Fig. 1. Endoscopic sclerotherapy. (A) Endoscope with retracted sclerotherapy needle. (B) Endoscope with extended sclerotherapy needle. (C) Injection of sclerosing agent into varix.
Endoscopic variceal ligation (EVL), also referred to as variceal banding, is an endoscopic therapy for acute esophageal variceal bleeding, and for elective eradication of varices after the initial episode of hemorrhage. EVL technique for the esophageal varices is similar to endoscopic treatment of rectal hemorrhoids. The ligation is accomplished by placement of an elastic band on the varix, which strangulates a blood vessel, resulting in vessel thrombosis. The thrombosed varix undergoes necrosis and sloughs off, to be replaced by fibrous tissue in the process of mucosal healing.
A small cylinder, which is preloaded with bands, is loaded onto the tip of the endoscope and the connecting wire is passed down the biopsy channel of the endoscope to be attached to a band-releasing device mounted into other end of that channel. Since the introduction of devices preloaded with multiple bands, there is no need for endoscope removal after each ligation, therefore, there is no need for overtube use. The endoscope with the device is placed over the varix, which is then suctioned into the device's plastic cylinder at the end of an endoscope. With the use of the trigger device, a ligating band is deployed. After the ligation process is completed, suction is stopped, and a puff of air is used to release the ligated varix from the device (Fig. 2). It is important to start ligation at the level of gastroesophageal junction and proceed proxi-mally, because banded varices may obstruct esophageal lumen, making access to varices below them impossible. When ligating an actively bleeding varix, the band is placed directly over the bleeding point or just below it, but never above it, for the same reason. Typically, five to ten bands are placed in one session.
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