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Sugiura Procedure

Discussion in 'Surgery and Surgical Subspecialties' started by ArcherM2, Jan 30, 2008.

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  1. ArcherM2

    ArcherM2 Senior Member

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    I'm currently on an ICU rotation and we had a guy bleed out yesterday despite using a blakemore to try and bridge him to surgery. Anyway, my homework assignment is to review the surgical interventions for refractory variceal bleeds. After doing some research, it seems like shunts are the preferred form of definitive treatment unless the person has extensive mesenteric thrombosis. In these cases some prefer to use the Sugiura procedure. Now after reading several articles describing the procedure I'm still a little lost.

    The indication for the surgery is to stop variceal bleeding. In the procedure you ligate the penetrating esophageal veins that originate from the portal system - stopping the bleeding. This makes sense.

    In order to maintain venous drainage of the esophagus and stomach the left gastric and paraesophageal veins are spared. Their anastomoses with the azygous system allows venous drainage. Also makes sense.

    And a splenectomy is performed. I suspect because it has become congested and nonfunctional (?).

    My question: why transect the esophagus?

    I thought my understanding of anatomy would help me with this but I'm thinking I'm not seeing the "big picture" here. Thanks in advance to anyone who wants to help me out! (oh and please feel free to make a fool out of me if I'm missing something completely obvious. It's already been that kind of week...)
  2. smq123

    smq123 John Singer Sargent Administrator SDN Senior Moderator SDN Advisor

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    I think that a splenectomy was traditionally done because they thought that if the spleen were left in, the splenic veins would eventually spontaneously form portal-systemic shunts.

    There's a group in Mexico that does a lot of research in the Sugiura procedure. According to one of their abstracts:

    An alternate low risk technique for esophageal transection in the Sugiura-Futagawa procedure.

    [Mercado MA, Takahashi T, Orozco H. Portal Hypertension Clinic, Instituto Nacional de la Nutricion, Salvador Zubiran, Mexico City, Mexico.]

    The Sugiura-Futagawa procedure is an effective non-shunting operation to treat bleeding esophageal varices. The goal of the esophageal transection is the interruption of submucosal varices. The rate of esophageal fistula reported after transection is 5 to 8 per cent. This complication has high morbidity and mortality rates. The technique and results of an alternate variant of the esophageal transection are described. After devascularization of the esophagus is achieved, the anterior muscular layer is opened, and the entire mucosal cylinder is dissected free from the muscular layer. Without opening the mucosa, a circumferential continuous running suture with fine non-absorbable material is placed, involving both mucosa and submucosa, interrupting the varicose veins. Our experience with this technique has been encouraging, having observed no stenosis or fistulization in 10 patients on whom we operated. Re-bleeding rate is low (10% in this series). The advantages of this modification are: 1) since we do not cut open the mucosal layer, we believe that the risk of fistulization is reduced, and 2) it allows an early initiation of oral feeding, thus reducing the hospital stay.
  3. ArcherM2

    ArcherM2 Senior Member

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    I guess this begs the question: does the original Sugiura procedure include the following: "After devascularization of the esophagus is achieved, the anterior muscular layer is opened, and the entire mucosal cylinder is dissected free from the muscular layer. Without opening the mucosa, a circumferential continuous running suture with fine non-absorbable material is placed, involving both mucosa and submucosa, interrupting the varicose veins." or is this the Futagawa modification? If it is the Futagawa mod, then what was the utility of transecting the esophagus in the original procedure if the varices were left alone?

    How would the splenic veins form spontaneous portosystemic shunts? Would they become so congested they would fistulize to arteries or caval circulation?

    Thanks for the reply. It's given me direction and some more stimulus for thought.
  4. XoQo

    XoQo PGY1 Retractor

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    Disclaimer: i'm a ms4. I could be completely wrong...but i couldn't resist taking a stab at the question. Sources were Schwartz's 8th edition and emedicine.



    My answer:

    Remember that the submucosal venous plexus of the esophagus is continuous with that of the stomach. A circular transection and reanastomosis at the esophagus would essentially isolate the esophageal submucosal plexus from the stomach's.


    There are two sources of blood bleeding out of your varices -- the blood from the penetrating veins entering the esophagus and also blood entering the submucosal plexus adjacent to your varix.

    With the Sugiura, you target both sources of "higher" pressure venous blood: by ligating the penetrating veins and stapling off submucosal plexus. You end up repairing the transection to preserve GI function, but you maintain disruption of the submucsal plexus at the level of transection.
  5. ArcherM2

    ArcherM2 Senior Member

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    BOO YA! This sounds like excellent reasoning to me! Strong work and thank you for the help!

    MS4: 1 MS3: 0
  6. XoQo

    XoQo PGY1 Retractor

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    The original Sugiura/Futgawa involved near complete transection (including the mucsosa of the esophagus) I believe. The new mexico group describes what appears to be a less traumatic method -- they divide the veins but do not touch the mucosa.

    here's the NM team's description from this 1998 paper:

    http://archsurg.ama-assn.org/cgi/content/full/133/10/1046



    CLASSIC TRANSECTION [Sugiura-Futagawa]

    ...Transection is performed about 2.5 cm from the esophagogastric junction. Between 2 noncrushing clamps, the muscularis externa is severed, exposing the mucosal cylinder. The mucosa is severed keeping the posterior portion and remaining muscularis externa intact. An end-to-end anastomosis is done with a fine nonabsorbable suture material. The muscular layer is also sutured and the pleura is closed....


    MODIFIED TECHNIQUE OF TRANSECTION [new mexico's thing...]

    ...The anterior muscularis externa is severed and the mucosal cylinder dissected free from the posterior muscularis externa, which is also partially severed in its lateral aspects. After the entire circumference of the mucosa is dissected and freed, traction sutures are placed in 4 quadrants. A circumferential running suture is sewn between the traction sutures. Each stitch has less than a 1-mm interval and affects the whole mucosal layer. With mobilization (rotating) of the clamp from the junction, a complete exposure of the whole cylinder is obtained. The running suture obliterates the submucosal varices without opening the mucosa....



    (bolds added -- not in the original text)
  7. Seems like you med students should be discussing this in the Clinical Rotations forum. ;)

    I kid, I kid!
  8. Tired

    Tired Boned. Again.

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    You're just pissy because you had no idea what the answer was. :D
  9. :laugh:

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