This video details our case as well as our method for successfully eradicating varices immediately prior to esophageal endoscopic submucosal dissection to minimize risks of variceal hemorrhage.
Abbreviations:EIS (endoscopic injection sclerotherapy), ESD (endoscopic submucosal dissection), EVL (endoscopic variceal ligation), RDI (red dichromatic imaging), TIPS (transjugular intrahepatic portosystemic shunt)
- 1.Endoscopic variceal ligation (EVL) prior to ESD. As mentioned before, multiple reports document successful variceal ligation prior to initiation of ESD to eradicate the esophageal varices and decrease risk of hemorrhage.1,2,3,4Cases show that this is a safe technique when completed on an earlier date or even on the same day as ESD. Unfortunately, esophageal varices often require multiple sessions for complete eradication, which can significantly delay ESD.
- 2.Endoscopic injection sclerotherapy (EIS) prior to ESD. There are no reported cases of sclerotherapy of esophageal varices in anticipation of ESD. Nevertheless, it has been done prior to esophageal EMR. This is not ideal as EIS causes submucosal fibrosis and scarring and may subsequently prevent the lesion from lifting with injection.5Additionally, the variceal response to EIS is slower than with EVL.1
- 3.Procoagulation of varices. This method has been used in multiple cases to treat submucosal varices encountered during dissection when variceal ligation is no longer an option.6,7No reports have documented adverse events.
- 4.Red dichromatic imaging (RDI). This is a new image-enhancing endoscopic technology that uses 3 long wavelengths of irradiating light to enhance the visualization of blood vessels. RDI has been used to identify submucosal esophageal varices during ESD to better avoid them during injection.8This helps minimize risk of hemorrhage or hematoma formation; however, it does not abolish varices should their location in relation to the lesion be too close for complete avoidance.8,9
- 5.Water-pocket ESD. Seen in one case report of a patient with esophageal adenocarcinoma and esophageal varices, this ESD technique incorporates tunneling dissection through a water pool created in the submucosa under the target lesion. This method prevents coagulation smoke from impeding visualization and magnifies the tissue to identify blood vessels more readily. In the setting of submucosal varices, this enables pre-emptive coagulation of large vessels.
- 6.Transjugular intrahepatic portosystemic shunt (TIPS). One study compared TIPS against EVL as pretreatment of esophageal varices prior to planned ESD.5With TIPS, they found less frequent and less severe intraprocedural bleeding. TIPS was also felt to cause fewer submucosal adhesions and scarring, which impedes successful ESD. However, this comparison was made with only 2 patients in each group.5Additionally, TIPS has many associated risks such as acute liver failure, encephalopathy, and damage to surrounding organs. With such a limited study, it is too early to consider this a truly superior method, particularly while we have reviewed many case series of successful ESD following variceal ligation.
- 7.Thrombopoietin receptor agonist. In one case, avatrombopag was administered to a patient with decompensated cirrhosis 5 days before ESD.7Platelet transfusions are often administered before invasive procedures in those with chronic liver disease and thrombocytopenia as a means to decrease periprocedural bleeding. Unfortunately, the benefit of platelet transfusion is fleeting, and thrombopoietin receptor agonists such as avatrombopag or lusutrombopag have been able to produce greater increases in platelet count for longer durations.10Following ESD, this sustained rise in platelet count may have added benefit while the defect heals.
- 8.Avoiding varices. Variceal treatment may not always be necessary. There have been multiple case reports of endoscopists successfully completing esophageal ESD in patients with esophageal varices without ligation or any form of variceal eradication when there was sufficient distance between the lesion of interest and the varices.1,5,11
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