Overview
Definition:
Portal hypertension is an abnormal increase in pressure within the portal venous system, typically caused by resistance to blood flow through the liver
Devascularization procedures, such as the Sugiura procedure, aim to reduce portal pressure by ligating or resecting portosystemic collaterals and performing a splenorenal shunt, thereby preventing or treating variceal bleeding.
Epidemiology:
Portal hypertension is most commonly seen in patients with advanced liver cirrhosis, with prevalence directly correlating with the severity of liver disease
The incidence of variceal bleeding in patients with cirrhosis ranges from 25-60%
Devascularization procedures are considered in specific scenarios, particularly in Asian countries where they have a longer history of use.
Clinical Significance:
Portal hypertension is a critical condition that can lead to life-threatening complications, most notably gastroesophageal variceal hemorrhage
It also contributes to ascites, hepatic encephalopathy, and hypersplenism
Surgical interventions like the Sugiura procedure are reserved for patients who fail medical management or endoscopic therapy, or for those with specific indications like gastric varices unresponsive to other treatments.
Indications
Indications For Devascularization:
Primary indications include recurrent variceal bleeding despite optimal medical and endoscopic therapy
Specific indications may include gastric varices, especially those with red wale marks or threatening stigmata of recent hemorrhage, and bleeding from ectopic varices
It is also considered in patients with portal vein thrombosis refractory to anticoagulation and who are not candidates for liver transplantation or TIPS.
Contraindications:
Absolute contraindications include decompensated liver function (Child-Pugh C with severe coagulopathy) or significant comorbidities that preclude major surgery
Relative contraindications may include patients with successful TIPS or those who are immediate candidates for liver transplantation.
Preoperative Preparation
Assessment:
Thorough evaluation of liver function (Child-Pugh score, MELD score), nutritional status, and comorbidities is essential
Endoscopic evaluation for varices and stigmata of recent hemorrhage is mandatory
Imaging (CT/MRI angiography) is crucial to assess portal vein patency, collaterals, and suitability for shunting.
Medical Optimization:
Patients should be optimally managed medically prior to surgery
This includes beta-blockers for variceal prophylaxis, management of ascites and encephalopathy, and correction of coagulopathy
Nutritional support and consultation with a hepatologist are vital.
Surgical Team And Setting:
This is a complex procedure requiring an experienced surgical team in a well-equipped tertiary care center
Preoperative planning with anesthesiologists and intensivists is important.
Procedure Steps Sugiura
Approach:
The procedure is typically performed via a midline or subcostal laparotomy
The abdomen is explored, and the gastrohepatic ligament is divided to expose the esophagus and stomach.
Esophageal And Gastric Devascularization:
The key steps involve meticulous dissection and ligation of the left gastric vein, esophageal veins (azygos and hemiazygos), and short gastric veins
Periesophageal and paraesophageal venous plexuses are also dissected and ligated to obliterate portosystemic collaterals at the gastroesophageal junction.
Splenorenal Shunt:
A distal splenorenal shunt (e.g., Warren shunt) is then constructed, connecting the splenic vein to the left renal vein
This aims to decompress the portal system while preferentially shunting blood away from the varices and encephalopathy.
Gastric And Esophageal Transection:
In some variations, transection of the stomach and esophagus may be performed after devascularization to further reduce the risk of recurrent bleeding.
Postoperative Care
Monitoring:
Close monitoring in an intensive care unit is required
This includes hemodynamic monitoring, vigilant fluid management, and vigilant monitoring for bleeding, infection, and signs of hepatic encephalopathy.
Pain Management And Nutrition:
Adequate pain control is essential
Early enteral nutrition should be initiated as tolerated, with attention to fluid and electrolyte balance
Prophylactic antibiotics are typically administered.
Managing Complications:
Prompt recognition and management of complications such as intra-abdominal bleeding, infection, shunt thrombosis, and hepatic encephalopathy are crucial
Regular laboratory monitoring (CBC, LFTs, coagulation profile) is performed.
Complications
Early Complications:
Hemorrhage (from staple lines, residual varices, or shunt site)
intra-abdominal infection/abscess
shunt thrombosis
acute renal failure
pneumonia
deep vein thrombosis.
Late Complications:
Hepatic encephalopathy (ranging from mild to severe)
recurrent variceal bleeding (due to incomplete devascularization or shunt stenosis/thrombosis)
shunt stenosis or occlusion
ascites refractory to medical management
malnutrition.
Prevention Strategies:
Meticulous surgical technique with complete devascularization and proper shunt construction are paramount
Careful patient selection, preoperative optimization, and diligent postoperative care, including timely management of complications, are vital for reducing morbidity and mortality.
Key Points
Exam Focus:
Understand the indications for devascularization in portal hypertension, particularly the role of the Sugiura procedure for gastric varices
Differentiate it from TIPS and other surgical options
Know the critical steps of devascularization and shunt creation.
Clinical Pearls:
The Sugiura procedure is technically demanding and requires extensive experience
Careful dissection to avoid injury to the vagal nerves is important
Postoperative encephalopathy is a significant concern and requires proactive management.
Common Mistakes:
Incomplete devascularization leading to recurrent bleeding
failure to adequately assess liver function and risk stratify patients
poor shunt construction leading to thrombosis or stenosis
delayed recognition and management of postoperative complications.