Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication

Abstract

BACKGROUND Bleeding esophageal varices (BEV) is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25% within six weeks of the index variceal bleed. After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selective β-blockers to prevent further bleeding and eradicate EV. AIM To assess the efficacy of endoscopic variceal ligation (EVL) in controlling acute variceal bleeding, preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices (EV) in patients who present with BEV. METHODS A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018. Control of acute bleeding, variceal recurrence, rebleeding, eradication and survival were analyzed using Baveno assessment criteria. RESULTS One hundred and forty patients (100 men, 40 women; mean age 50 years; range, 21–84 years; Child-Pugh grade A = 32; B = 48; C = 60) underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions. One hundred and fourteen (81%) of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV, while 26 (19%) patients had complicated and refractory variceal bleeding. EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients (95.7%). Six patients required balloon tamponade for control and 4 other patients rebled in hospital. Overall 5-d endoscopic failure to control variceal bleeding was 7.1% ( n = 10) and four patients required a salvage transjugular intrahepatic portosystemic shunt. Index admission mortality was 14.2% ( n = 20). EV were completely eradicated in 50 of 111 patients (45%) who survived > 3 mo of whom 31 recurred and 3 rebled. Sixteen (13.3%) of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital. Overall rebleeding from all sources after 2 years was 21.7% ( n = 26). Sixty-nine (49.3%) of the 140 patients died, mainly due to liver failure ( n = 46) during follow-up. Cumulative survival for the 140 patients was 71.4% at 1 year, 65% at 3 years, 60% at 5 years and 52.1% at 10 years. CONCLUSION EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of whom 62% recurred, there was a significant reduction in subsequent rebleeding.

Efficient Initial Eradication of Large Esophageal Varices by Balloon-compression Endoscopic Injection Sclerotherapy

“…Krige et al 12 described the advantages of EVL associated with a higher rate of variceal eradication, lower incidence of rebleeding, and complications. However, in real clinical practice, the performance of EVL is contraindicated in patients with EVs with large diameters (>2 cm) because of their inability to be suctioned into the ligation device or the risk of drooping out with potential lethal hemorrhaged from post-procedural ulcers 3,12–14. EVL shows a higher frequency of variceal recurrence owing to the residual small varices and patency of interconnecting and feeding vessels in the deeper esophageal wall layers 15.…”

A Retrospective Analysis of the Efficacy of Endoscopic Variceal Ligation versus Endoscopic Tissue Adhesive Injection in the Treatment of Esophagogastric Variceal Bleeding

“…However, clinical studies at home and abroad in recent years have shown that EVL for GV still has certain limitations due to the following reasons: (1) the gastric mucosa is thicker than the esophageal mucosa, increasing the di culty of inhalation during snare; (2) the gastric varices are relatively thick and di cult to enter the snare completely, which can easily cause cutting and bleeding; (3) snare only partially brosis the varices, which can easily cause postoperative rebleeding and variceal regeneration. [13][14][15] TAI injections of tissue adhesive into varicose veins cause rapid aggregation, solidi cation and occlusion of the vessel to control varicose bleeding and thus achieve haemostasis. However, a higher dosage of tissue adhesive increases the risk of ectopic embolism and increases the likelihood of bleeding from draining ulcer and pulmonary embolism in patients with large gastric-renal shunts and hepatopulmonary syndrome.…”

Novel balloon compression-assisted endoscopic injection sclerotherapy and endoscopic variceal ligation in the treatment of esophageal varices: a prospective randomized study

“…Total variceal eradication was defined as the disappearance of varices after treatment, including thrombosed varices [ 7 ]. Variceal recurrence was defined as the reappearance of eradicated varices on endoscopy [ 1 ]. The final assessment of variceal eradication or recurrence had to be agreed upon by two experienced endoscopists.…”

“…According to a study performed by Krige et al . [ 1 ], EVL seems not to be superior to EIS in terms of the lower rate of variceal eradication. EVL eradicates superficial varices through mechanical strangulation with rubber bands [ 2 ] but cannot achieve complete eradication of the interconnecting perforating and feeder vessels in the deeper esophageal wall layers [ 3 ].…”

“…EVL eradicates superficial varices through mechanical strangulation with rubber bands [ 2 ] but cannot achieve complete eradication of the interconnecting perforating and feeder vessels in the deeper esophageal wall layers [ 3 ]. Additionally, mucosal fibrosis and scarring induced by repeated EVL procedures limit the pliability of the mucosa and preclude further successful banding application [ 1 ]. In contrast, EIS can be conducted either intravariceally or paravariceally to obliterate varices by thrombosing the veins or by thickening the mucosa overlying the veins in this area, respectively [ 4 ].…”