An Unusual Complication of Esophageal Variceal Band Ligation: Iatrogenic Esophageal Foreign Body

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We present here an unusual complication after endoscopic variceal ligation (EVL). A 48-year-old man had been followed for 2 years because of hepatitis B-associated chronic liver disease. He was admitted to our unit because of hematemesis occurring 15 days before. An upper gastrointestinal endoscopic examination was performed and esophageal varices were diagnosed. An EVL session was decided for the patient. EVL was performed successfully using an Olympus GIF XQ-240 video endoscope and a Wilson-Cook Saeed Four-Shooter device (Cook Ireland Limited, Limerick, Ireland). During the removal of the endoscope, the Opti-Vu plastic barrel of the ligation set became dislodged from the endoscope at the middle part of the esophagus (Figure [1]). Initial attempts to capture the barrel with a basket and grasping forceps failed. Successful removal of the barrel was achieved when an esophageal-type controlled radial expansion (CRE) dilation balloon (Boston Scientific Microvasive Corp., Massachusetts, United States) was used. The balloon was placed through the barrel, inflated with air, and then easily removed with the endoscope from the esophagus (Figure [2]).

Figure 1 The dislodged Opti-Vu barrel at the middle part of the esophagus.

Figure 2 The Opti-Vu barrel, which was successfully removed using a controlled radial expansion (CRE) balloon.

Wilson-Cook, the manufacturer of the Four-Shooter device, advise that it be used with endoscopes of diameter 9.5 - 13 mm. We performed in our routine endoscopy practice more than one hundred EVL sessions using the same endoscope with a diameter of 9.2 mm, but we hadn't before encountered such a complication. We believe the cause of this unusual complication was not following the diameter range suggested by the manufacturers. Therefore we wish to call the attention of all users of ligation devices to this point. Wendell et al. [1] have also reported a case of a dislodged barrel. The reason for the complication in their case was lower esophageal stricture due to prior endoscopic sclerotherapy sessions [1]. In our case the barrel was removed very easily without complication using a CRE balloon, which was placed through the barrel and then inflated with air.

In conclusion, it must be kept in mind that the barrel of a ligation set can fall into the esophagus, therefore equipment for the removal of foreign bodies and a balloon should be ready for use.

References

• 1 Wendell K C, Eliathamby K, Sreenivasa S J, Owen J S.. Iatrogenic esophageal foreign body and extrinsic tracheal compression during esophageal band ligation.  Gastrointest Endosc. 1998;  47 106