Esophageal Dislodgment of a Variceal Ligator Cap Due to Size Mismatch Between the Ligator Cap and the Endoscope

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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 The gastroscope was withdrawn, loaded with a variceal ligator (Six-Shooters S MBL-6; Wilson-Cook Medical, Winston-Salem, North Carolina, USA) and EVL was performed.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.

References

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