Underwater Endoscopic Injection Sclerotherapy for Gastroesophageal Varices

Summary

Underwater endoscopic injection sclerotherapy might be a choice for patients with gastroesophageal varices (GEVs). The decreased peristalsis of the esophagus underwater can increase the success rate of intravascular injection and stabilize the vision.

Abstract

The underwater technique is an important innovation in gastrointestinal endoscopy, which has been used for the treatment of colonic lesions, esophageal, and gastric neoplasms. Endoscopic injection sclerotherapy (EIS) is a safe and effective way to treat and prevent gastroesophageal variceal bleeding (GEVB). However, paravascular submucosal injection may result in the failure of the procedure, bleeding esophageal ulcers, or esophageal stenosis. Esophageal peristalsis is an important problem when the endoscopist injects the sclerosant into the varices. This may cause the needle inside the vein to become unstable and be removed, and the endoscopic vision may become unclear during injection. In our clinical experience, decreased peristalsis of the esophagus can be observed in an underwater environment. To decrease peristalsis of the esophagus and improve the success rate of intravascular injection, we propose a method called underwater endoscopic injection sclerotherapy that requires filling up the esophageal lumen with water before sclerotherapy. A case involving a 57-year-old male patient with gastroesophageal Type 1 varices is described to illustrate the underwater endoscopic injection sclerotherapy.

Introduction

The use of water instead of gas insufflation for endoscopic treatment was proposed by Falchuk et al. in 1984 to solve technical problems caused by diverticulosis¹. In 2012, Binmoeller et al.² first practiced underwater endoscopic mucosal resection (UEMR), which is now widely used for the treatment of colonic lesions. In recent years, underwater endoscopy has been used to treat esophageal, gastric neoplasms and in peroral endoscopic myotomy (POEM)^3,4,5,6.

Gastroesophageal variceal bleeding (GEVB) is a common cause of upper gastrointestinal tract hemorrhage with a high risk of death⁷. Timely management of hemostasis and preventive hemostasis is important to improve the survival rate⁸. Endoscopic injection sclerotherapy (EIS) is a safe and effective way to treat gastroesophageal varices (GEVs), which is now widely used in treating acute bleeding and preventing rebleeding⁹. A meta study showed that the overall rebleeding rate of the sclerotherapy group was 33.1%, and the mortality was 24.6% (the mean follow-up period ranged from 6 to 34 months)¹⁰. Traditional EIS for GEVs includes intravascular and paravascular injection of sclerosant^11,12. The intravascular injection can induce thrombosis to block the varicose vein, while the paravascular injection forms a protective fibrotic layer to press the vein¹². However, paravascular injection might lead to esophageal ulcers, recurrent bleeding, and esophageal stenosis owing to incorrect injection technique or overdosing of the sclerosant¹¹. Precise intravascular injection can effectively reduce the risk of tissue necrosis¹³. Thus, it is essential to perform intravascular injection during EIS for GEVs.

In our clinical experience, esophageal peristalsis became a big problem when an endoscopist injects the sclerosant into the variceal vein, which causes the needle to become unstable, leading to the failure of intravascular injection. However, the obviously decreased esophageal peristalsis can be observed in an underwater environment. So, we proposed performing an underwater endoscopic injection sclerotherapy procedure, which fills up the esophageal lumen with water before sclerotherapy. The decreased esophageal peristalsis can improve the success rate of intravascular endoscopic injection.

CASE PRESENTATION:
This case involved a 57-year-old male patient with a history of hepatitis B virus cirrhosis for 10 years without active bleeding. He had no history of hepatic ascites or hepatic encephalopathy. His Child-Pugh score was 6, and his MELD score was 12. Four gastroesophageal Type 1 varices (GOV1) with red wale signs and no active bleeding were observed by the CT scan and endoscopy (Figure 1 and Figure 2A,B).

Protocol

The procedure was approved by the Second Affiliated Hospital of Soochow University, and written informed consent was obtained from this patient.

1. Preoperative steps

1. Exclude patients with contraindications for upper gastrointestinal endoscopy, uncorrectable diffuse intravascular coagulation (DIC) or multiple organ dysfunction syndrome (MODS), or allergy to lauromacrogol.
2. Perform CT scan and gastroscopy to diagnose GEVB or GEVs with high risk factors for bleeding.

2. Procedure

1. Preoperative preparation
   1. Position the patient in the left lateral position. Ensure the patient is under general anesthesia with endotracheal intubation.
2. Fill up the esophageal lumen with water.
   1. Before injecting the lauromacrogol into the varices vein, infuse the room temperature water to fill up the esophageal lumen through the endoscope.
   2. For patients with active bleeding, before infusing water, use clips or cyanoacrylate to stop the active bleeding. When using clips for hemostasis, press the clips against the bleeding point. When performing cyanoacrylate injection, ensure that cyanoacrylate is injected into the varices at the bleeding point.
3. Sclerotherapy injection
   1. Insert the 23 G needle on the anal side (inflow vein) of the varices (the lower esophagus).
   2. Then inject a mixture of 40 mL of lauromacrogol (10 mL per vial) and 2 mL of Methylene Blue (2 mL per ampoule) into the varices in an underwater environment with obviously decreased frequency and amplitude of esophageal peristalsis. After the injection of lauromacrogol, inject cyanoacrylate through the same needle to occlude the puncture site.
4. Inspection
   1. After the procedure is completed, check the esophagus again to ensure that all varices have turned blue after being filled with the mixture of lauromacrogol and Methylene, which means that the procedure has been completed successfully.
   2. Finally, draw out the water from the esophageal lumen with the endoscopy.

3. Postoperative care

1. After the procedure, routinely treat the patient with ceftizoxime 2 g (as the sodium salt) twice daily, somatostatin 3 mg (as the sodium salt) every 8 h for one dose, and esomeprazole 40 mg (as the sodium salt) every 8 h for one dose for three days for preventing rebleeding and infection.
2. Start the patient on a liquid diet on postoperative Day 2 without dysphagia.
3. Discharge the patient on postoperative Day 4 without complication.
4. In the follow-up, perform gastroscopy 3 months after discharge.

Results

After the procedure, no signs of rebleeding and no complications were observed during the follow-up period. Gastroscopy was performed 3 months after discharge and showed that the variceal elimination rate reached 100% (Figure 2F). The esophageal peristalsis decreased in the underwater environment.

Discussion

EIS has been used for the treatment of GEVs since the mid-1970s, as it can provide good hemostasis with a low rate of recurrence⁹. However, a higher rate of complications is associated with paravascular injection and the high volumes of sclerosant^14,15, including injection-induced bleeding, recurrent bleeding, esophageal ulcer, and esophageal perforation that can be observed after the procedure. In order to reduce the above-mentioned compl...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
EVIS LUCERA ELITE	QLYMPUS	CF-HQ290L/I
Injection Therapy Needle Catheter	Boston Scientific Corporation	23ga
Lauromacrogol Injection	Tianyu Pharmaceutical Co. Ltd.	H20080445
Methylthioninium Chloride Injection	JUMPCAN PHARMACEUTICAL GROUP CO.LTD	H32024827
Tissue Adhesive	B. Braun Surgical S.A	1050060