Comments on “Band-on-band endoscopic variceal ligation: a technique for the treatment of esophageal varices in case of band misplacement”

We agree that band-on-band endoscopic variceal ligation [1] is an useful treatment for esophageal varices in the case of band misplacement. However, we propose two alternative options that may be more suitable for the rescue treatment of esophageal varices.

The authors described that the position of the band was suboptimal because of inadequate tissue elevation. A careful check of the suction power must be urgently conducted and any issues with the suction device should be promptly resolved. Moreover, if the incomplete suction has been due to scar formation from previous band ligation, in this case 5 years ago, there is a high possibility of poor tissue elevation when placing the second band on top of the first one, which increases the risk of bleeding if the first band dislodges and placement of the second one fails.

We suggest two options for dealing with this scenario. The first option is to inject sclerosant directly into the culprit varices within the previous band to achieve vascular elimination, which can minimize the risk of bleeding in case of premature band dislodgement. Indeed, we have experience in locating the band ligation directly on the bleeding varices where blood still oozed slowly from the culprit varices. Sclerotherapy was then applied to achieve hemostasis. The second option is to place another band cap below the previous one, namely more proximal to the cardia, if there is sufficient space for suction, targeting the same varicose vein so that even if the first rubber band dislodges there will be no life-threatening bleeding.

In conclusion, band endoscopic variceal ligation is a high risk procedure. We propose two methods, namely injection of a sclerosing agent into the culprit varix within the band, and band-below-band ligation targeting the same varix, which may be more appropriate in case of band misplacement.

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 (Suppl. 01) E211-E212