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Modified sugiura procedure

Modified sugiura procedure We read with interest the article by Dr Selzner and colleagues 1 describing their experience with a transabdominal modification of the Sugiura devascularization-transection procedure in the management of variceal bleeding. We congratulate them on their good results, which they have achieved by limiting this operation to patients with well-preserved hepatic synthetic function. This is certainly a useful salvage operation for this group of cirrhotic patients, when they are unsuitable for transjugular intrahepatic portosystemic shunt (TIPS) or liver transplantation, and have failed nonsurgical therapies. It is even more satisfying in patients with extrahepatic portal venous obstruction. 2 But we disagree with their technique of esophageal transection: they choose to transect the esophagus 4 to 6cm above the gastroesophageal junction. The majority of esophageal variceal bleeds occur from the lower 2 to 3cm of the esophagus. 3 After operation, we have rarely seen residual or recurrent varices above the level of esophageal transection, but they are occasionally found below the anastomosis. Others have also reported this finding. 4 Did their patient with recurrent esophageal variceal bleeding have varices below the anastomosis? It would be interesting to know whether any other patients had residual or recurrent varices, where they were situated, and whether endoscopic therapy was used postoperatively. In our experience, placing the staple line close to the cardia can decrease this problem. We, among others, recommend performing the transection just 1 to 2cm above the gastroesophageal junction; 3,5 after transection of the doughnut, the anastomosis then sits just above the cardia. We do not have any data to support our technique, but, having encountered the problem, believe that it is an important step of the procedure that we seek to clarify. The authors also advise TIPS for noncirrhotic and Childs A cirrhotic patients with refractory variceal bleeding, if the splenic vein is less than 1cm. But the longterm patency of TIPS has proved disappointing, with approximately 50% primary patency rates at 2 years. 6 Close surveillance and numerous interventions are frequently required. In patients with good liver synthetic function, who are unlikely to need liver transplantation for many years, shunt surgery is preferable to TIPS, even when the splenic vein is unsuitable. 7 In noncirrhotics who are not shuntable, an elective devascularization procedure has given excellent results. So we would hold the view that TIPS should, with rare exceptions, be reserved for Childs B and C patients.</P> http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the American College of Surgeons Elsevier
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