Endoscopy 2021; 53(09): E328-E329
DOI: 10.1055/a-1275-9674
E-Videos

Ligation-occluded endoscopic injection sclerotherapy: a novel retrograde strategy for gastroesophageal varices obliteration

Wei Wu
1  Department of Gastroenterology, Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
,
Qukai Liu
1  Department of Gastroenterology, Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
,
Weiguang Li
1  Department of Gastroenterology, Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
,
Jiali Kan
2  Endoscopy Center, Wuxi Branch of Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Wuxi, China
,
Qi Wang
1  Department of Gastroenterology, Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
,
Lifu Wang
1  Department of Gastroenterology, Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
› Author Affiliations
 

We propose a novel retrograde obliteration strategy, ligation-occluded endoscopic injection sclerotherapy (LOEIS), for management of gastroesophageal varices. We report on a patient with GOV1 + 2 varices who benefitted from this strategy ([Fig. 1 a]). She underwent endoscopy for recurrent variceal bleeding. Conventional variceal obturation with sclerosant [1] (1 % lauromacrogol with methylene blue as tracer agent) to the first two cardiac varices was successful [2]. We tried to obturate a third cardiac varix with a caliber of 1.8 – 2.5 mm on endosonography, but failed to achieve accurate injection; unfortunately, this attempt also resulted in active bleeding ([Fig. 1 b]). We decided to perform LOEIS.

Zoom Image
Fig. 1 GOV1 + 2 varices in a patient with hepatitis B virus liver cirrhosis. a Cardiac varices before endoscopic treatment. b Active bleeding during endoscopic variceal obturation.

The downstream esophageal extension of the bleeding cardiac varix was carefully identified. Esophageal variceal ligation (Super 7; Boston Scientific, Marlborough, Massachusetts, USA) was performed. Injection therapy was then carried out on this varix at 1 – 2 cm distal to the rubber band and 2 cm proximal to the dentate line. As the pre-secured rubber band blocked the hepatofugal drainage, the sclerosant was forced to flow toward the cardia ([Fig. 2 a]). In this way, the role of the rubber band was similar to that of a dilated balloon in balloon-occluded retrograde transvenous obliteration and endoclip in clip-assisted gastric variceal obturation [3]. A combination of 7 mL foam sclerosant (1 % lauromacrogol: room air = 1:3), 1 mL tissue adhesive (N-butyl-2-cyanoacrylate), and 2.5 mL of normal saline was injected using a needle with a transparent catheter (23G; Boston Scientific) ([Video 1]). Hemostasis was successfully achieved ([Fig. 2 b]). Enhanced computed tomography confirmed effective obliteration of varices. The patient was discharged in good condition.

Zoom Image
Fig. 2 Ligation-occluded endoscopic injection sclerotherapy. a Injection therapy was performed in the downstream esophageal varix corresponding to the bleeding cardiac varix, at the distal side of a pre-secured rubber band. Arrows indicate sclerosant flow. b Hemostasis was successfully achieved.

Video 1 Ligation-occluded endoscopic injection sclerotherapy as a novel retrograde strategy for gastroesophageal varices obliteration.


Quality:

LOEIS is particularly suitable for GOV1/2 with large esophageal and small gastric varices. When applied properly, LOEIS is both safe and efficient. It is highly complementary to conventional endoscopic obliteration methods and should be integrated into the technical arsenal for management of gastroesophageal varices.

Endoscopy_UCTN_Code_TTT_1AO_2AD

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.

This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos


#

Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Wei Wu, MD, PhD
Department of Gastroenterology
Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine
197 Ruijin Er Road
Shanghai 200025
China   
Fax: +86-21-64150773   

Publication History

Publication Date:
23 October 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 GOV1 + 2 varices in a patient with hepatitis B virus liver cirrhosis. a Cardiac varices before endoscopic treatment. b Active bleeding during endoscopic variceal obturation.
Zoom Image
Fig. 2 Ligation-occluded endoscopic injection sclerotherapy. a Injection therapy was performed in the downstream esophageal varix corresponding to the bleeding cardiac varix, at the distal side of a pre-secured rubber band. Arrows indicate sclerosant flow. b Hemostasis was successfully achieved.