- Email: [email protected]
Complications of esophageal variceal band ligation
22. Stiegmann GV, Goff JS, Michaletz-Onody PA, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med 1992;326:1527-32. 23. Young MF, Sanowski RA, Raschke R. Comparison and characterization of ulcerations induced by endoscopic ligation of esophageal varices versus endoscopic sclerotherapy. Gastrointest Endosc 1992;38:285 [Abstract]. 24. Jensen DM, Weisz N, Hirabayashi K, et al. Randomized controlled study of rubber band ligation and sclerotherapy for active esophageal varix bleeding in dogs [Abstract]. Gastroenterology 1991;100:A92.
25. Goldschmiedt M, Haber G, Kandel G, et al. A safety maneuver for placing overtubes during endoscopic variceal ligation. Gastrointest Endosc 1992;38:399-400. 26. Cotton PB. Overtubes (sleeves) for upper gastrointestinal endoscopy. Gut 1983;24:863-6. 27. Stiegmann GV, Goff JS, Sun JH, et al. Endoscopic variceal ligation: an alternative to sclerotherapy. Gastrointest Endosc 1989;35:431-4.
Complications of esophageal variceal band ligation
performed 12 days after the last emergency sclerotherapy session. Endoscopy revealed grade 3 to 4 esophageal varices with red wale markings that were non-bleeding, fundic varices and portal gastropathy. An overtube was advanced over the endoscope before elective band ligation therapy. However, massive esophageal bleeding started as soon as the overtube was placed. The bleeding occurred from the rupture of a large column of varices distal to the overtube. Poor vision during massive blood loss and the inability to adequately suction when the a rings were loaded on the endoscope did not permit the continued use of the banding technique. With some difficulty, the bleeding was controlled by injection sclerotherapy. The patient has subsequently had placement of a transjugular intrahepatic portosystemic shunt (TIPS). At 4-month follow-up he has had no further gastrointestinal bleeding and is awaiting liver transplantation.
John R. Saltzman, MD Sanjeev Arora, MD
Band ligation of esophageal varices is a recent advance in endoscopic therapy that is generally considered safer than injection sclerotherapy. Previous series of endoscopic band ligation therapy have not noted any acute complications of therapy.!' 2 In addition, a randomized, controlled trial comparing endoscopic sclerotherapy with endoscopic band ligation in patients with cirrhosis and bleeding from esophageal varices concluded that the rate of complications in the sclerotherapy group was significantly higher (22 % versus 2%, p < 0.001) than in the ligation group.3 We describe the following two cases of previously unreported major acute complications of esophageal band ligation therapy: (1) massive esophageal variceal bleeding caused by the insertion of an overtube before elective band ligation therapy; and (2) acute esophageal obstruction caused by occlusion of the lumen by banded esophageal varices. CASE REPORTS Case 1
A 39-year-old man with cirrhosis caused by primary sclerosing cholangitis presented to another hospital with gastrointestinal bleeding. Upper endoscopy showed that the bleeding was due to esophageal varices and was acutely controlled by injection sclerotherapy. Because of recurrent bleeding from esophageal varices, the patient underwent another session of injection therapy and then was transferred to the New England Medical Center for liver transplantation evaluation. An elective endoscopy with planned band ligation was From the New England Medical Center, Boston, Massachusetts. Reprint requests: John R. Saltzman, MD, Division of Digestive Disease and Nutrition, UMass Medical Center, 55 Lake Avenue North, Worcester, MA 01655. 0016-5107/93/3902-0185$1.00 + .10
GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
37/4/43489
VOLUME 39, NO.2, 1993
Case 2
A 58-year-old man with cirrhosis caused by hepatitis C was evaluated after two sessions of injection sclerotherapy because of bleeding from esophageal varices. Elective upper endoscopy revealed grade 3 esophageal varices. Band ligation with the placement of four bands was performed without difficulty. Repeat elective upper endoscopy 3 weeks later again revealed grade 3 esophageal varices. Band ligation with the placement of four bands was again performed without difficulty. The patient was observed for 3 hours after completion of the procedure and remained stable without complaints. After the patient's gag reflex returned to normal, he ate a meal containing chicken and bread. Immediately after eating he complained of a burning chest discomfort that was not relieved with 30 ml of Maalox. He then began to complain of worsening chest pain and sialorrhea. The patient underwent an emergent second upper endoscopy, which showed pieces of chicken and bread stuck in the esophagus above the banded varices. The food was carefully pushed down into the stomach around the bands. It was felt that the newly banded varices completely obstructed the esophageal lumen, impeding the passage ofthe bolus offood. After the second endoscopy, the patient recovered uneventfully and was placed on a liquid diet for 24 hours and subsequently resumed a normal diet.
DISCUSSION
Esophageal band ligation for esophageal varices is a new technique that appears to be as effective as injec185
tion sclerotherapy. Moreover, the incidence of treatment-related complications related to band ligation therapy is less than that associated with injection sclerotherapy.3 Previous series of band ligation have noted no major complications,1, 2and the double-blind trial of sclerotherapy versus band ligation in 129 patients by Stiegmann et a1. 3 noted pneumonia in one patient as the only obvious complication in the band ligation group. Indeed, in a series of 17 consecutive patients who underwent endoscopic band ligation therapy and were prospectively evaluated for signs of bacteremia, only one patient had a bacteremia noted at 5 minutes but not at 30 minutes after the procedure, which was not clinically significant. 4 Although apparently safer than injection sclerotherapy, endoscopic band ligation therapy has distinct associated complications that are now being recognized. Recently, a case of esophageal perforation caused by overtube placement during band ligation was reported. 5 Overtube insertion is an integral part of esophageal band ligation because repeated esophageal intubations are required to place the rubber 0 rings. We hypothesize that overtube insertion in patients with high esophageal variceal pressures may result in blockage of venous outflow by compressing the varices in the mid esophagus. This may further increase an already high intravariceal pressure, resulting in rupture of esophageal varices.
Case 2 is the first reported case of acute esophageal obstruction caused by occlusion of the esophageallumen by banded varices. The early ingestion of a regular diet precipitated acute esophageal obstruction. This necessitated an emergent upper endoscopy with removal of the foreign body. The cause of this esophageal obstruction was the newly banded and distended varices that swelled into the esophageal lumen. We suggest that patients who have undergone esophageal band ligation be placed on a liquid diet for at least 24 hours to allow for shrinkage of banded varices and to prevent acute esophageal obstruction. Although the reported incidence of complications from band ligation therapy is low, endoscopists should be aware ofthese two potential major complications of overtube insertion.
"Pinch" injury during overtube placement in upper endoscopy
to the placement of an overtube. 5 No reports have been
Charles Berkelhammer, Gopal Madhav, Susan Lyon, Jack Roberts,
MD MD MD MD
Overtubes are likely to be increasingly used in UGI endoscopy for the purposes of foreign body extraction,1,2 push enteroscopy,3 and endoscopic band ligation of esophageal varices. 4 Only one report has been published regarding an esophageal perforation related From Christ Hospital and Medical Center, Oak Lawn, Illinois. Reprint requests: Charles Berkelhammer, MD, Christ Hospital and Medical Center, 4440 W. 95th Street, Oak Lawn, IL 60453. 0016-5107/93/3902-0187$1.00 +.10
GASTROINTESTINAL ENDOSCOPY Copyright @ 1993 by the American Society for Gastrointestinal Endoscopy
37/4/43488
186
REFERENCES 1. Stiegmann GV, Goff JS, Sun JH, Hruza D, Reveille RM. Endoscopic ligation of esophageal varices. Am J Surg 1990;159:21-6. 2. Saeed ZA, Michaletz PA, Winchester CB, et al. Endoscopic variceal ligation in patients who have failed endoscopic sclerotherapy. Gastrointest Endosc 1990;36:572-4. 3. Stiegmann GV, Goff JS, Michaletz-Onody P A, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med 1992;326:1527-32. 4. Tseng CC, Green R, Burke SK, Connors PJ, Carr-Locke DL. Bacteremia after endoscopic band ligation of esophageal varices. Gastrointest Endosc 1992;38:336-7. 5. Goldschmiedt M, Haber G, Kandel G, Kotran P, Marcon N. A safety maneuver for placing overtubes during esophageal variceal ligation. Gastrointest Endosc 1992;38:399-400.
published regarding precipitation of variceal bleeding
by the passage of an overtube. We report two cases of "pinch" injury related to the passage of a commercially available overtube. In the first case, placement of the overtube resulted in a cricopharyngeal submucosal dissection with benign pneumomediastinum. In the second case, proximal variceal bleeding was induced by passage of the overtube. CASE 1
A 78-year-old man came to the emergency department with complete dysphagia to solids and liquids soon after consuming a meal of tuna fish. He was unable to swallow his own secretions. Medical history was significant for intermittent dysphagia to solids for a period of several years. Three months earlier, he presented with a meat impaction in the distal esophagus. This was treated by endoscopic snare extraction without the use of an overtube. At that time, a Schatzki's ring at the gastroesophageal junction 40 cm from the incisors was dilated using a 48F Maloney dilator. The
GASTROINTESTINAL ENDOSCOPY
25. Goldschmiedt M, Haber G, Kandel G, et al. A safety maneuver for placing overtubes during endoscopic variceal ligation. Gastrointest Endosc 1992;38:399-400. 26. Cotton PB. Overtubes (sleeves) for upper gastrointestinal endoscopy. Gut 1983;24:863-6. 27. Stiegmann GV, Goff JS, Sun JH, et al. Endoscopic variceal ligation: an alternative to sclerotherapy. Gastrointest Endosc 1989;35:431-4.
Complications of esophageal variceal band ligation
performed 12 days after the last emergency sclerotherapy session. Endoscopy revealed grade 3 to 4 esophageal varices with red wale markings that were non-bleeding, fundic varices and portal gastropathy. An overtube was advanced over the endoscope before elective band ligation therapy. However, massive esophageal bleeding started as soon as the overtube was placed. The bleeding occurred from the rupture of a large column of varices distal to the overtube. Poor vision during massive blood loss and the inability to adequately suction when the a rings were loaded on the endoscope did not permit the continued use of the banding technique. With some difficulty, the bleeding was controlled by injection sclerotherapy. The patient has subsequently had placement of a transjugular intrahepatic portosystemic shunt (TIPS). At 4-month follow-up he has had no further gastrointestinal bleeding and is awaiting liver transplantation.
John R. Saltzman, MD Sanjeev Arora, MD
Band ligation of esophageal varices is a recent advance in endoscopic therapy that is generally considered safer than injection sclerotherapy. Previous series of endoscopic band ligation therapy have not noted any acute complications of therapy.!' 2 In addition, a randomized, controlled trial comparing endoscopic sclerotherapy with endoscopic band ligation in patients with cirrhosis and bleeding from esophageal varices concluded that the rate of complications in the sclerotherapy group was significantly higher (22 % versus 2%, p < 0.001) than in the ligation group.3 We describe the following two cases of previously unreported major acute complications of esophageal band ligation therapy: (1) massive esophageal variceal bleeding caused by the insertion of an overtube before elective band ligation therapy; and (2) acute esophageal obstruction caused by occlusion of the lumen by banded esophageal varices. CASE REPORTS Case 1
A 39-year-old man with cirrhosis caused by primary sclerosing cholangitis presented to another hospital with gastrointestinal bleeding. Upper endoscopy showed that the bleeding was due to esophageal varices and was acutely controlled by injection sclerotherapy. Because of recurrent bleeding from esophageal varices, the patient underwent another session of injection therapy and then was transferred to the New England Medical Center for liver transplantation evaluation. An elective endoscopy with planned band ligation was From the New England Medical Center, Boston, Massachusetts. Reprint requests: John R. Saltzman, MD, Division of Digestive Disease and Nutrition, UMass Medical Center, 55 Lake Avenue North, Worcester, MA 01655. 0016-5107/93/3902-0185$1.00 + .10
GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
37/4/43489
VOLUME 39, NO.2, 1993
Case 2
A 58-year-old man with cirrhosis caused by hepatitis C was evaluated after two sessions of injection sclerotherapy because of bleeding from esophageal varices. Elective upper endoscopy revealed grade 3 esophageal varices. Band ligation with the placement of four bands was performed without difficulty. Repeat elective upper endoscopy 3 weeks later again revealed grade 3 esophageal varices. Band ligation with the placement of four bands was again performed without difficulty. The patient was observed for 3 hours after completion of the procedure and remained stable without complaints. After the patient's gag reflex returned to normal, he ate a meal containing chicken and bread. Immediately after eating he complained of a burning chest discomfort that was not relieved with 30 ml of Maalox. He then began to complain of worsening chest pain and sialorrhea. The patient underwent an emergent second upper endoscopy, which showed pieces of chicken and bread stuck in the esophagus above the banded varices. The food was carefully pushed down into the stomach around the bands. It was felt that the newly banded varices completely obstructed the esophageal lumen, impeding the passage ofthe bolus offood. After the second endoscopy, the patient recovered uneventfully and was placed on a liquid diet for 24 hours and subsequently resumed a normal diet.
DISCUSSION
Esophageal band ligation for esophageal varices is a new technique that appears to be as effective as injec185
tion sclerotherapy. Moreover, the incidence of treatment-related complications related to band ligation therapy is less than that associated with injection sclerotherapy.3 Previous series of band ligation have noted no major complications,1, 2and the double-blind trial of sclerotherapy versus band ligation in 129 patients by Stiegmann et a1. 3 noted pneumonia in one patient as the only obvious complication in the band ligation group. Indeed, in a series of 17 consecutive patients who underwent endoscopic band ligation therapy and were prospectively evaluated for signs of bacteremia, only one patient had a bacteremia noted at 5 minutes but not at 30 minutes after the procedure, which was not clinically significant. 4 Although apparently safer than injection sclerotherapy, endoscopic band ligation therapy has distinct associated complications that are now being recognized. Recently, a case of esophageal perforation caused by overtube placement during band ligation was reported. 5 Overtube insertion is an integral part of esophageal band ligation because repeated esophageal intubations are required to place the rubber 0 rings. We hypothesize that overtube insertion in patients with high esophageal variceal pressures may result in blockage of venous outflow by compressing the varices in the mid esophagus. This may further increase an already high intravariceal pressure, resulting in rupture of esophageal varices.
Case 2 is the first reported case of acute esophageal obstruction caused by occlusion of the esophageallumen by banded varices. The early ingestion of a regular diet precipitated acute esophageal obstruction. This necessitated an emergent upper endoscopy with removal of the foreign body. The cause of this esophageal obstruction was the newly banded and distended varices that swelled into the esophageal lumen. We suggest that patients who have undergone esophageal band ligation be placed on a liquid diet for at least 24 hours to allow for shrinkage of banded varices and to prevent acute esophageal obstruction. Although the reported incidence of complications from band ligation therapy is low, endoscopists should be aware ofthese two potential major complications of overtube insertion.
"Pinch" injury during overtube placement in upper endoscopy
to the placement of an overtube. 5 No reports have been
Charles Berkelhammer, Gopal Madhav, Susan Lyon, Jack Roberts,
MD MD MD MD
Overtubes are likely to be increasingly used in UGI endoscopy for the purposes of foreign body extraction,1,2 push enteroscopy,3 and endoscopic band ligation of esophageal varices. 4 Only one report has been published regarding an esophageal perforation related From Christ Hospital and Medical Center, Oak Lawn, Illinois. Reprint requests: Charles Berkelhammer, MD, Christ Hospital and Medical Center, 4440 W. 95th Street, Oak Lawn, IL 60453. 0016-5107/93/3902-0187$1.00 +.10
GASTROINTESTINAL ENDOSCOPY Copyright @ 1993 by the American Society for Gastrointestinal Endoscopy
37/4/43488
186
REFERENCES 1. Stiegmann GV, Goff JS, Sun JH, Hruza D, Reveille RM. Endoscopic ligation of esophageal varices. Am J Surg 1990;159:21-6. 2. Saeed ZA, Michaletz PA, Winchester CB, et al. Endoscopic variceal ligation in patients who have failed endoscopic sclerotherapy. Gastrointest Endosc 1990;36:572-4. 3. Stiegmann GV, Goff JS, Michaletz-Onody P A, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med 1992;326:1527-32. 4. Tseng CC, Green R, Burke SK, Connors PJ, Carr-Locke DL. Bacteremia after endoscopic band ligation of esophageal varices. Gastrointest Endosc 1992;38:336-7. 5. Goldschmiedt M, Haber G, Kandel G, Kotran P, Marcon N. A safety maneuver for placing overtubes during esophageal variceal ligation. Gastrointest Endosc 1992;38:399-400.
published regarding precipitation of variceal bleeding
by the passage of an overtube. We report two cases of "pinch" injury related to the passage of a commercially available overtube. In the first case, placement of the overtube resulted in a cricopharyngeal submucosal dissection with benign pneumomediastinum. In the second case, proximal variceal bleeding was induced by passage of the overtube. CASE 1
A 78-year-old man came to the emergency department with complete dysphagia to solids and liquids soon after consuming a meal of tuna fish. He was unable to swallow his own secretions. Medical history was significant for intermittent dysphagia to solids for a period of several years. Three months earlier, he presented with a meat impaction in the distal esophagus. This was treated by endoscopic snare extraction without the use of an overtube. At that time, a Schatzki's ring at the gastroesophageal junction 40 cm from the incisors was dilated using a 48F Maloney dilator. The
GASTROINTESTINAL ENDOSCOPY