Sugiura Procedure

Sugiura procedure

Sugiura procedure is a surgical intervention on portal hypertension, primarily done to manage bleeding of esophageal and gastric varices. It usually comes into picture when endoscopic treatment and pharmacological treatment do not or cannot work. This is a procedure that was first described by Dr. Sugiura in Japan and is most commonly applied in patients having non-cirrhotic portal hypertension or in some patients with cirrhosis but preserved liver function.

Indications

Sugiura procedure can be suggested in the cases of:

• Repeated variceal hemorrhage of the esophagus or stomach. 
• Failure of endoscopic band ligation or sclerotherapy. 
• Portosystemic shunt surgery contraindications.
• Portal hypertension and with good liver reserve.
• In certain adaptations, hypersplenism and splenomegaly.

Types of Sugiura Procedure

Classic (Two -stages) Sugiura Procedure

• Abdominal stage
• Thoracic stage

Altered (Single-stage) Sugiura Procedure

• Most often carried out nowadays.
• Avoids thoracotomy

Sugiura Procedure- Surgery Steps

• This is done through the process of esophagogastric devascularization to avoid bleeding varices.

Key Components

• Splenectomy (not necessary, based on the patient)
• Distal esophagus devascularization.
• Stomach upper devascularization.
• Esophageal transection and re anastomosis..
• Pyloroplasty (to assist in gastric emptying)
• Vagotomy (in selected cases)
• It is aimed at occluding the blood flow to varices without causing a shunt.

Advantages

• Good management of variceal bleeding.
• No portal blood flow diversion.
• Reduced risk of hepatic encephalopathy as opposed to shunt surgeries.
• Applicable in the case of contraindication of TIPS or shunt surgery.

Sugiura procedure surgery

Sugiura procedure is a type of non-shunting surgery for portal hypertension designed to prevent the bleeding of esophagogastric varices by means of an extensive devascularization combined with esophageal transection. 

Preparation before Surgery

• General anaesthesia
• Insertion of nasogastric tube
• Review of systems: broad-spectrum antibiotics. 
• Cross-matched blood products.
• Supine position (upper midline laparotomy).

Modified (Single-Stage) Sugiura Procedure -Steps

Abdominal Access

• Upper midline laparotomy
• Evaluation of Liver, Spleen and Portal Hypertension.

Splenectomy (when indicated)

• Ligation of the splenic artery and vein. 
• Removal of spleen
• Eliminates portal pressure and hypersplenism.

Gastric Devascularization

Division and ligation of:

• Left gastric (coronary) vein and artery.
• Short gastric vessels
• Posterior gastric veins
• Left gastroepiploic vessels.
• Indication: eradicate gastric varices blood circulation.

Devascularization of the Inferior Esophageal Artery

• Displacement of the last 6-8 cm of the esophagus. 

Ligation of:

• Paraesophageal veins
• Perforating veins
• Branches to esophagus of left gastric vein.

Esophagus Transection and Re-anastomosis

• T2 transverse esophageal cut 2-3 cm superior to gastroesophageal junction.
• End-to-end esophageal anastomosis was performed in a single stage.
• Usually with the aid of a circular stapler. 
• Purpose: disruption of submucosal variceal channels.

Pyloroplasty

• Heineke–Mikulicz pyloroplasty
• This prevents stasis of the stomach after devascularization and vagal disruption.

Vagotomy (optional)

• Additional truncal vagotomy can be done in the selected cases.

Hemostasis and Placement of Drains

• Meticulous hemostasis
• Abdominal drains placed
• Closure of laparotomy

Standard (Two-Stage) Sugiura Procedure

Stage 1 – Abdominal

• Splenectomy
• Gastric devascularization

Stage 2 – Thoracic

• Left thoracotomy
• Esophageal devascularization
• Esophageal transection and re-anastomosis

Postoperative Care

• ICU monitoring
• Nil by mouth first - gradual feeding.
• Contrast study prior to oral intake (to eliminate leak)
• Endoscopic surveillance in the long-run.

Sugiura procedure complications

Sugiura complications may be classified as early (postoperative) and late (long-term) complications.

Early Complications

• Hemorrhage
• Esophageal Anastomotic Leak
• Esophageal Stricture
• Pulmonary Complications
• Infection
• Gastric Emptying Delay
• Ascites

Late Complications

• Recurrent Variceal Bleeding
• Portal Hypertensive Gastropathy
• Nutritional Problems
• Hypersplenism
• Incisional Hernia

Sugiura procedure recovery

The recovery process following a Sugiura is considered to be more severe and prolonged than the less invasive treatment as it is considered a major operation of the abdomen (and occasionally thorax). The objective is to promote healing of the esophageal anastomosis, prevent complications, and gradually reinstitute feeding and activity. 

Postoperative Recovery (Day 0-3) 

ICU Monitoring:

• Pulse, urine output, oxygen saturation. 
• Hemodynamic support when required.

Nil Per Oral (NPO):

• Averts stress along esophageal anastomosis.

Nasogastric Tube (NGT):

• Decomposition stomach suction.
• Typically, if no bleeding, removed in a couple of days.

Pain Control:

• IV analgesics 
• Thoracic epidural in case of thoracotomy.

Fluid and Electrolyte Management:

• IV fluids, replacement of electrolyte imbalances.

The initial phase of postoperative care (Day 4-10) is the early phase

Gradual Oral Feeding:

• Start with clear liquids
• Proceed to soft diet when contrast study shows that there is no leak at anastomosis.

Observations of Complications:

• Fever → infection
• Pain in the chest or shortness of breath - pulmonary complication.
• Vomiting - delay of gastric emptying.
• Abdominal distension, bleeding or ascites.

Mobilization:

• Timely ambulation in prevention of deep vein thrombosis (DVT) and pulmonary complications.

Drains:

• Abdominal drains removed with decreased output, no leakage, bleeding.

Intermediate Phase (Weeks 2–4)

Diet:

• Progressively resume normal diet.
• Minimal, regular meals suggested.
• Spicy, acidic or extremely hard foods are to be avoided.

Activity:

• Light activity at home
• Limit heavy lifting to a minimum of 6 weeks.

Follow-Up:

• Clinical check-up
• Lab Liver, hemoglobin, electrolytes.

Long-Term Recovery (Weeks 4–6+)

Full Activity:

• In majority of patients, recovery takes place in 4-6 weeks.
• Patients with thoracotomy might take a long time before recovery.

Endoscopic Surveillance:

• 1st endoscopy typically at 6-8 weeks.
• Identifies the presence of recurrent varices or stricture.

Nutritional Support:

• Healing high-protein diet.
• Take vitamins supplements where needed.

Complication Monitoring:

• Dysphagia → possible esophageal dilation may be required.
• Recurrent varises -endoscopically treated.
• The portal hypertension symptoms → frequent follow-up.

Best hospital for Sugiura procedure India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

The Sugiura procedure is a non-shunt operation, aimed at regulating esophageal and gastric variceal bleeding in patients with portal hypertension, in case endoscopic or medical treatment has not been effective or contraindicated by shunt surgery. Entails esophagogastric devascularization, esophageal transection, optional splenectomy, vagotomy and pyloroplasty. Maintains portal blood flow thereby reducing the risk of hepatic encephalopathy in comparison with shunt surgeries. Proven to be effective in the prevention of recurrent variceal bleeding, but not to cure portal hypertension. The recovery process is long and there is a need to observe anastomotic leakages, strictures, bleeding, pulmonary complications, and nutritional problems. Endoscopic monitoring is necessary in the long term to identify the recurrence of varices or other complications.

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FAQ

Is it a cure for portal hypertension?

• No. The process manages the bleeding of varicose veins but fails to lower the portal pressure or reverse the underlying liver disease.

What are its benefits compared to shunt surgeries?

• Preserves portal blood flow
• Less susceptibility to hepatic encephalopathy
• Without diversion of portal blood, effective bleeding control is possible.

Can it be done in children?

• Yes, portal hypertension isolated patients can get the Sugiura procedure, though with changes to minimize morbidity.

What are the alternatives of Sugiura?

• Endoscopic therapy 
• The TIPS
• Surgical shunts (eg, portocaval shunt)
• Liver transplantation in end-stage cirrhosis