A Modified Sugiura Procedure

doi:10.1016/S0003-4975(10)62494-0

The Annals of Thoracic Surgery

Volume 34, Issue 3, September 1982, Pages 258-264

https://doi.org/10.1016/S0003-4975(10)62494-0 Get rights and content

Abstract

The Sugiura procedure for esophageal varices combines splenectomy with esophagogastric devascularization, which destroys the intraesophageal portacaval shunt but preserves periesophageal portacaval shunts. We have modified the total vagotomy and pyloroplasty and sutured esophageal anastomosis of the original operation. A single left thoracoabdominal incision is used. Esophagogastric devascularization is performed without dividing the main vagus trunks; only a proximal gastric vagotomy is done, thereby avoiding a pyloroplasty. The esophageal transection and reanastomosis are performed with the circular End-to-End Anastomosis stapler and protected with a loose fundal wrap.

Fifteen of 20 patients have had good to excellent results, with rapid recovery and no recurrent esophagogastric bleeding or any hepatic encephalopathy in follow-up of two months to two years. Four patients, who were bleeding massively at the time of operation and who were in Child's class C with gross ascites, muscle wasting, and coagulopathy, died in the postoperative period.

Conceptually, the operation is original and exciting because it preserves hepatic blood flow and the beneficial periesophageal shunt, while destroying the harmful intraesophageal shunt. Our early experience encourages us to continue using this operation, except in those patients who bleed massively and are in Child's C, end-stage, class.

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Cited by (28)

Chapter 84-Portal hypertensive bleeding: Operative devascularization
2016, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth Edition
Esophageal varices: Operative devascularization and splenectomy
2012, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas
Operative Devascularization and Esophageal Transection
2006, Surgery of the Liver, Biliary Tract and Pancreas: Volumes 1-2, Fourth Edition
Current indication of a modified Sugiura procedure in the management of variceal bleeding
2001, Journal of the American College of Surgeons
Background:
The role of gastroesophageal devascularization (Sugiura-type procedures) for the treatment of variceal bleeding remains controversial. Although Japanese series reported favorable longterm results, the technique has not been widely accepted in the Western Hemisphere because of a high postoperative morbidity and mortality. The reasons for the different outcomes are unclear. In a multidisciplinary team approach we developed a therapeutic algorithm for patients with recurrent variceal bleeding.
Study design:
The Sugiura procedure was offered only to patients with well-preserved liver function (Child A or Child B cirrhosis without chronic ascites) who were not candidates for distal splenorenal shunt, transhepatic porto-systemic shunt, or liver transplantation.
Results:
Fifteen patients with recurrent variceal bleeding underwent a modified Sugiura procedure between September 1994 and September 1997. All but one patient (operative mortality 7%) are alive after a median followup of 4 years. Recurrent variceal bleeding developed in one patient; esophageal strictures, which were successfully treated by endoscopic dilatation, developed in three patients; and one patient experienced mild encephalopathy. Major complications were noted only in patients with impaired liver function (Child B cirrhosis) or when the modified Sugiura was performed in an emergency setting. The presence of cirrhosis or the cause of portal hypertension had no significant impact on the complication rate.
Conclusions:
This series was performed during the last decade when all modern therapeutic options for variceal bleeding were available. Our results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.
Variceal rebleeding after portosystemic shunting: Strategies and solutions to a vexing problem
1991, Surgical Clinics of North America
Portosystemic shunting continues to be the mainstay of treatment for variceal hemorrhage secondary to cirrhosis and portal hypertension. Should the shunt fail, rebleeding is often severe, necessitating prompt control and resuscitation. Although attempts to re-establish shunt patency with angiographic techniques may prove fruitful, operative decompression in a previously untouched area of the portal system may become necessary. If these options are available, repeated endoscopic sclerotherapy beomes the best remaining alternative.
Emergency surgical treatment of variceal hemorrhage
1990, Surgical Clinics of North America
Emergency surgery should be considered one of the treatment options for the patient with acute variceal bleeding in whom the usual nonsurgical modes of therapy fail, and who is deemed fit to tolerate a major operation. A total shunt (portacaval or mesocaval) is recommended for most of these patients, although a distal splenorenal shunt might be considered for some very good risk, nonalcoholic patients who have only moderate bleeding. Devascularization procedures have a limited role in the emergency situation, but they may be useful in patients who are nonshuntable because of splanchic venous thrombosis. The Sugiura type of operation is appropriate for the nonalcoholic patient, and esophageal transection is appropriate for the alcoholic patient with cirrhosis. Patients with end-stage nonalcoholic liver disease should also be considered for liver transplantation.

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: Presented at the Eighteenth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 11–13, 1982.

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A Modified Sugiura Procedure

Abstract

J Thorac Cardiovasc Surg

Am J Surg

Further evaluation of the Sugiura procedure in the treatment of esophageal varices

Arch Surg

Transection operation for portal hypertension

Thorax