Esophageal variceal ligation

Endoscopic sclerotherapy is an effective mctho<l for treating and eradicating acutely bleeding varices in repeated sessions; however, it is not ideal hecause of numerous serious complications. Endoscopic variceal ligation, developed to circumvent some of the side effects of sclerotherapy, controls actively hleeding varices m about 90% of cases. Of 146 patients treated with endoscopic variceal ligation, variceal eradication was achieved in 80% of surviv, ing patients in a mean of 5.5 treatment sessions. Recurrent bleeding developed in 39%. Complications were very rare. It is concluded that endoscopic variccal liganon is at least as effective as sclerotherapy hut associated with fewer complications. Can J Gastroenterol 1990;4(9):639-642

Figure l) Endoscopic ligating det~ce.The larger cylmder is atra.ched to the tip of the endoscope.The rripwire is passed down the biopsy channel of rhe endoscope and hooked inside the smaller cylinder.The small cyliruler is preloaded with the black 0-ring, and once attached to the mpwire , is seared w1thm the large cylindL>r on che rip of the endoscope At the University of Colorado, a device has been developed that is attached to the enJ of an endoscope anJ can be used to place small elastic 0rings around esophageal varices in a manner similar to hemorrhoidal ligation (7-10).The device consists of two plastic cylinders, a mpw1re, and the 0ring (Figure 1 ).The larger of the two cylinders is attached to the end of the endoscope, while the 0-ring is stretched over the smaller cylinder.The tripwire is passed through the biopsy channel cl the endoscope and attached to the smaller of the cylinders.The smaller cylinder is then seared in the larger cylinder at the end of the endoscope.With this arrangement, pulling the tripwire slides the smaller cylinder further into the larger one and strips off the 0-ring.
Endoscopic variceal ligation is done on patients currently bleeding or who have recently bled from esophageal varices.The endoscope is passed through the patient's mouth in the standard fashion.An overtube is placed on the shaft of the endoscope so that the endoscope can be used as a guide for passing the overtube (Figure 2).The author has been using a custom-made overtube 25 cm long with a built-in mouth piece at one end.The overtube allows repeated passage of the endoscope without excessive trauma to the pharyngeal area.Once the endoscope is passed and the overtube in place, a thorough endoscopic examination is performed.The endoscope is then removed, the endoscopic variceal ligatton device placed on the tip of the 640 ,, II ,.
Figure 2) Overrube for use w1Lh the ligation device.The tube is sem1flexible with a beveled disuil op and a rigid mnuth piece built in to the proximal end  The base where the band is located i.1 ro the right endoscope, and the whole thing repassed through the overtube into the distal esophagus.The endoscope tip 1s positioned over a varicc<1l column m the distal esophagus at or just he low the Z-line.Suction is applied to draw the esophageal mucosa and varix up into the deadspace created by the two cylinders at the tip of the endoscope.When the tissue is fu lly inside the cylinders, the tripwire is pulled and the 0-ring slipped around the tissue bolus.The endoscope is removed, reloaded with a fresh 0-ring, and repassed into the esophagus (Figure 3 ).
The procedure is repeated as many times as needed until all varices are ligated at least once ( Figure 4).The numberofO-rings placed will vary from one to l 2 .The whole process is repeated after one week and every two weeks after that until all varices are visibly gone.The patients are followed with repeat endoscopies every three to six months to ensure no varices recur.
The first l 46 patients treated with endoscopic variceal ligation had a mean age of 52 years: 96 of them were men.Ninety-three haJ Laennec's cirrhosis.Using the modified Child-Pugh system, patients were equally divided between three classes (A,B,C).One hundred an<l thirty-twQ of the patients had ceased bleeding prior to the first session, while the other 33 were still actively bleeding.Of the patients not actively bleeding, 5% <lid not survive the initial hospitalization, while 43% of the active bleeders did not survive.Overall, the fatality rate for the enrire duration of the study (mean fo llow-up 15 months) was 27%.Of those who survived their initial hospitalization, 57% experienced 72 episodes of recurrent hemorrhage before their vances were eradicated.In general, it took an average of five sessions and 18 0-nngs to eradicate a patient's varices.All of these figures are comparable to those seen in patients treated with repeated sclerotherapy sessions, except the comp lication rate.Only three patients developed nonblceding complicattons: a meat impaction without significant stricture, and two strictures that required a solitary dilation (Table I).
Active varicea l hemorrhage was controlled in 90% of patients.Two ~)f the uncontrollable patients had undergone sclerotherapy at other hospitals before endoscopic variceal ligation and had resultant large esophageal ulcerattons.Endoscopic vanceal ligation also produces esophageal ulcerations, but these arc superficial and have resulted m a low incidence of bleeding ( 11 % ) despite the presence of major coagulation problems m many of the patients.Recurrent esophageal varices developed in approximately one-third of patients who had long term followup.These were easily re-eradicated with one or two further sessions which is comparable to the experience reporte<l for sclerothcrapy.ln the actively bleeding patient, there may be two advantages to endoscopic variceal ligation over sclero-TABLE 1 Esophageal variceal liga tion therapy besides those described above.The placement of the 0-ring need only he near a variceal column to be effec-1 ivc, while sclcrotherapy should be Jone intravariccally, if at all possible, co avoid comp I ications from the sclerosant necrosing rhe esophageal wall.lntravanceal injections can he very difficult in the pre~cnce of large amounts of blooJ in the esophageal lumen.Use of the nverrube may prevent aspiration during a procedure on an actively bleeding patient because it directs the gastric anJ esophageal conrents out of the patient's mouth and thus protects rhe airway.Endoscopic variccal ligation may offer an advantage over sclerotherapy because it is simple to perform, has fewer complications, and may be equally effective.Whether ir is truly as effective or more effective than sclerothcrapy is yet to be proven, hut a retrospective comparison at the author's ho~pital strongly suggested this conclusion ( 1 l ).The author is currently resting this hypothesis with a mult1centre, ranJom1ze<l trial comparing the two techniques.
The question remain ing is whether or not a more efficient endoscopic method for eradicating esophageal varices can be developed so that there will be a shorter time between initiation of therapy and variccal eradicauon.Th is would be Je~irable, since most rebleeding occurs during the mterval before total varicea l eradication is achieved.Preliminary work at the author's hospital has suggested that a combination of endoscopic variceal

Figure 3 )
Figure 3) Endoscopic ligacinn technique .Upper left The ligating device is appro>..1mated to t.he,arix in the wall of the esophagus.Suction is applied and tissue containing the varix 1s aspirated mto rlit dead.spacewithm che ligating device (Upper right).Lower left The siu.tation immediately a[tt'r rk e1u.loscopist pulls on the guidewire and releases the 0-ring around the aspirated nssue.Lower right The final product

Figure 4 )
Figure 4) Endoscopic view of a ligated varix.The dark baU m the centre 1s rhe ligated varix.The base where the band is located i.1 ro the right

Esophageal variceal ligation (EVL) results at 36 months
72%ligation and sclermherapy 1 s able to eradicate gastric and e~ophageal varices more quickly than e ither method alone.