Banding of Esophageal Varices 
Mehret Dessalegn and Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
Introduction:  
 
Band ligation is one of the mechanical 
hemostatic procedures used to control both upper 
and lower GI bleedings. Endoscopic band ligation is 
done by using the endoscope as a delivering 
instrument to control bleeding or prophylactically 
band vessels to prevent subsequent bleeding. Band 
ligation for esophageal varices is more effective 
than sclerotherapy, with a lower complication rate. 
It is also easier to use and train sustainably in a low-
resource setting.  
Indications include:  
● Oesophageal varices with acute hemorrhage 
● Other lesions amenable to band application such 
as a Dieulafoy lesion 
● Prophylactic band application for chronic 
esophageal varices patients to minimize. Risk of 
re- bleeding (therapy combined with B blockers 
for a maximized effect) 
 
Band ligation for esophageal varices is more 
effective than sclerotherapy with a lower 
complication rate and ease to train and practice in a 
low resource setting. 
The procedure is performed with a device 
affixed to the end of the endoscope which is loaded 
with ready to deploy bands. The device provides a 
chamber into which the targeted tissue is suctioned 
creating a pseudopolyp. A band is then applied to 
the base of the tissue. Multi-band ligating devices 
allow for application of more than one band per 
passage of the endoscope. 
The operation proceeds in deliberate steps:  
● Resuscitation, including IV access and typing  
and crossmatching of blood if appropriate 
● Anesthetic selection: general anesthesia is 
appropriate for patients with acute hemorrhage 
● Initial endoscopy to survey the esophagus, 
stomach, and duodenum and to plan the 
placement of the bands. Visualization will be 
limited once the banding device is in place.  
● Loading of the banding device onto the scope. 
● Endoscopy and placement of the bands 
● Repeat endoscopy with the device removed to 
assure proper placement of the bands (optional.)  
 
Steps: 
1. Patient needs to be stabilized, started on fluids, 
blood transfusion started before patient is on 
table, more blood prepared in case there is a 
need to transfuse on table. 
2. Preanesthetic evaluation. For the patient with 
acute hemorrhage, general anesthesia is 
preferred.  
3. OGD is done without the device in place, to 
identify the variceal columns and properly grade 
them for subsequent intervention. Look for 
stigmata of recent or active bleeding, such as a 
small red dot on the surface of the varix. If none 
are visible, bands will be applied to the column 
of varices that bulges the most, closest to the 
gastroesophageal junction. Orient the locations 
for banding, as on a clock face. Memorize their 
position relative to the gastroesophageal 
junction, which is a reliable landmark.  
 
Sites of recent bleeding appear as red dots at the center of the 
varices (“Red Wale Spots”) Source: 
https://en.wikipedia.org/wiki/Esophageal_varices 
Banding of Esophageal Varices 
Mehret Dessalegn and Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
Platelet-fibrin plug (“White Nipple Sign”) Source: World J 
Gastrointest Pharmacol Ther 2019;10(1):1-21 
https://www.wjgnet.com/2150-5349/full/v10/i1/1.htm 
 
 
Active bleeding from a varix. This lesion may be difficult to 
find once the banding device is in place, as  visualization and 
suction will be limited. Source: World J Gastrointest 
Pharmacol Ther 2019;10(1):1-21 
https://www.wjgnet.com/2150-5349/full/v10/i1/1.htm 
 
No stigma of recent bleeding. Bands will be applied to these 
two columns of varices, to the largest bulging area that is 
closest to the gastroesophageal junction (Blue Arrows.)  
 
4. Pass the scope to the stomach and the duodenum 
to identify any other pathology, check for 
gastric varices, assess presence of blood in the 
stomach and irrigate and suction for a better 
view. Carefully assess the posterior duodenal 
bulb, the most common location of life-
threatening peptic ulcer hemorrhage. 
5. Once the position of the columns to be banded 
is identified and memorized, withdraw the scope 
6. The banding device is then loaded onto the scope. 
It is helpful for all of the team to be familiar with 
this process so that it can be done quickly when 
a patient is unstable. The surgeon must be able to 
perform every step unassisted, in case the on-call 
personnel is not able to prepare the device. The 
steps for loading the device are explained later in 
this chapter.  
7. Insert the scope and device into the esophagus. 
Locate the previously identified variceal 
columns. If visualization and orientation are 
difficult, go to the gastroesophageal junction 
and withdraw the scope, trying to orient them as 
they were seen before the device was placed.  
Banding of Esophageal Varices 
Mehret Dessalegn and Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
Visualization with the banding device in place is more 
difficult. In case of disorientation, return to the 
gastroesophageal junction (dark area seen distally in this 
photo.)  
 
8. Go to the identified column and suction it into 
the cup lumen. Once it enters in well, you will 
see only mucosa up close. Release the band by 
rotating the controlling wheel at the proximal 
end of the working port. The tension on the 
wheel will increase noticeably as the string pulls 
the rubber band, then it will decrease suddenly 
when the band is released from the device and 
applied.  Release the suction to let the banded 
segment fall out of the cap 
 
Demonstration of the banding device using a pink balloon. 
Left: Engaging suction draws the mucosa into the lumen of the 
device. Right: When the controlling wheel is rotated, the band 
is pulled downwards to the neck of the pseudopolyp. The 
operator feels a release in tension on the wheel when this 
occurs, as the band is released. Inset: During deployment, the 
mucosa enters the device and covers the lens of the scope, 
blocking the operator’s view.  
 
 
Pseudopolyp with band at base after successful application 
(Red Arrow.) The next column (Blue Arrow) will now be 
banded, more proximally.  
 
9. Proximal banding on the same column could be 
applied as needed  
10. Once all the identified columns are banded 
withdraw the scope  
11. It is optional to repeat the endoscopy without 
the device on the scope, with better visualization 
to assess the banding.  
12. In patients with acute bleeding there is often an 
excessive amount of blood in the esophagus and 
it can be difficult to assess the band placement 
with the limited visualization caused by having 
the device in place. An esophageal stent can be 
placed and left in place until the patient is 
hemodynamically stable (up to two weeks) 
followed by endoscopy and banding of the 
varices at the location of the previous bleeding, 
if this can be located, or else just above the 
gastroesophageal junction.  
Banding of Esophageal Varices 
Mehret Dessalegn and Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
Rapid bleeding from an esophageal varix. If the lesion can not 
be reliably seen at initial endoscopy, finding it with the device 
in place will be impossible. Consider temporary tamponade of 
the bleeding with an esophageal stent or a Sengstaken-
Blakemore tube. Source: World J Gastrointest Pharmacol 
Ther 2019;10(1):1-21 https://www.wjgnet.com/2150-
5349/full/v10/i1/1.htm 
 
Pitfalls 
 
● Missed diagnosis of bleeding duodenal ulcer in 
a patient who coincidentally has varices. Be sure 
to perform a complete endscopy before deciding 
to band varices. 
● Inability to control bleeding due to excessive 
and rapid blood loss. Options at this point 
include temporary esophageal stent application 
if one is available, or placement of a 
Sengstaken-Blakemore tube. In both cases, 
repeat endoscopy and attempt at banding should 
be done when the patient stabilizes.  
● Dislodged band and rebleed: this pitfall can be 
avoided by assuring that the mucosa has 
completely entered the device (and is firmly 
opposed to the camera lens) when deploying a 
band.  
● Transient dysphagia from narrowed lumen: 
Patient should be reassured that this will pass 
once the edema subsides and the pseudopolyp 
sloughs off 
● Ulcer formation: Temporary ulcers will be seen 
up to 3 weeks after banding, in the location that 
the ulcers have sloughed. These should heal in a 
patient with adequate nutrition and hepatic 
protein synthesis.  
● Post banding stricture: This complication is 
avoided by only banding within the variceal 
columns, rather than circumferentially.  
● Spontaneous bacterial peritonitis (in patients 
with ascites): All patients with variceal upper GI 
bleed are given intravenous antibiotics directed 
against enteric organisms in the acute phase of 
management.  
 
Guide: Loading the endoscopic banding device on 
to the endoscope.  
1. Pass the String retriever through the proximal 
end of the working port of the scope. Attach 
the string to the string retriever at the distal 
end of the working port. Withdraw the string 
back through the proximal end.  
 
The string retriever (Red Arrow) is passed through the proximal 
working port of the scope and used to retrieve the end of the 
string. It is then pulled through the channel. A biopsy forceps 
can also be used to retrieve the string.  
 
Banding of Esophageal Varices 
Mehret Dessalegn and Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
2. Pass the string retriever through the handle 
unit and pull the string up to the wheel. There 
is a rubber seal here that allows use of suction 
and insufflation during endoscopy without 
losing pressure.  
 
The string retriever is used to pass the string through handle 
unit, which has a seal to prevent loss of suction or insufflation 
during endoscopy. Note that the rubber cap that usually covers 
the working port of the endoscope has been removed. Other 
brands of handle units will require the cap to remain in place. 
 
3. Wrap the string around the controlling wheel 
and load it int the slot, keeping tension on 
the string 
 
Insert the string into the slot and then tighten the controlling 
wheel as the string is wrapped around the barrel.  
 
4. Bring the ligating unit loaded with the bands 
and snugly attach it to the tip of the 
endoscope, while tightening the string on the 
control wheel on the other end of the 
working port. This allows the unit to fit 
tightly onto the tip of the endoscope while 
controlling the string tension on the 
controlling wheel 
Banding of Esophageal Varices 
Mehret Dessalegn and Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
As the string is tightened on the controlling wheel, the ligating 
unit is fitted onto the tip of the scope and the string is pulled 
tight. The bands are now ready to be deployed by turning the 
wheel and applying further tension to the string.  
 
5. Rotate the ligating unit on the tip of the 
scope to allow good visualization by 
positioning the strings well. Because of the 
device in place, the view will now be 
“tunnel vision.”  
 
The strings pass through the working port, then through the 
field of view of the scope. If the banding device is rotated 
improperly (Inset,) strings pass directly in front of the camera 
and block the view. Rotate the banding device until the strings 
are as much out of the way as possible.  
 
Guide: Reloading of an endoscopic banding 
device 
 
Endosopic banding devices are intended for 
single 
use. 
However, 
in 
a 
resource-limited 
environment the string and the plastic-silicone 
device can be chemically sterilized and reused. (See 
Chapter: Sterilization.) This will be addressed in a 
subsequent edition of this chapter.  
 
Mehret Enaro Dessalegn MBBS 
AIC Kijabe Hospital 
Kenya 
 
Richard Davis, MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
February 2022 
 
