Hassab’s operation for bleeding gastric varices

Catastrophic bleeding from gastric varices rupture is a life-threatening emergency. In many instances a SengstakenBlakemore balloon tube cannot stop the bleeding and this area is also beyond the field of sclerotherapy. Surgery seems the only definite therapy, which may offer chances for survival, no recurrent bleeding and no hepatic encephalopathy [1]. Herein we present a 67-year-old patient with alcoholic cirrhosis and concomitant hepatocellular carcinoma who was admitted due to massive upper gastrointestinal tract bleeding. The patient was diagnosed seven years ago with severe alcoholic cirrhosis and with esophageal grade I varices. Despite medical recommendations the patient continued to drink heavily and was not compliant at all with medical treatment with beta-blockers. Furthermore the patient missed his regular follow up at the outpatient clinic. One year ago and due to continuous epigastric pain the patient was referred to the emergency department. He was admitted and diagnosed with inoperable hepatocellular carcinoma. The patient refused any kind of palliative medical therapy for his cancer and was discharged with proton pump inhibitors and beta-blockers. On admission the patient was actively vomiting large amounts of fresh blood and was in hypovolemic shock with blood pressure at 70/40 mmHg and heart rate at 140 bpm. Hemoglobin on admission was 6.2 g/dL and platelet count at 47,000/mm3. Emergency transfusion was performed but hypovolemic shock was not managed and the patient was massively vomiting blood. Endoscopy on emergency showed esophageal grade II varices and gastric varices (Fig. 1) with active bleeding (GOV-2 in the Sarin classification). Hassab’s operation (or Hassab-Paquet procedure) was successfully performed and on the six-month follow up the patient had an acceptable quality of life. The radical resection procedures such as terminal esophagectomy, proximal gastrectomy or cardiectomy and the stapler technique to resect en bloc the tortuous gastric varices, interrupt the normal esophago-gastric continuity and are too invasive for cirrhotic patients with co-morbidities. Hassab’s operation in the management of bleeding varices consists basically of gastro-esophageal decongestion and splenectomy. Perhiatal devascularization of lower esophagus, complete separation of the stomach from its bed, ligation of the left gastric artery at the lesser curvature, peritonization of greater curvature and suction drainage of the splenic bed are essential technical points. Hassab’s operation is effective in controlling bleeding by portal vein flow restoration and in hepatic encephalopathy correction