VIDEO LAPAROSCOPY FOR THE TREATMENT OF BLEEDING ESOPHAGEAL-VARICES

Bleeding from esophageal varices is the major cause of death in patien ts with portal hypertension. The ideal surgical procedure should effec tively control bleeding, with as little impairment of Liver function a s possible and with low rates of encephalopathy. Based on this objecti ve, we propose the azygoportal disconnection (APD) with splenic artery ligation, and suturing of the gastric and esophageal varices without opening the esophagus, by video laparoscopy. With the patient placed i n a semigynecologic position, we use five trocars, and the interventio n begins by dissection of the diaphragmatic hiatus and isolation of th e esophagus. Then devascularization of the gastric fundus is accomplis hed. After that, dissection and ligature between clips of the splenic artery are performed. The surgery proceeds with dissection and ligatio n of the vessels of the lesser curvature. After orally introducing a 1 2-mm Fouchet probe, we suture the varices of the distal esophagus tran smurally, with interrupted sutures. The procedure is accomplished with a floppy Nissen valve. Between March 1994 and May 1995, four patients were treated with this method, two men and two women with a mean age of 54 pears. All of them had hepatic cirrhosis. Three patients were cl assified Child B and the other Child C. Surgical indication in all sub jects was persistent bleeding of the esophageal varices, after failure of such clinical attempts as endoscopic sclerosis and tamponade with the Sangstaken-Blakemore balloon. The operation mean time was 177 min. Neither bleeding nor hemodynamic changes occurred during the surgery. The patients were sent to the intensive care unit (ICU) postoperative ly for a mean time of 3 days, and they were discharged from the hospit al between days 8 and 10. The evolution demonstrated stabilization of the hepatic function and regression of the varices from grades III and IV to grade I. No bleeding recurred. Although this study had a small number of patients, we believe that this operation made by mini-invasi ve technique permits a quick recovery, reducing the global morbidity o f this procedure.