Korean J Gastroenterol.  2018 Oct;72(4):188-196. 10.4166/kjg.2018.72.4.188.

Risk Factors and On-site Rescue Treatments for Endoscopic Variceal Ligation Failure

• Kim DH
• Cho E
• Jun CH
• Son DJ
• Lee MJ
• Park CH
• Cho SB
• Park SY
• Kim HS
• Choi SK
• Rew JS

• KMID: 2424110
• DOI: http://doi.org/10.4166/kjg.2018.72.4.188

Abstract

BACKGROUND/AIMS
The success rate of endoscopic variceal ligation (EVL) is about 85-94%. There is only a few studies attempting to determine the cause of EVL failure, and to date, on-site rescue treatments remains unestablished. This study aimed to elucidate the risk factors for EVL failure and the effectiveness of on-site rescue treatment.
METHODS
Data of 454 patients who underwent emergency EVL at Chonnam National University Hospital were retrospectively analyzed. Enrolled patients were divided into two groups: the EVL success and EVL failure groups. EVL failures were defined as inability to ligate the varices due to poor endoscopic visual field, or failure of hemostasis after band ligation for the culprit lesion.
RESULTS
Forty-seven patients experienced EVL failure. In the multivariate analysis, male patients, initial hypovolemic shock, active bleeding on endoscopy, and history of previous EVL were independent risk factors for EVL failure. During endoscopic procedure, we came across the common causes of EVL failure, including unsuctioned varix due to previous EVL-induced scars followed by insufficient ligation of the stigmata and inability to ligate the varix due to poor endoscopic visual field. Endoscopic variceal obturation using N-butyl-2-cyanoacrylate (48.9%) was the most commonly used on-site rescue treatment method, followed by insertion of Sangstaken Blakemore tube (14.9%), and EVL retrial (12.8%). The rescue treatments successfully achieved hemostasis in 91.7% of those in the EVL failure group.
CONCLUSIONS
The risk factors of EVL failure should be considered before performing EVL, and in case of such scenario, on-site rescue treatment is needed.

Keyword

Esophageal and gastric varices; Treatment failure; Salvage therapy

MeSH Terms

Christianity
Cicatrix
Emergencies
Enbucrilate
Endoscopy
Esophageal and Gastric Varices
Hemorrhage
Hemostasis
Humans
Jeollanam-do
Ligation*
Male
Methods
Multivariate Analysis
Retrospective Studies
Risk Factors*
Salvage Therapy
Shock
Treatment Failure
Varicose Veins
Visual Fields
Enbucrilate

Figure

• 

  Fig. 1. (A) Endoscopic picture of the SRH (black arrow) adjacent to the previous EVL induced ulcer scar (white arrow). (B) Insufficient ligation of the varix due to the adjacent EVL scar. (C) Insufficient ligation of the varix with SRH (black arrow) out of the EVL band. SRH, stigmata of recent hemorrhage; EVL, endoscopic variceal ligation.

• 

  Fig. 2. Endoscopic findings of rescue treatments for EVL failure. (A) The varix was insufficiently ligated due to previous EVL induced scar.(B) Immediate spontaneous detachment of the EVL band and blood oozing from the varix was noted. (C) Glue was injected into the bleeding varix with immediate hemostasis. (D) In another patient, retrial of EVL achieved successful hemostasis after EVL failure (note two EVL bands over the varix, white arrows). EVL, endoscopic variceal ligation.

• 

  Fig. 3. Flow chart of the on-site rescue treatments for EVL failure. EVL, endoscopic variceal ligation; EVO, endoscopic variceal obturation; TIPS, transjugular intrahepatic portosystemic shunt; SB tube, Sengstaken– Blakemore tube.

• 

  Fig. 4. Relationship between the numbers of EVL session and EVL failure. EVL, endoscopic variceal ligation.

Reference

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