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CAN ENDOSCOPIC FEATURES IDENTIFYING THE LAST ENDOSCOPIC BAND LIGATION SESSION BEFORE GASTROESOPHAGEAL VARICEAL ERADICATION?
Stefano Pontone*1, Cristina Panetta1, Rossella Palma1, Angelo Antoniozzi2, Antonietta Lamazza2
1Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy; 2Policlinico "Umberto I", "Sapienza" University of Rome, Rome, Rome, Italy
Introduction: Endoscopic Band Ligation (EBL) is performed to decrease the risk of variceal bleeding. Initially proposed for the treatment of esophageal varices as a method for obtaining hemostasis in acute bleeding, EBL has also been used electively for the prophylaxis of recurrent variceal bleeding. Furthermore, at the consensus workshop of Baveno V it was concluded that either non-selective beta-blockers or band ligation are recommended also for the prevention of a first variceal bleeding of medium or large varices. The aim of this study is to find endoscopic parameters who could alone identify the last EBL before the eradication and the other endoscopic sessions.
Patients and Methods: We selected from August 2013 to September 2016, 287 EBL sessions. Among the 287 sessions, we distinguished the ligation that preceded the eradication (Second to last Session) from all the others for each patient who underwent EBL. All patients included were followed from the first upper gastrointestinal bleeding to the variceal eradication. We excluded the first endoscopic session in which the diagnosis was performed and all the endoscopic sessions in which the eradication has not been recorded.
The following endoscopic parameters of esophageal varices were recorded: size (F1-F2-F3 according to the Japanese classification), blue tone (the percentage of varices with bluish coloration), and red color signs. Congestive gastropathy was evaluated. Gastric varices were graded as absent or present and were distinguished in GOV and IGV, while red color signs were classified. Bands’ number used during ligation was also recorded and was calculated as ≤3 or >3.
Results: 95 endoscopic sessions were included. 51 were classified as second to last (Group A), and 44 as other sessions (Group B). The variceal size and red color signs ( χ 2= 0,070) are represented in Tables 1. The blue tone was 97,9% and 100% respectively. The number of arranged bands was ≤4 in 11 and 19 sessions respectively (61,1% vs 82,6 %) and > 4 in 7 and 4 sessions for each group (38,9% vs 17,4%) (χ 2= 0,123) . There were no statistically significant differences in the grade of congestive gastropathy between the two groups (χ 2= 0.432). The distribution of GOVs in each group is represented in Table 3. In the 87,2% of cases GOVs are not detected during the second to last sessions and none session who precede the eradication presented GOV2. (χ 2= 0,019).
Conclusions: In our experience the variceal size according to the Japanese classification and the presence of gastroesophageal varices could be considered useful endoscopic indicators that can predict the eradication failure of esophageal varices and can be used to indirectly identify the last session before the variceal eradication. Other studies that include also clinical and biochemical datas are needed.
Table 1= Variceal size according to the Japanese Classification. Red color signs classified as absent (-), mild to moderate (+), or diffuse presence in all varices (++).
| Size of varices | F1 | F2 | F3 | χ2 | | Group A | 0 | 34 (66.7%) | 17 (33.3%) | 0.049* | | Group B | 0 | 20 (46.5%) | 23 (53.5%) | --- | | Red Color Signs | - | + | ++ | χ2 | | Group A | 9 | 34 | 8 | 0.070 | | Group B | 14 | 19 | 11 | ---- |
*statistically significant Table 2= Distribution of GOVs in both groups | ---- | Group A | Group B | | No GOV | 41 (87.2%) | 26 (61.9%) | | GOV1 | 6 (12.8%) | 15 (35.7%) | | GOV2 | 0 | 1 (2.4%) |
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