Endoscopically Guided Stapled Gastric Fundectomy in Treatment of Bleeding Fundal Varices

Aim: To evaluate endoscopically guided stapled gastric fundectomy with peri-esophagogastric devascularization and splenectomy in treatment of bleeding fundal varices.
Patients and methods: This study was performed on 24 patients (18 males and 6 females) with bleeding gastric varices hospitalized for either bleeding gastric fundal varices or previous episodes of variceal bleeding. Gastric fundectomy and periesophagogastric devascularization was undertaken. The site of fundal varices was determined with intraoperative endoscopy, Application of non-crushing curved intestinal clamp until the disappearance of fundal varices was done. After disappearance of fundal varices as noted by the endoscope, resection of the fundus bearing varices at this site of clamping was done using linear stapler for anastomosis.
Over sewing of the staple line was done. The mean length of follow up was 49.3 ±10.2 months Results: Mean age was 48.6 ±12.6 years. Patients had 2.42± 1.56 bleeding attacks.
Endoscopic sclerotherapy succeeded in 20 patients (83.33%), 4 patients (16.67 %) were treated with balloon tamponade and in 2 patients (8.33%), operation was performed for uncontrollable bleeding. 21 patients (87.50%) belonged to A, 2 patients (8.33%) were B while the remaining 1 patient (8.33%) was C Child-Pugh scoring. He was operated for uncontrollable hematemesia. 14 patients (58.33%) had isolated gastric varices and 10 patients (41.47%) had
gastroesophageal varices. 11 patients (33.33%) had positive serum hepatitis C virus antibody.
The patient with C Child-Pugh scoring deceased due to hepatocellular failure. Seven patients (29.16%) experienced one or more early postoperative complications: 3 wound sepsis, 2 small subphrenic collections, 2 pleural effusions, 1 bronchitis, and 1 portal vein thrombosis.
One patient developed delayed gastric emptying. One patient developed incisional hernia.
There was no bleeding from gastric varices and no endoscopic recurrences. Three patients had 1- 3 attacks of hematemesis from esophageal varices that was successfully controlled by sclerotherapy.3 patients developed malignancies: 2 hepatocellular carcinomas and 1 uterine cancer. Four patients died of hepatic failure, including the 2 with hepatocellular carcinomas. 
By univariate analysis, age, Child Pugh scoring and absence of malignancy were significantly associated with survival. Postoperative downgrading of Child-Pugh scoring of patients was noticed. Mean hemoglobin level at the time of admission was 7.99 ±1.35 g/dL. By the third month, it reached 11.90 ±0.89 g/dL (p less than 0.0001).
Conclusions: Gastric fundectomy and periesophagogastric devascularization is associated with a low incidence of recurrent bleeding and offers good long-term survival. It is an effective therapeutic intervention in patients with fundal variceal bleeding. Intra-operative endoscopy helps to guide accurate localization and complete eradication of varices and to minimize the resected area of the gastric fundus.