LETTERS TO THE EDITOR
Modiﬁed Sugiura Procedure
, SK Mathur,
Swansea, United Kingdom
We read with interest the article by Dr Selzner and col-
describing their experience with a transabdom-
inal 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 tran-
sjugular intrahepatic portosystemic shunt (TIPS) or
liver transplantation, and have failed nonsurgical thera-
pies. It is even more satisfying in patients with extrahe-
patic portal venous obstruction.
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.
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
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 situ-
ated, and whether endoscopic therapy was used
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;
of the doughnut, the anastomosis then sits just above the
cardia. We do not have any data to support our tech-
nique, but, having encountered the problem, believe
that it is an important step of the procedure that we seek
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
Close surveillance and numerous interventions
are frequently required. In patients with good liver syn-
thetic function, who are unlikely to need liver transplan-
tation for many years, shunt surgery is preferable to
TIPS, even when the splenic vein is unsuitable.
cirrhotics who are not shuntable, an elective devascular-
ization procedure has given excellent results. So we
would hold the view that TIPS should, with rare excep-
tions, be reserved for Childs B and C patients.
1. Selzner M, Tuttle-Newhall JE, Dahm F, et al. Current indication
of a modified Sugiura procedure in the management of variceal
bleeding. J Am Coll Surg 2001;193:166–173.
2. Mathur SK, Shah SR, Nagral SS, Soonawalla ZF. Transabdominal
extensive esophagogastric devascularization with gastroesopha-
geal stapling for management of noncirrhotic portal hyperten-
sion: long-term results. World J Surg 1999;23:1168–1175.
3. Hosking SW, Johnson AG. What happens to esophageal varices
after transection and devascularization? Surgery
4. Gouge T, Ranson J. Esophageal transection and paraesophago-
gastric devascularization for bleeding esophageal varices. Am J
Surg 1986;151:47–54 [discussion].
5. Mathur SK, Shah SR, Soonawalla ZF, et al. Transabdominal ex-
tensive oesophagogastric devascularization with gastro-
oesophageal stapling in the management of acute variceal bleed-
ing. Br J Surg 1997; 84:413–417.
6. Rosch J, Keller FS. Transjugular intrahepatic portosystemic
shunt: present status, comparison with endoscopic therapy and
shunt surgery, and future perspectives. World J Surg
7. Becker YT, Reed G, Lind CD, Richards WO. The role of elective
operation in the treatment of portal hypertension. Am Surg 1996;
Devascularizations in Portal
Mexico City, Mexico
We enjoyed the article by Selzner and coworkers.
It is in-
teresting that the Sugiura-Futagawa operation and its vari-
© 2002 by the American College of Surgeons ISSN 1072-7515/02/$21.00
Published by Elsevier Science Inc. PII S1072-7515(01)01146-2