What is the procedure for endoscopic variceal ligation in a patient with esophageal varices due to liver cirrhosis or portal hypertension?

Endoscopic Variceal Ligation Procedure

Endoscopic variceal ligation (EVL) is the recommended endoscopic treatment for esophageal varices, performed by placing elastic bands around varices to achieve mechanical obliteration, and should be combined with vasoactive drugs in acute bleeding scenarios. 1

Pre-Procedure Preparation

Patient Stabilization

• Initiate vasoactive drugs (octreotide, terlipressin, or somatostatin) immediately upon suspicion of variceal bleeding, before endoscopy 1
• Administer prophylactic antibiotics to reduce mortality, bacterial infections, and rebleeding risk 1
• Target restrictive packed red blood cell transfusion maintaining hemoglobin 7-9 g/dL 1
• Ensure adequate IV access and hemodynamic monitoring 1

Sedation Considerations

• Use general anesthesia or deep sedation, particularly in children and high-risk patients 2
• Exercise caution in Fontan patients where deep sedation may be contraindicated due to hemodynamic concerns 1

Technical Procedure Steps

Equipment and Technique

• Utilize a multi-band ligator device capable of deploying multiple bands (typically 2-6 bands per session depending on varix size and number) 2
• Begin ligation at the gastroesophageal junction and work proximally in a spiral pattern 3
• Apply bands to varices by suctioning the varix into the ligation cylinder until a "red-out" is achieved, then deploy the elastic band 3
• Space bands approximately 1-2 cm apart to avoid excessive tissue necrosis 3

Session Frequency and Eradication

• Repeat EVL sessions every 2-8 weeks until complete variceal eradication is achieved 1
• Average 2-3 sessions required for eradication (significantly fewer than sclerotherapy which requires 4-5 sessions) 1
• In primary prophylaxis settings, eradication typically achieved in 90% of patients after 2 sessions at 3-month intervals 2

Clinical Scenarios and Outcomes

Acute Variceal Bleeding

• EVL combined with vasoactive drugs achieves 77% 5-day hemostasis compared to 58% with endoscopic treatment alone 1
• EVL controls active bleeding in 85-90% of cases 1
• EVL is superior to sclerotherapy with lower rebleeding rates (OR 0.52), lower mortality (OR 0.67), and fewer complications 1

Primary Prophylaxis

• EVL prevents first variceal bleed with 98% success rate in high-risk patients (only 2% failed prophylaxis in transplant candidates) 4
• Equally effective as non-selective beta-blockers for primary prophylaxis, though beta-blockers may have survival advantage in long-term follow-up 1

Secondary Prophylaxis (Rebleeding Prevention)

• Combination of EVL plus non-selective beta-blockers is superior to either therapy alone, reducing rebleeding risk (RR 0.44) compared to EVL alone 1
• Begin secondary prophylaxis on day 6 following initial bleeding episode 5

Post-Procedure Management

Immediate Complications

• Post-EVL ulcer bleeding occurs in 2.7-7.8% of patients, typically 10-14 days after band placement 6
• Administer proton pump inhibitor therapy immediately after EVL to reduce ulcer complications 6
• Band-induced acute hematemesis occurs in approximately 1.2% of cases 4

Surveillance After Eradication

• Perform endoscopic follow-up every 3 months initially to assess for recurrence 2
• Variceal recurrence occurs in approximately 10% of patients at 12-28 months post-eradication 2
• Continue surveillance even after eradication as varices can recur 1

Rescue Therapy for EVL Failure

Salvage Options

• If EVL fails to control bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with covered stents is the recommended rescue treatment 1, 6
• Early TIPS within 72 hours should be considered in high-risk patients (Child-Pugh B with active bleeding or Child-Pugh C with MELD <14) 1
• Balloon tamponade (Sengstaken-Blakemore tube) or self-expanding covered metallic esophageal stent can serve as temporary bridge therapy for 24-48 hours until definitive treatment 1, 3

Important Caveats

Specific Populations

• In Fontan-associated liver disease, the bleeding risk from varices is very low (6%), and primary prophylaxis with EVL cannot be systematically recommended due to sedation risks 1
• GOV1 gastric varices extending from esophagus disappear in 64.7% of cases after esophageal EVL, so separate treatment is usually unnecessary 6

Contraindications to Alternatives

• Sclerotherapy may be used if EVL is technically difficult or unavailable, but has higher complication rates 1
• TIPS is contraindicated in Fontan patients due to hemodynamic concerns 1