Endoscopic findings and overtube-related complications associated with esophageal variceal ligation

Esophageal variceal ligation (EVL) has emerged as a popular alternative to endoscopic sclerotherapy (ES), with equal efficacy as ES in control of active bleeding, rebleeding rate, and variceal eradication. The complication rate for EVL has been reported lower than for ES in several clinical trials. However, several unique complications inherent to EVL have been recognized. Overtube injury to the pharynx and proximal esophagus has been the most serious complication. Transient vocal cord paralysis, cricopharyngeal perforation, proximal esophageal laceration, varix rupture, and free esophageal perforation have also been reported. Direct banding-induced complications have been limited to rebleeding from banded ulcers, transient esophageal obstruction, and simple strictures. Pulmonary as well as serious systemic complications have yet to be reported. We report four complications of EVL, review the literature, and suggest strategies for the recognition, management, and prevention of EVL complications.