Clinical Evaluation of Combined Endoscopic Variceal Ligation and Sclerotherapy of Gastric Varices in Liver Cirrhosis

Background and Study Aims: Endoscopic injection sclerotherapy (EIS) using cyanoacrylate and balloon-occluded retrograde transvenous obliteration (B-RTO) are the main procedures used to treat gastric varices. However, neither technique is free of problems. EIS for gastric varices may cause embolism in other organs; B-RTO requires a gastrorenal shunt and may aggravate esophageal varices. We have developed a combined form of endoscopic therapy involving band ligation and sclerotherapy which is an effective and safe procedure for treating gastric varices.
Patients and Methods: Fifty-six patients with gastric varices and liver cirrhosis were treated at Almeida Memorial Hospital from June 1997 to May 2002 using the combined procedure. Each gastric varix was tightly ligated with O-rings, and 1 % polidocanol was injected into the submucosa around the ligated varix. If necessary, additional sclerotherapy was carried out after the initial treatment.
Results: The rate of hemostasis for variceal bleeding was 100 %, and no critical complications were noted. Complete disappearance of the gastric varices was observed endoscopically in all cases. Computed tomography showed that collateral vessels outside the gastric wall were not occluded by the treatment. Endoscopic follow-up examinations were carried out, and gastric varices recurred in seven patients (12.5 %). Only two of the patients (3.6 %) had a small amount of oozing bleeding. Additional endoscopic variceal ligation (EVL) and/or EIS were performed in these seven cases, and none of the patients died as a result of a bleeding gastric varix.
Conclusions: The combined procedure was easily performed immediately after endoscopic examination, and required no special apparatus. It was found to be a safe and effective method of treating gastric varices.

References

• 1 Van Stiegmann G, Cambre T, Sun J H. et al . A new endoscopic elastic band ligation device.  Gastrointest Endosc. 1986;  32 230-233
• 2 Nakase H, Kawasaki T, Komori H. et al . Endoscopic ligation versus endoscopic injection sclerotherapy: comparison of hepatic and renal function.  Am J Gastroenterol. 1996;  91 2170-2173
• 3 Lo G H, Lai K H, Cheng J H. et al . The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: a prospective, randomized trial.  Hepatology. 1998;  28 391-395
• 4 Bhargava D K, Pokharne R. Endoscopic variceal ligation versus endoscopic variceal ligation and endoscopic sclerotherapy: a prospective randomized study.  Am J Gastroenterol. 1997;  92 950-953
• 5 Cheng Y S, Pan S, Lien G S. et al . Adjuvant sclerotherapy after ligation for the treatment of esophageal varices: randomized long-term study.  Gastrointest Endosc. 2001;  53 566-571
• 6 Watanabe K, Kimura K, Matsutani E. et al . Portal hemodynamics in patients with gastric varices: a study of 230 patients with esophageal and gastric varices using portal vein catheterization.  Gastroenterology. 1988;  95 334-340
• 7 Pontes J M, Leitao M C, Portela F A. et al . Endoscopic ultrasonography in the treatment of oesophageal varices by endoscopic sclerotherapy and band ligation: do we need it?.  Eur J Gastroenterol Hepatol. 1995;  7 41-46
• 8 Soehendra N, Grimm H, Nam V C. et al . N-butyl-2-cyanoacrylate: supplement to endoscopic sclerotherapy.  Endoscopy. 1987;  19 221-224
• 9 Kanagawa H, Mima S, Kouyama H. et al . Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration.  J Gastroenterol Hepatol. 1996;  11 51-58
• 10 Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy.  J Vasc Interv Radiol. 2001;  12 327-336
• 11 Irisawa A, Obara K, Sato Y. et al . Adherence of cyanoacrylate which leaked from gastric varices to the left renal vein during endoscopic injection sclerotherapy: a histopathologic study.  Endoscopy. 2000;  32 804-806
• 12 Bhasin D K, Malhi N JS. Variceal bleeding and portal hypertension: much to learn, much to explore.  Endoscopy. 2002;  34 119-128
• 13 Idezuki Y. General rules for recording endoscopic findings of esophagogastric varices (1991). Japanese Research Society for Portal Hypertension.  World J Surg. 1995;  19 420-423
• 14 Villanueva C, Ortis J, Sabat M. et al . Somatostatin alone or combined with emergency sclerotherapy in the treatment of acute esophageal variceal bleeding: a prospective randomized trial.  Hepatology. 1999;  30 384-389
• 15 Kind R, Guglielmi A, Rodella L. et al . Bucrylate treatment of bleeding gastric varices: 12 years’ experience.  Endoscopy. 2000;  32 512-519
• 16 Shim C S, Cho D Y, Kim O J. et al . A case of portal and splenic vein thrombosis after Histoacryl injection therapy in gastric varices.  Endoscopy. 1996;  28 461
• 17 Vitte R L, Eugene C, Fingerhut A. et al . Fatal outcome following endoscopic variceal ligation.  Gastrointest Endosc. 1996;  43 82
• 18 Yoshida T, Harada T, Shigemitsu T. et al . Endoscopic management of gastric varices using a detachable snare and simultaneous endoscopic sclerotherapy and O-ring ligation.  J Gastroenterol Hepatol. 1999;  14 730-735