Endoscopy 2021; 53(11): E419-E420
DOI: 10.1055/a-1324-2591
E-Videos

Esophageal variceal treatment using a novel Doppler probe method

Yasutoshi Shiratori
Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
,
Takaaki Yoshimoto
Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
,
Kazuki Yamamoto
Division of Gastroenterology, St. Luke’s International Hospital, Tokyo, Japan
› Author Affiliations
 

Esophageal variceal recurrence after endoscopic treatment is a frequent event [1] [2] [3] [4]. Some studies have reported that endoscopic treatment assisted by endoscopic ultrasonography (EUS) that can evaluate variceal size and hemodynamics is effective in preventing variceal recurrence [3] [4]. Additionally, color Doppler evaluation by EUS is less invasive and enables endoscopists to identify the varices to be treated [4]. However, the Doppler-EUS method has issues related to its use: it is time-consuming, it is complicated to use convex transducers, and it requires scope replacement for additional treatment. The latest method, Doppler probe ultrasonography, uses a through-the-scope Doppler probe (Compumedics, DWL, Singen, Germany) ([Fig. 1 a]) that can evaluate the direction, waveform (that helps distinguish between arteries and veins), and the amount of blood flow ([Fig. 1 b, c]) [5]. Moreover, Doppler probe ultrasonography is simple, noninvasive, and requires no scope replacement for additional treatment. The procedure involves 1) identification of more risky varices, 2) detection of penetrating varices, 3) assisting appropriate hemostasis, and 4) evaluation after hemostatic treatment. Here we demonstrate two variceal treatments using this novel approach ([Video 1]).

Zoom Image
Fig. 1 a The image of the Doppler system with a reusable Doppler probe (diameter of 2 mm, 16 MHz). The Doppler system has audio and visual output signals. (Reproduced with permission from Compumedics.) b The visual graphic display reveals Doppler flow corresponding to the esophageal varix. c The Doppler flow disappeared after additional endoscopic variceal ligation.

Video 1 Effective endoscopic hemostasis using the novel Doppler probe method.


Quality:

Case 1 involved a patient with a history of esophageal variceal rupture. Although he had undergone repeated endoscopic variceal ligations, recurrence of varices was observed ([Fig. 2 a]). We evaluated high-risk varices using Doppler probe ultrasonography ([Fig. 2 b]). Because varices previously treated with endoscopic variceal ligation had a penetrating vein and massive blood flow, we performed an additional ligation at the site of vein penetration ([Fig. 2 c]). Varices were evaluated afterwards and the effectiveness of hemostasis was confirmed ([Fig. 2 d]).

Zoom Image
Fig. 2 a Endoscopic view of the patient with esophageal variceal recurrence. b Evaluation of esophageal varices using the Doppler probe. The Doppler probe was maneuvered while observing the blood flow. c Additional band ligation was performed at a site where there was massive blood flow that we considered to have penetrating veins. d Confirmation by Doppler probe after band ligation was performed. If the blood flow had remained, additional variceal ligation would have been considered.

Case 2 had a history of hemostasis for gastric variceal rupture ([Fig. 3 a]). Subsequently, esophageal varices developed. Esophageal varices continuous with the stomach were identified, and endoscopic variceal ligation was performed ([Fig. 3 b]).

Zoom Image
Fig. 3 a Endoscopic view of gastric varices with scar formation due to previous variceal ligation. b Esophageal varices continuous with gastric varices were identified by the novel Doppler probe method; thereafter, esophageal varices were effectively treated by variceal ligation.

Both cases were treated effectively with endoscopic variceal ligation assisted by our novel Doppler probe ultrasonography.

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Competing interests

The authors declare that they have no conflict of interest.

  • References

  • 1 Lv Y, Qi X, He C. et al. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial. Gut 2018; 67: 2156-2168
  • 2 Mansour L, El-Kalla F, El-Bassat H. et al. Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices. Gastrointest Endosc 2017; 86: 307-315
  • 3 Carneiro FO, Retes FA, Matuguma SE. et al. Role of EUS evaluation after endoscopic eradication of esophageal varices with band ligation. Gastrointest Endosc 2016; 84: 400-407
  • 4 Hino S, Kakutani H, Ikeda K. et al. Hemodynamic analysis of esophageal varices using color Doppler endoscopic ultrasonography to predict recurrence after endoscopic treatment. Endoscopy 2001; 33: 869-872
  • 5 Shiratori Y, Ikeya T, Oguri N. et al. Endoscopic Doppler probe ultrasonography for detecting blood flow at post-endoscopic submucosal dissection ulcers of the stomach. Endosc Int Open 2020; 8: E1086-E1090

Corresponding author

Yasutoshi Shiratori, MD
9-1 Akashi-cho Chuo-ku
Tokyo 104-8340
Japan   

Publication History

Article published online:
27 January 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Lv Y, Qi X, He C. et al. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial. Gut 2018; 67: 2156-2168
  • 2 Mansour L, El-Kalla F, El-Bassat H. et al. Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices. Gastrointest Endosc 2017; 86: 307-315
  • 3 Carneiro FO, Retes FA, Matuguma SE. et al. Role of EUS evaluation after endoscopic eradication of esophageal varices with band ligation. Gastrointest Endosc 2016; 84: 400-407
  • 4 Hino S, Kakutani H, Ikeda K. et al. Hemodynamic analysis of esophageal varices using color Doppler endoscopic ultrasonography to predict recurrence after endoscopic treatment. Endoscopy 2001; 33: 869-872
  • 5 Shiratori Y, Ikeya T, Oguri N. et al. Endoscopic Doppler probe ultrasonography for detecting blood flow at post-endoscopic submucosal dissection ulcers of the stomach. Endosc Int Open 2020; 8: E1086-E1090

Zoom Image
Fig. 1 a The image of the Doppler system with a reusable Doppler probe (diameter of 2 mm, 16 MHz). The Doppler system has audio and visual output signals. (Reproduced with permission from Compumedics.) b The visual graphic display reveals Doppler flow corresponding to the esophageal varix. c The Doppler flow disappeared after additional endoscopic variceal ligation.
Zoom Image
Fig. 2 a Endoscopic view of the patient with esophageal variceal recurrence. b Evaluation of esophageal varices using the Doppler probe. The Doppler probe was maneuvered while observing the blood flow. c Additional band ligation was performed at a site where there was massive blood flow that we considered to have penetrating veins. d Confirmation by Doppler probe after band ligation was performed. If the blood flow had remained, additional variceal ligation would have been considered.
Zoom Image
Fig. 3 a Endoscopic view of gastric varices with scar formation due to previous variceal ligation. b Esophageal varices continuous with gastric varices were identified by the novel Doppler probe method; thereafter, esophageal varices were effectively treated by variceal ligation.