Sugiura procedure

Last updated
Sugiura procedure
Specialty gastroenterology

The Sugiura procedure is a surgical technique that involves the removal and transection of the blood vessels that supply the upper portion of the stomach and the esophagus. The procedure also involves a splenectomy. The operation was originally developed to treat bleeding esophageal varices (commonly a complication of liver cirrhosis) that were untreatable by other conventional methods. It was originally developed as a two-step operation, but has been modified numerous times by many surgeons since its original creation.

Contents

Introduction

The Sugiura procedure was originally developed to treat bleeding esophageal varices and consisted mainly of an esophagogastric devascularization. It was developed in Japan in 1973 [1] as a nonshunting technique that achieved variceal bleeding hemostasis by interrupting the variceal blood flow along the gastroesophageal junction. The procedure consists primarily of paraesophagogastric devascularization achieved by dividing the perforating veins of the esophagus and the stomach while maintaining the plexus of collaterals that connect the coronary gastric vein to the azygous system. The original procedure also consisted of an esophageal transection, splenectomy, vagotomy, and pyloroplasty.[ citation needed ]

The Sugiura procedure was originally associated with significant morbidity and mortality; in recent years, though, this procedure and its modifications have been performed in many hepatobiliary and pancreatic surgical centers with improving morbidity and mortality rates. [2] [3] [4] [5] [6] [7] [8]

Indications

Elective procedure

The modified Sugiura procedure is indicated in patients with well-preserved liver function (Child-Pugh class A or B without chronic ascites) and who are not candidates for transjugular intrahepatic portosystemic shunt, distal splenorenal shunt, or liver transplantation. [9] [10]

Emergent procedure

Emergency Sugiura procedure is indicated when Child-Pugh class A or B cirrhotic patients are acutely bleeding from gastroesophageal varices that are not responsive to medical or radiological therapies. [10]

Pediatrics

A study of 15 children, aged 2–12 years old who all had multiple episodes of severe esophageal bleeding varices, and a mean follow-up time of 10 years 4 months, demonstrated 0% mortality and 80% resolution with disappearance of the varices and no evidence of recurrent bleeding. No cases of esophageal stenosis, gastroesophageal reflux disease, hiatal hernia, encephalopathy or hepatic dysfunction were documented. The Sugiura procedure is a safe and effective surgical treatment of esophageal varices in the pediatric population. [5]

Procedure

Original technique

The original technique described by Sugiura and Futagawa was a two-step operation consisting of an initial thoracic operation followed by the abdominal operation 3–4 weeks later. The thoracic operation consists of an extensive paraesophageal devascularization up to the inferior pulmonary vein and esophageal transection. The abdominal operation consists of a splenectomy, devascularization of the abdominal esophagus and cardia, and a selective vagotomy with pyloroplasty. [1]

Thoracic operation

Access is gained through a left lateral thoracotomy incision below the sixth rib. The inferior mediastinum is exposed to the level of the anterior aspect of the descending aorta. All of the shunting veins that direct blood to the collateral veins from the esophagus are ligated, taking special consideration to preserving the extraesophageal systemic venous collaterals (azygous veins). Usually between 30 and 50 shunting veins are present. Once devascularization is complete, the esophagus is clamped in two areas with esophageal clamps, and esophageal transection is done at the level of the diaphragm. The anterior muscular and mucosal layers are divided, but the posterior layer is left intact. Sutures are then placed and the divided varices are occluded. The muscle layer is then reattached. A nasogastric tube is left in situ, and the mediastinum is closed.[ citation needed ]

Abdominal operation

Access is gained through an upper midline incision with left lateral extension. Splenectomy is then performed. The abdominal esophagus is devascularized from the stomach. The posterior gastric vagus nerve requires ligation due to its close proximity. The lesser curvature of the stomach and abdominal esophagus are then devascularized, and the cardioesophageal branches of the left gastric vessels are ligated and divided. The esophagus and cardia are then entirely mobilized. The anterior gastric vagus nerve was previously divided and therefore pyloroplasty is performed. A drain is inserted in the surgical cavity and the incision is closed.[ citation needed ]

Modified Sugiura procedure

Since the majority of documented Sugiura procedures performed outside Japan failed to achieve the exceptionally low mortality and morbidity rates, various authors have proposed modifications to make the procedure less complex. [2] [11] [12] [13] [14] One common modification uses a single abdominal operation to achieve gastroesophageal devascularization. A splenectomy is initially performed and is followed by devascularization of the distal esophagus through the diaphragm hiatus and the superior two-thirds of the major and lesser gastric curve taking careful consideration to not ligate the left gastric vein. To ensure complete separation of the azygous vein system from the intramucosal venous plexus, an end-to-end anastomosing stapling device transects and anastomosis a region of the esophagus 4–6 cm above the gastroesophageal junction. This anastomosis can then be reinforced with vicryl suture. A pyloroplasty is routinely followed to facilitate gastric emptying. [9]

Morbidity and mortality

Early experience with the Sugiura procedure demonstrated, following the procedures, the overall operative mortality was 32% and overall morbidity occurred in 33% of the patients. [15] Significant causes of morbidity and mortality were related to complications of the esophageal transection as anastomotic leakage occurred in 8.6% of patients undergoing emergent surgery versus 4.8% in elective cases. All patients who developed an esophageal leak died. [16] For this reason, modification of the original procedure was introduced to avoid the risk of perioperative mortality due to esophageal transection.[ citation needed ]

Retrospective analyses of patients who received the Sugiura procedure between 1967 and 1984 for either elective, emergency, or prophylactic setting demonstrate that operative mortality was greatest in the emergency setting (13.3%), followed by prophylactic (3.9%) and elective surgery (3.0%). [10]

Outcomes

Recent reports of selected patients undergoing Sugiura procedure reported that recurrence of gastroesophageal variceal bleeding occurs in only 2.3% of patients. [8]

Related Research Articles

<span class="mw-page-title-main">Esophagus</span> Vertebrate organ through which food passes to the stomach

The esophagus or oesophagus, colloquially known also as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach. The esophagus is a fibromuscular tube, about 25 cm (10 in) long in adults, that travels behind the trachea and heart, passes through the diaphragm, and empties into the uppermost region of the stomach. During swallowing, the epiglottis tilts backwards to prevent food from going down the larynx and lungs. The word oesophagus is from Ancient Greek οἰσοφάγος (oisophágos), from οἴσω (oísō), future form of φέρω + ἔφαγον.

<span class="mw-page-title-main">Gastroesophageal reflux disease</span> Medical condition

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications. Symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma. In the long term, and when not treated, complications such as esophagitis, esophageal stricture, and Barrett's esophagus may arise.

<span class="mw-page-title-main">Hiatal hernia</span> Type of hernia

A hiatal hernia or hiatus hernia is a type of hernia in which abdominal organs slip through the diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. Other symptoms may include trouble swallowing and chest pains. Complications may include iron deficiency anemia, volvulus, or bowel obstruction.

<span class="mw-page-title-main">Upper gastrointestinal bleeding</span> Medical condition

Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

Coffee ground vomitus refers to a particular appearance of vomit. Within organic heme molecules of red blood cells is the element iron, which oxidizes following exposure to gastric acid. This reaction causes the vomitus to look like ground coffee.

<span class="mw-page-title-main">Budd–Chiari syndrome</span> Medical condition

Budd–Chiari syndrome is a very rare condition, affecting one in a million adults. The condition is caused by occlusion of the hepatic veins that drain the liver. The symptoms are non-specific and vary widely, but it may present with the classical triad of abdominal pain, ascites, and liver enlargement. It is usually seen in younger adults, with the median age at diagnosis between the ages of 35 and 40, and it has a similar incidence in males and females. The syndrome can be fulminant, acute, chronic, or asymptomatic. Subacute presentation is the most common form.

<span class="mw-page-title-main">Nissen fundoplication</span> Surgical procedure to treat gastric reflux and hiatal hernia

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal, Belsey, Dor, Lind, and Toupet fundoplications are alternative procedures with somewhat different indications and outcomes.

<span class="mw-page-title-main">Esophagogastroduodenoscopy</span> Diagnostic endoscopic procedure

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

<span class="mw-page-title-main">Esophageal varices</span> Medical condition

Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendency to develop severe bleeding which left untreated can be fatal. Esophageal varices are typically diagnosed through an esophagogastroduodenoscopy.

<span class="mw-page-title-main">Gastric varices</span> Medical condition

Gastric varices are dilated submucosal veins in the lining of the stomach, which can be a life-threatening cause of bleeding in the upper gastrointestinal tract. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis. Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins that drain the fundus of the stomach flow. The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours, as well as hepatitis C. Gastric varices and associated bleeding are a potential complication of schistosomiasis resulting from portal hypertension.

<span class="mw-page-title-main">Pancreaticoduodenectomy</span> Major surgical procedure involving the pancreas, duodenum, and other organs

A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours from the head of the pancreas. It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis. Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach.

Perioperative mortality has been defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the hospital. Globally, 4.2 million people are estimated to die within 30 days of surgery each year. An important consideration in the decision to perform any surgical procedure is to weigh the benefits against the risks. Anesthesiologists and surgeons employ various methods in assessing whether a patient is in optimal condition from a medical standpoint prior to undertaking surgery, and various statistical tools are available. ASA score is the most well known of these.

<span class="mw-page-title-main">Transjugular intrahepatic portosystemic shunt</span> Artificial channel within the liver

Transjugular intrahepatic portosystemic shunt is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. It is used to treat portal hypertension which frequently leads to intestinal bleeding, life-threatening esophageal bleeding and the buildup of fluid within the abdomen (ascites).

<span class="mw-page-title-main">Distal splenorenal shunt procedure</span>

In medicine, a distal splenorenal shunt procedure (DSRS), also splenorenal shunt procedure and Warren shunt, is a surgical procedure in which the distal splenic vein is attached to the left renal vein. It is used to treat portal hypertension and its main complication. It was developed by W. Dean Warren.

<span class="mw-page-title-main">Laparoscopic hiatal hernia repair</span> Medical procedure

Laparoscopic hernia repair is the repair of a hiatal hernia using a laparoscope, which is a tiny telescope-like instrument. A hiatal hernia is the protrusion of an organ through its wall or cavity. There are several different methods that can be used when performing this procedure. Among them are the Nissen Fundoplication and the general laparoscopic hernia repair.

<span class="mw-page-title-main">Sengstaken–Blakemore tube</span> Medical device

A Sengstaken–Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage due to esophageal varices. The use of the tube was originally described in 1950, although similar approaches to bleeding varices were described by Westphal in 1930. With the advent of modern endoscopic techniques which can rapidly and definitively control variceal bleeding, Sengstaken–Blakemore tubes are rarely used at present.

<span class="mw-page-title-main">Portal hypertensive gastropathy</span> Changes in the mucosa of the stomach in patients with portal hypertension

Portal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension; by far the most common cause of this is cirrhosis of the liver. These changes in the mucosa include friability of the mucosa and the presence of ectatic blood vessels at the surface. Patients with portal hypertensive gastropathy may experience bleeding from the stomach, which may uncommonly manifest itself in vomiting blood or melena; however, portal hypertension may cause several other more common sources of upper gastrointestinal bleeding, such as esophageal varices and gastric varices. On endoscopic evaluation of the stomach, this condition shows a characteristic mosaic or "snake-skin" appearance to the mucosa of the stomach.

Hassab's decongestion operation is an elective surgical procedure to treat esophageal varices in patients with portal hypertension as a result of cirrhosis of the liver. It was created by Dr. Mohammed Aboul-Fotouh Hassab, a professor of surgery at Alexandria University in Egypt.

Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.

Anorectal varices are the dilation of collateral submucosal vessels due to backflow in the veins of the rectum. Typically this occurs due to portal hypertension which shunts venous blood from the portal system through the portosystemic anastomosis present at this site into the systemic venous system. This can also occur in the esophagus, causing esophageal varices, and at the level of the umbilicus, causing caput medusae. Between 44% and 78% of patients with portal hypertension get anorectal varices.

References

  1. 1 2 Sugiura M, and Futagawa S. A new technique for treating esophageal varices. The Journal of Thoracic and Cardiovascular Surgery. 1973;66(5):677.
  2. 1 2 Ginsberg RJ, Waters PF, Zeldin RA, Spratt EH, Shandling B, Stone RM, and Strasberg S. A modified Sugiura procedure. The Annals of Thoracic Surgery. 1982;34(3):258-264.
  3. ↑ Dagenais M, Langer B, Taylor BR, and Greig PD. Experience with radical esophagogastric devascularization procedures (Sugiura) for variceal bleeding outside Japan. World J Surg. 1994;18(2):222-8.
  4. ↑ Mariette D, Smadja C, Borgonovo G, Grange D, and Franco D. The Sugiura procedure: a prospective experience. Surgery. 1994;115(3):282-289.
  5. 1 2 Belloli G, Campobasso P, and Musi L. Sugiura procedure in the surgical treatment of bleeding esophageal varices in children: Long-term results. Journal of Pediatric Surgery. 1992;27(11):1422-1426.
  6. ↑ Wright AS, and Rikkers LF. Current management of portal hypertension. Journal of gastrointestinal Surgery. 2005;9(7):992-1005.
  7. ↑ Sugiura M, and Futagawa S. Results of six hundred thirty-six esophageal transections with paraesophagogastric devascularization in the treatment of esophageal varices. J Vasc Surg. 1984, Mar;1(2):254-60.
  8. 1 2 Sugiura M, and Futagawa S. Further evaluation of the Sugiura procedure in the treatment of esophageal varices. Archives of Surgery. 1977;112(11):1317.
  9. 1 2 Selzner M, Tuttle-Newhall JE, Dahm F, Suhocki P, and Clavien PA. Current indication of a modified Sugiura procedure in the management of variceal bleeding. J Am Coll Surg. 2001, Aug;193(2):166-73.
  10. 1 2 3 Sugiura M, and Futagawa S. Esophageal transection with paraesophagogastric devascularizations (the Sugiura procedure) in the treatment of esophageal varices. World J Surg. 1984, Oct;8(5):673-9.
  11. ↑ Pierce GE, Thomas JH, and Estes NC. A transthoracic devascularization procedure for control of bleeding esophageal varices: preliminary report. Am J Surg. 1977, Dec;134(6):794-8.
  12. ↑ Mir J, Ponce J, Morena E, Juan M, Garrigues V, Pina R, and Berenguer J. Esophageal transection and paraesophagogastric devascularization performed as an emergency measure for uncontrolled variceal bleeding. Surg Gynecol Obstet. 1982, Dec;155(6):868-72.
  13. ↑ Mathur SK, Shah SR, Soonawala ZF, Karandikar SS, Nagral SS, Dalvi AN, and Mirza DF. Transabdominal extensive oesophagogastric devascularization with gastro-oesophageal stapling in the management of acute variceal bleeding. Br J Surg. 1997, Mar;84(3):413-7.
  14. ↑ Weese JL, Starling JR, and Yale CE. Control of bleeding esophageal varices by transabdominal esophageal transection, gastric devascularization, and splenectomy. Surg Gastroenterol. 1984;3(1):31-6.
  15. ↑ Barbot DJ, and Rosato EF. Experience with the esophagogastric devascularization procedure. Surgery. 1987;101(6):685-690.
  16. ↑ Gouge TH, and Ranson JH. Esophageal transection and paraesophagogastric devascularization for bleeding esophageal varices. The American Journal of Surgery. 1986;151(1):47-54.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.