Use of the Six-Shooter Ligation Device in the Management of Bleeding Esophageal Varices: A Developing-Country Experience

Abstract

Endoscopic variceal ligation has emerged as a superior alternative to endoscopic injection sclerotherapy, however, the "single-shot" mechanism of the generally used Stiegman-Goff ligator made the procedure tedious and time-consuming and required overtube placement, associated with discomfort and potentially life-threatening complications. In this study we describe our experience with the Saeed Six-Shooter (multiple-ligation device). Fifty consecutive patients with variceal bleeding were prospectively studied. After initial endoscopic ligation, subsequent sessions were every 2 weeks. Study outcomes were: the ability to control active bleeding, the frequencies of rebleeding, the number of treatment sessions and time required for irradication, the percentage eradication of varices, complications, and mortality. Active bleeding was controlled in all eight (100%) patients. Four (8%) patients rebled, three from esophageal varices, and one from portal hypertensive gastropathy. Esophageal varices were eradicated in 47 (94%) patients (3.1 +/- 1.3 sessions). Time needed till eradication was 6.2 +/- 1.9 weeks. Chest pain was reported in two (4%), low, grade pyrexia in two (4%), and pneumonia in one (2%) patient. There were three deaths, none due to exsanguination. The Six-Shooter is a safe and efficient device for the endoscopic ligation of esophageal varices which has overcome the limitations of the single-shot ligator: (1) Visualization is better (the endoscopic "tunnel vision" and internal light reflection from the stainless-steel banding cylinder of the single-shot device are avoided); and (2) the use of an overtube is no longer necessary and serious complications can be avoided.

A Prospective Randomized Study on the Risk of Bacteremia in Banding versus Sclerotherapy of Esophageal Varices

“…Limitations of our study include the relatively small numbers of patients in each group and limited power for the demonstration of statistically significant differences. This study was initiated soon after the introduction of the single band ligator and, therefore, did not study the risk of bacteremia after EVL using current multiband ligators ( 30 , 31 ). However, most studies of bacteremia after banding have been done with single band ligators, so that the data on bacteremia after multiband esophageal ligation are limited, and none of the studies utilize the current equipment popular in the United States.…”

New Developments in Managing Variceal Bleeding

“…For the next procedures, a 1-week ligation interval is often recommended. 24 The decision regarding ligation intervals may be individualized based on physician and patient preferences and local logistics and resources.…”

Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication

“…Despite initial scepticism and concerns that EVL would prove less effective than sclerotherapy in achieving control of actively bleeding varices as blood or clot filling the cap during profuse bleeding may obscure vision and limit accurate band deployment, there were very few failures of acute hemostasis in this study. In three small non-randomized studies by El-Saify[ 16 ], Saeed[ 17 ] and Hou[ 18 ], active variceal bleeding control was reported in 100% of patients. Patient numbers in these studies, however, were small and there was no consistency in the definition of duration of control of active bleeding.…”