Esophagogastric Devascularization

Esophagogastric devascularization procedures are performed to control bleeding from varices in the esophagogastric region. They are not intended as treatment of the underlying disease, and they do not control bleeding from ectopic varices. Splenectomy is commonly performed as part of esophagogastric devascualrization.

Portal hypertension (PH), defined as portal pressure greater than 5 mm Hg, is a main consequence of cirrhosis. Clinically significant PH typically involves a portal pressure of 10 mm Hg or higher and is associated with an increased risk that gastroesophageal varices (GEVs) will develop. GEVs are found in approximately 50% of cirrhotic patients and contribute to the elevated morbidity and mortality among patients with PH. The reported 6-week mortality following each episode of variceal bleeding is in the range of 15-20%. ^{[1, 2]}

Nonoperative therapies are the mainstay of treatment for acute and prophylactic variceal hemorrhage (VH). These therapies include the following:

• Medications - Beta blockers, vasopressin and its analogues, somatostatin and its analogues
• Endoscopic procedures - Endoscopic variceal ligation, sclerotherapy, glue injection
• Interventional radiologic procedures - Balloon-occluded retrograde transvenous obliteration (BRTO), transjugular intra-hepatic portosystemic shunt (TIPS)

Surgical management of VH includes shunting and nonshunting operations. Nonshunting operations include esophagogastric devascularization, esophageal transection, and splenectomy. ^[2]

In PH, there is abnormal upward and increased flow through the portal system, creating large dilated venous varices. Specifically, serial section of the venous drainage of the esophagus in PH has shown that large vessels in the lamina propria communicate directly with engorged intraepithelial channels via epithelial papillae. Ideally, esophagogastric devascularization procedures control bleeding varices by permanently obliterating the vessels in the lower periesophageal vessels and dilated intraepithelial vessels.

The idea of transthoracic ligation of esophageal varices was first proposed by Crile (1950), with many modifications of the procedure following its initial conception. Boerema (1949) and Vosschulte (1957) used the button technique for transabdominal esophageal transection; however, this procedure was associated with major stricture formation. Walker (1964) and Tanner (1961) proposed a vertical incision of the muscle layers of esophagus, with transverse division of mucosa and submucosa and subcardiac portoazygos disconnection with gastric transection, respectively.

In 1967, Hassab introduced a method of gastroesophageal decongestion and splenectomy (GEDS) for management of bleeding varices secondary to schistosomiasis, which yielded a remarkably low rate of rebleeding. In 1973, Sugiura and Futagawa formulated the Sugiura procedure, which included extensive transthoracic paraesophageal devascularization, esophageal transection combined with an abdominal component consisting of splenectomy, devascularization of the upper stomach, vagotomy, and pyloroplasty. ^[3]  

Several modifications of the Hassab and Sugiura procedures were subsequently developed. Vankemmel (1974) was the first to report the use of a circular stapling gun for esophageal transection. Inokuchi (1985) modified the Sugiura procedure with a singular abdominal approach. Hashizume et al (1998) were the first to use a laparoscopic technique to perform the Hassab procedure and splenectomy. Johnson et al (2006) proposed a transabdominal modified devascularization procedure without esophageal stapler transection. ^{[3, 4]}  

Both procedures continue to be modified in subtle ways by a multitude of surgeons. ^{[5, 6]}  The goal of all of these procedures is to treat variceal bleeding while maintaining portal perfusion and long-term hepatic and systemic hemodynamics in patients with cirrhosis, thereby reducing the incidence of postoperative encephalopathy. The specific approach chosen should be based on the experience and comfort level of the operating surgeon.

Currently, in the western hemisphere, there are few indications for nonshunting operations to treat esophageal varices in patients with cirrhosis. Practice guidelines from the American Association for the Study of Liver Diseases (AASLD) have not include devascularization procedures in their recommendations in either the acute or the prophylactic setting. ^[2] Recommendations include nonselective beta blockade with endoscopic ligation therapy for prophylaxis and rebleeding episodes. If these therapies fail, TIPS ^[7] or a selective shunt is considered. ^[8] The goal is a bridge to liver transplantation whenever possible.

Devascularization procedures are rarely the treatment of choice in the emergency setting; the operative mortality has been as high as 100% in Child C patients in some series. ^[9] Nevertheless, when nonsurgical procedures fail and radiologic therapies are not feasible, devascularization procedures can salvage critical situations of variceal bleeding. Furthermore, in the elective setting, when the vascular anatomy is unsuitable for shunt procedures because of extensive portal, splenic, and superior mesenteric vein thrombosis and when other modalities have failed, devascularization procedures should be considered. ^{[10, 11]}  (See the image below.)

There is a clear indication for esophagogastric devascularization in combination with postoperative endoscopic treatment in patients with a hepatosplenic form of schistosomiasis causing portal hypertension. ^{[12, 13, 14]}

Esophagogastric devascularization is absolutely contraindicated in patients who are unstable or medically unfit to undergo surgical procedures. It is relatively contraindicated in Child C patients and when other treatment options for esophageal varices have not been exhausted.

Best practices

Esophagogastric devascularization procedures should be performed only by specially trained surgeons who have previous experience with the procedure in a hospital equipped to handle complicated surgical intensive care unit (SICU) patients.

Procedural planning

In the elective setting, patients should undergo preoperative evaluation by a cardiologist and hepatologist. Ideally, the patient should have developed a working relationship with his or her hepatologist prior to arriving at the decision to perform esophagogastric devascularization. Such patients should be crossmatched, with packed red blood cells (PRBCs) available. Platelets and fresh frozen plasma (FFP) should be available. If the prothrombin time (PT) is elevated on preoperative testing, FFP may be infused prior to or at the start of the procedure.

Perioperative mortality figures vary among series and differ depending on whether the procedure is performed in the elective or the emergency setting, as well as on the patient’s liver function status.

Sugiura and Futagawa published one of the largest series in 1984. ^[15] A total of 363 elective and 104 emergency procedures were performed, with a perioperative mortality of 3% for the former and 13% for the latter. These results were difficult to reproduce in the Western literature, where perioperative mortality for elective procedure was as high as 22%. ^[16]  In one of the larger Western studies, published by Mathur et al, mortality for emergency esophagogastric devascularization was 28%. ^[17]

Subsequently, Qazi et al published outcomes on 142 consecutive patients in whom nonoperative management with endoscopic sclerotherapy failed, necesitating esophagogastric devascularization in the emergency setting. ^[18] Their outcomes were similar to those of Sugiura and Futagawa, with a perioperative mortality of 12.7%. In this study, 15-year survival rates were recorded on the basis of the Child-Pugh classification at the time of the procedure. The survival rate was 44% in Child A patients, 22.5% in Child B patients, and 0% in Child C patients. In other series, the 5-year overall survival rate ranged from 58% to 93%. ^{[11, 16, 19]}  

In 2013, Liu et al published one of the largest modified Hassab series (562 cases). The reported 12-month and 5-year variceal bleeding rates were 1% and 9.7%, respectively. ^[20]

Zhang et al (1991) compared treatment of variceal bleeding treated by means of gastroesophageal decongestion with splenectomy (GEDS) or GEDS with esophageal transection and found that GEDS alone was sufficient, with a 2-year upper GI bleeding rate of 3.1%. The addition of esophageal transection did not change the bleeding rate and was associated with more early postoperative complications.

In a subsequent retrospective study, Wang et al (2016) compared the modified Sugiura and Hassab procedures and found that in their 66 patients, the rates of long-term rebleeding and recurrence of esophageal varices was lower in the modified Sugiura group. ^[21]  

A later retrospective study by Zhang et al (2019) compared open modified Hassab and Sugiura procedures with splenectomy and did not show any significant differences between the two procedures in 1-, 3-, and 5-year survival or in the rate of deadly variceal bleeding. ^[22] For the Hassab and Sugiura procedures, respectively, the 5-year survival rates were 71.43% and 75.31%, and the rates of mortality related to variceal bleeding were 7.69% and 3.70%.

In 2020, Deng et al published a retrospective analysis comparing laparoscopic with open splenectomy and esophagogastric devascularization. ^[23]  They found no significant differences in hospital mortality or variceal rebleeding between the two groups. Furthermore, the open procedure was associated with more intraoperative blood loss, a longer hospital stay, and a higher rate of postoperative complications.

Yang et al (2020) echoed these findings. ^[24] They reported that once deaths not related to variceal rebleeding were excluded, there was no significant difference in overall survival between the open and laparoscopic groups; they further concluded that esophagogastric devascularization and splenectomy can be performed successfully and safely in elderly patients aged 65 years or older.