Clin Endosc.  2018 Sep;51(5):491-494. 10.5946/ce.2018.011.

Removal of Esophageal Variceal Bands to Salvage Complete Esophageal Obstruction

• Jalil AA
• Hammoud G
• Ibdah JA
• Samiullah

• KMID: 2427723
• DOI: http://doi.org/10.5946/ce.2018.011

Abstract

Esophageal varices develop in almost half of the patients with cirrhosis, and variceal hemorrhage constitutes an ominous sign with an increased risk of mortality. Variceal banding is considered an effective and mostly safe measure for primary and secondary prophylaxis. Although adverse events related to banding including dysphagia, stricture formation, bleeding, and ligation-induced ulcers have been described, complete esophageal obstruction is rare, with only 10 reported cases in the literature. Among those cases, 6 were managed conservatively; 1 patient had esophageal intraluminal dissection from an attempt to remove the bands using biopsy forceps but ultimately recovered with conservative management. Three patients developed strictures following removal of the bands, requiring repeated sessions of dilation therapy. We report on a patient who developed absolute dysphagia and complete esophageal obstruction after variceal banding. We successfully used the endoloop cutter hook to release the bands intact and restore luminal integrity.

Keyword

Band ligation; Cirrhosis; Dysphagia; Esophageal obstruction; Endoscopy

MeSH Terms

Biopsy
Constriction, Pathologic
Deglutition Disorders
Endoscopy
Esophageal and Gastric Varices
Fibrosis
Hemorrhage
Humans
Mortality
Phenobarbital
Surgical Instruments
Ulcer
Phenobarbital

Figure

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  Fig. 1. (A) Pre-band ligation endoscopic image showing 2 large columns of varices in distal esophagus. (B) Post-band ligation endoscopic image.

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  Fig. 2. (A) Barium esophagram showing complete distal esophageal obstruction. (B, C) Complete esophageal obstruction, necrotic varix with band at its base.

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  Fig. 3. (A, B) Endoloop cutter (closed & open).

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  Fig. 4. Restoration of esophageal lumen after removal of variceal bands using endoloop cutter hook.

Reference

1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46:922–938.

2. Merli M, Nicolini G, Angeloni S, et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol. 2003; 38:266–272.

3. D’Amico G, De Franchis R. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003; 38:599–612.

4. Khuroo MS, Khuroo NS, Farahat KL, Khuroo YS, Sofi AA, Dahab ST. Meta-analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding. Aliment Pharmacol Ther. 2005; 21:347–361.

5. Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev. 2012; CD004544.

6. Petrasch F, Grothaus J, Mössner J, Schiefke I, Hoffmeister A. Differences in bleeding behavior after endoscopic band ligation: a retrospective analysis. BMC Gastroenterol. 2010; 10:5.

7. Saltzman JR, Arora S. Complications of esophageal variceal band ligation. Gastrointest Endosc. 1993; 39:185–186.

8. Elizondo-Rivera RL, González-González JA, Garcia-Compean D, Maldonado-Garza HJ. Complete esophageal obstruction after endoscopic variceal band ligation. Endoscopy. 2014; 46 Suppl 1 UCTN:E457–E458.

9. Nawaz A, Sarwar S, Batul A. Complete esophageal occlusion following esophageal variceal band ligation: an unusual complication: a case report. Visible Human Journal of Endoscopy. 2010; 9:1–4.

10. de Melo SW. Complete esophageal occlusion after band ligation. Endoscopy. 2011; 43 Suppl 2 UCTN:E259.

11. Kwiatt JT, Merchant P. Successful removal of an esophageal band causing complete esophageal obstruction after variceal ligation. Gastrointest Endosc. 2016; 83:1030–1031.

12. Chahal H, Ahmed A, Sexton C, Bhatia A. Complete esophageal obstruction following endoscopic variceal band ligation. J Community Hosp Intern Med Perspect. 2013; 3.

13. Verma D, Pham C, Madan A. Complete esophageal obstruction: an ususual complication of esophageal variceal ligation. Endoscopy. 2009; 41 Suppl 2:E200–E201.

14. Nikoloff MA, Riley TR 3rd, Schreibman IR. Complete esophageal obstruction following endoscopic variceal ligation. Gastroenterol Hepatol (N Y). 2011; 7:557–559.

15. Maric L, Alonso Y, Alvarez A, Erim T. Endoscopic variceal band ligation leading to acute onset dysphagia. Am J Gastroenterol. 2016; 111:S692.

16. Mansour M, Abdel-Aziz Y, Awadh H, Shah N, Ajmera A. Complete esophageal obstruction after endoscopic variceal band ligation in a patient with a sliding hiatal hernia. ACG Case Rep J. 2017; 4:e8.

17. Goff JS, Reveille RM, Van Stiegmann G. Endoscopic sclerotherapy versus endoscopic variceal ligation: esophageal symptoms, complications, and motility. Am J Gastroenterol. 1988; 83:1240–1244.