World J. Surg. 23, 1168 –1175, 1999 WORLD Journal of SURGERY © 1999 by the Socie ´te ´ Internationale de Chirurgie Transabdominal Extensive Esophagogastric Devascularization with Gastroesophageal Stapling for Management of Noncirrhotic Portal Hypertension: Long-term Results Surendra K. Mathur, M.S., Sudeep R. Shah, M.S., Sanjay S. Nagral, M.S., Zahir F. Soonawala, M.S. Department of Surgery and Gastroenterology Surgical Services, King Edward VII Memorial Hospital, Bombay 400 012, India Abstract. Outside Japan portosystemic shunts have been favored as the surgical procedure of choice for the management of portal hypertension of noncirrhotic etiology. Devascularization procedures have resulted in high rebleed rates probably owing to a limited extent of devascularization. We performed this study to assess the efficacy of our modification of Sugiura’s procedure for long-term control of variceal bleeding in patients with noncirrhotic portal hypertension. Forty-six patients with extrahepatic portal venous obstruction (EHPVO) and 22 with noncirrhotic portal fibrosis (NCPF) were subjected to transabdominal extensive esophago- gastric devascularization with esophageal or gastric stapled transection (modified Sugiura’s procedure), 38 in an emergency situation and 30 electively. Follow-up endoscopies were performed every 6 months. Oper- ative mortality, morbidity, variceal status, and causes of recurrent bleed- ing were evaluated. The postoperative mortality was 4%. Early procedure- related complications were seen in 6%, and esophageal strictures formed in 7 of 45 survivors undergoing esophageal transection (15%). Over a mean  SD follow-up of 53  34 months, 95% of patients were free of varices. Seven survivors (11%) had a rebleed, but only 5% were due to varices (two esophageal, one gastric). Six (9%) patients developed gas- tropathy. The 5-year survival was 88%. The modified Sugiura’s procedure is safe and effective for long-term control of variceal bleeding especially in the emergency setting and in patients with anatomy unsuitable for shunt surgery or if surgical expertise for a shunt operation is not available. Currently, endoscopic variceal sclerotherapy is the mainstay in the management of portal hypertension [1, 2]. However, alternative treatment in the form of surgery is needed for certain patients: those who continue to bleed despite endoscopic variceal sclero- therapy [1], those with bleeding from fundal gastric varices [3], and those unable to follow up for lifelong endoscopic surveillance [4]. These patients require a one-time procedure that can achieve good long-term control of variceal hemorrhage. This is of partic- ular importance in patients where the etiology of portal hyperten- sion (PHT) is extrahepatic portal venous obstruction (EHPVO) or noncirrhotic portal fibrosis (NCPF); because the liver is normal in these patients, effective control of variceal bleeding should lead to a normal life expectancy. Hence some authors recommend surgery as the primary modality of therapy for these patients [5– 8]. Regarding the choice of surgery, portosystemic shunts are fa- vored for management of noncirrhotic PHT in the West [6 –10] and in India [5, 11–13] in contrast to Japan, where nonshunt surgeries in the form of the Sugiura’s procedure and its modifi- cations are preferred, being associated with a low rate of enceph- alopathy and variceal rebleed on long-term follow-up [14, 15]. The excellent results of the Japanese have not been duplicated by centers in the West [1] or India [5, 13], probably due to the limited extent of devascularization. Furthermore, the original Sugiura’s procedure is considered a formidable operation by some [16]. We have modified the original Sugiura’s procedure to simplify the technique and have found our procedure of a transabdominal esophagogastric devascularization with gastroesophageal stapling (TAEGD + GES) to be an effective, safe procedure for control- ling acute variceal hemorrhage in patients with PHT of different etiologies [17]. In the present study, we report long-term results of this procedure for control of variceal bleeding in patients with noncirrhotic PHT. Patients and Methods Between January 1985 and June 1996 a series of 291 patients with PHT of noncirrhotic origin were managed for variceal bleeding in a surgical unit that is a referral unit for PHT. Of these patients, 97 were subjected to surgery (devascularization 68, lienorenal shunt 29). The remaining patients were treated with endoscopic sclero- therapy. This study includes 68 patients subjected to TAEGD with gastric or esophageal stapling (Table 1). The selection criteria for TAEGD were as follows: (1) all patients requiring emergency surgery for control of bleeding; and (2) patients in whom a suitable splenic vein was not available for shunting. Among these 68 patients, 38 were subjected to emergency surgery for control of acute variceal bleeding that could not be controlled with either emergency sclerotherapy or balloon tamponade and vasopressin infusion; all these patients were operated on while actively bleed- ing. The remaining 30 patients were operated on electively. The indications for elective surgery were failure of chronic endoscopic variceal sclerotherapy (life-threatening rebleed on regular follow- up), bleed from fundal gastric varices, noncompliance or inability to follow up for regular endoscopic variceal sclerotherapy, or the Correspondence to: S.K. Mathur, M.S., Surgical Gastroenterology and Liver Transplantation Unit, Bombay Hospital and Medical Centre, 12 New Marine Lines, Mumbai 400 020, India.