Novel gel-immersion endoscopic injection sclerotherapy method for prophylactic hemostasis of esophageal varices: A pilot feasibility and safety study (with video)

Abstract

Endoscopic injection sclerotherapy (EIS) is a useful prophylactic hemostatic procedure for esophageal varices. However, injecting sclerosing agents into blood vessels is technically challenging and often ineffective. Gel-immersion EIS (GI-EIS) may facilitate easier intravascular sclerosing agent injection by dilating the varices and enhancing scope stability by maintaining low intra-gastrointestinal pressure. Therefore, we aimed to evaluate the effectiveness and safety of this procedure. This retrospective study included 18 patients (14 men and four women; median age, 70 years; age range, 18-83 years) who underwent GI-EIS at Osaka Medical Pharmaceutical University Hospital between December 1, 2022, and January 30, 2024. Patients who were at least 18 years of age at the time of treatment were included. No patients were excluded from the study. Thirty-four punctures were performed. The donor vessel angiography success rate was 88.2% (30 of 34 punctures). The clinical success rate was 94.4% (17 of 18 patients). Esophageal varices in most patients disappeared or were reduced by 1 month after treatment. Adverse events related to the procedure included fever (three patients) and chest pain (one patient); however, both were resolved with conservative treatment. No respiratory deterioration due to aspiration occurred during the procedure. The results of this study demonstrate that GI-EIS is a safe, clinically feasible, and effective treatment option for prophylactic hemostasis of esophageal varices.

Keywords: digestive system endoscopy; endoscopic injection sclerotherapy; esophageal varices; gel immersion endoscopy; prophylactic hemostasis.

FIGURE 1

Schemas and typical intra‐procedure images of gel‐immersion endoscopic injection sclerotherapy (GI‐EIS) and those of conventional EIS for comparison. (a, b) Schema comparing the conventional EIS method with the GI‐EIS method. With the GI‐EIS method, the varicose vein is dilated and the lumen is wider, thus allowing easier puncture. (c) Schema and image of the GI‐EIS method. GI‐EIS is performed using an external irrigation tube (ERCP‐Catheter; MTW Endoskopie W Haag KG) for additional gel infusion. (d) Multiple F2 esophageal varices are present in the lower esophagus. (e) After the air is deflated from the esophagus and stomach, a sufficient amount of gel is injected to fill the lumen of the esophagus. With the gel, the pressure in the esophageal lumen is reduced and the varices are dilated. (f) After puncturing the varicose vein and confirming the presence of backflow, a sclerosing agent is injected. (g) A sufficient amount of sclerosis agent is injected to confirm that the donor vessel has achieved contrast under fluoroscopy. (h and i) After injecting a sufficient amount of sclerosing agent, the needle is removed and the puncture site is ligated.

FIGURE 2

(a) With the gel, the endoscopic image is magnified and appears closer because of the difference in the refractive index. (b) An image of a measuring tool used for endoscopes, with 1 scale point comprising 2 mm (A, bendy type; Olympus Optical Co., Ltd.). (c) The measuring tool is fixed at the tip of the scope and actual endoscopic images obtained with gel as well as with air are shown. (d) Image of air‐immersion endoscopy. Almost all measurements at the scope tip are visible on the endoscopic image. (e) Image of gel‐immersion endoscopy. Approximately 4 mm of the measurement is outside the endoscopic field of view in the foreground and is not visible.

FIGURE 3

Images of the total reflections. (a) Total reflection has occurred, and the lumen of the puncture needle is reflected and invisible, similar to a mirror surface. (b) Image obtained after the lumen was filled with saline solution and air was flushed out. The lumen of the puncture needle is clearly visible.