A new method of endoscopic variceal ligation-injection sclerotherapy (EVLIS) for gastric varices

Abstract

Objectives: For esophageal varices, endoscopic variceal sclerotherapy and band ligation have been effectively and frequently used, but these methods were not effective for gastric varices. In gastric varices, because of rich networks of feeding vessels and shunts that may exist in many cases, an effective therapeutic level of sclerosant is difficult to be maintained. Accordingly, we propose a new method called "Endoscopic Variceal Ligation-Injection Sclerotherapy (abbreviated EVLIS)" for gastiric varices, with focus on maintenance of the effective therapeutic level of a sclerosant by partially blocking the blood flow of gastric varices using the band ligation method. The study was undertaken prospectively to evaluate the efficacy and safety of EVLIS for the treatment of gastric varices.

Methods: EVLIS was performed in a group of 32 patients with gastric varices. Active bleeding varices were 11 and non-bleeding 21. Five cases were grade A, 12 grade B, and 14 grade C of Child's classification. Nine cases were type 1, 22 type 2, and 1 was type 3 of Hosking-Johnson's classification.

Results: The results of EVLIS were excellent, active bleeding of gastric varices in the 11 cases were successfully controlled and all the gastric varices of 32 cases including those bleeding varices were completely eradicated. The bleeding status, the Child's grade and the Hosking-Johnson's class do not appear to correlate in any way with the efficacy of this technique. No perforation or re-bleeding was observed in any of the patients until the mean 10.6 months of the follow-up period.

Conclusions: EVLIS should be considered as an effective and safe treatment for gastric varices.

Fig. 1.

A. Endoscopic picture shows mass-like varices on fundus. B. Endoscopic picture shows an endoscopic band ligation of varix, for the first procedure of EVLIS. The stigma of target varix is shown in the middle of endoscopic visual field. C. Endoscopic picture shows the end of the band ligation procedure. D. Following the band ligations, the submucosal injections with 5% EO on 2–3 places around each pseudopolyp formed after the band ligations and the intravariceal injections with 5% EO between the pseudopolyps were performed. E. Endoscopic picture taken 10 days after EVLIS shows gastric mucosal swelling and ulceration. F. Endoscopic picture taken 2 months after EVLIS shows complete eradication of the gastric varices.

Fig. 2.

A. Endoscopic picture shows jet-like bleeding from gastric varix on fundus. B. Endoscopic picture was taken during band ligation. In the case with active gastric bleeding, the approach towards the varix for EVLIS laterally was preferable for better visual field. C. Endoscopic picture shows the end of EVLIS and active gastric bleeding was successfully controlled. D. Endoscopic picture taken 2 months after EVLIS shows complete eradication of the gastric varices.

Fig. 3.

A. Endoscopic picture shows huge mass-like gastric varices on fundus. B. Endoscopic picture shows the band ligations at the connecting points between huge mass-like varices and its feeding vessels, in order to block the blood flow from these vessels. C. Endoscopic picture shows the intravariceal injection with 5% EO into the remained huge mass-like gastric varices after the band ligations. D. Endoscopic picture taken 10 days after EVLIS shows necrosis of the huge mass-like gastric varices. E. Endoscopic picture taken 2 months after EVLIS shows complete eradication of the huge mass-like gastric varices.

Fig. 4.

A, B. Endoscopic picture shows a wide spread of several varices over fundus and body. In this case, these varices should be divided into segments in terms of their connection to each other. C. Endoscopic picture taken 10 days after EVLIS shows necrosis of the gastric varices. D. Endoscopic picture taken 2 months after EVLIS shows complete eradication of the gastric varices.