Greetings, let us learn about band ligator. Band ligator is like putting a ligature and here you can see the application of band ligator to ligate esophageal varices to prevent bleeding as well as treat bleeding. In addition to esophageal variceal bleeding control, band ligator has also been used in the control of arterial bleeding. Here is an example of band ligation of diverticular bleeding. It has also been used for management of dullafoil bleeding as well. Another application of band ligation is in resection of flat lesions. Here is an example of band ligation followed by resection of Barrett's mucosa. Band ligation EMR has also been used to manage rectal carcinoids. So among all the different uses, band ligation of varices is used quite often in practice and before we learn about band ligation of varices, let us take some time to learn about how varices form and thereby you can understand better how to use band ligation. Here is a normal anatomy of the portal venous system. Portal vein drains blood from the gastrointestinal tract and also portal vein drains blood from the spleen. So let us look at the blood flow. So here is a splenic vein that is draining blood from the spleen and the splenic vein also drains blood from the left portion of the colon and that dumps blood via the inferior mesenteric vein. So the splenic vein goes and joins the superior mesenteric vein to form the portal vein and the portal vein, like any vein, once it goes into the liver, it branches, becomes capillaries and supplies the liver cells and then from the liver, hepatic veins start draining the liver and then they enter the inferior vena cava and the inferior vena cava goes into the right atrium. Two systems of veins are very important in esophageal varices and these are right and left gastric veins which drain into the portal vein. So we have learned about portal venous system and let us take a little bit of a deep dive into the liver lobule to understand the flow of blood from the portal vein to the hepatic vein. So here is a liver lobule. It's a normal liver lobule. You have portal triads consisting of portal vein, hepatic artery and hepatic ducts. The blood flow from the portal vein reaches the central vein via a bunch of sinusoids. The flow of blood from the portal vein goes to the central vein. From the central vein, it goes into the hepatic vein branches and finally the hepatic veins and the inferior vena cava. In cirrhosis of the liver, the liver lobular architecture is destroyed and there is resistance to the flow of blood from the portal vein to the central vein and there is also development of communications between the veins and the arteries, portal venous system and hepatic arterial system and these disturbances increase the pressure in the portal venous system and increase in pressure in the portal vein lead to the development of varices. So let us look at the anatomy of the esophageal varices in a little more detail. So here is the lower esophagus and let us look at it in magnification and as you can see here, the venous anatomy, understanding the venous anatomy of the GE junction and lower esophageal segment of the esophagus is critical. So you have with portal hypertension, the adventitial veins become bigger, the perforator veins become bigger and the deep venous plexus inside the esophageal wall, especially in the submucosa, become bigger and they develop as varices. The perforators are maximum closer to the GE junction, hence you see large varices developing at the GE junction and as you go up the esophagus from the distal esophagus to mid to proximal esophagus, the size of the veins become smaller. Learning this anatomy of especially the importance of the perforator veins, the distribution of the perforator veins and the density of the perforator veins closer to the GE junction is very important for endoscopists. Larger perforator veins, denser amount of perforator veins in the lower esophagus allows the esophageal varices in the lower esophagus to become very big and once the veins become very big, they are at high risk for bleeding. So here are large esophageal varices and as the veins become larger, sometimes the wall becomes thinner and you could see the blood in the vein as red veiled spots or red veiled signs and these are signs of increased risk for bleeding. These large esophageal varices with red veiled signs can rupture and cause vomiting of blood otherwise known as hematemesis or the blood can go down the GI tract and the patient can present with either melanoma that is dark black stool or if there's a lot of bleeding at one time to the point of shock, they can even pass bright red blood per rectum otherwise known as hematopoietia and these setbacks could be prevented by using band ligation of the esophageal varices. They prevent bleeding, they're also useful in treating active bleeding and prevent re-bleeding. So now let us learn about how do you set up a band ligator. A band ligator set, there are several different types of band ligators. For this example, I'm going to use one that we have been using routinely in our lab and here is a band ligator. This is the control handle and then you have a loading catheter and then you have a trip wire with band ligators attached to the cap and an irrigation adapter. So let us learn about band ligator first. This is a control handle and as you can see here, there are two marks, a two-way mark and a firing mark. If the band ligator is in a two-way position, it allows us to set up the band ligator because the band ligator can, the wheel can move in both clockwise and anticlockwise direction, makes it favorable for setting up the band ligator and also allows us to introduce the endoscope because it doesn't make the tip stiff. So that is having the band ligator in a two-way position. If you press the band ligator against the control handle, the head against the control handle, it goes into firing position. When it is in firing position, it only moves in the clockwise direction, allows the bands to be deployed. So the key is when you want to set up the band ligator, keep the knob in a two-way position and this allows the loading of the device. So I'm repeating it because it's very important to understand the concept of two-way position and firing position. You take the handle and insert into the biopsy port and once you insert into the biopsy port, next you've taken the irrigation adapter and puncture the seal with the irrigation adapter and that allows you to insert the loading catheter into the channel easily. So you push the loading catheter down the biopsy channel and you push it until the loading catheter comes out of the endoscope. And once it comes out, you take the trigger card attached to the band ligator and attach it to the loading catheter. And once you attach it, you remove the loading catheter and the trigger card through the channel. And once you have the trigger card out, you load the trigger card into the notch on the device and anchor the knot onto the groove and rotate the knob clockwise to wrap the trigger card around the device. By this time, you could attach the band ligator cap to the distal tip of the endoscope. One thing that is important is to make sure the trigger card is not in the middle of the view. So you could rotate the cap to align the trigger cards to be in line with the biopsy channel. So that is very important so that when you go down with the scope, you have a beautiful view, although view with the cap is limited. So you have the endoscope with the cap and bands attached to the distal end, and the band ligator handle is at the biopsy port. So before you introduce the scope, you want to keep the band ligator handle in the two-way position. This is very important. If you put it in the two-way position and you move your up-down knob, the tip of the scope will move easily because the trigger card can move forwards and backwards without restriction. On the other hand, if you try to do this thing in the firing position and want to introduce the endoscope, first of all, the scope becomes stiff and it is dangerous. It is dangerous to insert the endoscope into the mouth with the band ligators set up in the firing position. I've heard about cases where somebody accidentally put a band into the pharynx or into the vulva because they introduced the band ligator into the mouth in the firing position. So important step. When, as an endoscopy assistant, gives the scope to the endoscopist, keep the band ligators set up in the two-way position, not in the firing position. Once the endoscopist pushes the scope down the esophagus to the GE junction, then he will put the band ligator in firing position before he fires the bands. We have the scope and coming to the GE junction in firing position, the band ligator in firing position, and you rotate in clockwise direction and the band gets released. That's how bands are placed. It is important to start placing the bands as close to the GE junction as possible. I preferably start putting it at the Z-line or the squamous columnar junction, at the GE junction, I should put it, and then I focus my next bands in the lower esophagus, in the lower five centimeters. That's where most of the perforators are there, providing large amounts of blood supply and feeding those veins to form. There's no point in putting bands in the middle, third or upper esophagus. So variceal banding, if you're planning to do to prevent bleeding after seeing large varices or varices with the red veil signs, the American Society for Liver Diseases, American Association for Liver Diseases, recommends banding at two to eight week interval until your varices are completely obliterated. If a patient presents with bleeding and you control the bleeding with banding, then at one to four week interval until the varices are completely obliterated. So what are the side effects of banding? It's important to share with the patient that they may have some chest discomfort for a few days and they may have some difficulty swallowing for a few days. Rarely, bands can fall off prematurely and can cause bleeding. That is very rare. Patients who undergo band ligation are typically advised to be on liquids for the first day or so and recommended to take proton pump inhibitors also to allow the band ligation ulcers to heal faster. So we covered band ligation of varices and let us look at other applications of band ligation. That is band ligation, EMR in patients with barrett's esophagus. In this case, you again use a multiband ligator, although you see in the image a single band and people may decide to put the band straight or some people may do a little bit of injection and then put a band followed by snare resection and extend the amount of resection that need to be done by applying more bands and repeating the steps. Band ligation can also be used for treating bleeding from different arterial sources, either a malary wide stair bleed or dullify bleed or diverticular bleed. These are, these users have been reported in different cases, but the approved indication is mostly for variceal banding. So here is a band ligation of a diverticular bleeding. So you go in, you suck the diverticulum and place the band and the diverticulum gets inverted and the band catches on the bleeding vessel. I hope this is useful. Thank you.

band ligators

medical procedures

blood vessels

esophageal variceal bleeding

portal venous system