Reply to Syn et al.

We thank Syn et al. for their interest in our article [1]. With their report and ours and another one in a recent issue of Endoscopy [2], six cases of dislodgment of ligator caps have now been described. All the cases occurred when upper gastrointestinal endoscopes were being upgraded to slimmer models, and the endoscopists were unaware of a mismatch between the outer diameters of the upgraded endoscopes and the fitting sizes of the band ligator caps. Table [1] shows the different sizes of some of the currently available endoscopes and variceal band ligator caps.

Table 1 External diameters and fitting sizes of commonly used endoscopes and band ligator caps External diameter, mm Fitting sizes of cap, mm Upper gastrointestinal endoscopes GIF-Q160, Olympus 9.5 GIF XQ230, Olympus 9.2 GIF XQ240, Olympus 9.0 GIF-160, Olympus 8.6 EG-450HR/EG-250HR, Fujinon 9.4 EG-2930K, Pentax 9.8 EG-2730K, Pentax 9.0 Variceal band ligators Six-shooter S MBL-6, Wilson-Cook 9.5 to 13.0 Six-shooter MS MBL-6, Wilson-Cook 8.6 to 9.2 Super 7 multiple band ligator, Boston-Scientific 8.6 to 11.5

In addition to the endoscopic retrieval of the ligator cap using a rat-tooth forceps, Syn et al. mentioned three alternative methods of managing dislodgment of caps: retrieval using an ERCP balloon catheter, by inflating the balloon after passing it through the cap; re-engagement of the cap into the tip of the endoscope against the stomach wall; and pushing the cap into the stomach to avoid aspiration and for spontaneous passage. Their experience provides useful tips for those who fail to retrieve the dislodged cap using forceps. However, we hope that endoscopists will never again have to resort to retrieval of the cap.

Instead, we would like to emphasize the importance of routine checking of the models and sizes of endoscopes and ligator caps before performing any variceal band ligation. With the increasing recognition of this problem, we urge manufacturers of variceal band ligators to consider inserting a boxed warning label on the equipment packet to inform endoscopists of the importance of matching endoscopes with the correct band ligator caps.

References

• 1 Wai C T, Ho K Y, Kwok F Y. Esophageal dislodgment of a variceal ligator cap due to size mismatch between the ligator cap and the endoscope.  Endoscopy. 2003;  35 191
• 2 Leung C S, Chan C W, Chow W H. et al . A potentially serious disadvantage of multiband device over conventional ligation using an overtube.  Endoscopy.. 2003;  35 190