Use of the six-shooter ligation device in the management of bleeding esophageal varices: a developing-country experience

Endoscopic variceal ligation has emerged as a superior alternative to endoscopic injection sclerotherapy, however, the "single-shot" mechanism of the generally used Stiegman-Goff ligator made the procedure tedious and time-consuming and required overtube placement, associated with discomfort and potentially life-threatening complications. In this study we describe our experience with the Saeed Six-Shooter (multiple-ligation device). Fifty consecutive patients with variceal bleeding were prospectively studied. After initial endoscopic ligation, subsequent sessions were every 2 weeks. Study outcomes were: the ability to control active bleeding, the frequencies of rebleeding, the number of treatment sessions and time required for irradication, the percentage eradication of varices, complications, and mortality. Active bleeding was controlled in all eight (100%) patients. Four (8%) patients rebled, three from esophageal varices, and one from portal hypertensive gastropathy. Esophageal varices were eradicated in 47 (94%) patients (3.1 +/- 1.3 sessions). Time needed till eradication was 6.2 +/- 1.9 weeks. Chest pain was reported in two (4%), low, grade pyrexia in two (4%), and pneumonia in one (2%) patient. There were three deaths, none due to exsanguination. The Six-Shooter is a safe and efficient device for the endoscopic ligation of esophageal varices which has overcome the limitations of the single-shot ligator: (1) Visualization is better (the endoscopic "tunnel vision" and internal light reflection from the stainless-steel banding cylinder of the single-shot device are avoided); and (2) the use of an overtube is no longer necessary and serious complications can be avoided.