Hemodynamics of esophageal varices on three‐dimensional endoscopic ultrasonography and indication of endoscopic variceal ligation

Abstract

Background: Esophageal varices are treated by endoscopic variceal ligation or sclerotherapy, but the indications for each procedure are not standardized. The present study was designed to determine the indication of endoscopic variceal ligation based on vascular pattern classified by 3‐dimensional endoscopic ultrasonography (3‐D‐EUS).Methods: The pattern of variceal blood flow detected on 3‐D images was classified into type 1 (cardial‐inflow without paraesophageal veins), type 2 (cardial‐inflow with paraesophageal veins), type 3 (azygos‐perforating pattern) and type 4 (complex pattern). 3‐D‐EUS was performed in 89 patients with esophageal varices. Subsequently, ligation was performed in 44 patients, while sclerotherapy with 5% ethanolamine oleate was applied in 45 patients in a prospective randomized trial. Clinical outcome was assessed.Results: Based on the 3‐D‐EUS data, 41 patients (46.1%) were classified as type 1, 12 (13.5%) as type 2, seven (7.9%) as type 3 and 29 patients (32.6%) as type 4. The cumulative recurrence‐free probability at 24 months after treatment was 28.9% for ligation versus 71.1% for sclerotherapy (P < 0.05) in type 1, while the respective probabilities were 72.9% versus 50.0% (NS) for type 2 varices, 100% versus 100% (NS) for type 3 varices and 61.9% versus 64.8% (NS) for type 4 varices.Conclusions: Classification of the vascular pattern of esophageal varices by 3‐D‐EUS enabled us to clarify the criteria for selection of endoscopic procedure. Ligation is indicated for patients who have collaterals, such as paraesophageal veins running parallel to the varices, as the blood flow can be diverted to these blood vessels and controlled by localized ligation.