Transabdominal extensive esophagogastric devascularization with gastroesophageal stapling for management of noncirrhotic portal hypertension: long-term results.

Abstract

Outside Japan portosystemic shunts have been favored as the surgical procedure of choice for the management of portal hypertension of noncirrhotic etiology. Devascularization procedures have resulted in high rebleed rates probably owing to a limited extent of devascularization. We performed this study to assess the efficacy of our modification of Sugiura's procedure for long-term control of variceal bleeding in patients with noncirrhotic portal hypertension. Forty-six patients with extrahepatic portal venous obstruction (EHPVO) and 22 with noncirrhotic portal fibrosis (NCPF) were subjected to transabdominal extensive esophagogastric devascularization with esophageal or gastric stapled transection (modified Sugiura's procedure), 38 in an emergency situation and 30 electively. Follow-up endoscopies were performed every 6 months. Operative mortality, morbidity, variceal status, and causes of recurrent bleeding were evaluated. The postoperative mortality was 4%. Early procedure-related complications were seen in 6%, and esophageal strictures formed in 7 of 45 survivors undergoing esophageal transection (15%). Over a mean +/- SD follow-up of 53 +/- 34 months, 95% of patients were free of varices. Seven survivors (11%) had a rebleed, but only 5% were due to varices (two esophageal, one gastric). Six (9%) patients developed gastropathy. The 5-year survival was 88%. The modified Sugiura's procedure is safe and effective for long-term control of variceal bleeding especially in the emergency setting and in patients with anatomy unsuitable for shunt surgery or if surgical expertise for a shunt operation is not available.