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Background and study aims  The preferred management of bleeding esophageal varices includes endoscopic band ligation. Endoscopic ligation devices (ELDs) are expensive and designed for single use, limiting their uptake in developing countries. We aimed to assess the efficacy of reprocessing ELDs using terminal microbial cultures and adenosine triphosphate (ATP) testing. Materials and methods  ELDs were recovered after clinical use and their components (cap, handle, and cord) were subjected to reprocessing. This included manual cleaning, automated high-level disinfection (HLD), and drying with forced air. Using sterile technique, ELD components were sampled for ATP at three stages: before manual cleaning, after manual cleaning, and after HLD. Components were sent to an external laboratory for culturing. Cultures were interpreted as positive upon identification of Gram-negative bacilli. Results  A total of 14 clinically used ELDs were studied, and 189 ATP tests and 41 cultures were evaluated. Overall, 95 % (39/41) of components and 86 % (12/14) of ELDs were culture-negative or did not yield Gram-negative bacilli. Two components (5 %; one handle and one cord) harbored Gram-negative bacilli in quantities of 1 CFU per component. There was no apparent correlation between ATP at any juncture of reprocessing and terminal cultures. Conclusions  Reprocessing of ELDs is effective, resulting in infrequent and minimal microbial contamination. Microbial culturing can be used to ensure adequacy of ELD reprocessing if pursued. Until reusable ELDs are commercially available, continued efforts to better define the adequacy and long-term effects of reprocessing ELDs are needed., Competing Interests: Competing interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Colonic diverticular hemorrhage is the most common cause of lower intestinal bleeding. We tried to develop a convenient and reliable hemostatic method, endoscopic detachable snare ligation (EDSL), to treat diverticular hemorrhage and retrospectively explored its safety and efficacy., Patients and Methods: The definitive bleeding diverticulum was ligated with a detachable snare, instead of a rubber band, in a procedure similar to endoscopic band ligation. Removal of the scope to attach a ligation device and reinsertion for treatment are not needed in this method., Results: From November 2013 to September 2014, EDSL was used to treat 8 patients with colonic diverticular hemorrhage. The mean procedure time required for hemostasis after identification of the bleeding diverticulum was 5 ± 2 minutes. Sustained hemostasis was achieved in 7 patients (88 %), and early rebleeding occurred in 1 patient, in whom the applied suction seemed inadequate. No complications occurred in any patient., Conclusions: EDSL may be a safe and effective treatment for colonic diverticular hemorrhage. However, additional studies are warranted to confirm these initial exploratory data., (© Georg Thieme Verlag KG Stuttgart · New York.)

Colonic lipomas are benign adipose tumors that occasionally cause symptoms. Endoscopic resection of large lipomas may be associated with the risk of hemorrhage or perforation. Experience with endoscopic resection of colonic lipomas with the assistance of a prototype single-use ligating Endoloop device, with a detachable snare unit, has not been previously reported. Three patients with a total of four large symptomatic colonic lipomas successfully underwent endoscopic resection with the aid of this device. One patient had self-limiting minor rectal bleeding which settled without consequence. All patients were well on follow-up, with resolution of their symptoms. This novel endoscopic technique should be considered during resection of large lipomas (> 10 mm diameter) to reduce the potential risk of bleeding.

Background and Study Aims: Endoscopic band ligation (EBL) is currently considered to be the treatment of choice for esophageal variceal bleeding. This study reports on the efficacy and safety of EBL in patients with Dieulafoy-like bleeding lesions in the upper gastrointestinal tract., Patients and Methods: Between December 1994 and February 2000, 23 patients with upper gastrointestinal tract hemorrhage (median age 58, range 28-75) were treated using EBL. EBL was used as a rescue therapy in four patients and as the initial treatment in 19 patients., Results: The site of bleeding was the stomach in 10 patients, Billroth II anastomosis in 10, the first part of the duodenum in one, the second part of the duodenum in one, and the jejunum in one patient. Endoscopic band ligation was successful in 22 of the 23 patients. The remaining patient, a young man with a Dieulafoy-like lesion in the jejunum, had recurrent bleeding on day 5 after EBL and underwent elective surgery., Conclusions: Endoscopic band ligation is an effective and safe endoscopic treatment for Dieulafoy-like lesions. It is easy to use and relatively inexpensive.

Background and Study Aims: Variceal bleeding is a major cause of mortality in liver cirrhosis. Therapeutic options include medical (vasoconstrictive/vasoactive drugs) and endoscopic (sclerotherapy/ligation) treatments. Most studies evaluating acute esophageal bleeding have included patients with both ongoing and recent bleeding. Therefore therapeutic efficacy in ongoing bleeding may not have been adequately determined in these studies. A meta-analysis was performed for two reasons: first to compare directly the various treatments in the case of ongoing bleeding, as this would not be accomplished by a single trial, and secondly, to determine the success rates of each treatment option based on a larger number of patients., Methods: An extensive Medline search identified 13 randomized controlled trials with precise statements of the number of patients with ongoing bleeding and their clinical outcomes. All studies followed a similar design and a Q test excluded heterogeneity of the studies. Data were pooled and cumulative success rates were calculated., Results: Ligation appeared to be the most effective treatment (91.0 %, 95 % CI 82.4-96.3 %); it was significantly more successful than vasoconstrictive treatment (vasopressin/terlipressin 68.7 %, 61.7-75.2 %; P < 0.002, chi-squared-test) or vasoactive treatment (somatostatin/octreotide, 75.9 %, 68.1-82.6 %; P < 0.02) treatment, but was not statistically better than sclerotherapy (81.1 %, 71.7-88.4 %). The latter therapy was not statistically superior to medical treatment options. Calculations of estimated true effects, which take into account the weight of each study, rendered similar results., Conclusion: Ligation is the most effective treatment option. No significant difference was found between the efficacy of sclerotherapy and treatment with somatostatin or octreotide.

Background and Study Aims: Recent advances in endoscopic technology have led to the development of multiple-banding devices which avoid the use of an overtube in endoscopic variceal ligation. In the present study we prospectively examined the safety and efficacy of one such device compared with the conventional single-band ligator., Patients and Methods: A total of 45 patients undergoing band ligation were randomly assigned to receive ligation using conventional techniques (n = 22), or multiband ligation (n = 23)., Results: The use of the multiband device was associated with a significant reduction in sedation requirements (midazolam 7.1 mg vs. 9.9 mg, P < 0.01, multiband vs. conventional, respectively), less discomfort (4% vs. 23% severe discomfort, P < 0.05). The total time of the endoscopic session was reduced in the multiband group (8 minutes 25 seconds vs. 12 minutes 21 seconds, P < 0.01), as was the time required for application of all the bands (2 minutes 22 seconds vs. 5 minutes 34 seconds, P < 0.001), and average time taken per individual band application (36 seconds vs. 1 minute 36 secs, P < 0.01). In three patients who underwent ligation using the conventional method, the procedure was stopped because of trauma secondary to overtube application., Conclusions: Multiband ligation is safer, quicker, and associated with less patient discomfort and morbidity when compared with conventional ligation.

A new multiband ligator is presented which is fully reusable. Experience in 67 patients (22 with varices and 45 with early cancers undergoing mucosal resection) showed good technical function and no significant complications. Use of this device may significantly reduce the costs of endoscopic ligation.

Background and Study Aims: Endoscopic ligation (EVL) and endoscopic variceal sclerotherapy (EVS) are known to be equally effective in eradicating bleeding esophageal varices in patients with hepatic cirrhosis, but the long-term safety and efficacy of the two techniques have not been clearly established. The aim of this study was to determine the relative frequency of rebleeding, recurrence of varices, and survival after treatment with the two techniques during a relatively long follow-up period., Patients and Methods: A total of 111 patients without bleeding at the index endoscopy were randomly assigned to either EVL (n = 57) or EVS (n = 54). After eradication of the varices, the patients received endoscopic examinations every three months and for each episode of rebleeding., Results: The mean follow-up periods were 534 +/- 42 days in the EVS group and 496 +/- 40 days in the EVL group. The two techniques were equally effective in eradicating varices (93% in EVL group and 92.5% in EVS group). The mean number of sessions required to obtain eradication was slightly lower (mean +/- SE) in the EVL group (3.5 +/- 0.1 vs. 4.0 +/- 0.1, P = 0.004), while the time required for eradication was longer (33.8 +/- 2.1 vs. 27.3 +/- 1.4, P = 0.01). The comparison of the Kaplan-Meier estimates of survival and time to first rebleeding did not show any statistically significant differences between the two groups. The rate of complications was significantly higher in the EVS group than in the EVL group (31% vs. 11%, P = 0.001), while the rate of recurrent varices during follow-up was higher in the EVL group (30% vs. 13%, P = 0.03)., Conclusions: While the two techniques are equally effective, ligation treatment shows greater advantages in the short-term follow-up, but is associated with more frequent recurrence of varices in the longer term. These two aspects should be considered for evaluation in the cost-benefit ratio and quality of life analysis. All patients should have frequent endoscopic evaluations (every three or four months) throughout the first year of follow-up.

Background and Study Aims: Endoscopic variceal sclerotherapy (EVS) is a procedure frequently used to control bleeding from esophageal varices in adults. The use of EVS has been restricted in children due to the associated risks. The present paper describes the safety and efficacy of a new apparatus for endoscopic variceal ligation with clipping (EVLC)., Patients and Methods: Endoscopic variceal ligation using a clipping apparatus (HX-3 L, Olympus, Tokyo, Japan), was carried out in 12 children with portal hypertension (four with extrahepatic portal vein obstruction and eight with congenital biliary atresia; four boys and eight girls, age range 2-14 years). A total of 417 variceal clipping procedures were carried out in 56 separate EVLC sessions; 118 esophageal varices and 65 gastric fundic varices were ligated using 417 clips. Initially, the EVLC sessions were repeated at approximately monthly intervals until the varices were eradicated, but the interval was gradually extended to twice a year or once a year., Results: Varices were successfully ligated at the first attempt in 414 (99.3%) of the 417 clipping procedures. The esophageal varices were initially eradicated in all patients. The follow-up period ranged from nine to 48 months, and complete variceal eradication or reduction of the grade of the varices was obtained in 11 of the 12 patients after initial eradication during this period., Conclusions: These data indicate that EVLC offers advantages in the treatment of patients with esophageal varices combined with gastric fundic varices.

Background and Study Aims: Rubber-band ligation is superior to sclerotherapy, and is considered to be the endoscopic treatment of choice for bleeding varices. The single-shot mechanism of the ligation device generally used is inherently inefficient, and makes the procedure tedious. It also requires overtube placement, associated with discomfort and complications. This study describes the Saeed Six-Shooter, a multiple ligation device., Patients and Methods: Twenty-seven consecutive patients with variceal bleeding were prospectively studied. After initial endoscopic ligation, subsequent sessions were every 7-10 days. The parameters studied were the ease of use, the ability to control active bleeding and eradicate varices, survival, and complications., Results: Active bleeding was controlled in all seven (100%) patients. Esophageal varices were eradicated in 70% (3.2 +/- 1.2 sessions), and gastric varices in 88% of patients (2 +/- 1.2 sessions). Five patients re-bled, two from esophageal varices, two from gastric varices, and one from treatment-induced ulcer. There were four deaths, none due to exsanguination. A single complication, esophageal stricture, resolved with balloon dilation. Intubation was no more difficult with the endoscope loaded with the Six-Shooter than with the endoscope alone (P > 0.3). Six ligations were performed in 39% of cases within 60 seconds, and in 74% of cases within 90 seconds. For gastric varices, the device was effectively used with the endoscope retroflexed., Conclusions: The Saeed Six-Shooter is a safe and efficient instrument for the endoscopic ligation of varices, and has overcome the limitations of the single-shot ligator.

We present here a modified technique for endoscopic mucosal resection using the technique of esophageal variceal ligation for minute gastric cancer. This method of endoscopic mucosal resection requires only the commonly-used one-channel endoscope, an esophageal variceal ligation device, and some clinical experience with the ligation of esophageal varices and snare polypectomy. It can therefore be considered technically simple and safe. We treated four patients with minute gastric cancer using this endoscopic mucosal resection technique. All tumors were completely resected without major complications. Resected specimens were 1.0-1.5 cm in diameter, sufficient for histopathological evaluation, and curative resection was achieved in all patients.

A new technique of endoscopic treatment for gastric varices is presented here, which was applied in 10 patients, either electively (n = 9) or as emergency therapy for bleeding (n = 9) or as emergency therapy for bleeding (n = 1). A detachable snare is placed endoscopically, tightened around the varix, and then detached using a similar principle to that of band ligation. Following one or two treatment sessions (one snare applied in seven cases, two snares applied in three cases), eradication of gastric varices was observed in all patients. No significant complications were encountered, and nine of 13 snares passed spontaneously, the remaining ones being removed when found during follow-up endoscopy. Short-term follow-up (4-12 months, mean: 7.2 months) did not show either reappearance of varices or rebleeding in any of the patients. Angiography and endoscopic ultrasonography performed in four patients before and after treatment showed regression or disappearance of intramural vessels. Further studies will show the relative value of this new technique compared to other treatment modalities such as banding or cyanoacrylate injection.