PMC6497474_01
Abdominal Doppler ultrasonography with ascites, dilatation of portal vein, and low portal vein peak velocity.
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The abdominal Doppler ultrasonography presented noncirrhotic liver with average size (13 cm), splenomegaly (13.9 cm), dilatation of portal vein (1.27 cm), low portal vein peak velocity (19.4 cm/s), and ascites (Figure 1).
Contrast-enhanced abdominal CT scan with dilatation of portal vein with thrombus and dilatation of splenic vein.
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This finding was confirmed with contrast-enhanced abdominal computed tomography (CT) scan, which revealed dilatation of portal vein with thrombus, normal liver parenchymal, normal biliary tract, splenomegaly with dilatation of splenic vein, and ascites (Figure 2).
Esophagogastroduodenoscopy, esophageal varices grade 3 with the positive red color sign (left), esophagogastric junction (middle), and cardia stomach varices (right).
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He was examined used esophagogastroduodenoscopy, which revealed esophageal varices grade 3 with the positive red color sign and stomach varices (Figure 3). 
Step by step the operation. Left subcostal incision (A); splenectomy (B); transection and end-to-end anastomosis of the lower esophagus (C); devascularization of the upper 2/3 of the major gastric curvature (D); pyloroplasty (E); proximal splenorenal shunt (F).
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We performed the modified Sugiura technique through left subcostal incision (Figure 4A) and proximal splenorenal shunt. We performed splenectomy first (Figure 4B) followed by devascularization of the distal esophagus using harmonic scalpel through hiatus of diaphragm. Then, we made a transection and end-to-end anastomosis of the lower esophagus (Figure 4C) using a CDH29A stapling device (Ethicon curved intraluminal stapler). We performed devascularization of the upper 2/3 of the lesser and major gastric curvature (Figure 4D) and then pyloroplasty to facilitate gastric emptying (Figure 4E). The last procedure we anastomosed end-to-side of the splenic vein to left renal vein (Figure 4F).
Esophagogastroduodenoscopy 2 months after surgery, esophageal varices grade 2 with the negative red color sign (left), cardia stomach edema (middle), and gastric snakeskin (right).
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Two months after surgery, we examined esophagogastroduodenoscopy and revealed esophageal varices grade 2 with the negative red color sign, cardia stomach edema, no gastric varices, and gastric snakeskin (Figure 5).