A prospective evaluation of the endoscopic spectrum of overtube-related esophageal mucosal injury

Background: Placement of an overtube is required for endoscopic variceal ligation. The spectrum of overtube-related esophageal mucosal injury is unknown. We made a prospective comparison of two types of overtubes and a determination of the frequency, severity, and risk factors for overtube- related injury. Methods: Two overtubes (60F, 20 cm, 'new' overtube; and 60F, 25 cm, 'old' overtube) were used and placed using the bougie-assisted technique. Mucosal integrity was documented before and after variceal ligation. Overtube contact time, bands number, setting (emergent versus elective), type of overtube, degree of coagulopathy, and development of symptoms after variceal ligation were recorded. Results: Fifty sessions in 29 patients were analyzed; 24% of sessions were emergent. The old overtube was used in 24 sessions and the new in 26. Mucosal injury occurred in 72% of sessions. Mean overtube contact time was 11.58 ± 0.97 minutes, the mean number of bands placed per session was 6.4 ± 0.4, and the mean international normalized ratio was 1.47 ± 0.06. No risk factors correlated with mucosal injury except for the old overtube, which was associated with tears (p = 0.02). Conclusions: Mucosal injury related to the overtube is frequent but clinically unimportant. Because mucosal tears occurred significantly more often with the old overtube, we suggest that its use should be avoided.