Surgical Treatment: Sugiura Procedure and Hassab’s Operation

Abstract

Non-shunt operations, such as the Sugiura procedure and Hassab’s operation, consist of extensive interruption of collateral vessels connecting the high-pressure portal venous system in combination with splenectomy. Hemodynamic studies have suggested non-shunt operations do not divert portal blood flow, do not decompress the portal venous system, and maintain portal blood flow toward the liver. Among various kinds of non-shunt operations, the Sugiura procedure was the most effective because it was an extensive esophagogastric devascularization combined with esophageal transection and splenectomy. Its morbidity and mortality, however, were higher than those of other procedures. Accordingly, various authors have proposed modifications to make the procedure less complex. One common modification uses a single abdominal operation to achieve gastroesophageal devascularization. To achieve complete separation of the azygous vein system from the intramucosal vein and following anastomosis, an end-to-end anastomosing stapling device is used. Hassab’s operation is also a single abdominal operation consisting of splenectomy and devascularization of the esophagus and the proximal part of the stomach. Different from the Sugiura procedure, it does not include esophageal transection. Recently, laparoscopic approaches have been increasingly indicated in various fields, including for patients with liver cirrhosis and portal hypertension. There have been some reports describing the techniques and outcomes of laparoscopic non-shunt operations. Since 2008, we have completed 14 hand-assisted laparoscopic surgeries for Hassab’s operation. In this chapter, we review the characteristics of each non-shunt operation and showed our latest results.