Reply to Matsushita et al.

First of all, we would like to thank Professor M. Matsushita and colleagues for the valuable and insightful comments on our procedure. We completely agree with the opinion that endoscopic band ligation (EBL) is not the most effective treatment for active gastric variceal bleeding, because of the reasons mentioned in their letter. We also do not attempt EBL initially for patients with active cardiac or gastric variceal bleeding. Rather, we practice according to treatment principles that are similar to theirs.

However, as is well known, endoscopic injection sclerotherapy (EIS) with cyanoacrylate has several limitations in emergency situations [1]. First, EIS assistants should be well trained (they have to be more skilful). Secondly, compared with EBL, EIS needs endoscopists who are more experienced. Thirdly, endoscopic channels may be accidentally obliterated by sclerosant. Fourthly, there may be still the possibility of development of complications, such as rebleeding, bacteremia, embolization, and extravasation of sclerosant.

Therefore, we have performed EIS with cyanoacrylate only in situations where both highly experienced endoscopists and well-trained assistants were available, after obtaining informed consent from patients, or their families, who have been made aware of the complications associated with EIS. Otherwise, EBL has initially been applied as an emergency measure to control the acute bleeding. In the second stage, patients have undergone EIS with cyanoacrylate, with highly skilled endoscopists and assistants and as a non-emergency procedure, within 3 days of the EBL, after the vital signs have become stable and informed consent has been obtained (Figures [1] and [2]) [2]. If the patient refuses a further endoscopic procedure (that is, EIS) but has no contraindications, we administer the beta-blocker (propranolol), which might not be inferior to repeated EIS for the secondary prevention of rebleeding as well as with regard to development of complications [3]. In fact, emergency EBL of acute cardiac variceal bleeding has been performed in seven patients between March 2004 and June 2006. None of them experienced immediate rebleeding from ulceration of the EBL site within 7 days or until EIS was done (unpublished data).

Figure 1 A 58-year-old man with alcoholic liver cirrhosis presented with active bleeding from a cardiac varix. At the first stage, it was successfully controlled by endoscopic band ligation.

Figure 2 The patient’s vital signs became stable, and 3 days later the cardiac varices were totally obliterated by endoscopic injection therapy with cyanoacrylate, without any complications.

In conclusion, although EBL cannot become an alternative therapy to EIS with cyanoacrylate, we think that it may be a useful strategy for controlling acute gastric variceal bleeding, at least, as Matsushita and colleagues commented, as a bridging measure to more definitive therapy when the necessary endoscopic expertise is available.

Competing interests: None

References

• 1 Seewald S, Sriram P VJ, Naga M. et al . Cyanoacrylate glue in gastric variceal bleeding.  Endoscopy. 2002;  34 926-932
• 2 Arakaki Y, Murakami K, Takahashi K. et al . Clinical evaluation of combined endoscopic variceal ligation and sclerotherapy of gastric varices in liver cirrhosis.  Endoscopy. 2003;  35 940-945
• 3 Evrard S, Dumonceau J M, Delhaye M. et al . Endoscopic histoacryl obliteration vs. propranolol in the prevention of esophagogastric variceal rebleeding: a randomized trial.  Endoscopy. 2003;  35 729-735