Esophageal Variceal Band Ligation as a Means of Eradicating Barrett’s Esophagus

Abstract

Introduction: Barrett’s esophagus (BE) is a precancerous condition involving intestinal metaplasia of the tubular esophagus. Eradication of BE can decrease the risk of progression to esophageal adenocarcinoma. Currently available endoscopic therapies for BE include band-ligation endoscopic mucosal resection (EMR), which has been used to excise focal areas of concern as well as entire BE segments. It is believed that, following removal of the metaplastic mucosa, neosquamous epithelium is generated in the absence of further acid exposure. We describe a case of band ligation without resection leading to partial BE eradication. A 61-year-old Caucasian male with known BE and a strong family history of esophageal cancer (2 brothers) presented for evaluation. Past history was notable for liver transplantation to treat alcoholic cirrhosis, complicated by portal vein thrombosis (PVT) and subsequent portal hypertension with development of varices. Upper endoscopy revealed ultra-long segment BE (C8M10 by Prague classification) without any dysplasia present on transepithelial brush biopsies performed in place of forceps sampling due to the presence of large esophageal varices and moderate thrombocytopenia. A gastric varix and portal hypertensive gastropathy also were seen. Given his BE segment length and family history, the decision was made to first eradicate his esophageal varices and then ablate his BE once the risk of variceal complications was minimized. A first round of endoscopic variceal band ligation was performed without difficulty. Within six days of the second banding procedure, the patient presented with acute upper gastrointestinal bleeding manifested by hematemesis and melena. Upper endoscopy demonstrated circular ulcerations at the banding sites without active bleeding. No intervention was performed at that time. Over the course of five weeks, recurrent life-threatening bleeding was treated with additional band placement, ethanolamine injections, and insertion of two Blakemore tubes. PVT precluded standard radiologic interventions, and ultimately an emergent surgical shunt was placed, followed by radiologic decompression of his portal vein and obliteration of his gastric varices. After these interventions, his bleeding ceased. Repeat endoscopy one month later showed resolution of the ulcerations with circular neosquamous islands at the banding sites. It is unclear if the band ligation itself or subsequent ulceration ultimately led to formation of the neosquamous epithelium. Further investigation is required to evaluate whether band ligation, which does not involve energy-mediated tissue trauma, could be an alternate method for BE eradication when more standard techniques are not possible.