Results of a Modified Sugiura′s Devascularisation in theManagement of “Unshuntable” Portal Hypertension

Abstract

The results of a modified Sugiura devascularisation procedure were assessed in 14 patients with thrombosis of the portal and splenic vein requiring surgery for variceal hemorrhage, with no vein suitable for orthodox shunt surgery. The venous anatomy was determined by ultrasonography with Doppler studies and portovenography. Liver biochemistry as well as liver architecture on histopathology was normal in all. The surgery was elective in 9 cases for documented bleed from diffuse fundal gastric varices (FGV) and emergency in 5 cases, 3 having bleeding FGV and 2 for failure of emergency esophageal variceal sclerotherapy. All were subjected to a transabdominal extensive devascularisation of the upper two third of the stomach and lower 7–10cm of the esophagus. Stapled esophageal transection (n=11) or esophageal variceal under-running (n=1) was performed in all with esophageal varices. FGV were underrun. Follow up endoscopies were done six monthly. There were 9 males and 5 females with a mean age of 17.2 years (SD 12.8). There was no operative mortality. Acute variceal bleeding was controlled in all patients. Over a mean follow up of 38 months, all but one remain free of recurrent bleeding. We conclude that a modified Sugiura devascularisation procedure is effective in the immediate and medium term control of variceal bleeding in patients with “unshuntable” portal hypertension.

Review article: portal vein thrombosis – new insights into aetiology and management

“…In patients with PVT associated with splenomegaly and clinical features of hypersplenism, splenectomy may be of benefit. Surgical devascularization of gastro‐oesophageal varices has been reported as being safe and effective in patients with PVT (certainly in comparison with this approach in patients with underlying liver disease), 75, 76 but should rarely be necessary, in view of the availability of endoscopic approaches to controlling acute and recurrent variceal bleeding.…”

Oesophageal Transection for Bleeding Varices: Case Report and Literature Review

“…Bleeding oesophageal varices are a common problem in South Africa [1]. Acute bleeding from oesophageal varices presents in 70% of patients with liver cirrhosis [1,2]. As it carries a 20% mortality rate in the first 6 weeks it is clear that the gauntlet is flung at the treating physicianeven more so in a rural setting where patients often present late and there are limited resources [1].…”

“…Oesophageal transection with circular stapling devices, reported initially by Venkemmel in 1974, as part of acute management is less discussed in recent years. This is largely due to widespread access to endoscopic therapy which has fewer complications and very favourable results [2,6]. Initially introduced as an option for Child's A or B patients who do not qualify for shunting or liver transplant as part of the Sugiura procedure, oesophageal transection became an option in emergencies where haemostasis could not be achieved [2,6].…”

The modified Sugiura procedure as bridge surgery for liver transplantation: a case report

“…In the early era, operations for managing EV bleeding were considered as a contraindication for patients who were candidates for liver transplantation because they could cause significant upper abdominal adhesions, which might relate to increased intraoperative bleeding and changes of anatomical structures and would result in difficulties with the subsequent transplantation. However, in recent decades, because of the advancement of adhesion-proof materials and the nature of nonshunting operations that do not alter vascular anatomy and hemodynamic stability, these nonshunting operations are considered to become a short-term bridge therapy to liver transplantation without the complication of postoperative severe adhesion, especially for patients with splanchnic thrombosis-caused refractory EV bleeding or to earn more time for the patient and family to consider liver transplantation and also to complete the preoperative evaluations [ 3 , 8 - 11 ]. Besides, if the patient refused to have a liver transplantation eventually, the modified Sugiura operation could also serve as a long-term bleeding control management with less incidence of encephalopathy and fewer hemodynamic changes [ 8 , 9 , 12 ].…”