Journal List > Korean J Gastroenterol > v.72(4) > 1106222

Kim, Cho, Jun, Son, Lee, Park, Cho, Park, Kim, Choi, and Rew: Risk Factors and On-site Rescue Treatments for Endoscopic Variceal Ligation Failure



The success rate of endoscopic variceal ligation (EVL) is about 85–94%. There is only a few studies attempting to determine the cause of EVL failure, and to date, on-site rescue treatments remains unestablished. This study aimed to elucidate the risk factors for EVL failure and the effectiveness of on-site rescue treatment.


Data of 454 patients who underwent emergency EVL at Chonnam National University Hospital were retrospectively analyzed. Enrolled patients were divided into two groups: the EVL success and EVL failure groups. EVL failures were defined as inability to ligate the varices due to poor endoscopic visual field, or failure of hemostasis after band ligation for the culprit lesion.


Forty-seven patients experienced EVL failure. In the multivariate analysis, male patients, initial hypovolemic shock, active bleeding on endoscopy, and history of previous EVL were independent risk factors for EVL failure. During endoscopic procedure, we came across the common causes of EVL failure, including unsuctioned varix due to previous EVL-induced scars followed by insufficient ligation of the stigmata and inability to ligate the varix due to poor endoscopic visual field. Endoscopic variceal obturation using N-bu-tyl-2-cyanoacrylate (48.9%) was the most commonly used on-site rescue treatment method, followed by insertion of Sangstaken Blakemore tube (14.9%), and EVL retrial (12.8%). The rescue treatments successfully achieved hemostasis in 91.7% of those in the EVL failure group.


The risk factors of EVL failure should be considered before performing EVL, and in case of such scenario, on-site rescue treatment is needed.


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Fig. 1.
(A) Endoscopic picture of the SRH (black arrow) adjacent to the previous EVL induced ulcer scar (white arrow). (B) Insufficient ligation of the varix due to the adjacent EVL scar. (C) Insufficient ligation of the varix with SRH (black arrow) out of the EVL band. SRH, stigmata of recent hemorrhage; EVL, endoscopic variceal ligation.
Fig. 2.
Endoscopic findings of rescue treatments for EVL failure. (A) The varix was insufficiently ligated due to previous EVL induced scar.(B) Immediate spontaneous detachment of the EVL band and blood oozing from the varix was noted. (C) Glue was injected into the bleeding varix with immediate hemostasis. (D) In another patient, retrial of EVL achieved successful hemostasis after EVL failure (note two EVL bands over the varix, white arrows). EVL, endoscopic variceal ligation.
Fig. 3.
Flow chart of the on-site rescue treatments for EVL failure. EVL, endoscopic variceal ligation; EVO, endoscopic variceal obturation; TIPS, transjugular intrahepatic portosystemic shunt; SB tube, Sengstaken– Blakemore tube.
Fig. 4.
Relationship between the numbers of EVL session and EVL failure. EVL, endoscopic variceal ligation.
Table 1.
Baseline Clinical Characteristics of the Enrolled Patients and Comparison of Characteristics between the EVL Failure and EVL Success Groups
  Total enrolled patients (n=454) EVL failure group (n=47) EVL success group (n=407) p-value
Sex (male) 386 (85) 45 (95.7) 341 (83.8) 0.03
Age (years) 59.0±11.3 58.6±11.4 59.0±11.3 0.84
Cause of cirrhosis        
HBV/HCV/HBV+HCV/ 118 (26)/63 (13.9)/1 (0.2)/ 8 (17)/7 (14.9)/0 (0)/ 110 (27)/56 (13.7)/1 (0.2)/ 0.73
   alcohol/others 248 (54.6)/24 (5.3) 30 (63.8)/2 (4.3) 218 (53.6)/22 (5.4)  
CPT classification        
   A/B/C 114 (25.1) /258 (56.8) /82 (18.1) 12 (25.5)/27 (57.4)/8 (17.0) 102 (25.1)/231 (56.8)/74 (18.2) 0.98
CPT score 7.8±1.8 7.7±1.8 7.9±1.8 0.55
MELD score 11.9±3.9 12.8±4.1 11.8±3.9 0.09
APRI score 4.4±10.4 3.2±4.4 4.6±10.9 0.38
Form of EV        
   F1/F2/F3 5 (1.1)/107 (23.6)/ 342 (75.3) 0 (0)/10 (21.3)/37 (78.7) 5 (1.2)/97 (23.8)/305 (74.9) 0.68
Active bleeding on endoscopy 185 (40.7) 36 (76.6) 149 (36.6) <0.01
   Oozing/spurting 73 (16.1)/112 (24.7) 14 (29.8)/22 (46.8) 59 (14.5)/90 (22.1)  
Inactive bleeding on endoscopy (SRH) 269 (59.3) 11 (23.4) 258 (63.4) <0.01
Previous history of EVL 219 (48.2) 37 (78.7) 182 (44.7) <0.01
Associated PVT 108 (23.8) 16 (34) 92 (22.6) 0.08
Associated HCC 82 (18.1) 5 (10.6) 77 (18.9) 0.16
Initial hypovolemic shock k 194 (42.7) 28 (59.6) 166 (40.8) 0.01
Initial Hb (g/dL) 9.0±2.1 9.1±2.0 9.0±2.1 0.66
Initial PLT count (/mm3) 82.3±46.4 83.6±65.7 82.1±43.8 0.84
Bleeding related death 32 (7.0) 6 (12.8) 26 (6.4) 0.11

Values are presented as mean±standard deviation or n (%).

EVL, esophageal variceal ligation; HBV, hepatitis B virus; HCV, hepatitis C virus; F, form; CPT, Child-Pugh-Turcotte; MELD, model for end-stage liver disease; APRI, AST to platelet ratio index; EV, esophageal varix; SRH, stigmata of recent hemorrhage; PVT, portal vein thrombosis; HCC, hepatocellular carcinoma; Hb, hemoglobin; PLT, platelet.

Table 2.
Univariate and Multivariate Analyses of Potential Risk Factors for EVL Failure
Variable OR 95% CI p-value
   Univariate analysis 4.36 1.03–18.39 0.045
   Multivariate analysis 4.44 1.01–19.52 0.048
Age (years)      
   Univariate analysis 1.00 0.97–1.02 0.84
MELD score      
   Univariate analysis 1.06 0.99–1.14 0.10
Initial hypovolemic shock      
   Univariate analysis 2.14 1.16–3.96 0.02
   Multivariate analysis 2.01 1.04–3.87 0.04
Active bleeding on endoscopy      
   Univariate analysis 5.68 2.80–11.47 <0.01
   Multivariate analysis 5.12 2.49–10.55 <0.01
Previous history of EVL      
   Univariate analysis 4.57 2.22–9.45 <0.01
   Multivariate analysis 4.18 1.97–8.86 <0.01
Associated PVT      
   Univariate analysis 1.76 0.92–3.36 0.09

EVL, esophageal variceal ligation; OR, odds ratio; CI, confidence interval; MELD, model for end-stage liver disease; PVT, portal vein thrombosis.


Chung Hwan Jun

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