A modified Sugiura procedure

The Sugiura procedure for esophageal varices combines splenectomy with esophagogastric devascularization, which destroys the intraesophageal portacaval shunt but preserves periesophageal portacaval shunts. We have modified the total vagotomy and pyloroplasty and sutured esophageal anastomosis of the original operation. A single left thoracoabdominal incision is used. Esophagogastric devascularization is performed without dividing the main vagus trunks; only a proximal gastric vagotomy is done, thereby avoiding a pyloroplasty. The esophageal transection and reanastomosis are performed with the circular End-to-End Anastomosis stapler and protected with a loose-fundal wrap. Fifteen of 20 patients have had good to excellent results, with rapid recovery and no recurrent esophagogastric bleeding or any hepatic encephalopathy in follow-up of two months to two years. Four patients, who were bleeding massively at the time of operation and who were in Child's class C with gross ascites, muscle wasting, ad coagulopathy, died in the postoperative period. Conceptually, the operation is original and exciting because it preserves hepatic blood flow and the beneficial periesophageal shunt, while destroying the harmful intraesophageal shunt. Our early experience encourages us to continue using this operation, except in those patients who bleed massively and are in Child's C, end-stage, class.