Esophagogastric Devascularization 

Updated: Apr 18, 2018
Author: Nicholas Sikalas, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS 

Overview

Background

Gastroesophageal varices have been and continue to be a major source of morbidity and mortality among patients with portal hypertension. The reported 6-week mortality following each episode of variceal bleeding remains in the range of 15-20%.[1]

To understand the function that esophagogastric devascularization and transection (EDT) serves, an understanding of the underlying anatomy that results in esophagogastric varices must be understood. The coronary vein and gastric veins are connected to tributaries of the superior vena cava by collateral channels in the submucosa of the esophagus, between the two muscular layers, and in the periesophageal area (adventitial plexus). This represents a conduit between the portal and systemic system.

In portal hypertension, there is abnormal upward and increased flow through this system, creating large dilated venous varices. The goal of the esophagogastric devascularization procedures is to disconnect the esophagus and stomach from this collateral system while maintaining a portosystemic shunt in place via the adventitial plexus surrounding the esophagus.

Myriad nonshunting surgical techniques used to correct esophageal varices have been described in the literature.

Sugiura and Futagawa first introduced their technique of extensive gastroesophageal devascularization and transection for the treatment of esophageal varices in 1973. This technique involves paraesophagogastric devascularization with esophageal transection and splenectomy via thoracic and abdominal incisions.[2]

After the initial description in 1973, this technique was modified by Peracchia et al in 1980 to involve only a single abdominal incision and the use of circular stapling devices for esophageal transection.[3] This appears to be a variation of techniques described earlier.

In 1967, Hassab described esophagogastric devascularization via a single abdominal incision without esophageal transection. In 1974, Vankemmel first used a circular stapling device for performing esophageal transection.

This procedure continues to be modified in subtle ways by a multitude of surgeons.[4, 5] The goal of all these procedures is to treat variceal bleeding without the encephalopathy and liver failure associated with decompressive surgical shunts.

The approach chosen should be based on the experience and comfort level of the operating surgeon. Nonetheless, a pure abdominal approach is generally performed.

Indications

Currently, there are few indications for EDT in the Western Hemisphere for the treatment of esophageal varices in patients with cirrhosis. American Association for the Study of Liver Diseases (AASLD) practice guidelines have not included devascularization procedures in their recommendations in the acute or prophylactic setting. Recommendations include nonselective beta blockade with endoscopic ligation therapy for prophylaxis and episodes of rebleed.

If these therapies fail, transjugular intrahepatic portosystemic shunt (TIPS)[6] or selective shunt is considered.[7] The goal is a bridge to liver transplantation whenever possible.

EDT is rarely indicated in the emergency setting; the operative mortality is as high as 100% in Child C patients in some series.[8] However, EDT does have an emergency role when vascular anatomy is unsuitable for shunt procedures in patients with good liver function. Generally, these patients have extensive portal, splenic, and superior mesenteric vein thrombosis.[9] Even in an elective setting, EDT should be considered in a patient with cirrhosis in whom other treatment options have failed or who is not a candidate for alternative treatments.[10]  (See the image below.)

Management of patients with variceal bleeding refr Management of patients with variceal bleeding refractory to medical treatment

There is a clear indication for EDT in combination with postoperative endoscopic treatment in patients with a hepatosplenic form of schistosomiasis causing portal hypertension.[11, 12, 13]

Contraindications

EDT is absolutely contraindicated in patients who are unstable or medically unfit to undergo a surgical procedure.

EDT is relatively contraindicated in Child C cirrhosis and when other treatment options for esophageal varices are not exhausted.

Technical Considerations

Best practices

EDT 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. The patient should have hopefully developed a working relationship with his or her hepatologist prior to arriving at the decision to perform EDT. Such patients should be cross-matched, with packed red blood cells available. Platelets and fresh frozen plasma should be available. If the prothrombin time is elevated on preoperative testing, fresh frozen plasma may be infused prior to or at the start of the procedure.

Outcomes

Perioperative mortality figures vary among series and differ depending on whether the procedure is performed in the elective or emergency setting.

Sugiura and Futagawa published one of the largest series in 1984. 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.[14] These results were difficult to reproduce in the Western literature, where perioperative mortality for elective procedure was as high as 22%.[15]  In one of the larger Western studies, published by Mathur et al, emergency EDT mortality was 28%.[16]

Subsequently, Qazi et al published outcomes on 142 consecutive patients in whom nonoperative management with endoscopic sclerotherapy failed, necesitating EDT in the emergency setting. 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 procedure. The survival rate was 44% in Child A patients, 22.5% in Child B patients, and 0% in Child C patients.[17]

In other series, the 5-year overall survival rate ranged from 58% to 93%.[10, 15, 18]

 

Periprocedural Care

Preprocedural Planning

Most patients who undergo an esophagogastric devascularization procedure have cirrhosis and underlying coagulopathy, so significant intraoperative blood loss can be expected.

Regardless of whether the procedure is performed in the elective or the urgent setting, adequate intravenous access is necessary. This should include large-bore central venous access. In the elective setting, placement of a Swan-Ganz catheter for intraoperative monitoring can be considered.

A complete set of preoperative laboratory studies, including complete blood count count, comprehensive metabolic panel, coagulation studies, and type and crossmatch, should be performed.

Multiple units of packed red blood cells and fresh frozen plasma must be readily accessible.

A nasogastric tube should be placed. Great care should be taken for nasogastric tube placement because this by itself could cause esophageal varices to bleed.

If an endoscopic procedure was performed before surgery, a nasogastric sump tube should be left at that time.

Equipment

Special equipment includes the following:

  • End-to-end anastomosis (EEA) circular stapler (25-29 mm) (modified Sugiura procedure)
  • Tissue sealant device (optional)
  • Argon beam (optional)

Patient Preparation

Anesthesia

General anesthesia is necessary for the procedure. A transplant anesthesiologist, if available, should be involved in intraoperative care. When a thoracic approach is used, selective ventilation of the right lung using a double-lumen endotracheal tube is prudent.

Positioning

When a traditional Sugiura procedure is performed, the patient is positioned in a standard right lateral decubitus position. An axillary role should be placed under the chest in order to avoid a brachial plexus injury.

When a modified Sugiura procedure is performed, the patient is positioned supine, and a gel pad or blankets can be used to expose the lateral aspect of the left subcostal region. The patient may also be airplaned to the right on the surgical table.

Monitoring & Follow-up

The patient should be monitored in a surgical intensive care unit (SICU) setting immediately following the operation. Total parenteral nutrition (TPN) should be started if it was not already begun in the preoperative period.

On postoperative day 5-7, contrast esophagography should be performed to evaluate for leak, fistula, or narrowing at the transection line. If the test results are satisfactory, clear liquids may be started and the diet advanced slowly. A feeding jejunostomy or an intraoperatively placed postpyloric feeding tube may be of value in achieving early nutritional support in the postoperative period.

Esophagogastroduodenoscopy (EGD) should be performed 1 month postoperatively to evaluate the transection site for stricture formation. Any strictures should be dilated.

The patient should meet regularly with the surgeon or hepatologist for serial endoscopies.

 

Technique

Sugiura Procedure

Traditionally, the Sugiura procedure was performed as a two-step operation—a thoracic approach first, followed by an abdominal procedure 4-6 weeks after the initial thoracic operation. It is currently performed as a single procedure with synchronous abdominal and thoracic incisions.

The patient is placed in a right lateral decubitus position.

Thoracic portion

The thoracic portion of the procedure is performed via a left lateral thoracotomy at the sixth or seventh intercostal space.

Once the chest is opened, the anesthesiologist should proceed with selective right-lung ventilation.

The mediastinal pleura over the lower esophagus is opened longitudinally, exposing a vast and dilated adventitial venous plexus that communicates with submucosal varices via large perforators. Each perforator must be meticulously ligated, with great care taken not to damage the adventitial plexus that will continue to serve as a portosystemic shunt. A total of 30-50 perforator vessels may need to be ligated over a 13- to 18-cm length of esophagus from the esophageal hiatus to the level of the inferior pulmonary vein.

Esophageal transection is then performed at the level of the hiatus. If a nasogastric tube is in place, it should be pulled back proximal to the transection point.

The anterior muscular layer and the entire mucosa is transected, with the posterior muscular layer left intact. During transection, all encountered varices are ligated.

The mucosa is subsequently closed with 5-0 nonabsorbable sutures in an interrupted fashion.

Before closure of the anterior mucosa, the nasogastric tube should carefully be advanced past the suture line and into the stomach. The anterior muscular layer is subsequently closed with 4-0 absorbable sutures, completing the thoracic portion of the operation.

The thorax is closed in standard fashion, and one or more chest tubes are left in place for drainage.

Abdominal portion

The abdominal operation described by Sugiura and Futagawa in 1973 was performed through a left subcostal incision, though an upper midline incision can be used at the discretion of the surgeon.

First, a splenectomy is carefully performed. Removal of the spleen, which is generally enlarged secondary to portal hypertension, allows for better exposure for paraesophagogastric devascularization.

The abdominal esophagus is devascularized, followed by the cardia and the greater curvature of the stomach. Great care should be taken to ligate all short gastric vessels and stay close to the stomach as not to injure the gastroepiploic vessels. For this part of the operation, a vessel sealant device may be used.

The posterior vagus nerve is subsequently divided, and the cardioesophageal branches off the left gastric vein are divided. The left gastric vein should be preserved. Seven centimeters from the cardia or at least two thirds of the gastric wall should be devascularized.

In the description of the original procedure, the anterior vagus nerve is transected in order to facilitate devascularization, which necessitates a pyloroplasty that is performed just prior to abdominal closure. The abdomen is closed with appropriate drainage. (See the image below.)

Sugiura procedure. Sugiura procedure.

Modified Sugiura Procedure

The patient is rotated slightly to the right.

The procedure can be performed through bilateral subcostal incisions with posterior extension of the left subcostal incision. Another option is an S-shaped incision beginning posteriorly at the tip of the left tenth rib and extending across the midline approximately 8 cm.

A splenectomy is performed first, providing better exposure for gastric devascularization.

The abdominal portion of the procedure is similar to that described for the Sugiura procedure.

In some instances, it may be possible to spare both vagal trunks by displacing them up and medially toward the right. While devascularization of the lesser curvature is performed, dissection should cease just before the insertion of the anterior nerves of Latarjet into the antrum, as described by Ginsberg et al.[8] This preserves pylorus function, and a pyloroplasty will not be necessary. In some cases transection of both vagal trunks is necessary to facilitate esophageal devascularization.

The abdominal portion of the esophagus is freed from surrounding tissue. Dissection in this particular area may be difficult owing to venous congestion and possible scarring and fibrosis from previous sclerotherapy.

Once the abdominal esophagus is free, a Penrose drain is passed posteriorly and used for countertraction during the thoracic esophageal dissection.

The esophageal hiatus is opened, and the pericardium is dissected from the esophagus and pushed anteriorly. Esophageal devascularization is extended superiorly for 8-10 cm, with great care taken to divide only veins running in the transverse direction. A vessel sealant device or vascular clips may facilitate this portion of the procedure.

Once devascularization is complete, esophageal transection is performed.

A small horizontal gastrotomy is created in the anterior gastric wall. The nasogastric tube should be pulled back into the proximal esophagus. Obturator sizers are carefully passed through the gastrotomy and into the esophagus to determine the appropriate stapler size. A 0 suture is passed behind the esophagus.

The stapler is introduced into the esophagus through the gastrotomy. The stapler is opened about 4 cm and positioned 2 cm above the esophagogastric junction. The suture is tied down into the opening of the stapler device. The device is subsequently closed and the trigger is pulled.

Carefully remove the stapler and inspect the excised tissue for completeness. (See the image below.)

Modified Sugiura procedure. Transection and anasto Modified Sugiura procedure. Transection and anastomosis with EEA stapler.

A finger can be placed into the gastrotomy in order to inspect the staple line and guide a nasogastric tube past the esophageal anastomosis. The gastrotomy is closed in one or two layers.

A Nissen fundoplication may be performed to prevent gastroesophageal reflux. At this point, a feeding jejunostomy may be placed in order to facilitate early postoperative feeding.

The abdomen is closed with appropriate drainage. (See the image below.)

Current indication of modified Sugiura procedure i Current indication of modified Sugiura procedure in management of variceal bleeding.

Esophagogastric devascularization without splenectomy (EDWS) was described by Ni et al[19]  and has been assessed by others.[5] In a retrospective study involving 55 patients, Ni et al reported that EDWS was a safe and effective treatment for esophagogastric varices secondary to portal hypertension in selected patients.[19] Patients treated with EDWS were found to have  a lower complication rate of portal venous system thrombosis than those treated with conventional esophagogastric devascularization.

Complications

There are subsets of postoperative complications particular to esophagogastric devascularization procedures.

Esophageal stricture at the transection site has been reported, ranging in frequency from 2% to 28%.[3, 14]  Esophagogastroduodenoscopy (EGD) should be performed 3-4 weeks postoperatively for evaluation of stricture formation and dilation, as necessary.

The reported incidence of portal vein thrombosis is between 1% and 6.3%.[3, 16]  However, the true incidence may be higher, because this reproted range generally includes only symptomatic patients. A portal vein diameter greater than 13.5 mm and a history of upper gastric bleeding have been reported as independent risk factors for the development of protal vein thrombosis postoperatively.[20]

Rates of esophageal fistula or leak are reported to be about 6-7%.[10, 16]  When reported, the treatment of clinical leaks generally involved drainage alone.

Sugiura and Futagawa reported the lowest rate of rebleeding, at 1.5%. In the remaining literature, rebleeding rates vary greatly, ranging from 6% to 32%, as does the duration of follow-up.[15, 16, 17, 18] Mariette et al reported a 24% rebleed rate at 5-year follow-up.[21]