Variceal Ligator Cap Dislodgment, and Retrieval Techniques

We read with interest the recent article by Wai et al. entitled ”Esophageal dislodgment of a variceal ligator cap due to size mismatch between the ligator cap and the endoscope” [1].

We have been using the Olympus gastroscope GIF XQ240 (external diameter 9.0mm) since 1999 and are also currently phasing out the use of the older Olympus gastroscope GIF XQ230 (external diameter 9.2 mm). For the treatment of esophageal varices, in both acute and follow-up settings, we use the Wilson-Cook 6-shooter MBL-6 variceal ligator, which has a fitting diameter of between 9.5 and 13.0 mm.

In the last year, we have experienced the dislodgment of four ligator caps whilst using the XQ240 gastroscopes. This was despite taping the ligator cap onto the end of the XQ240 gastroscope on one occasion. All the caps were similarly dislodged at the level of the inferior constrictor. In three cases, the caps were retrieved. Two were re-engaged by advancing the tip of the gastroscope into the ligator cap and using the stomach wall as support. Another was retrieved using an endoscopic retrograde cholangiopancreatography (ERCP) balloon catheter, which was passed through the gastroscope and ligator cap and then inflated; with traction on the balloon catheter, the ligator cap was wedged against the gastroscope and removed successfully. In the fourth case, the ligator cap could not be retrieved and was therefore pushed distally into the stomach to minimize the risk of aspiration. There was no subsequent complication.

We also recommend careful checks on both gastroscopes and ligator caps to ensure compatibility prior to any variceal ligation [1] [2]. In addition, one should ensure that both the wheels on the XQ240 gastroscopes are unlocked prior to extubation, to allow for maximum flexibility of the gastroscope tip. We have highlighted here alternative techniques for variceal ligator cap retrieval.

References

• 1 Wai C T, Ho K Y, Kwok F Y. Esophageal dislodgment of a variceal ligator cap due to size mismatch between the ligator cap and the endoscope.  Endoscopy. 2003;  35 191
• 2 Leung C S, Chan C W, Chow W H. et al . A potentially serious disadvantage of multiband device over conventional ligation using an overtube.  Endoscopy. 2003;  35 190