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Endoscopic variceal ligation

Author
John S Goff, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF

INTRODUCTION

Endoscopic variceal ligation (EVL) was developed in an effort to find an effective means of treating esophageal varices endoscopically with fewer complications than endoscopic sclerotherapy (ES) [1-4]. The concept was based upon many years of experience treating hemorrhoids with rubber band ligation in patients with and without portal hypertension. EVL works by capturing all or part of a varix resulting in occlusion from thrombosis. The tissue then necroses and sloughs off in a few days to weeks, leaving a superficial mucosal ulceration, which rapidly heals. EVL avoids the use of sclerosant and thus eliminates the deep damage to the esophageal wall that occurs after ES. Collateral vessels near the cardia decrease after EVL and EVL may promote the development of deep gastric collaterals. These factors may also contribute to the effectiveness of EVL for preventing further variceal bleeding [5,6]. Another interesting finding is that during acute variceal bleeding, the hepatic venous pressure gradient (which correlates with the risk of variceal bleeding) increases after ES, but not after EVL [7].

The first patient was treated with EVL in 1986. Since then, advances in the technique have led to its routine use in the care of patients with esophageal varices. One of the biggest advances was the development of the multiple band ligator (Saeed Six-Shooter and Speedbander), which has simplified and improved the safety of EVL.

The technical considerations involved in EVL and the data supporting its technical efficacy will be reviewed here. The role of EVL in the care of patients with varices is discussed separately. (See "Methods to achieve hemostasis in patients with acute variceal hemorrhage" and "Prevention of recurrent variceal hemorrhage in patients with cirrhosis".)

TECHNIQUE

Endoscopic variceal ligating devices are placed on the tip of standard endoscopes. The device has a soft sheath potion that fits over the tip of the endoscope and a hard plastic portion. Bands are stretched over the hard portion at the distal end of the device and later deployed onto the varices. Currently available devices are designed for standard and therapeutic sized endoscopes.

The procedure begins after a thorough upper endoscopy to identify the esophageal varices that are to be treated. Actively bleeding varices or those with stigmata indicating recent bleeding (such as a fibrin plug or a "red wale" sign) should be primary targets even if they are not located at the gastroesophageal junction (picture 1A-B). There are no absolute restrictions on coagulation parameters that preclude performing EVL, although in patients with active bleeding, attempts should be made to improve the coagulation status [8].

                       

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Literature review current through: Nov 2016. | This topic last updated: Fri Nov 20 00:00:00 GMT+00:00 2015.
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References
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