“Whoa! It’s like Spotify but for academic articles.”

Instant Access to Thousands of Journals for just $40/month

Try 2 weeks free now

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
Loading next page...
1 Page

You’re reading a free preview. Subscribe to read the entire article.

DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy unlimited access and
personalized recommendations from
over 12 million articles from more than
10,000 peer-reviewed journals.

All for just $40/month

Try 2 weeks free now

Explore the DeepDyve Library

How DeepDyve Works

Spend time researching, not time worrying you’re buying articles that might not be useful.

Unlimited reading

Read as many articles as you need. Full articles with original layout, charts and figures. Read online, from anywhere.

Stay up to date

Keep up with your field with Personalized Recommendations and Follow Journals to get automatic updates.

Organize your research

It’s easy to organize your research with our built-in tools.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from Springer, Elsevier, Nature, IEEE, Wiley-Blackwell and more.

All the latest content is available, no embargo periods.

See the journals in your area

Simple and Affordable Pricing

14-day free trial. Cancel anytime, with a 30-day money-back guarantee.

Monthly Plan

  • Read unlimited articles
  • Personalized recommendations
  • Print 20 pages per month
  • 20% off on PDF purchases
  • Organize your research
  • Get updates on your journals and topic searches


Best Deal — 25% off

Annual Plan

  • All the features of the Professional Plan, but for 25% off!
  • For the normal price of 10 articles elsewhere, you get one full year of unlimited access to articles.

billed annually