Sclerotherapy Failure Salvage by Oesophageal Transection?

staple transection as a salvage procedure after failure of acute in]ection sclerotherapy. It is not clear which therapy should be used in patients with bleeding esophageal varices that are not controlled by emergency sclerotherapy. This is a high-risk group with reported mortality rates of between 70% and 90%. We report our 7-year experience with staple transection of the esophagus in this patient group. Of 168 patients (280 bleeding episodes) treated with sclerotherapy, 22 had emergency staple transection for failure to control bleeding. Bleeding was controlled in 20 patients (90%), and 10 patients (45%) survived to leave the hospital, including 4 of 10 patients (40%) with Pugh grade C liver disease. We suggest that emergency staple transection is an effective salvage treatment for this high-risk group. The present article has explored the possibility of using the salvage procedure of oesophageal transection, in a group of patients in whom sclerotherapy has failed and who carry an extremely high risk of mortality. Emergency sclerotherapy is now a well established procedure for acute variceal bleeding. It is successful in controlling active bleeding in nearly 90% of patients1'2. Failure of sclerotherapy is considered, if despite two or three sessions, the bleeding continues. The prognosis remains poor in these patients with mortality rates in excess of 50% 4. In this group of patients, the possibilities include the use of emergency shunt procedures, devascularization, transjugular intrahepatic portosys-temic shunts (TIPS), orthotopic liver transplantation (OLT) or staple transection of the oesophagus. At present, there are no clear guidelines to recommend one procedure over the other. The single stage staple gun transabdominal transection is simple and better tolerated, though the extent of devascularization is less (8-10 cm) than in the two stage, transthoracic approach used in the Sugiura's procedure (15-16 cm). While McCormack et al. in the present series from the Royal Free Hospital5, have recommended this procedure, a careful look at their data is needed. Only 22 of the 40 sclerotherapy failures could be taken up for transection. While primary haemostasis could be achieved in 20 (90%) patients, only 10 (45%) could leave the hospital and of these, 8 rebled (either from transection line