- Email: [email protected]
Elective treatment of bleeding varices with the Sugiura operation over 10 years
Elective Treatment of Bleeding Varices With the Sugiura Operation Over 10 Years Hector Orozco, MD, Miguel Angel Mercado, MD, Takeshi Takahashi, MD, Jorge Hernandez-Ortiz, Juan Fdlix Capellan S., MD, Guadalupe Garcia-Tsao, MD, Mexico City, Mexico
A lO-year experience with the devascularixation operation described by Sugiura is reported here. The operation was performed electively in 100 patients in whom it was not possible to place a shunt, all of whom had different hinds of hepatopathies (63 Child’s A, 32 Child’s B, and 5 Child’s C) . In 15 patients, the procedure was done in one stage (6% operative mortality, 1 patient), and, in 51, it was performed in two stages. Eight deaths were recorded in the 63 patients of the Child’s A group, with a total of 111 operations. The operative mortality rate for this group was 12% and, as related to the number of operative procedures, 7% (8 of 111 operations). Seventeen patients were not considered for a second stage. Rebleeding in the early postoperative period was 4% and at long-term 6%. Incapacitating encephalopathy was found in 2 of the 71 surviving patients (3%). Survival (as determined by Kaplan-Meier tests) was 75% ( 1 year), 70% (5 years), and 69.2% ( 10 years). Six esophageal fistulas were observed secondary to transection. The Sugiura operation is an excellent complement to the therapeutic armamentarium used to treat portal hypertension, with low rehleeding and encephalopathy rates.
I
n 1973, Sugiura described an operation for the treatment of bleeding esophageal varices [I]. The operation consisted of extensive esophagogastric devascularization, esophageal transection that interrupts submucosal varices (at their lower third), vagotomy (as a consequence of devascularization), pyloroplasty (to prevent gastric emptying complications secondary to vagotomy), and splenectomy (Figure 1). Thus, the dangerous esophagogastric area is devascularized, reducing the risk of bleeding and maintaining portal perfusion of the liver. The operation is usually performed in two operative stages, with a 6- to lo-week interval between the stages. In selected patients with very good liver function, it is possible to perform the operation in a single stage. Although devascularization procedures are generally not considered a good choice for the treatment of portal hypertension because of a high rebleeding rate on longterm follow-up [2], the Sugiura procedure has been shown to be effective, with a low rebleeding rate and a low incidence of postoperative encephalopathy [3,4]. In the last 10 years, we have performed the Sugiura procedure at the Instituto National de la Nut&ion Salvador Zubiran in Mexico City as an alternative to selective shunts. Herein, we report the encouraging results we have obtained with the Sugiura procedure in the elective treatment of patients with bleeding esophageal varices. PATIENTS
From the Depxtmeot of Surgery, Instituto National de la Nutrition Salvador Zubiran, Mexico City, Mexico. Requests for reprints should be addressed to Hector Orozco, MD, Department of Surgery, Instituto National de la Nut&ion Salvador Zubiin, Vasco de Quiroga 15, Deleg. Tlalpan, Mexico City, 14000 Mexico. Manuscript submitted August 16, 1990, and accepted in revised form May 21,191.
MD,
AND METHODS
Patients with portal hypertension and endoscopically proven hemorrhage are carefully evaluated once the acute bleeding episode has been controlled. The evaluation includes liver function tests, liver ultrasound, angiography to evaluate the patency and anatomy of the mesenterico-spleno-portal system (during the venous phase, selective injections of the splenic and the mesenteric arteries are performed to evaluate the characteristics of the splenic, mesenteric, and portal veins), and cavography with catheterization of the left renal vein, specifically evaluating the drainage of the left renal vein as well as the distance between splenic and renal veins. In patients in whom transaminase levels are elevated greater than live times the normal limits, a liver biopsy is performed. Only patients classified as Child’s A and B are considered for elective surgery. Patients with “active” liver disease (transaminase levels greater than five times normal limits and a liver biopsy showing a marked inflammatory reaction) are not considered surgical candidates. Patients who have a suitable vascular anatomy (patent renal and splenic veins with a diameter greater than 1 cm, nontortuous splenic vein, a distance between spienic and renal veins smaller than two vertebral bodies, and direct left renal drainage into the inferior vena cava but not through
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 JUNE 1992
585
OROZCO ET AL
TABLE I Indications for the Sugiura Procedure
Indications
No. of Patients
Splenoportal thrombosis Anatomic abnormalities from renal and splenic veins Abnormalities of the kidney Severe hypersplenism Peptic ulcer disease Thrombosed shunts
36 52 4 4 2 2
TABLE II Causes of Liver Disease and Portal Hypertension* No. of Patients
Causes Liver cirrhosis Portal fibrosis Idiopathic portal hypertension (normal biopsy in light microscopy) Primary biliary cirrhosis Chronic hepatitis Biopsy not done
Rgure 1. schematic of the complete sugiura procedure.
gonadal or lumbar veins) are considered for a distal splenorenal (Warren) shunt. Patients whose vascular anatomy is unsuitable or patients with severe hypersplenism (in whom splenectomy might be beneficial) or peptic ulcer disease (in whom vagotomy and pyloroplasty will be beneficial) are considered for the Sugiura procedure. In the past 10 years, the Sugiura procedure has been performed in 100 patients at the Instituto National de la Nut&ion Salvador Zubiran. Indications for performing the Sugiura procedure instead of the Warren shunt in these patients are shown in Table I. Clinical charts of these 100 patients were reviewed. Survival curves were constructed according to the Kaplan-Meier method [5]. The operative technique we used is the same as that described by Sugiura and Futagawa [I] with minor modifications. In the abdominal stage, devascularization of the esophagogastric area is performed through a midline incision, leaving the right gastric artery and vein at the antrum level and the right gastroepiploic artery and vein undisturbed. Unlike Sugiura, we ligate the right gastric vein on the lesser curvature of the stomach. Splenectomy is performed, and truncal vagotomy (Sugiura does a selective vagotomy) and pyloroplasty are performed. No sutures are placed at the hiatus, and no attempt is made to fm the esophagogastric junction [q. In the thoracic stage, devascularization of the esophagus is done, and transection is performed between two noncrushing intestinal clamps at about 1 inch from the esophagogastric junction. The anterior muscular layer is severed, and the mucosa is transected, leaving the posterior muscular layer of the esophagus intact. An anastomosis is created with a running suture, using fine, nonabsorbable synthetic ma586
THE AMERICAN JOURNAL OF SURGERY
*Twenty-two
patients with liver cirrhosis had alcoholic
43 26 22 4 3 2
liver injury.
terial (5-O). The mediastinal pleura is not closed, and a chest tube is placed. The tube is removed as soon as possible after surgery, and, when the anastomosis is shown to be free of leakage as demonstrated by esophagography, oral feeding is initiated. Patients are routinely followed up in the postoperative period, with clinical and laboratory evaluations every 3 to 6 months. Rebleeding, encephalopathy, and quality of life are recorded. Rebleeding is defined by the presence of hematemesis and/or melena with a significant decrease in hematocrit that requires blood transfusion. The presence of encephalopathy is determined clinically, by the number connection test, and, in some cases, by electroencephalography. Incapacitating encephalopathy is defined as that in which the patient is unable to care for himself and requires frequent admissions for worsening encephalopathy. RESULTS In a 1O-year period, an elective Sugiura procedure was performed in 100 patients. Their mean age was 43.7 years (range: 11 to 77 years). Fifty-seven were male, and 43 female. Causes of portal hypertension in these patients are shown in Table II. Cirrhosis and severe portal fibrosis were the most common causes of portal hypertension in these patients (69%). In 22 patients, no cause of portal hypertension was evident (idiopathic portal hypertension). Sixty-three patients were classified as Child’s A, 32 were Child’s B, and 5 were Child’s C. A total of 151 operations were performed: 15 patients underwent both stages in a single operation; 51 patients underwent both stages of the Sugiura procedure with a
VOLUME 163 JUNE 1992
SJJGJJIRA OPFRATJON FOR ______&___________._~”
delay between the two stages; and the remaining 34 patients underwent only one of the stages of the Sugiura procedure. Seventeen died after the first stage, and, therefore, the second stage could not be performed. Seventeen either refused to have the second operation, or their clinical condition did not allow a second operation. In 79 patients, the procedure was started with the abdominal stage, and, in six, it was started with the thoracic stage. In the 51 patients in whom both stages could be performed, the mean interval between stages was 13 weeks. Thus, 66 patients had the complete procedure. Mortality (Tables III and IV): Of the 15 patients in whom a single operation was performed, 1 died (6%) because of rebleeding and multi-organ failure. Of the 85 patients in whom both stages of the Sugiura procedure were planned, 19 died (22%): 17 after the first stage was completed, and 2 after both stages were completed. The mortality rate for patients after the abdominal stage was 14% (12 patients), and for patients in the thoracic stage 11% (7 patients). The operative mortality rate in the Child’s A group was 12% (8 deaths in 63 patients with 111 operations) (i.e., 7% when related to the number of operative procedures), and, in the Child’s B group, it was 3 1% (10 deaths in 32 patients with 49 operations) (i.e., 20% when related to the number of operative procedures). Of the live Child’s C patients, only one survived. Due to this high operative mortality rate, no Child’s C patients have been operated on in the last 9 years. Morbidity: Complications of both the thoracic and abdominal stages are listed in Tables III and IV. Six esophageal fistulas secondary to the transection were observed and caused the deaths of three patients [7]. Rebleeding: Four patients (4%) rebled in the early postoperative period. These patients died despite attempts to arrest bleeding by means of balloon tamponade and transendoscopic sclerotherapy. Of the long-term survivors (7 1 patients) who were followed up, 4 (6%) rebled between the 12th and 24th postoperative months, 1 of whom died. No history of rebleeding was recorded in the remaining patients. Encephalopathy: Of the 71 long-term survivors, only 2 (3%) presented with encephalopathy. In both, encephalopathy is chronic and has required in-hospital management. Survival: In Fv 2, the survival curve for the 100 patients is depicted. As observed, there is a 75% survival rate at 1 year, 70% at 5 years, and 60% at 10 years. Patients with cirrhosis had a 5- and lo-year survival rate of 66%, and noncirrhotic patients a 5- and lo-year survival rate of 76%. COMMENTS
The goal of surgical treatment of portal hypertension is the control of variceal bleeding without the induction of hepatic failure. Preservation of portal blood flow to the liver is essential to obtain satisfactory results, which is why selective shunts, such as the Warren shunt, are considered the surgical treatment of choice in preventing recurrent variceal hemorrhage [8,9]. Nevertheless, there THE AMERICAN
RJ
FFDTNG ___.-- VARICES --.----
TABLE III Early Mortality (0 to 30 Days) for Patients in Child’s A, B, and C Classes ~_______.___ No. of Patients
Abdominal Stage
2 2 1* 3 2
Rebleeding Hepatic failure Sepsis + rebleeding Multiple organ failure Sepsis Acute pulmonary edema Myocardial infarction Intra-abdominal bleeding Total
No. of Thoracic Stage Patients ______
I -!
Sepsis Hepatic failure Esophageal fistula Muitiple organ failure Total
3 2 8
1 1 1 13
‘This patient had a one-stage thoracoabdominal
operation.
TABLE IV Late Mortality for Patients In Child’s A, 8, and C (Longast Follow-Up: 10 Years) No. of Patients
Causes of Mortality Rebleeding Liter failure Bleeding peptic ulcer CREST syndrome Intestinal obstruction + myowdial
1 4 1 1 infarction
. l. . . . . . . . . . . . . . . . . . ..NON-CIRRHOTIC w---------_-.TOTAL GROUP *CIRRHOTIC
,
I
5
IO YEARS
:@ra 2. Survhmlcuve acawdingto Kaplan-Me&.
are instances in which a Warren shunt is difficult (or impossible) to perform [IO]. In such cases, devascularization is indicated, since it preserves a larger amount of portal flow to the liver in comparison to a nonselective shunt, perhaps with the exception of the low-diameter portosystemic shunt [I 1,121, whose recent development does not allow a long-term evaluation at this time. The results of devascukkation procedures are not uniform, JOURNAL
OF SURGERY
VOLUME
163
JUNE 1992
587
OROZCO ET AL
TABLE
V
Postoperatlve Complications (No Deaths Recorded) Complications
No. of Patients
Intra-abdominal abscess Wound infection Esophagopleural fistula Empyema Pneumonia Intractable ascites
4 2 6 1 1 2
and, in the United States, their performance is not widely recommended [ 31. Certain characteristics of the Sugiura devascularization procedure are responsible for its good results. A very extensive devascularization is performed achieving portoazygos disconnection at the level of the esophagogastric area, which is the area where most variceal hemorrhages occur. Additionally, esophageal transection interrupts submucosal varices, which are normally not interrupted in other types of devascularization procedures. The collaterals that connect the portal vein and the azygos vein outside from the esophagogastric area are maintained. Only the porto-azygos connections through the esophagogastric area are interrupted. The operation is accomplished while maintaining portal perfusion. Vessel patency or suitable vascular anatomy is not needed to perform the procedure, and, in fact, a preoperative angiography is not needed. The procedure has the disadvantage of having to be done in two separate stages in most patients. The results of the Sugiura procedure in Japan are very encouraging. Sugiura and coworkers showed very low mortality and complication rates in more than 700 patients [ 21. They also demonstrated very low encephalopathy and rebleeding rates, and, therefore, they recommend the procedure for the prophylaxis of variceal hemorrhage. Ours is a heterogeneous group of patients with portal hypertension. Different etiologies and diverse degrees of liver functioning are present. Patients were excluded from receiving a Warren shunt, and the indications for the Sugiura procedure are listed in Table II. It must be mentioned that, in most of our patients (around SS%), a Warren shunt can be performed. Our results with respect to the operative mortality rate, the postoperative complication rate, rebleeding, and encephalopathy are comparable to our results with selective operations [IO], and thus, in our hands, the Sugiura procedure is an excellent alternative to the Warren shunt. In carefully selected cases, specifically young, thin patients with “entirely normal” liver function and with no previous abdominal surgeries, the procedure can be done in a single operation. Our results in this subgroup of patients are good, with only a 6% operative mortality rate and good long-term results (no rebleeding or encephalopathy). In most patients in whom two stages are planned, it is possible to complete the procedure. However, in some cases, the clinical condition of the patient does not allow the performance of a second surgical procedure, and, in 588
THE AMERICAN JOURNAL OF SURGERY
such cases, the combination with some other treatment modality such as sclerotherapy is recommended (Sugiura M., personal communication). The results of the operation performed in one stage are encouraging. Nevertheless, the performance of the operation in one stage is not routinely recommended [2]. A one-stage procedure is a time-consuming operation, and only patients with remarkably good liver function are to be considered. If the operation is routinely performed in one stage without patient selection, a high mortality rate with postoperative liver failure is certainly to be expected. As in other series, our patients’ survival curve is affected by the operative mortality, which accounts for the early decrease in survival. Thereafter, the curve stabilizes and is, as expected, better for noncirrhotic patients than for patients with cirrhosis. Surgical complications (Table V) are similar to those reported in other kinds of operations for portal hypertension, except for the presence of esophageal fistulas in the Sugiura procedure that are secondary to esophageal transection. Fistulas are a dangerous complication that carries a high mortality (50% in our series), but their frequency is fortunately low (6%). Some modifications of the transection have been suggested to avoid this complication, and they have now been performed by our group. The use of stapler devices to transect the esophagus ap pears promising. The Sugiura procedure is an excellent alternative to selective shunts in the prevention of recurrent variceal hemorrhage. The procedure maintains portal flow, effectively preventing rebleeding, and is accompanied by a low rate of encephalopathy. It is important to follow the guidelines described by its originator to obtain good results. The issue is not that it is a better operation, but that it is one more element in the surgeon’s therapeutic armamentarium to treat the problem of portal hypertension. The characteristics of the individual patient as well as the surgeon’s experience will dictate the surgical procedure of choice. This may be the largest series of such operationsin the Western world. Do note that the patients were all good risks and thatall operationswereelective.Halfthe patientshad anatomicabnormalitiessaid to preclude the Warren or distal splenorenal shunt as a treatmentoption,a high figure based on the experience in the United States. REFERENCES 1. Sugiura M, Futagawa S. A new technique for treating esophageal varicea. J Thorac Cardiovasc Surg 1973; 66: 677-85. 2. Warren WD. Control of variceal bleeding. Am J Surg 1983; 145: 8-16. 3. Sugiura M, Watanabe I. Stellenwert der Sugiura Operation Zur Verhtltung von rezidivierenden Oaophagus varizen bei Leberzirrho tikem. Indikation und Langzeitresultate. Chir Gastroenterol 1987; 3: 77-88. 4. Orozco H, Jtirez F, Uribe M, ef al. Sugiura procedure outside Japan. The Mexican experience. Am J Surg 1986; 152: 539-42. 5. Kaplan EL, Meier P. Non-parametric estimation from incom-
VOLUME 163 JUNE 1992
SUGUIRA OPERATION FOR BLEEDING VARICES
plete observations. J Am Stat Asscc 1958; 53: 457-81. 6. Orozco H, Juarez F, Pardo A, et al.Abnormalities of the esophageal hiatus after Sugiura’s procedure. Rev Invest Clin (M&x) 1985; 37: 85-9. 7. Orozco H, Mercado MA, Takahashi T, et al. Frequency, diagno sis and treatment of fistulas secondary to transection in the thoracic Sugiura procedure. Submitted for publication. 8. Orozco H, Juarez F, Santillln P, et al. Ten years of selective shunts for hemorrhagic portal hypertension. Surgery 1988; 103: 27-31. 9. Paquet KJ, Mercado MA, Koussouris P, et al. Improved results
with selective distal splenorenal shunt in a highly selected patient population. A prospective study. Ann Surg 1989; 210: 184-9. 10. Orozco H, Mercado MA, Takahashi T, et al. The role of the distal splenorenal shunt in Mexico and Latin America. Am J Surg 1990; 160: 86-9. 11. Paquet KJ, Mercado MA, Kalk JF. 100 mesocaval interposition-shunts for recurrent variceal hemorrhage in portal hypertension. A prospective study. Rev Invest Clin (Mtx) 1989; 41: 309-18. 12. Rypins EB, Rosenberg KM, Sarfeh IJ, et al. Computer analysis of portal hemodynamics after small diameter portocaval H-grafts: the theoretical basis for partial shunting. J Surg 1987; 42: 354-61.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 JUNE 1992
589
A lO-year experience with the devascularixation operation described by Sugiura is reported here. The operation was performed electively in 100 patients in whom it was not possible to place a shunt, all of whom had different hinds of hepatopathies (63 Child’s A, 32 Child’s B, and 5 Child’s C) . In 15 patients, the procedure was done in one stage (6% operative mortality, 1 patient), and, in 51, it was performed in two stages. Eight deaths were recorded in the 63 patients of the Child’s A group, with a total of 111 operations. The operative mortality rate for this group was 12% and, as related to the number of operative procedures, 7% (8 of 111 operations). Seventeen patients were not considered for a second stage. Rebleeding in the early postoperative period was 4% and at long-term 6%. Incapacitating encephalopathy was found in 2 of the 71 surviving patients (3%). Survival (as determined by Kaplan-Meier tests) was 75% ( 1 year), 70% (5 years), and 69.2% ( 10 years). Six esophageal fistulas were observed secondary to transection. The Sugiura operation is an excellent complement to the therapeutic armamentarium used to treat portal hypertension, with low rehleeding and encephalopathy rates.
I
n 1973, Sugiura described an operation for the treatment of bleeding esophageal varices [I]. The operation consisted of extensive esophagogastric devascularization, esophageal transection that interrupts submucosal varices (at their lower third), vagotomy (as a consequence of devascularization), pyloroplasty (to prevent gastric emptying complications secondary to vagotomy), and splenectomy (Figure 1). Thus, the dangerous esophagogastric area is devascularized, reducing the risk of bleeding and maintaining portal perfusion of the liver. The operation is usually performed in two operative stages, with a 6- to lo-week interval between the stages. In selected patients with very good liver function, it is possible to perform the operation in a single stage. Although devascularization procedures are generally not considered a good choice for the treatment of portal hypertension because of a high rebleeding rate on longterm follow-up [2], the Sugiura procedure has been shown to be effective, with a low rebleeding rate and a low incidence of postoperative encephalopathy [3,4]. In the last 10 years, we have performed the Sugiura procedure at the Instituto National de la Nut&ion Salvador Zubiran in Mexico City as an alternative to selective shunts. Herein, we report the encouraging results we have obtained with the Sugiura procedure in the elective treatment of patients with bleeding esophageal varices. PATIENTS
From the Depxtmeot of Surgery, Instituto National de la Nutrition Salvador Zubiran, Mexico City, Mexico. Requests for reprints should be addressed to Hector Orozco, MD, Department of Surgery, Instituto National de la Nut&ion Salvador Zubiin, Vasco de Quiroga 15, Deleg. Tlalpan, Mexico City, 14000 Mexico. Manuscript submitted August 16, 1990, and accepted in revised form May 21,191.
MD,
AND METHODS
Patients with portal hypertension and endoscopically proven hemorrhage are carefully evaluated once the acute bleeding episode has been controlled. The evaluation includes liver function tests, liver ultrasound, angiography to evaluate the patency and anatomy of the mesenterico-spleno-portal system (during the venous phase, selective injections of the splenic and the mesenteric arteries are performed to evaluate the characteristics of the splenic, mesenteric, and portal veins), and cavography with catheterization of the left renal vein, specifically evaluating the drainage of the left renal vein as well as the distance between splenic and renal veins. In patients in whom transaminase levels are elevated greater than live times the normal limits, a liver biopsy is performed. Only patients classified as Child’s A and B are considered for elective surgery. Patients with “active” liver disease (transaminase levels greater than five times normal limits and a liver biopsy showing a marked inflammatory reaction) are not considered surgical candidates. Patients who have a suitable vascular anatomy (patent renal and splenic veins with a diameter greater than 1 cm, nontortuous splenic vein, a distance between spienic and renal veins smaller than two vertebral bodies, and direct left renal drainage into the inferior vena cava but not through
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 JUNE 1992
585
OROZCO ET AL
TABLE I Indications for the Sugiura Procedure
Indications
No. of Patients
Splenoportal thrombosis Anatomic abnormalities from renal and splenic veins Abnormalities of the kidney Severe hypersplenism Peptic ulcer disease Thrombosed shunts
36 52 4 4 2 2
TABLE II Causes of Liver Disease and Portal Hypertension* No. of Patients
Causes Liver cirrhosis Portal fibrosis Idiopathic portal hypertension (normal biopsy in light microscopy) Primary biliary cirrhosis Chronic hepatitis Biopsy not done
Rgure 1. schematic of the complete sugiura procedure.
gonadal or lumbar veins) are considered for a distal splenorenal (Warren) shunt. Patients whose vascular anatomy is unsuitable or patients with severe hypersplenism (in whom splenectomy might be beneficial) or peptic ulcer disease (in whom vagotomy and pyloroplasty will be beneficial) are considered for the Sugiura procedure. In the past 10 years, the Sugiura procedure has been performed in 100 patients at the Instituto National de la Nut&ion Salvador Zubiran. Indications for performing the Sugiura procedure instead of the Warren shunt in these patients are shown in Table I. Clinical charts of these 100 patients were reviewed. Survival curves were constructed according to the Kaplan-Meier method [5]. The operative technique we used is the same as that described by Sugiura and Futagawa [I] with minor modifications. In the abdominal stage, devascularization of the esophagogastric area is performed through a midline incision, leaving the right gastric artery and vein at the antrum level and the right gastroepiploic artery and vein undisturbed. Unlike Sugiura, we ligate the right gastric vein on the lesser curvature of the stomach. Splenectomy is performed, and truncal vagotomy (Sugiura does a selective vagotomy) and pyloroplasty are performed. No sutures are placed at the hiatus, and no attempt is made to fm the esophagogastric junction [q. In the thoracic stage, devascularization of the esophagus is done, and transection is performed between two noncrushing intestinal clamps at about 1 inch from the esophagogastric junction. The anterior muscular layer is severed, and the mucosa is transected, leaving the posterior muscular layer of the esophagus intact. An anastomosis is created with a running suture, using fine, nonabsorbable synthetic ma586
THE AMERICAN JOURNAL OF SURGERY
*Twenty-two
patients with liver cirrhosis had alcoholic
43 26 22 4 3 2
liver injury.
terial (5-O). The mediastinal pleura is not closed, and a chest tube is placed. The tube is removed as soon as possible after surgery, and, when the anastomosis is shown to be free of leakage as demonstrated by esophagography, oral feeding is initiated. Patients are routinely followed up in the postoperative period, with clinical and laboratory evaluations every 3 to 6 months. Rebleeding, encephalopathy, and quality of life are recorded. Rebleeding is defined by the presence of hematemesis and/or melena with a significant decrease in hematocrit that requires blood transfusion. The presence of encephalopathy is determined clinically, by the number connection test, and, in some cases, by electroencephalography. Incapacitating encephalopathy is defined as that in which the patient is unable to care for himself and requires frequent admissions for worsening encephalopathy. RESULTS In a 1O-year period, an elective Sugiura procedure was performed in 100 patients. Their mean age was 43.7 years (range: 11 to 77 years). Fifty-seven were male, and 43 female. Causes of portal hypertension in these patients are shown in Table II. Cirrhosis and severe portal fibrosis were the most common causes of portal hypertension in these patients (69%). In 22 patients, no cause of portal hypertension was evident (idiopathic portal hypertension). Sixty-three patients were classified as Child’s A, 32 were Child’s B, and 5 were Child’s C. A total of 151 operations were performed: 15 patients underwent both stages in a single operation; 51 patients underwent both stages of the Sugiura procedure with a
VOLUME 163 JUNE 1992
SJJGJJIRA OPFRATJON FOR ______&___________._~”
delay between the two stages; and the remaining 34 patients underwent only one of the stages of the Sugiura procedure. Seventeen died after the first stage, and, therefore, the second stage could not be performed. Seventeen either refused to have the second operation, or their clinical condition did not allow a second operation. In 79 patients, the procedure was started with the abdominal stage, and, in six, it was started with the thoracic stage. In the 51 patients in whom both stages could be performed, the mean interval between stages was 13 weeks. Thus, 66 patients had the complete procedure. Mortality (Tables III and IV): Of the 15 patients in whom a single operation was performed, 1 died (6%) because of rebleeding and multi-organ failure. Of the 85 patients in whom both stages of the Sugiura procedure were planned, 19 died (22%): 17 after the first stage was completed, and 2 after both stages were completed. The mortality rate for patients after the abdominal stage was 14% (12 patients), and for patients in the thoracic stage 11% (7 patients). The operative mortality rate in the Child’s A group was 12% (8 deaths in 63 patients with 111 operations) (i.e., 7% when related to the number of operative procedures), and, in the Child’s B group, it was 3 1% (10 deaths in 32 patients with 49 operations) (i.e., 20% when related to the number of operative procedures). Of the live Child’s C patients, only one survived. Due to this high operative mortality rate, no Child’s C patients have been operated on in the last 9 years. Morbidity: Complications of both the thoracic and abdominal stages are listed in Tables III and IV. Six esophageal fistulas secondary to the transection were observed and caused the deaths of three patients [7]. Rebleeding: Four patients (4%) rebled in the early postoperative period. These patients died despite attempts to arrest bleeding by means of balloon tamponade and transendoscopic sclerotherapy. Of the long-term survivors (7 1 patients) who were followed up, 4 (6%) rebled between the 12th and 24th postoperative months, 1 of whom died. No history of rebleeding was recorded in the remaining patients. Encephalopathy: Of the 71 long-term survivors, only 2 (3%) presented with encephalopathy. In both, encephalopathy is chronic and has required in-hospital management. Survival: In Fv 2, the survival curve for the 100 patients is depicted. As observed, there is a 75% survival rate at 1 year, 70% at 5 years, and 60% at 10 years. Patients with cirrhosis had a 5- and lo-year survival rate of 66%, and noncirrhotic patients a 5- and lo-year survival rate of 76%. COMMENTS
The goal of surgical treatment of portal hypertension is the control of variceal bleeding without the induction of hepatic failure. Preservation of portal blood flow to the liver is essential to obtain satisfactory results, which is why selective shunts, such as the Warren shunt, are considered the surgical treatment of choice in preventing recurrent variceal hemorrhage [8,9]. Nevertheless, there THE AMERICAN
RJ
FFDTNG ___.-- VARICES --.----
TABLE III Early Mortality (0 to 30 Days) for Patients in Child’s A, B, and C Classes ~_______.___ No. of Patients
Abdominal Stage
2 2 1* 3 2
Rebleeding Hepatic failure Sepsis + rebleeding Multiple organ failure Sepsis Acute pulmonary edema Myocardial infarction Intra-abdominal bleeding Total
No. of Thoracic Stage Patients ______
I -!
Sepsis Hepatic failure Esophageal fistula Muitiple organ failure Total
3 2 8
1 1 1 13
‘This patient had a one-stage thoracoabdominal
operation.
TABLE IV Late Mortality for Patients In Child’s A, 8, and C (Longast Follow-Up: 10 Years) No. of Patients
Causes of Mortality Rebleeding Liter failure Bleeding peptic ulcer CREST syndrome Intestinal obstruction + myowdial
1 4 1 1 infarction
. l. . . . . . . . . . . . . . . . . . ..NON-CIRRHOTIC w---------_-.TOTAL GROUP *CIRRHOTIC
,
I
5
IO YEARS
:@ra 2. Survhmlcuve acawdingto Kaplan-Me&.
are instances in which a Warren shunt is difficult (or impossible) to perform [IO]. In such cases, devascularization is indicated, since it preserves a larger amount of portal flow to the liver in comparison to a nonselective shunt, perhaps with the exception of the low-diameter portosystemic shunt [I 1,121, whose recent development does not allow a long-term evaluation at this time. The results of devascukkation procedures are not uniform, JOURNAL
OF SURGERY
VOLUME
163
JUNE 1992
587
OROZCO ET AL
TABLE
V
Postoperatlve Complications (No Deaths Recorded) Complications
No. of Patients
Intra-abdominal abscess Wound infection Esophagopleural fistula Empyema Pneumonia Intractable ascites
4 2 6 1 1 2
and, in the United States, their performance is not widely recommended [ 31. Certain characteristics of the Sugiura devascularization procedure are responsible for its good results. A very extensive devascularization is performed achieving portoazygos disconnection at the level of the esophagogastric area, which is the area where most variceal hemorrhages occur. Additionally, esophageal transection interrupts submucosal varices, which are normally not interrupted in other types of devascularization procedures. The collaterals that connect the portal vein and the azygos vein outside from the esophagogastric area are maintained. Only the porto-azygos connections through the esophagogastric area are interrupted. The operation is accomplished while maintaining portal perfusion. Vessel patency or suitable vascular anatomy is not needed to perform the procedure, and, in fact, a preoperative angiography is not needed. The procedure has the disadvantage of having to be done in two separate stages in most patients. The results of the Sugiura procedure in Japan are very encouraging. Sugiura and coworkers showed very low mortality and complication rates in more than 700 patients [ 21. They also demonstrated very low encephalopathy and rebleeding rates, and, therefore, they recommend the procedure for the prophylaxis of variceal hemorrhage. Ours is a heterogeneous group of patients with portal hypertension. Different etiologies and diverse degrees of liver functioning are present. Patients were excluded from receiving a Warren shunt, and the indications for the Sugiura procedure are listed in Table II. It must be mentioned that, in most of our patients (around SS%), a Warren shunt can be performed. Our results with respect to the operative mortality rate, the postoperative complication rate, rebleeding, and encephalopathy are comparable to our results with selective operations [IO], and thus, in our hands, the Sugiura procedure is an excellent alternative to the Warren shunt. In carefully selected cases, specifically young, thin patients with “entirely normal” liver function and with no previous abdominal surgeries, the procedure can be done in a single operation. Our results in this subgroup of patients are good, with only a 6% operative mortality rate and good long-term results (no rebleeding or encephalopathy). In most patients in whom two stages are planned, it is possible to complete the procedure. However, in some cases, the clinical condition of the patient does not allow the performance of a second surgical procedure, and, in 588
THE AMERICAN JOURNAL OF SURGERY
such cases, the combination with some other treatment modality such as sclerotherapy is recommended (Sugiura M., personal communication). The results of the operation performed in one stage are encouraging. Nevertheless, the performance of the operation in one stage is not routinely recommended [2]. A one-stage procedure is a time-consuming operation, and only patients with remarkably good liver function are to be considered. If the operation is routinely performed in one stage without patient selection, a high mortality rate with postoperative liver failure is certainly to be expected. As in other series, our patients’ survival curve is affected by the operative mortality, which accounts for the early decrease in survival. Thereafter, the curve stabilizes and is, as expected, better for noncirrhotic patients than for patients with cirrhosis. Surgical complications (Table V) are similar to those reported in other kinds of operations for portal hypertension, except for the presence of esophageal fistulas in the Sugiura procedure that are secondary to esophageal transection. Fistulas are a dangerous complication that carries a high mortality (50% in our series), but their frequency is fortunately low (6%). Some modifications of the transection have been suggested to avoid this complication, and they have now been performed by our group. The use of stapler devices to transect the esophagus ap pears promising. The Sugiura procedure is an excellent alternative to selective shunts in the prevention of recurrent variceal hemorrhage. The procedure maintains portal flow, effectively preventing rebleeding, and is accompanied by a low rate of encephalopathy. It is important to follow the guidelines described by its originator to obtain good results. The issue is not that it is a better operation, but that it is one more element in the surgeon’s therapeutic armamentarium to treat the problem of portal hypertension. The characteristics of the individual patient as well as the surgeon’s experience will dictate the surgical procedure of choice. This may be the largest series of such operationsin the Western world. Do note that the patients were all good risks and thatall operationswereelective.Halfthe patientshad anatomicabnormalitiessaid to preclude the Warren or distal splenorenal shunt as a treatmentoption,a high figure based on the experience in the United States. REFERENCES 1. Sugiura M, Futagawa S. A new technique for treating esophageal varicea. J Thorac Cardiovasc Surg 1973; 66: 677-85. 2. Warren WD. Control of variceal bleeding. Am J Surg 1983; 145: 8-16. 3. Sugiura M, Watanabe I. Stellenwert der Sugiura Operation Zur Verhtltung von rezidivierenden Oaophagus varizen bei Leberzirrho tikem. Indikation und Langzeitresultate. Chir Gastroenterol 1987; 3: 77-88. 4. Orozco H, Jtirez F, Uribe M, ef al. Sugiura procedure outside Japan. The Mexican experience. Am J Surg 1986; 152: 539-42. 5. Kaplan EL, Meier P. Non-parametric estimation from incom-
VOLUME 163 JUNE 1992
SUGUIRA OPERATION FOR BLEEDING VARICES
plete observations. J Am Stat Asscc 1958; 53: 457-81. 6. Orozco H, Juarez F, Pardo A, et al.Abnormalities of the esophageal hiatus after Sugiura’s procedure. Rev Invest Clin (M&x) 1985; 37: 85-9. 7. Orozco H, Mercado MA, Takahashi T, et al. Frequency, diagno sis and treatment of fistulas secondary to transection in the thoracic Sugiura procedure. Submitted for publication. 8. Orozco H, Juarez F, Santillln P, et al. Ten years of selective shunts for hemorrhagic portal hypertension. Surgery 1988; 103: 27-31. 9. Paquet KJ, Mercado MA, Koussouris P, et al. Improved results
with selective distal splenorenal shunt in a highly selected patient population. A prospective study. Ann Surg 1989; 210: 184-9. 10. Orozco H, Mercado MA, Takahashi T, et al. The role of the distal splenorenal shunt in Mexico and Latin America. Am J Surg 1990; 160: 86-9. 11. Paquet KJ, Mercado MA, Kalk JF. 100 mesocaval interposition-shunts for recurrent variceal hemorrhage in portal hypertension. A prospective study. Rev Invest Clin (Mtx) 1989; 41: 309-18. 12. Rypins EB, Rosenberg KM, Sarfeh IJ, et al. Computer analysis of portal hemodynamics after small diameter portocaval H-grafts: the theoretical basis for partial shunting. J Surg 1987; 42: 354-61.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 JUNE 1992
589