Transabdominal Extensive Esophagogastric Devascularization with Gastroesophageal Stapling for Management of Noncirrhotic Portal Hypertension: Long‐term Results

Abstract

Outside Japan portosystemic shunts have been favored as the surgical procedure of choice for the management of portal hypertension of noncirrhotic etiology. Devascularization procedures have resulted in high rebleed rates probably owing to a limited extent of devascularization. We performed this study to assess the efficacy of our modification of Sugiura's procedure for long-term control of variceal bleeding in patients with noncirrhotic portal hypertension. Forty-six patients with extrahepatic portal venous obstruction (EHPVO) and 22 with noncirrhotic portal fibrosis (NCPF) were subjected to transabdominal extensive esophagogastric devascularization with esophageal or gastric stapled transection (modified Sugiura's procedure), 38 in an emergency situation and 30 electively. Follow-up endoscopies were performed every 6 months. Operative mortality, morbidity, variceal status, and causes of recurrent bleeding were evaluated. The postoperative mortality was 4%. Early procedure-related complications were seen in 6%, and esophageal strictures formed in 7 of 45 survivors undergoing esophageal transection (15%). Over a mean +/- SD follow-up of 53 +/- 34 months, 95% of patients were free of varices. Seven survivors (11%) had a rebleed, but only 5% were due to varices (two esophageal, one gastric). Six (9%) patients developed gastropathy. The 5-year survival was 88%. The modified Sugiura's procedure is safe and effective for long-term control of variceal bleeding especially in the emergency setting and in patients with anatomy unsuitable for shunt surgery or if surgical expertise for a shunt operation is not available.

Current Role of Surgery in Portal Hypertension

“…An operative mortality of 4%, rebleeding rate of 11% (5% variceal), esophageal stricture rate of 15% and a 5-year survival of 88% were reported [24]. The authors concluded that this modified Sugiura procedure was safe and effective for long-term control of variceal bleeding in NCPH, especially in the emergency setting and in patients with anatomy unsuitable for shunt surgery or if surgical expertise for a shunt operation is not available [24]. Orozco et al [61] from Mexico reported similar results in a selected group of patients with EHPVO (n=38) undergoing the one-stage or two-stage Sugiura procedure.…”

“…In a series of 68 patients (44 EHO, 22 NCPF), transabdominal extensive esophagogastric devascularization with gastroesophageal stapling was done (emergency 38; elective 30) and were followed up for a mean period of 54 months. An operative mortality of 4%, rebleeding rate of 11% (5% variceal), esophageal stricture rate of 15% and a 5-year survival of 88% were reported [24]. The authors concluded that this modified Sugiura procedure was safe and effective for long-term control of variceal bleeding in NCPH, especially in the emergency setting and in patients with anatomy unsuitable for shunt surgery or if surgical expertise for a shunt operation is not available [24].…”

“…In general, patients with NCPH are better treated with decompressive shunts [7,9,26,43]. If suitable shuntable veins are not available, devascularization may be the only option [21,24].…”

“…To obviate the high incidence of encephalopathy following shunts, many centers have deliberately employed devascularization procedures such a extensive two-stage esophagogastric devascularization (transthoracic and transabdominal; Sugiura-Futgawa technique) [21], modified Hassab's (transabdominal esophagogastric devascularization with splenectomy, without esophageal transection) [22] or spleen-preserving esophagogastric devascularization with stapled esophageal/cardial transection [23,24] for secondary prophylaxis as well as for managing acute variceal bleeding (see above).…”

Idiopathic Portal Hypertension: Report of a Case

“…The prognosis of IPH is generally good if an effective prophylaxis and management of esophageal variceal bleeding take place [1,9]. Treatment options for esophageal varices in patients with IPH recently have become more diverse and include portal decompression procedures [4,6,10,11], devascularization procedures and splenectomy [12][13][14][15][16][17][18], endoscopic injection sclerotherapy (EIS) or variceal ligation (EVL) [6,[19][20][21], and interventional radiology [22,23]. To date, no clear consensus has been reached concerning the best method for treatment of esophageal varices due to IPH.…”