Band-on-band endoscopic variceal ligation and alternative treatment strategies: Reply to Hu et al.

We thank Hu et al. for their insightful comments regarding our technique for band-on-band endoscopic variceal ligation (EVL) [1].

We acknowledge that band-on-band EVL is one of the different options available for addressing band misplacement, and treatment should be tailored to the patient’s anatomical and clinical characteristics. We agree that the effectiveness of suction should always be tested before applying the elastic band. It is our practice to do so; therefore, we can exclude suction-related issues in this case.

Optimal tissue compliance in patients without esophageal fibrosis from previous treatments makes band-on-band EVL perhaps the most effective option for addressing superficial band placement. It significantly improves band positioning, mitigating the risk of premature band dislodgment and post-banding ulcer bleeding.

For patients with esophageal fibrosis resulting from prior treatments, band-on-band EVL remains a valid approach in cases of suboptimal, but still present tissue elevation. However, severe fibrosis may render this technique unfeasible. When dealing with fibrosis after a suboptimal banding, endoscopic sclerotherapy injection close to the misplaced band may be a viable alternative, though it carries a high complication rate (approximately 20%–25%) [2] [3] [4]. However, to the best of our knowledge, no data currently support the injection of the sclerosing agent directly into the ligated varix, and we think this practice may cause band dislodgment and immediate bleeding.

Lastly, placing an additional band below the misplaced one, closer to the gastroesophageal junction, may decrease the blood flow and pressure on the varix but also poses a high risk of detaching the first misplaced band, thus causing immediate bleeding. Moreover, esophageal fibrosis from previous EVL tends to be more pronounced in the distal esophagus, often making this approach difficult to apply. In our opinion, the band-on-band EVL technique is the safest and most effective approach to band misplacement during EVL.

Publication History

Article published online:
19 December 2024

• References

• 1 Sorge A, Pessarelli T, Elli L. et al. Band-on-band endoscopic variceal ligation: a technique for the treatment of esophageal varices in case of band misplacement. Endoscopy 2024; 56: E211-E212
• 2 Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995; 123: 280-287
• 3 Lo GH, Lai KH, Cheng JS. et al. Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. Hepatology 1997; 25: 1101-1104
• 4 Lo GH, Lai KH, Cheng JS. et al. A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices. Hepatology 1995; 22: 466-471