Endoscopic variceal ligation (EVL) is an effective therapy for prophylaxis and treatment
of bleeding varices [1]
[2]
[3]. We describe a case of dislodgment of the ligator cap in a patient without esophageal
stricture.
A 53-year-old man with cryptogenic cirrhosis was found to have grade III esophageal
varices on endoscopy. Primary EVL was performed without sequelae. At 2 weeks later,
a repeat EVL was attempted. Endoscopy using an Olympus gastroscope GIF XQ240 showed
four cords of grade II esophageal varices. The gastroscope was withdrawn, loaded with
a variceal ligator (Six-Shooters S MBL-6; Wilson-Cook Medical, Winston-Salem, North
Carolina, USA) and EVL was performed. However, upon withdrawal of the endoscope, the
ligator cap fell from the endoscope and became lodged in the mid-esophagus (Figure
[1]). The cap was retrieved with rat-tooth forceps without complication.
Figure 1 Endoscopic view showing the dislodged ligator cap in the mid-esophagus.
Clarkston et al. reported a case of dislodgment of the ligator cap in a patient with
esophageal stricture [4]. As far as we are aware, dislodgment of the ligator cap as a complication of EVL
has not been described in patients without esophageal stricture [5]
[6].
At our endoscopy unit, we have been using the Olympus gastroscope GIF XQ230 (external
diameter 9.2 mm) since 1996 and the GIF XQ240 (external diameter 9.0 mm) since the
year 2000. With the phasing out of the XQ230 model, most of the upper endoscopes in
our unit are now the slimmer XQ240 model, whose diameter is smaller than the recommended
fitting diameter for the distal cap of the MBL-6 of 9.5 to 13.0 mm. The size mismatch
caused dislodgment of the ligator cap. We reported the incident to the supplier of
the ligators and we have since been supplied with MBL-6-XS ligators, whose distal
caps fit scopes with a diameter of 8.6 mm to 9.2 mm.
We recommend careful checking of the endoscope diameter and matching it with the correct
size of ligator cap before performing variceal ligation, in order to avoid such a
complication.
