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Fatal outcome following endoscopic fundal variceal ligation
Fatal outcome following endoscopic fundal variceal ligation
Rene-Louis Vitte, MD Claude Eugene, MD Abe Fingerhut, MD, FACS Carom Felsenheld, MD Jacques Merrer, MD Leon Touhladjan Hospital Poissy, France
To the Editor: S t i e g m a n n et al. 1 have shown t h a t endoscopic variceal ligation (EVL) is equivalent to endoscopic sclerotherapy (ES) in controlling active bleeding by r u p t u r e of esophageal varices and in preventing their recurrence. Moreover, patients t r e a t e d with EVL h a d less complications and their survival r a t e was b e t t e r t h a n t h a t of p a t i e n t s t r e a t e d with ES. 1 Short-term success with ligation of gastric varices using a detachable snare h a s also been proposed. 2 We r e port herein a case of gastric variceal ligation with elastic O rings t h a t illustrates the inadequacy of the method for the stomach. A 39-year-old m a n was a d m i t t e d for h e m a t e m e s i s J a n u a r y 1, 1994. Upon admission, t h e p a t i e n t was jaundiced, his pulse rate was 140 beats rain., a n d he h a d ascites. Laboratory tests showed the following values: prothrombin time 34%; factor V 29%; hemoglobin 7.2 g/100 ml; bilirubin 210 mcM/L; ASAT 394 (N ( 40 IU/L); a n d ALAT 55 (N ( 50 IU/L). Gastroscopy revealed bright r e d blood t h a t precluded correct examination of the stomach a n d grade II esophageal varices t h a t were sclerosed by polidocanol. Prednisolone, 40 m g a day, was i n i t i a t e d once the diagnosis of alcoholic hepatitis associated with cirrhosis was established through biopsy. Two further ES sessions of esophageal varices were achieved at 1-week intervals (Jan 13 and 20). Nodular gastric varices were t h e n d e m o n s t r a t e d and t r e a t m e n t with propanolol was begun to prevent thei r rupture. Because predictive factors of r u p t u r e were present (nodular character, site, a n d degree of hepatocellular insufficiency), EVL was done. Six days after ligation, the p a t i e n t rebled massively and eventually died in spite of an emergency proximal gastrectomy for hemostasis. Histologic examination of the stomach disclosed two acute 8 m m ulcerations at the level of the fundus where the ligations were done and a r u p t u r e d varice at the bottom of one of the ulcerations. Gastric varices are observed in 11% to 75% of cirrhotic patients with portal hypertension. 3 The incidence of bleeding by r u p t u r e of gastric varices ranges from 3% to 30%. 3 This r i s k is superior for varices of the fundus as compared with the cardia 4 a n d for nodular varices with red spot, located on the g r e a t e r curvature. 5 The necessity of preventive t r e a t m e n t after r u p t u r e of gastric varices is no longer questioned. The best endoscopy t r e a t m e n t to prevent rebleeding, however, r e m a i n s unknown. Bucrylate is considered by certai n authors as an efficient t r e a t m e n t of bleeding varices and prevention of rebleeding from fundal varices. 3 Ligation is a n attractive method of hemostasis and was proposed by Yoshida et al. 2 who described a detachable snare to t r e a t .gastric varices. In t h a t study, 10 patients were treated, and all h a d postligation gastric ulcerations, one of which rebled. As regards our patient, it is possible t h a t ligation failed because the entire varix was not destroyed and rebled when the eschar was discarded. In any event, EVL with O rings a p p e a r s to be a dangerous technique and should not be used in the t r e a t m e n t of gastric varices because of the high r i s k of rebleeding.
82 G A S T R O I N T E S T I N A L E N D O S C O P Y
REFERENCES 1. Stiegmann GV, GoffJS, Michaletz-Onody PA, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding varices. N Engl J Med 1992;326:1527-32. 2. Yoshida T, Hayashi N, Suzumi N, et al. Endoscopic ligation of gastric varices using a detachable snare. Endoscopy 1994;26: 502-5. 3. Merican I, Burroughs AK. Gastric varices. European Journal of Gastroenterology and Hepatology 1992;4:511-20. 4. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343-9. 5. Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K. Endoscopic classification of gastric varices. Gastrointest Endosc 1990;36:276-80.
Perforations after Maloney esophageal dilation Dear Editor: Since 1991, when Pilling-Weck (Washington, Penn.) replaced traditional Maloney-type esophageal dilators with a much shorter distal t a p e r in efforts to decrease tip and dilator retroversion, I a m aware of two perforations in Arlington a n d another in Dallas. All operators were more t h a n a dozen years postfellowship with extensive Maloney experience. Both Arlington patients were post-EGD, and were dilated in left l a t e r a l decubitus position. At endoscopy, I routinely r e p a s s the scope after dilations to assess adequacy of dilation, rings appreciated only after dilation, or degree of t r a u m a t h a t might limit or modify furt h e r dilation at t h a t session or in future office dilations. Over the years, a p a t i e n t of mine h a d h a d a n u m b e r of uncomplicated in-office dilations by long, t a p e r e d Maloneys. He was due for endoscopic reassessment. W i t h a 44F short t a p e r I sensed resistance, stopped, and i m m e d i a t e l y relooked. There was a through-the-wall perforation about the size of the tip, 1.5 cm above a short ring stricture, with no other visible t r a u m a : He h a d an uncomplicated course on intensive, nonoperative m a n a g e m e n t . A n o t h e r gastroenterologist sensed no problems passing a 52F, b u t Contrast study for postprocedure p a i n showed a leak, corrected surgically with a benign course. The surgeon believed t h a t extensive postcholecystectomy adhesions fixating the esophagus at the hiatus was the major predisposing factor. I h a d dilated another p a t i e n t in the office with long tapers, and performed a simple dilation with a short t a p e r 48F prior to colonoscopy for polyps. (The hospital h a d j u s t tossed out, without telling us, our few r e m a i n i n g long t a p e r s because they h a d "expired.") The dilator passed into the stomach with a mild b u t not u n u s u a l sense of resistance. After the
VOLUME 43, NO. 1, 1996
Rene-Louis Vitte, MD Claude Eugene, MD Abe Fingerhut, MD, FACS Carom Felsenheld, MD Jacques Merrer, MD Leon Touhladjan Hospital Poissy, France
To the Editor: S t i e g m a n n et al. 1 have shown t h a t endoscopic variceal ligation (EVL) is equivalent to endoscopic sclerotherapy (ES) in controlling active bleeding by r u p t u r e of esophageal varices and in preventing their recurrence. Moreover, patients t r e a t e d with EVL h a d less complications and their survival r a t e was b e t t e r t h a n t h a t of p a t i e n t s t r e a t e d with ES. 1 Short-term success with ligation of gastric varices using a detachable snare h a s also been proposed. 2 We r e port herein a case of gastric variceal ligation with elastic O rings t h a t illustrates the inadequacy of the method for the stomach. A 39-year-old m a n was a d m i t t e d for h e m a t e m e s i s J a n u a r y 1, 1994. Upon admission, t h e p a t i e n t was jaundiced, his pulse rate was 140 beats rain., a n d he h a d ascites. Laboratory tests showed the following values: prothrombin time 34%; factor V 29%; hemoglobin 7.2 g/100 ml; bilirubin 210 mcM/L; ASAT 394 (N ( 40 IU/L); a n d ALAT 55 (N ( 50 IU/L). Gastroscopy revealed bright r e d blood t h a t precluded correct examination of the stomach a n d grade II esophageal varices t h a t were sclerosed by polidocanol. Prednisolone, 40 m g a day, was i n i t i a t e d once the diagnosis of alcoholic hepatitis associated with cirrhosis was established through biopsy. Two further ES sessions of esophageal varices were achieved at 1-week intervals (Jan 13 and 20). Nodular gastric varices were t h e n d e m o n s t r a t e d and t r e a t m e n t with propanolol was begun to prevent thei r rupture. Because predictive factors of r u p t u r e were present (nodular character, site, a n d degree of hepatocellular insufficiency), EVL was done. Six days after ligation, the p a t i e n t rebled massively and eventually died in spite of an emergency proximal gastrectomy for hemostasis. Histologic examination of the stomach disclosed two acute 8 m m ulcerations at the level of the fundus where the ligations were done and a r u p t u r e d varice at the bottom of one of the ulcerations. Gastric varices are observed in 11% to 75% of cirrhotic patients with portal hypertension. 3 The incidence of bleeding by r u p t u r e of gastric varices ranges from 3% to 30%. 3 This r i s k is superior for varices of the fundus as compared with the cardia 4 a n d for nodular varices with red spot, located on the g r e a t e r curvature. 5 The necessity of preventive t r e a t m e n t after r u p t u r e of gastric varices is no longer questioned. The best endoscopy t r e a t m e n t to prevent rebleeding, however, r e m a i n s unknown. Bucrylate is considered by certai n authors as an efficient t r e a t m e n t of bleeding varices and prevention of rebleeding from fundal varices. 3 Ligation is a n attractive method of hemostasis and was proposed by Yoshida et al. 2 who described a detachable snare to t r e a t .gastric varices. In t h a t study, 10 patients were treated, and all h a d postligation gastric ulcerations, one of which rebled. As regards our patient, it is possible t h a t ligation failed because the entire varix was not destroyed and rebled when the eschar was discarded. In any event, EVL with O rings a p p e a r s to be a dangerous technique and should not be used in the t r e a t m e n t of gastric varices because of the high r i s k of rebleeding.
82 G A S T R O I N T E S T I N A L E N D O S C O P Y
REFERENCES 1. Stiegmann GV, GoffJS, Michaletz-Onody PA, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding varices. N Engl J Med 1992;326:1527-32. 2. Yoshida T, Hayashi N, Suzumi N, et al. Endoscopic ligation of gastric varices using a detachable snare. Endoscopy 1994;26: 502-5. 3. Merican I, Burroughs AK. Gastric varices. European Journal of Gastroenterology and Hepatology 1992;4:511-20. 4. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343-9. 5. Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K. Endoscopic classification of gastric varices. Gastrointest Endosc 1990;36:276-80.
Perforations after Maloney esophageal dilation Dear Editor: Since 1991, when Pilling-Weck (Washington, Penn.) replaced traditional Maloney-type esophageal dilators with a much shorter distal t a p e r in efforts to decrease tip and dilator retroversion, I a m aware of two perforations in Arlington a n d another in Dallas. All operators were more t h a n a dozen years postfellowship with extensive Maloney experience. Both Arlington patients were post-EGD, and were dilated in left l a t e r a l decubitus position. At endoscopy, I routinely r e p a s s the scope after dilations to assess adequacy of dilation, rings appreciated only after dilation, or degree of t r a u m a t h a t might limit or modify furt h e r dilation at t h a t session or in future office dilations. Over the years, a p a t i e n t of mine h a d h a d a n u m b e r of uncomplicated in-office dilations by long, t a p e r e d Maloneys. He was due for endoscopic reassessment. W i t h a 44F short t a p e r I sensed resistance, stopped, and i m m e d i a t e l y relooked. There was a through-the-wall perforation about the size of the tip, 1.5 cm above a short ring stricture, with no other visible t r a u m a : He h a d an uncomplicated course on intensive, nonoperative m a n a g e m e n t . A n o t h e r gastroenterologist sensed no problems passing a 52F, b u t Contrast study for postprocedure p a i n showed a leak, corrected surgically with a benign course. The surgeon believed t h a t extensive postcholecystectomy adhesions fixating the esophagus at the hiatus was the major predisposing factor. I h a d dilated another p a t i e n t in the office with long tapers, and performed a simple dilation with a short t a p e r 48F prior to colonoscopy for polyps. (The hospital h a d j u s t tossed out, without telling us, our few r e m a i n i n g long t a p e r s because they h a d "expired.") The dilator passed into the stomach with a mild b u t not u n u s u a l sense of resistance. After the
VOLUME 43, NO. 1, 1996