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.

Given that most patients who undergo an esophagogastric devascularization procedure have cirrhosis and underlying coagulopathy, 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 (CBC), comprehensive metabolic panel, coagulation studies, liver function tests (LFTs), and type and crossmatch, should be performed.

Multiple units of packed red blood cells (PRBCs) and fresh frozen plasma (FFP) must be readily available. 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. This can be done under the guidance of esophagogastroduodenoscopy (EGD). If an endoscopic procedure was performed before surgery, a nasogastric sump tube should be left at that time.

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)

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 roll 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.

When a Hassab or a modified Hassab procedure is performed, the patient is in a supine position with 30º reverse Trendelenburg for optimal exposure of the operative field.

The patient should be monitored in a surgical intensive care unit (SICU) setting immediately after 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 leakage, 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.

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.

Traditionally, the Sugiura procedure was performed as a two-step operation—a thoracic procedure 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 have 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 are 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, affords 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 to stay close to the stomach so 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. About 7 cm 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.)

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.[25, 26]

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.[9] 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. The stapler is then carefully removed, and the excised tissue is inspected for completeness. (See the image below.)

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

Esophagogastric devascularization without splenectomy (EDWS) was described by Ni et al[27]  and has been assessed by others.[6] 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 (PH) in selected patients.[27] Patients treated with EDWS were found to have a lower complication rate of portal venous system thrombosis than those treated with conventional esophagogastric devascularization.

The patient is in a supine position with 30º reverse Trendelenburg for optimal operative field exposure. Typically, a midline incision is sufficient; however, in cases of extreme splenomegaly, an extended left subcostal incision or L-shaped incision in the upper abdomen may be utilized. The left hemiliver is retracted out of the operative field; the hepatic ligaments may have to be divided to provide better exposure.

The first step in the procedure is splenectomy. The gastrohepatic ligament is divided, exposing the right crus of the esophageal hiatus. An incision is made on the anterior esophagus, extending superiorly and inferiorly to the left side of the esophagus until the left crus of the eosphageal hiatus is identified to free the esophagus from peritoneal reflections. The abdominal esophagus is freed circumferentially, and an umbilical tape is used for retraction. Perihiatal devascularization of the lower 3-4 inches of the esophagus is carried out by ligation of any vessel or vagus nerves ascending through the hiatus and diaphragm. The left gastric artery is ligated, as well as vessels feeding the proximal half of the stomach.[28]

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%.[4, 15]  Esophagogastroduodenoscopy (EGD) should be performed 3-4 weeks postoperatively for evaluation of stricture formation and dilation, as necessary. Rates of esophageal fistula or leakage are reported to be about 6-7%.[11, 17]  When reported, treatment of clinical leaks has generally involved drainage alone.

The reported incidence of portal vein thrombosis is between 1% and 6.3%.[4, 17]  However, the true incidence may be higher, because this reported 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 portal vein thrombosis postoperatively.[29]

Sugiura and Futagawa reported the lowest rate of rebleeding, at 1.5%. In the remaining literature, rebleeding rates have varied greatly, ranging from 6% to 32%, as has the duration of follow-up.[16, 17, 18, 19] Mariette et al reported a 24% rebleeding rate at 5-year follow-up.[30]