“Double band” technique for intractable or recurrent esophageal variceal hemorrhage: An alternative rescue method

Abstract

Dear Editor, Acute esophageal variceal bleeding is a serious medical emergency and may have very high rates of mortality and morbidity, particularly in patients with end-stage liver disease associated with intractable variceal hemorrhage. Early recurrent bleeding (within 5 days) can be observed in nearly 8%-20% of patients with cirrhosis and is associated with a high risk for death, particularly in patients with a high hepatic venous pressure gradient and fibrotic varix caused by previously repeated banding (1). For such patients, when bleeding control fails, a rescue therapy is often required and recommended (2). However, the current rescue methods such as self-expandable esophageal covered metal stent, transjugular intrahepatic portosystemic shunt, and shunt surgery are so expensive and complex that cannot be performed in every unit or they are also associated with additional mortalities such as encephalopathy, esophageal necrosis, or perforation (2). Consequently, attempting an alternative endoscopic intervention before suggesting any of the abovementioned complex rescue therapies may be a more appropriate approach. Herein, we describe a salvage rescue method called "double band" technique in a patient with cirrhosis and recurrent and intractable esophageal bleeding that arises from the fibrotic varix caused by previously repeated banding.A 40-year-old man with cirrhosis who had massive, recurrent, and intractable esophageal bleeding was admitted to our hospital. The patient was in a state of shock, with a high heart rate (150 rpm/min) and hemoglobin level of 6.1 g/dL (normal range, 12-15 g/dL). After resuscitation, endoscopic examination revealed an actively bleeding point arising from a large-sized esophageal varix at 5 cm above the gastroesophageal junction (Figure 1). Initially, four endoscopic variceal bands were carefully applied between the gastroesophageal junction and bleeding site. Despite recurrent attempts, the single band did not stably stay on the bleeding site and