The Cue-Stroke Band Ligator: A New Instrument for Variceal Ligation

Endoscopic variceal ligation has become the treatment of choice for eradicating esophageal varices [1]. It is safer than sclerotherapy and does not cause systemic side effects [2]. Ligation has also been proved to be superior to sclerotherapy for esophageal variceal obliteration [3]. An advantage of the multishooter ligators is that only one insertion is required, but these instruments apply bands using a pulling motion and this pulling pressure can damage the endoscope [4]. Our aim was to design our own ligator, the “cue-stroke band ligator” (CSBL), which works by pushing the band rather than pulling it. The name we gave the instrument was inspired by a stroke played in the game of billiards.

The CSBL instrument was assembled from easily available components (Figure [1]): a polycarbonate ligator cylinder with a built-in needle channel (17-gauge, 25-mm long), a teflon tube (1.27-mm-bore, 110-cm long), a three-way silicon valve, a length of steel wire (0.75-mm thick, 120-cm long), a needle tube (18-gauge, 20-mm long), nylon wire (1-mm thick, 40-mm long) and an 18-gauge needle.

Figure 1 The cue-stroke band ligator (CSBL) instrument, showing the rubber band and the loader.

A total of 32 patients with portal hypertension and grade IV varices (18 patients with cirrhosis, ten patients with noncirrhotic portal fibrosis, and four patients with extrahepatic portal venous obstruction) underwent variceal ligation with the CSBL instrument. The aim of treatment was primary prophylaxis in ten patients and secondary prophylaxis in 22 patients. Four patients had active bleeding.

The patients gave informed consent before the procedure. The CSBL cylinder was fixed to the tip of the endoscope and the ‘O’ ring was loaded onto the tip of the ligator cylinder. The endoscope was then introduced into the esophagus and the variceal column was sucked inside the cylinder. The band was then applied by pushing it with the nylon wire (Figure [2]). After each deployment, the loader reloaded the band over the ligator cylinder. Repeated introduction was required to apply the bands. The instrument was washed and sterilized at the end of procedure with 2 % glutaraldehyde for 30 minutes. The procedure was repeated at 1-week intervals until the varices were obliterated. The patients were followed up for 6 weeks after the treatment was complete.

Figure 2 The CSBL instrument in pre-shoot (above) and shoot positions.

Ligation with the CSBL instrument was performed successfully and safely in all the patients. The average time taken for a single band application was 2 minutes (range 1 - 3 minutes). A total of 200 bands were applied. Bleeding was controlled in all of the four patients who had active bleeding. Four patients developed variceal bleeding during the procedure due to severe retching, which was controlled with banding in the same session. No other complications were encountered. All the patients developed postligation ulcers, which healed within 2 weeks. Variceal obliteration was achieved in all 32 patients with the application of an average of 6.25 bands (range 3 - 24). The mean number of sessions required was 3.6 (range 2 - 4). None of the patients re-bled during the 6-week follow-up period.

The CSBL instrument affords an excellent view of the esophagus, not only through, but also across the wall of the ligator cylinder (Figure [3]). This circumvents the problems associated with the telescopic view provided by the multishooter ligator instruments. The instrument works by applying the band with a pushing motion, thus avoiding the pulling pressure effect on the endoscope described by Govil & Kumar [4]. In our experience, the CSBL instrument was also more versatile in the treatment of nonvariceal lesions like Dieulafoy’s lesion and blue rubber bleb nevus lesions in the fundus of the stomach, which require retroversion of the endoscope. The CSBL instrument deploys a single band on each introduction, making the procedure longer and less comfortable. However, treatment with the CSBL would be very cost-effective in patients with a lower grade and number of varices or in patients with recurrence of varices who require fewer bands. We found the CSBL to be a safe and effective instrument for band ligation of esophageal varices.

Figure 3 The endoscopic view of an esophageal varix through the CSBL ligator cylinder before ligation (a) and after band ligation (b).

References

• 1 Laine L. Ligation: endoscopic treatment of choice for patients with bleeding esophageal varices?.  Hepatology. 1995;  22 663-665
• 2 Sarin S K, Lamba G S, Kumar M. et al . Comparison of endoscopic ligation and propranolol for the primary prevention of variceal bleeding.  N Engl J Med. 1999;  340 988-993
• 3 Lo G H, Lai K H, Cheng J S. et al . A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices.  Hepatology. 1995;  22 466-471
• 4 Govil A, Kumar N. Endoscope break dances while the bands play.  Trop Gastroenterol. 1995;  16 64