Endoscopic ligation for benign and malignant lesions of upper digestive tract

Yu Long Chen,  Yong Zhong Chen,  Jian Xiang Zou,  Xue Li Li

Subject headings  esophageal and gastric varices;polyp;liver neoplasms

Chen YL, Chen YZ, Zou JX, Li XL. Endoscopic ligation for benign and malignant lesions of upper digestive tract.
China Nati J New Gastroenterol, 1997;3(3):195-196



INTRODUCTION
Endoscopic techniques have been used to treat variceal haemorrhage for over 50 years and now accepted as the first line treatment for esophageal varices bleeding. While injective sclerotherapy can control haemorrhage in approximately 90% cases, rebleeding may occur in up to 55%^£Û1£Ýand its complication rates being up to 40%^£Û2£Ý. In the light of these problems, better endoscopic treatment for the control of variceal haemorrhage has been studied continuously. Banding ligation was first reported in humans in 1990^£Û3£Ý, and has become  an important development in endoscopic therapy. The clinical practice showed that ligation management for esophageal varices has reliable effect. Enlightened  by the mechanism of ligation we used this method to resect polyp and early stage cancers of upper digestive tract, with satisfactory results.

PATIENTS AND METHODSª¤

Patients
One hundred and four patients received endoscopic ligation. Of these patients, 78 had variceal heamorrhage (including 4 patients with primary hepatic cancer, 10 reª²bleeding after resection of spleen and 2 re-bleeding after TIPS operation. Bleeding frequency of these patients differed from 1 to 8 times/year before li gation treatment averaging 2.35 times/year); 21 had polyp of upper digestive tr act (14 cases at the gastric antrum, 4 at the gastricª²body, 2 at the lower esop hagus, 1 at the duodenum. Morphologically, the polyp was classified into three types, i.e., long pedunculated, subª²pedunculated and thick, with a diameter of 0.3cm-0.9cm); and 5 had early stage cancer (2 early esophageal cancer, 3 cases gastric antral cancer in situ).

Methods
Endoscope (Olympus XQ10 XQ20) and ligation device, either plastic or stainless s teel were used. Other equipment included a silicon rubber band (used in ligation), trip wire, inner and outer-cylinder.The ligation device, which was fixed at the end of endoscope, was plunged into digestive tract, and approached to the lesion. After the lesion was sucked into l igation device, the prestressed rubber band was released over the entrapped lesi on by pulling the trip wire and the lesion was then ligated. All the patients un dertook reª²examination by endoscope and followed up for more than one year, the  therapeutic effect was evaluated by endoscopic observation and histopathologica l examinations.

RESULTS
Most of the 78 esophageal variceal patients undergoing ligation, were cured except 4 who died because the treatment did not stop the progress of the disease. The effectiveness was up to 94.8% (74/78, Table 1). Average bleeding frequency decreased from 2.35 times/year before treatment to 0.15 times/year after treat ment. Only 4 patients felt slight dysphagia and no other complications were observed.
Table 1  Ligation compared with sclerotherapy for the variceal bleeding

B-T: before treatment; A-T: after treatment; LT: ligation treatment; ST: sclerotherapy
    Table 2 shows the time of polyp and early stage cancers sloughing off, which ranged from 4 to 10 days after endoscopic ligation. The rate of lesions disappeara nce was up to 100%. In the cancer patients undergoing ligation, biopsies show ed no malignant cells in the resected specimen after ligation. A small ulcer was left in 18 cases after the lesions sloughed off, which usually healed 10 days later and no subsequent bleeding and recurrence of lesions were observed. The histopathological examination showed some inflammatory cells infiltration  at the site of wound, but no necrosis was observed.
Table 2  The sloughing off time for the ligated polyp and early cancers

TP: thick polyp; SP: sub pedunculated polyp; LP: Long pedunculated polyp. ¹No cancerous cells were found in the resected specimen of 5 early stage cancers.

DISSCUSSION
Banding ligation was the most important development in endoscopic therapy. We have carried out the endoscopic ligation (EL) for esophageal variceal bleeding since 1992, which showed a broad prospect. We made a comparative study on the banding ligation and sclerotherapy for management of esophageal variceal bleeding. The results indicated that EL was characterized by high effectiveness, quick recovery and low rebleeding rate. In the 78 patients undergoing the ligation for esophageal variceal bleeding, the number of treatment and treatment duration were reduced significantly in comparison with the conventional sclerotherapy. In addition, EL has fewer complications, in this study only 4 patients felt slight dysphagia and other complications occuring in sclerotherapy, such as fever, pleura infiltration and esophagus stricture were not observed.
    In comparison with portacaval shunt operation, EL has no effect on blood flow of liver. If splenic hyperfunction was not so obvious to perform splenectomy, EL can take the place of portalazygos disconnection in a sense. For rebleeding patients after portacaval shunt or portalazygos disconnection, EL is of first choice because of the advantages of safety, convenience and causing no injuries. We also treated 2 patients undergoing Tips operation and got satisfactory results.
    Endoscopic ligation treatment is a recently developed method for gastroenteric polyp and early cancer resection. Ligation by itself can block the blood flow to the polyp and cancer, and induce lesion ischemia or tissue necrosis, which make the ligated lesions falling off eventually. A very small ulcer could be found after lesions fell off, the ligation procedure was a progressive process, in which, tissue damage and healing occurred almost simultaneously when stretched silicon rubber band recovered.
   The methods should vary with different morphological types of lesion, similar to microwave resection^£Û4£Ý. For the sub pedunculated and thick polyp, th type of ¡°O¡± rubber band should be used and released at the base of polyp (so d id early stage cancer), while for the long pedunculated polyp, segmental ligatio n is performed. In the polyp with longer pedicle, the type of ¡°U¡± ligation met hod was applied to the polyp, which allowed ligation device approach to the conj unction of the polyp base and pedicle, suction was then made through the endosco pe and the rubber band was released over the entrapped polyp (¡°U¡± shape).
   The authors suggested that ligation management should be selected for the resection of early stage cancers of upper digestive tract, especially those in situ, which can relieve patients¡ä sufferings from operation. Once malignant cells were observed histopathologically, ligation should be made within 24 hours after biopsy so as to gurantee correct site of ligation. If esophageal cancer was confirmed, it may be stained with Lugol¡äs solution and then ligated at the lightly stained site^£Û5£Ý. Followª²up must be made regularly by endoscopy and histopathology after ligation treatment.
   The scaling time of the lesion depends on the hardness of lesion and the elasticity of ¡°O¡± rubber band, it is short in soft lesions with ¡°O¡± rubber band of better elasticity.
   The present inner cylinder available in markets usually has a diameter of 0.9cm, if the polyp is too large it can not be sucked into the device. Furthermore, the method is limited to colon polyp because of no colonoscope matched ligation device. The endoscopic ligation method, therefore, still need to be further deve loped.

REFERENCES
1  MacDougall BD, Westaby D, Theodossi A, Dawson JL, Williams R. Increased long-term survival in variceal haemorrhage using
    injection sclerotherapy: results of a controlled trial. Lancet, 1982;1(1):124-127
2  Schuman BM, Beckman JW, Tedesco FJ, Griffin JW, Assad R. Complications of injection sclerotherapy: a review. Am J
    Gastroenterol, 1987;82(5):823-829
3  Stiegmann GV, Goff JS, Sun JH, Hruza D, Reveille RM. Endoscopic ligation of esophageal varices. Am J Surg, 1990;159(1):21-26
4  Chen YL, Li JC and Tian DF. Studies on the endoscopic microwave method for gastroenteric-polyp resection.
    Endoscope, 1990;7(4):212-213
5  Yang CJ, Ren X, Tan CH, Zhu EQ, Zhu CN, Wang CJ. Evaluation of diagnosing esophageal lesions diagnosed with Lugol-s
    solution staining. Endoscope, 1995;12(4):195-197

¹Department of Gastroenterology, The First Affiliated Hospital of Henan Medical University, Zhengzhou,450052,Henan Province,China
²Department of Pathology, People¡äs Hospital of Henan Province, Zhengzhou 450003, Henan Provice, China
Correspondence to Dr. Yu Long Chen, Professor, having 30 papers and 3 books published.
Tel:0371¡¤3921761.
Received 1996-08-08  Revised 1996-09-02