Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices: Which is better?

Abstract

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies. Moreover, the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

Key Words: Gastric varices, Esophageal varices, Endoscopic band ligation, Endoscopic tissue adhesive injection, Endoscopic ultrasound

Core Tip: Deng et al proposed individualized treatment for type 1 gastric varices according to the different severity of varicose veins. However, the diagnosis of type 1 varicose veins by conventional endoscopy may not be accurate. The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies. The esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

TO THE EDITOR

We read with great interest the article by Deng et al[1] regarding a retrospective study evaluating the efficacy and safety of endoscopic band ligation (EBL) in the treatment of bleeding from type 1 gastric varices. Although there is currently no uniform standard for the endoscopic treatment of type 1 gastric variceal hemorrhage (GOV1), additional previous studies have shown that endoscopic tissue adhesive injection (TAI) appears to be a better therapeutic option[2]. For the first time, Deng et al[1] proposed individualized treatment for type 1 gastric varices (GVs) according to the severity of the varicose veins: EBL for mild to moderate varicose veins and TAI for severe conditions. These findings provide a new strategy for the treatment of bleeding from type 1 gastric varices. We congratulate them on their discovery, but there are several important issues that need to be explored further.

First, the diagnosis of type 1 varicose veins by conventional endoscopy may not be accurate, especially for mild varicose veins, where the diameter of rectilinear or slightly tortuous varices is < 3 mm. Prominent gastric folds might affect the evaluation of submucosal GVs, where endoscopic ultrasound (EUS) of high-frequency miniprobes may increase the sensitivity of identifying the minimal GV and provide an accurate preoperative assessment[3]. In predicting rebleeding after GOV1 endoscopic treatment, high-frequency intraluminal ultrasound measurements are also more accurate than esophagogastroduodenoscopy[4]. Therefore, the combination of EUS with endoscopic treatment of GOV1 may improve the robustness and generalizability of the findings in future studies.

Moreover, the efficacy of this study was evaluated only by the disappearance of gastric varices, not by the presence of esophageal varices, most of which are connected to GVs and reflect the therapeutic effect of type 1 varices. Qin et al[5] also demonstrated that esophageal varices could be alleviated or prevented by sufficient endoscopic selective varices devascularization, which reduced the rebleeding rate. Therefore, we suggest that esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

In summary, both ligation and tissue glue injection might be effective in the treatment of type 1 gastric varicose veins, but further prospective studies are needed to confirm which is better.