Esophageal variceal recurrence after endoscopic treatment is a frequent event [1]
[2]
[3]
[4]. Some studies have reported that endoscopic treatment assisted by endoscopic ultrasonography (EUS) that can evaluate variceal size and hemodynamics is effective in preventing variceal recurrence [3]
[4]. Additionally, color Doppler evaluation by EUS is less invasive and enables endoscopists to identify the varices to be treated [4]. However, the Doppler-EUS method has issues related to its use: it is time-consuming, it is complicated to use convex transducers, and it requires scope replacement for additional treatment. The latest method, Doppler probe ultrasonography, uses a through-the-scope Doppler probe (Compumedics, DWL, Singen, Germany) ([Fig. 1 a]) that can evaluate the direction, waveform (that helps distinguish between arteries and veins), and the amount of blood flow ([Fig. 1 b, c]) [5]. Moreover, Doppler probe ultrasonography is simple, noninvasive, and requires no scope replacement for additional treatment. The procedure involves 1) identification of more risky varices, 2) detection of penetrating varices, 3) assisting appropriate hemostasis, and 4) evaluation after hemostatic treatment. Here we demonstrate two variceal treatments using this novel approach ([Video 1]).
Fig. 1 a The image of the Doppler system with a reusable Doppler probe (diameter of 2 mm, 16 MHz). The Doppler system has audio and visual output signals. (Reproduced with permission from Compumedics.) b The visual graphic display reveals Doppler flow corresponding to the esophageal varix. c The Doppler flow disappeared after additional endoscopic variceal ligation.
Video 1 Effective endoscopic hemostasis using the novel Doppler probe method.
Case 1 involved a patient with a history of esophageal variceal rupture. Although he had undergone repeated endoscopic variceal ligations, recurrence of varices was observed ([Fig. 2 a]). We evaluated high-risk varices using Doppler probe ultrasonography ([Fig. 2 b]). Because varices previously treated with endoscopic variceal ligation had a penetrating vein and massive blood flow, we performed an additional ligation at the site of vein penetration ([Fig. 2 c]). Varices were evaluated afterwards and the effectiveness of hemostasis was confirmed ([Fig. 2 d]).
Fig. 2 a Endoscopic view of the patient with esophageal variceal recurrence. b Evaluation of esophageal varices using the Doppler probe. The Doppler probe was maneuvered while observing the blood flow. c Additional band ligation was performed at a site where there was massive blood flow that we considered to have penetrating veins. d Confirmation by Doppler probe after band ligation was performed. If the blood flow had remained, additional variceal ligation would have been considered.
Case 2 had a history of hemostasis for gastric variceal rupture ([Fig. 3 a]). Subsequently, esophageal varices developed. Esophageal varices continuous with the stomach were identified, and endoscopic variceal ligation was performed ([Fig. 3 b]).
Fig. 3 a Endoscopic view of gastric varices with scar formation due to previous variceal ligation. b Esophageal varices continuous with gastric varices were identified by the novel Doppler probe method; thereafter, esophageal varices were effectively treated by variceal ligation.
Both cases were treated effectively with endoscopic variceal ligation assisted by our novel Doppler probe ultrasonography.
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