Endoscopic Band Ligation for Dieulafoy Lesions: Disadvantages and Risks

We read with interest the article by Valera et al. [1] describing endoscopic band ligation (EBL) as the best therapeutic strategy for bleeding Dieulafoy lesions. The authors report on their successful experience in treating four such patients. We agree with the authors that EBL is especially useful when the esophagogastric junction or the posterior wall of the proximal body of the stomach are involved. However, EBL also has some disadvantages that the authors do not mention in the article.

Firstly, EBL requires permanent rubber-band placement. Secondly, perforation may occur after EBL, especially in the gastric fundus. Thirdly, necrotic ulcers after EBL may lead to recurrent bleeding. Although the authors do not report any cases of rebleeding after EBL in their experience or in the literature reviewed, there have been several reported cases of rebleeding after EBL for Dieulafoy lesions. Nikolaidis et al. [2] reported on one patient with rebleeding from a jejunal Dieulafoy’s lesion 5 days after EBL, which was subsequently treated surgically. Ertekin et al. [3] reported another case of rebleeding 2 days after EBL for Dieulafoy’s lesion at the gastric fundus, which was also treated surgically. Park et al. [4] reported one case of rebleeding from a necrotic ulcer in a patient with coagulopathy, which was successfully treated with endoscopic injection therapy.

We recently reported the first fatal case associated with EBL for Dieulafoy lesions [5]. We would suggest that the residual vessel at the base of the necrotic ulcer may cause delayed hemorrhage, and it may not be possible to predict this on the basis of an endoscopic examination. We would like to remind endoscopists of this potential complication when treating Dieulafoy lesions with EBL. Carrying out an endoscopic ultrasound examination after EBL in order to monitor complete occlusion of the vessel may be a better strategy in the treatment of Dieulafoy lesions.

Competing interests: None

References

• 1 Valera J M, Pino R Q, Poniachik J. et al . Endoscopic band ligation of bleeding Dieulafoy lesions: the best therapeutic strategy.  Endoscopy. 2006;  38 193-194
• 2 Nikolaidis N, Zezos P, Giouleme O. et al . Endoscopic band ligation of Dieulafoy-like lesions in the upper gastrointestinal tract.  Endoscopy. 2001;  33 754-760
• 3 Ertekin C, Taviloglu K, Barbaros U. et al . Endoscopic band ligation: alternative treatment method in nonvariceal upper gastrointestinal hemorrhage.  J Laparoendosc Adv Surg Tech A. 2002;  12 41-45
• 4 Park C H, Joo Y E, Kim H S. et al . A prospective, randomized trial of endoscopic band ligation versus endoscopic Hemoclip placement for bleeding gastric Dieulafoy’s lesions.  Endoscopy. 2004;  36 677-681
• 5 Chen Y Y, Su S S, Soon M S, Yen H H. Delayed fatal hemorrhage after endoscopic band ligation for gastric Dieulafoy’s lesion.  Gastrointest Endosc. 2005;  62 630-632