapy patients and 44% on control patients (p < 0.01). In the sclerotherapy group 59% died, and in the control group 51% (n.s.). In both groups, the mortality rate increased with the severity of liver function impairment. Sclerotherapy was not found to improve survival in patients, irrespective of the etiology of cirrhosis (alcoholic or nonalcoholic) or variceal size (low-grade or high-grade). We conclude that sclerotherapy is a suitable method to reduce the occurrence of the first variceal hemorrhage, but it does not appear to have an effect on survival.     

Gastric bleeding after endoscopic injection sclerotherapy for esophageal varices may be fatal.

Among 457 Japanese cirrhotic patients with esophageal varices, 28 (6%) bled from the upper gastrointestinal tract after the initial session of endoscopic injection sclerotherapy (EIS); 13 bled during the course of repeated EIS and 15 bled mainly from gastric lesions after eradication of the varices. Of these 28 patients, bleeding from gastritis occurred in 13 (46%), from esophageal varices in 10 (36%), from gastric varices in 4 (14%) and from gastric ulcer in one (4%). Six of 13 patients with gastritis-related bleeding and 3 of 4 patients with gastric variceal bleeding died of uncontrollable hemorrhage complicated liver failure, while 9 of 10 patients with esophageal variceal bleeding were controlled and reinjection was feasible. Ten (36%) of the 28 patients, with Child's grade B or C and severe ascites, died, mainly following bleeding from gastric lesions. This study shows that bleeding from gastric lesions after EIS can be uncontrollable and fatal in patients with poor liver function.     

The sources of recurrent hemorrhage during long-term sclerotherapy

The sources of recurrent hemorrhage during long-term sclerotherapy undertaken by a single surgeon were studied prospectively in a consecutive series of 53 patients for a period of 2 to 6 years. Recurrent hemorrhage, defined as upper gastrointestinal bleeding requiring transfusion or hospitalization or both, in the course of chronic sclerotherapy was investigated aggressively by means of endoscopy and the findings archived with videotape recording. In 24 patients 51 episodes of recurrent hemorrhage developed in the entire series. On the basis of endoscopic findings and serial comparison of videotape recordings, the most common source of recurrent hemorrhage was the original varices, which accounted for rebleeding in 18 patients. The risk of such bleeding was highest in the first month, diminishing thereafter until total variceal eradication. Rebleeding after eradication of varices was always from sources other than varices, as regenerated vessels were small and infrequent and never the source of bleeding. Continued sclerotherapy ultimately achieved total variceal eradication in 15 of 18 patients with variceal rebleeding. Sclerotherapy alone was successful in eradicating all varices in a total of 38 patients in this series, the mean time required being 13 +/- 4.1 months. Rebleeding from sources not amenable to sclerotherapy was treated with porto-azygos disconnection (6 patients) or distal splenorenal shunts (3 patients). There were 12 deaths: four attributed to hemorrhage (3 after surgery), five from liver failure, and three late deaths from causes not due to liver disease. Recurrent hemorrhage per se during the course of sclerotherapy may not be taken as a sign of treatment failure but must be vigorously investigated, since findings profoundly affect management and outcome.     

Follow-up of patients after variceal eradication. A comparison of patients with cirrhosis, noncirrhotic portal fibrosis, and extrahepatic obstruction.

One hundred one patients, 54 with cirrhosis of liver, 31 with noncirrhotic portal fibrosis (NCPF), and 16 with extrahepatic obstruction (EHO), were followed up at monthly intervals for a mean (+/- SD) period of 17.9 +/- 4.8 months after achieving total variceal eradication with endoscopic sclerotherapy. Recurrence of esophageal varices was seen in 19 (18.8%) patients, 12 with cirrhosis and seven with NCPF, within a mean (+/- SD) period of 5.7 +/- 1.6 months. No patient with EHO showed recurrence. Three (2.9%) patients rebled from the recurred varices. Mean (+/- SD) number of sclerotherapy sessions and the amount of absolute alcohol required for eradication of recurred varices were 1.6 +/- 0.8 and 3.6 +/- 1.8 ml, respectively. Dysphagia and esophageal stricture were present in 15 (14.9%) patients with nearly similar frequency in patients with cirrhosis, NCPF, and EHO. Dysphagia in four patients with stricture improved without dilatation. While there were no deaths in patients with NCPF and EHO, 11 patients with cirrhosis died. There was significant (p less than 0.01) improvement in the liver status of surviving patients with cirrhosis after variceal eradication. It can be concluded that variceal recurrence and rebleeding are not major problems after sclerotherapy. Sclerotherapy probably helps in spontaneous improvement of the liver status of surviving cirrhotics and reduces long-term morbidity and mortality of patients with NCPF and EHO.     

Management of Variceal Hemorrhage in Children with Extrahepatic Portal Venous Obstruction-Shunt Surgery Versus Endoscopic Sclerotherapy

Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertention in children. Esophageal variceal hemorrhage is a major cause of morbidity and mortality in these patients. For many decades, portal systemic shunts were considered as the most effective treatment of variceal hemorrhage. Endoscopic injection sclerotherapy (EIS) was first introduced for emergency management of bleeding varices and subsequently as definitive treatment to prevent recurrent hemorrhage. The purpose of the study was to compare the safety and efficacy of shunt surgery and endoscopic sclerotherapy for patients with proven esophageal variceal bleeding due to EHPVO. The study was a prospective randomized study of 61 children with bleeding esophageal varices due to EHPVO carried out jointly by the department of General Surgery and Gastroenterology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, between March 2001 and September 2003. Thirty patients received surgery and other 31 patients received EIS. Overall incidence of rebleeding was 22.6% in sclerotherapy group and 3.3% in shunt surgery group. Treatment failure occurred in 19.4% patients in sclerotherapy group and 6.7% in shunt surgery group. The rebleeding rate of sclerotherapy is significantly higher than that of shunt surgery. However, the therapy failure rate of sclerotherapy is not significantly different from that of shunt surgery.     

Evaluation of propranolol for prevention of recurrent bleeding from esophageal varices between sclerotherapy sessions

Forty-one patients admitted with first episode of bleeding from esophageal varices were enrolled in a trial of the efficacy of oral propranolol to prevent rebleeding during the course of endoscopic sclerotherapy until obliteration. Single-blind randomization to sclerotherapy alone or with propranolol was used. At monthly endoscopy the varices were injected with 1% Aethoxysclerol until obliteration. If bleeding recurred, additional sclerotherapy was given. There was no intergroup difference in time to eradication of varices (8.1 vs. 7.7 months). The cumulative number of bleedings from varices and from distal esophageal ulcerations was identical in the two study groups. Five patients in the control group but only one in the propranolol group died of bleeding in the study period, a difference of only borderline significance (chi 2 = 4.08, df = 1). There were no specific side effects of propranolol. Thus propranolol did not significantly reduce the frequency of rebleeding until variceal obliteration, but could have had some influence on the gravity of rebleeding.     

Acute bleeding varices: a five-year prospective evaluation of tamponade and sclerotherapy.

In a five-year study of massive upper gastrointestinal hemorrhage, 143 patients had esophageal varices diagnosed on emergency endoscopic examination. Seventy-one patients had active bleeding from varices and required Sengstaken tube tamponade during at least one hospital admission. The remaining patients included 33 with variceal bleeding which had stopped and 39 who were bleeding from another source. Sixty-six of the former group of 71 patients were referred for emergency injection sclerotherapy. These 66 patients were followed prospectively to August 1980, and had 137 episodes of endoscopically proven variceal bleeding requiring Sengstaken tube control followed by injection sclerotherapy during 93 separate hospital admissions. Definitive control of hemorrhage was achieved in 95% the patients admitted to the hospital (single injection 70%; two or three injections 22%). The death rate per hospital admission was 28%. No patient died of continued variceal bleeding, and exsanguinating variceal hemorrhage no longer poses a major problem at our hospital. The combined use of initial Sengstaken tube tamponade followed by injection sclerotherapy has simplified emergency treatment in the group of patients who continue to bleed actively from esophageal varices, despite initial conservative treatment.     

内镜下硬化与套扎治疗食管静脉曲张破裂出血疗效比较

目的：对比内镜下硬化治疗（EIS）、套扎治疗（EVL）及套扎联合硬化治疗（ESL）3种方法对食管静脉曲张破裂出血的临床疗效。方法：回顾分析中日友好医院消化内科2001—2005年内镜下治疗肝硬化单纯食管静脉曲张破裂出血149例,其中EIS46例、EVL32例、ESL71例,对3种方法的止血率、静脉曲张消失率及再出血率进行比较。结果：3种治疗方法止血率均在90%以上;静脉曲张消失率分别为EIS80.4%、EVL68.8%、ESL87.3%;2年内再出血率分别为EIS52.2%、EVL59.3%、ESL43.6%,差异无统计学意义（P〉0.05）。结论：内镜下EIS、EVL及ESL治疗肝硬化食管曲张静脉出血均可达到较好效果,临床实践中可结合患者实际情况综合考虑后选择。     

Endoscopic elastic band ligation for active variceal hemorrhage

The purpose of this study was to assess the efficacy of EVL for treatment of active variceal hemorrhage. Twenty-three consecutive patients with actively bleeding esophageal varices had EVL with a flexible gastroscope. Treatment was measured by initial control of bleeding, incidence of early and late rebleeding, survival, complications, and size of varices at subsequent endoscopy. Repeat EVL was performed as needed for bleeding and at two week intervals until varices were grade I or eradicated. Follow up of survivors ranged from 90 to 400 days (mean 280). Bleeding varices were initially controlled in 22 (95.6%) patients. Nine (39.1%) died, five from hepatic failure with no recurrent bleeding, four from continued (1) or early recurrent (3) hemorrhage. All deaths occurred within 3 to 24 days (mean = 9.4) of initial treatment for active bleeding. Twelve of 14 surviving patients have achieved variceal eradication or reduction in size to grade I or less with a mean of 5.5 repeat EVL sessions (range, 0-10). One refused further treatment; one is lost to follow up. Excluding rebleeding, there were no treatment-related complications in 80 EVL sessions. Active variceal bleeding requiring endoscopic control is associated with substantial mortality, especially in higher risk patients. EVL is effective for initial and long term control of bleeding. EVL appears to be associated with a low incidence of non-bleeding complications.     

Prophylactic sclerotherapy in children with esophageal varices: long-term results of a controlled prospective randomized trial

BACKGROUND/PURPOSE: Experience using endoscopic prophylactic sclerotherapy (PS) is restricted to adult patients and has led to conflicting results. There has not been a randomized, controlled study on the use of PS in children. The purpose of this study is to evaluate prospectively the value of PS to prevent the first hemorrhage from esophageal varices in children with portal hypertension and to assess the effect of PS on survival rate. METHODS: In a controlled, prospective, computer-based randomized trial, the effectiveness of PS was analyzed in 100 consecutive children allocated to a group receiving sclerotherapy (n = 50) or to a control group (n = 50) subjected only to regular clinical and endoscopic examinations. Clinical characteristics in both groups were similar. The minimum follow-up period was at least 18 months after the cessation of the sessions of sclerotherapy. RESULTS: After a median follow-up of 4.5 years, PS eliminated the esophageal varices in 47 of 50 (94%) patients but only 38 (76%) of them do not present upper digestive hemorrhage. Before complete obliteration of the varices, upper gastrointestinal bleeding occurred in 12 patients (24%). Six children (12%) had gastric varices, 3 of 6 of whom (50%) bled. Congestive hypertensive gastropathy was observed to occur in 8 (16%) patients, 4 of 8 of which (50%) had hemorrhagic episodes. Two patients bled from undetermined cause. In the control group, only 29 (58%) children remained free from esophageal variceal bleeding and 26 (52%) from any upper gastrointestinal bleeding (P<.05). During the follow-up period, the development of gastric varices was observed in 5 (10%) patients (P>.05) and of congestive hypertensive gastropathy in only 3 (6%) patients (P<.05), but none of them bled. PS does not improve survival rate. CONCLUSIONS: In children with cirrhotic and noncirrhotic portal hypertension, PS reduces the overall incidence of bleeding from esophageal varices that were eradicated in 94% of cases. The source of bleeding has been different in each group, being predominantly from esophageal varices in the control group and from the stomach in the prophylaxis group. When applied with appropriate technique, PS is a safe procedure with a low incidence of minor complications. PS does not change the incidence of gastric varices but increases the development of congestive hypertensive gastropathy. PS increases the risk of bleeding from the naturally formed gastric varices and from congestive hypertensive gastropathy. PS does not affect survival rate.     

What happens to esophageal varices after transection and devascularization?

In 14 patients who underwent endoscopic examination after esophageal transection and proximal gastric devascularization, varices disappeared in seven patients, were reduced in diameter or number in six patients, and were unchanged in one patient. No varices were present in any patient within 1 cm of the stapled anastomosis, and Doppler studies showed no flow in residual varices. During a mean follow-up of 20 months (range: 6 to 44 months), varices recurred in three patients and enlarged in five others. This study suggests that variceal obliteration, a reduction in variceal diameter, the removal of the bleeding zone in the esophagus, and undetectable blood flow in residual varices all contribute to the prevention of variceal rebleeding; although these changes are not always permanent, the return to the preoperative state may take many years.