Complete esophageal occlusion after band ligation

Esophageal variceal ligation (EVL) is commonly used to treat esophageal varices given its safety profile [1]. We report an unusual complication of EVL, complete esophageal obstruction, managed with the use of a clear cap attached to the gastroscope using a “can opener” maneuver.

An 84-year-old white woman with primary biliary cirrhosis intolerant to β-blockers underwent prophylactic EVL using the seven-shooter multiband ligator (Boston Scientific Inc., Natick, Massachusetts, USA) ([Fig. 1]). On arriving home, she reported inability to tolerate even water. Repeat upper endoscopy demonstrated complete esophageal obstruction with a single band ([Fig. 2]). Multiple attempts to remove the band using the endoscope, snare, and biopsy forceps were unsuccessful. A clear-cap (D-201 – 11 304, Olympus Inc., Tokyo, Japan) fitted gastroscope was then used to secure one side of the band and, just like the movement to remove a cap from a bottle, dislodge the band ([Fig. 3]). The patient returned 6 days later with similar complaints. An esophagogram showed a distal esophageal obstruction ([Fig. 4]). Repeat endoscopy demonstrated necrotic tissue occluding the esophagus, which was managed by dilation with a through the scope balloon and insertion of a nasoenteral feeding tube. After 2 weeks the nasoenteral feeding tube was removed and the esophageal stricture dilated to 15 mm ([Fig. 5]). The patient is now eating without restrictions and has remained asymptomatic for 6 months.

Fig. 1 Small esophageal varices seen on endoscopy.

Fig. 2 Complete esophageal ligation.

Fig. 3 Clear cap and the removed band.

Fig. 4 Gastrografin esophagogram with distal esophageal “ring.”

Fig. 5 Esophageal stricture after dilation.

Complete esophageal occlusion is a rare complication of EVL, however, removal of the occluding band may be challenging [3] [4] [5]. We report the novel use of a clear cap to successfully dislodge the band and relieve the obstruction.

Endoscopy_UCTN_Code_CPL_1AH_2AC

References

• 1 Garcia-Tsao G, Sanyal A J, Grace N D, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.  Hepatology. 2007;  46 922-938
• 2 Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis.  N Engl J Med. 2010;  362 823-832
• 3 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
• 4 Verma D, Pham C, Madan A. Complete esophageal obstruction: an ususual complication of esophageal variceal ligation.  Endoscopy. 2009;  41 Suppl 2 E200-201
• 5 Rai R R, Nijhawan S, Singh G. Post-ligation stricture: a rare complication.  Endoscopy. 1996;  28 406