BACKGROUND: The role of gastroesophageal devascularization (Sugiura-rype procedures) for the treatment of variceal bleeding remains controversial. Although Japanese series reported favorable longterm results, the technique has nor been widely accepted in the Western Hemisphere because of a high postoperative morbidity and mortality. The reasons for the different outcomes are unclear. In a multidisciplinary team approach we developed a therapeutic algorithm for patients with recurrent variceal bleeding. STUDY DESIGN: The Sugiura procedure was offered only to patients with well-preserved liver function (Child A or Child B cirrhosis without chronic ascites) who were not candidates for distal splenorenal shunt, transhepatic porto-systemic shunt, or liver transplantation. RESULTS: Fifteen patients with recurrent variceal bleeding underwent a modified Sugiura procedure between September 1994 and September 1997. All but one patient (operative mortality 7%) are alive after a median followup of 4 years. Recurrent variceal bleeding developed in one patient; esophageal strictures, which were successfully treated by endoscopic dilatation, developed in three patients; and one patient experienced mild encephalopathy. Major complications were noted only in patients with impaired liver function (Child B cirrhosis) or when the modified Sugiura was performed in an emergency setting. The presence of cirrhosis or the cause of portal hypertension had no significant impact on the complication rate. CONCLUSIONS: This series was performed during the last decade when all modern therapeutic options for variceal bleeding were available. Our results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.