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.
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.
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.
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
