Endoscopic esophageal varix ligation (EVL) is an effective treatment for ligating varicose veins with elastic rubber adhesive, which originates from mole ligation treatment. developed in the mid 1980s, it has been gradually and widely accepted due to its simplicity, safety, simplicity, and few complications. For the rapid elimination of esophageal varices, ligation is currently the more widely used microscopic. Under the treatment method, but the recurrence rate of varicose veins is higher formation, so the long-term efficacy needs to be further studied in the clinic. I. Indications and contraindications (I) Indications Bleeding from esophageal varices caused by cirrhosis and portal hypertension of various causes and cases in which bleeding may occur are the objects of endoscopic ligation. （Contraindications 1. Esophageal stenosis, esophageal distortion, esophageal diverticulum. 2. 2. Patients with bleeding fundal varices or bleeding gastric disease with portal hypertension. 3. Coagulation disorders. 4. Patients with known or suspected esophageal perforation. 5. Patients with unstable circulation. 6. Patients who are allergic to latex. Preoperative preparation 1. Communicate fully with the patient, explain to him/her the reasons for choosing endoscopic esophageal vein ligation, tell the patient about the possible sensations and how to cooperate in the ligation process, mobilize the patient’s enthusiasm, and do not make the patient overly fearful and nervous. 2. Prepare 1-2 units of blood of the same type for emergency use. 3. Routine establishment of intravenous route. 4. Anesthesia selection 4, anesthesia selection Preoperative administration: atropine 0.5mg intramuscular injection, Dolantine 25-50mg intramuscular injection, usually given 5-10 minutes before surgery. Oropharynx do mucosal local anesthesia. Selection and preparation of gastroscope and negative pressure suction device: 6. Patient’s position The patient takes the left side position with the head lightly flexed, and a curved disk is placed in the lower jaw to hold the bloody and oropharyngeal secretions during the operation. III. Methods and steps of operation (1) Instruments 1. lancing device: lancing device has single-shot (Stiegman-Goff) and multi-shot (Wilson-Cook). Currently, the multi-shot lancing device has replaced the single-shot device. HK-21L-1 lancing device is a lancing device developed by Olympus, which consists of a transparent cap installed on the front end of the endoscope and a number of nylon loops as well as a launching device. Its transparent cap does not affect the field of view and is relatively easy to operate. Ligation device generally consists of four parts: ① outer cover connected to the endoscope end; ② inner ring can be slid into the outer cover of the small circle, there is a gap connecting the operation of the wire; ③ “O” rubber ligature ring mounted in the inner ring, the wire loading cone and the inner wire connection; ④ pulling the wire for the 140cm diameter of 0.75mm steel wire, which has a 1.8mm at both ends of the small wing, through the wire loading cone The pulling wire is a 140cm diameter 0.75mm steel wire with 1.8mm small wings at both ends, through the wire loading cone will be “O” type rubber ligature ring stretched and loaded on the distal end of the inner ring, the small wings are stuck in the notch of the inner ring and firmly connected to the inner ring, and then the inner ring will be slid into the outer cover up to the “O” ring out, pulling the steel wire tightly. 2, endoscopy: available ordinary electronic gastroscope or fiberoptic gastroscope. The endoscopic clamp channel should be ≥2.8mm, and it is recommended to use the therapeutic endoscope with a working channel of 3.7mm. (2) Ligation method 1, single skin ring ligation method This is a conventional EVL treatment method, and its ligature includes outer casing, retracting line, inner sleeve column and skin ring, etc. During operation, first check the distribution, character and surface of esophageal varices with or without ulcers, erosions, and red signs, etc. If variceal ligation is required, then the inner lens end is put on the outer casing, and the skin ring and retracting line are installed, and then placed into the endoscope, and then the ligature is usually placed on the lower end of the esophagus from the cardia. After inserting the endoscope, generally speaking, the lower end of the esophagus is about 5cm away from the cardia to select the thicker varicose vein, put the endoscope against the varicose vein, start the negative pressure suction device to continuously suction, and the varicose vein can be seen under the endoscope to gradually enter into the inner ring of the inner column in a few seconds, and then the field of vision is reddened, which indicates that the inner column of the sleeve is full of the varicose vein, and then the traction line can be drawn, and the skin ring on the inner column can be pushed out and ligated to the mucous root of the sucked varicose vein; stop the negative pressure suction, and the endoscope is slowly drawn back. Stop the negative pressure suction, endoscopy slowly gas injection, you can see the ligation of the varicose vein was polyp-like, the color gradually turned purple, basically by the skin ring tight set. The endoscope is withdrawn from the endoscope, a new skin ring is installed, and then the endoscope is inserted through the outer casing to ligate other varicose veins. In order to simplify the insertion of a single-ring ligature into the cannula, repeated insertion of the mirror and installation of the skin ring operation, the United States has introduced a multi-ring ligature with a continuous skin ring, which does not require an outer casing for endoscopic ligation and can continuously ligate 5-8 varicose veins at one time, and can also be centrally ligated. The ligation points should not be chosen at the same level, so as not to obstruct the esophageal lumen with multiple ligated polypoid varicose veins, which may cause difficulty in swallowing. In the process of ligation or at the end of ligation, saline can be injected into the clamp channel through the special channel next to the traction knob to clean the surface of the mirror, to find out whether there is active bleeding and whether the ligation site is ideal. At the beginning, the site should be chosen as close as possible to the esophageal cardia junction of the varicose vein, venous aneurysm, or a site with overt bleeding. (2) Install the ligature, straighten the endoscope, insert the operating knob rotator into the biopsy hole, and tighten the traction wire on the rotating axis of the operating rotator. (3) Gently insert the endoscope with ligature, align the front end of the endoscope with the varicose vein to be ligated, and tighten the inner ring at the vein to be ligated so that there is no gap between them. (4) Start the suction device, negative pressure will be ligated vein sucked into the inner ring, at this time the field of view is red. (5) Rotate the rotator, the “O” shaped rubber ring will be dislodged from the inner ring and fixed at the root of the ligated vein, and a clicking sound can be heard, the ligation is successful, and the negative pressure is lifted by injecting gas, so that the ligated vein will be detached from the endoscopic orifice. (6) Observe that there is no bleeding before proceeding to the next vein ligation. Standard ligation is performed within 5 cm from the dentate line, with an average of 4-6 points. Standard ligation can be performed 1-2 weeks after the second ligation. Intensive ligation: Ligation is performed sequentially from the edge of the dentate line upward, with as many points as possible, 4-6 points for each varicose vein, and a total average of 14-20 points. This method blocks blood flow quickly, varicose veins occlusion, disappearance, scab removal are relatively fast, even if individual varicose veins scabs are scratched off, there are other ligated vein ball existence, does not cause hemorrhage. Intensive ligation does not cause major scar formation and esophageal stenosis. Postoperative rebleeding is significantly lower than with standard ligation. The intensive ligation method should be operated skillfully and gently, and the postoperative period should be characterized by strict dietary control, fluids and slag-free semifluids for 2 weeks, oral gentamicin and vitamin B2 mixture, and intravenous administration of acid-producing agents to reduce reflux. Some reports show that the comparison of the two methods: 1 month after the end of treatment, review of gastroscopy, intensive ligation group of varicose veins completely disappeared (9/9), the standard ligation group of 3 cases completely disappeared (3/9) 4, transparent cap nylon ring ligation method will be pressed on the front of the endoscopy of the transparent cap, will be sent to the cap of the nylon ring, open nylon ring to make the top to the brim of the cap, to attract the varicose veins into the cap, tighten the ring sleeve, lifting the attraction, promote the connection rod The ligated spherical varicose vein is pushed out of the transparent cap, and then the target vein is ligated again and again. Intraoperative accidents Endoscopic esophageal varices ligation is a very safe surgical method, with the large number of clinics, there are rare intraoperative accidents. Such intraoperative accidents can be broadly categorized into two types: one is the application of the outer casing; the other is due to the elastic rubber band and ligators. (1) Esophageal variceal vein hemorrhage Repeated intubation from the esophagus is required for placement of the rubber band when a single-ring ligature is used, as placement of the outer casing is part of the overall endoscopic esophageal variceal vein ligation procedure. There have been reports of sudden hemorrhage during placement of the outer casing prior to ligation, with a large amount of blood gushing from the outer casing, followed by atelectatic suctioning, with such poor visibility that ligation could not be performed, and failure to take timely action could result in dire consequences. This unexpected situation may occur when the oropharyngeal coat tube is inserted into the middle part of the esophagus, which pressurizes the varicose vein, causing obstruction of venous return, further increasing the pressure in the high-pressure vein, leading to the rupture of the varicose vein, and causing hemorrhage in the process of intubation. Treatment: 1. Draw the outer casing outward until the end reaches the pharynx of the cricoid cartilage. The blockage of varicose vein pressure by the catheter can be reduced. A withdrawal of 7-8 cm is usually sufficient. 2, because this is to find the exact bleeding point is very difficult, at this time you can quickly blind ligation, ligation method from the esophagogastric junction, upward blind ligation, generally as long as the firm ligation of 2-3 parts, due to the tightening of the mucous membrane compression, or some of the vascular blood flow blockage, bleeding tends to stop quickly, the esophageal fluid from bright red to light color, the field of view is also clearer, so that the further ligation treatment can be carried out smoothly. 3. If the bleeding is so heavy that it is impossible to operate or blind ligation fails or even circulatory instability occurs soon, the operation should be stopped immediately, and the outer casing should be pushed out and a triple-lumen, two-bladder tube should be placed for compression and hemostasis, and then ligation should be carried out when the circulation is stable and the bleeding is controlled for the time being. (2) Esophageal mucosal and submucosal injury and esophageal perforation When the outer casing is placed, there is a gap between the endoscope and the outer casing, and the esophageal mucosal and submucosal tissues are herniated into this gap and squeezed, resulting in injury. Usually, the inner diameter of the outer casing is 16mm, and the diameter of commonly used endoscopes is 9.8-12.6mm, and this gap is 4.4-7.2mm in size. Another reason is that the patient’s neck is over-extended and twisted during the operation, and the outer casing placed in the esophagus will slide hard in the esophagus and cause injury. Treatment: 1, once there is a submucosal esophagus, or even perforation of the esophagus, continue to place or advance the outer casing tube will be resisted and difficult to insert, the patient will complain of sore throat or chest pain, this situation should be quickly terminated the insertion of the outer casing tube, endoscopic examination, such as the formation of a false pathway in the esophagus under direct visualization, it will be confirmed that there is an esophageal or submucosal injury, should be terminated for endoscopic ligation treatment. 2. Perform contrast esophagography if necessary to further confirm the presence or absence of submucosal injury, the presence or absence of contrast penetration into the mediastinum, as well as the presence or absence of mediastinal emphysema and cervical subcutaneous tissue pneumoperitoneum. 3. Fasting, infusion and antibiotic treatment, and close observation. 4. If necessary, consult the chest department for timely and correct treatment. (3) Dislodgement of the inner sleeve Dislodgement of the inner sleeve refers to the withdrawal of the endoscope when the end of ligation at a site is achieved and the inner sleeve and retractor wire are embedded in the base of the ligature mass. Often, when the gastroscope is withdrawn from the outer casing, the retractor wire and the inner sleeve are still in the esophagus, with a certain degree of tension, and if violently dragged, it is likely to make the newly ligated mass tear off, which is prone to cause hemorrhage. Treatment: The endoscope will be dragged around the metal guide wire, and sent into the esophagus again, with the guidance of dragging the guide wire, it is easy to reset the inner sleeve into the outer sleeve, and gently rotate the gastroscope under direct vision, and drag the guide wire carefully, the inner sleeve and guide wire can be loosened from the ligated mass, and the complete launch of the ligature and the gastroscope. Prevention: When starting negative pressure suction, the negative pressure should be kept at 8-13KPa, and the pressure should not be too high, so as to avoid the formation of an oversized mass, which will make it difficult to withdraw the inner sleeve. (4) Loosening of ligature ring During the ligation process, a certain ligature ring may loosen, leave the ligation site and float in the esophageal lumen, the ligature mass disappears, and blood spills out of the mucosal tissues under negative pressure suction, and the originally clear field of vision may suddenly be blurred with a reddish color. Treatment: When using a single-ring ligature, the gastroscope should be quickly withdrawn and replaced with a new inner sleeve wearing a rubber band for re-ligation; if a multi-ring ligature is used, it can be re-ligated in time. At the lower or lateral end of the original ligation site, 1-2 cm from the original ligation site, decisive suction ligation, as long as the ligation is successful in 2-3 sites, often due to the nearby new ligation mass, the original loose ligation site mucosa is overly tight pressure, or due to the blood vessels at both ends of the ligature blocked again, bleeding is quickly controlled. The visual field can both change from a blurry red situation to a clear and crisp one. Repeated suction ligation at the original dislodged site is not allowed, as it may lead to lateral tearing and cause hemorrhage. Prevention: The causes of rubber band loosening are as follows: 1. The end of the ligature does not have 360-degree contact with the esophageal wall when ligation is performed, and after negative pressure suction is initiated, the mass inhaled is not large, and there is no great progress even though the suction force is increased, and the ligature is reluctantly ligated and caused to be loosened. 2. The ligation is completed, the mass is large, and the ligation is firm, but when ligating other parts again, the gastroscope enters and exits the esophageal lumen several times, and the ligature ring is dislodged. 3. The site of re-ligation is too close to the ligated mass, and negative pressure suction in the neighboring area makes the ligated mass tugged and loosened. 4. The rubber ring of the multi-ring ligature is fixed on the transparent cap, and sometimes the “fatigue” phenomenon may cause the ligature ring to come loose. The above reasons can lead to the ligation process, the rubber ring loose, as long as the operation carefully, to master the operation carefully, to master the essentials, the rubber ring off the phenomenon can be avoided. (5) The rubber band automatically pops down When ligation is implemented, the gastroscope has not yet arrived at the booked ligation site, or has reached the ligation site, and the suction mass has not yet been formed, and the rubber band automatically pops up or falls down in the esophageal lumen, or covers the top of the small mass, resulting in the failure of the ligation. Treatment and prevention methods: 1. Choose a rubber band with good elasticity, and do not use a rubber band that is loose and not tight on the inner sleeve. 2. 2, Place the rubber band on the inner sleeve, the rubber band should be 0.3-0.4mm away from the lower edge of the inner sleeve, too close to the edge of the automatic bounce. The operator’s hand should be placed on the handle of the multi-ring ligature when using the multi-ring ligature. Only when the varicose vein to be ligated is well exposed should the handle be placed in the firing position. During the ligation process, the ligation site must be well selected. For varicose veins that are too small to form clumps, although the negative pressure suction force is large, the formation of clumps is small, and the inner sleeve will slide towards the outer sleeve due to the large negative pressure, resulting in a premature auto-bounce phenomenon. Postoperative treatment 1. After operation, the patient’s blood pressure, pulse rate and general condition should be strictly detected. 2. Fasting for 24 hours to prevent the ligature ring from falling off due to eating. During the period of fasting, the patient should be given fluids; after 24 hours, the patient can be fed with fluids; after 72 hours, the patient can be fed with semi-fluids; and after one week, the patient can be fed with ordinary food. 3. After ligation, patients may have short-term retrosternal pain and swallowing discomfort, which will be relieved by themselves after 2-3 days and generally do not need special treatment. 4, endoscopic, observed local tissue changes: in the past without ligation treatment, the ligation mass diameter of about 8-10mm, dark red, the base of a rubber band visible, about 10 minutes began to cyanosis. 4-8 days began to necrosis, followed by necrotic tissue decay, the rubber band is also off, the remains of the base of the white, about 1-2mm in depth, the diameter of about 10-12mm, round or oval shallow ulcers, 2-3 weeks later covered with the upper part of a white ulcer. After 2-3 weeks, the covered epithelial tissue is repaired. 5. After ligation, it should be rested for 12-14 days and then ligated for the second time until the varicose vein is cured. Generally, the first review should be carried out in 3-4 months after eradication, and if the varicose veins recur, ligation should be performed again until eradication. Attention 1. The ligation should be fully attracted to avoid the early dislodgement of the coil due to insufficient attraction, in which case the thrombus formation in the vein is incomplete and hemorrhage is easily incurred. Advocate the application of spiral ligation point, so that the multi-point ligation is not in a plane, to avoid esophageal stenosis after esophageal vein ligation. 3. The second ligation should be at least 1.5cm away from the previous ligation. 4. Pay attention to the degree of tightening of the nylon ring in case of nylon ring ligation. 5. Endoscopic emergency ligation to stop bleeding when the field of vision is poor, due to the continuous fresh blood outflow, often blurred vision. At this time, as long as there is constantly fresh blood gushing out, often blurred vision. At this time, as long as the outline of the bleeding vein is roughly observed, ligation can be performed, or ligation of veins from the gastroesophageal junction to different planes of the cephalic end in turn, and generally 3-4 points of ligation can immediately stop bleeding. After hemostasis, rinse and suction to make the field of vision clear, observe the condition of varicose veins, and decide whether to continue ligation or not. 6. When ligating, attention should be paid to the accumulation of blood in the esophagus surging in the oral cavity to aspiration, if respiratory distress occurs, suction immediately, preferably with a thicker suction tube. 7. For acute hemorrhage, it is necessary to use multi-hair ligature, one entry continuous ligation, avoiding the use of single-hair ligature, so as to avoid repeated entry, prolonging the operation time, increasing the patient’s nausea and aggravating the hemorrhage. Clinical efficacy and application prospects 34% of patients with cirrhosis and half esophageal varices die from upper gastrointestinal hemorrhage and 32% die from liver failure. Therefore, effective control of acute bleeding is the key to reduce mortality and prolong survival. Endoscopic ligation hemostasis, safe, simple, high hemostasis rate, low cost, and few complications, is gradually widely accepted.Lay cs et al. reported that endoscopic ligation therapy and cardiac glycosides control study not only reduces the rate of the first bleeding but also has a few obvious points: ① endoscopic treatment has no anti-indication; ② treatment duration is short, acceptable to the patient; ③ does not need to take medication for an indefinite period of time. Therefore, some scholars in China believe that ligation treatment should be the main treatment measure for first-line prevention of esophageal variceal bleeding in cirrhosis. For patients in first-line prophylaxis, long-term monitoring and treatment should be continued. However, ligation treatment can only ligate the veins of the lamina propria, resulting in ischemia, thrombosis, aseptic inflammation, and occlusion of the veins, but the veins of the peritoneal layer and the traffic branches are still left, so that the veins of the lamina propria are recanalized, which leads to recurrence of variceal hemorrhage after EVL. Long-term efficacy is still to be further studied in the clinic. Whether esophageal vein ligation is superior to sclerotherapy is still much debated. Some randomized controlled studies have demonstrated that ligation and sclerotherapy have the same effect on controlling bleeding, except that ligation has fewer complications, and both methods are effective in reducing the risk of rebleeding, decreasing deaths caused by bleeding, and improving survival. For the smaller varicose veins remaining after ligation re-ligation is difficult, at this time, can be given a small dose of sclerotherapy, can make them disappear. The two and use to improve the efficacy. Meanwhile, due to the limitations of endoscopic equipment, ligation treatment is still a blind spot for fundal varices.