Esophagogastric Devascularization Technique

Updated: Sep 19, 2016
  • Author: Nicholas Sikalas, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Technique

Sugiura Procedure

Traditionally, this was performed as a two-step procedure—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.)

A modified Sugiura procedure. A modified Sugiura procedure.
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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. [5] 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 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.)

Transection and anastomosis with the EEA stapler. Transection and anastomosis with the 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 a modified Sugiura procedure Current indication of a modified Sugiura procedure in the management of variceal bleeding.

A novel procedure, esophagogastric devascularization without splenectomy (EDWS), was described by Ni et al. [16] In a retrospective study involving 55 patients, they reported that EDWS was a safe and effective treatment for esophagogastric varices secondary to portal hypertension in selected patients. Patients treated with EDWS were found to have  a lower complication rate of portal venous system thrombosis than those treated with conventional esophagogastric devascularization.

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Complications

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

Esophageal stricture at the transection site has been reported, ranging from 2%-28%. [3, 11]  Esophagogastroduodenoscopy (EGD) should be performed 3-4 weeks postoperatively to evaluate stricture formation and dilated, as necessary.

The reported incidence of portal vein thrombosis is between 1% and 6.3%. [3, 13]  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. [17]

Esophageal fistula/leak rates are reported to be about 6-7%. [7, 13]  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. [12, 13, 14, 15] Mariette et al reported a 24% rebleed rate at 5-year follow-up. [18]

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