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Comparison of Safety and Outcome Between Two Argon Plasma Coagulation Settings for Radiation Proctopathy in Patients with Prostate Cancer
*W1619 Hyperbaric Oxygen Therapy for Chronic Radiation Enteritis Gary T. Marshall, Richard C. Thirlby, James E. Bredfeldt, Neil B. Hampson
*W1621 The Right and Left Conundrum: Colonoscopy or Flexible Sigmoidoscopy for the Investigation of Isolated Rectal Bleeding (IRB) Maeve M. Skelly, Ramesh Arasaradnam, Mark T. Donnelly
HYPOTHESIS: Hyperbaric oxygen therapy (HBO2) is a useful treatment for chronic radiation enteritis. DESIGN: Retrospective case series of 58 consecutive patients treated with HBO2 for chronic radiation enteritis between July 1991 and December 2002. SETTING: A tertiary community teaching hospital. PATIENTS: 58 patients (33 male, 25 female; mean age 65 years) irradiated for malignant disease were treated with HBO2 for radiation injury to the alimentary tract. INTERVENTIONS: Patients were treated with an initial series of 30 daily treatments, each administering 90 minutes of 100% oxygen at 2.36 atmospheres absolute. Thirty patients with partial symptom response and/or endoscopic evidence of healing received an additional 6 to 30 treatments. MAIN OUTCOME MEASURES: Main outcome measures included resolution of bleeding, pain, weight loss, diarrhea and tenesmus. Endoscopic documentation of healing was used when available. RESULTS: The primary indication for hyperbaric oxygen treatment was bleeding in 49 patients, 15 of whom required transfusions. Additional symptoms were pain, urgency, diarrhea, ulceration, partial bowel obstruction, malabsorption and fistula formation. The mean interval between completion of radiation treatment and beginning HBO2 was 43 months (range = 2-288 months). For all patients, 28 (48%) had a complete response, 17 (29%) a partial response, and 13 (22%) failed to respond. Follow-up ranged from 1 to 60 months. Several patients responded during treatment but relapsed and are included with the failure or partial response groups as appropriate. The partial/ complete response rate for rectal disease was 77% and for all other sites was 80%. The partial/complete response rate for those with bleeding was 80% and for nonbleeding symptoms (eg obstruction, fistula, malabsorption) was 67%. CONCLUSION: The present series represents the largest report of hyperbaric oxygen therapy for radiation injury to the GI tract. Although this study is limited by the subjective nature of presenting symptoms and evaluation of response to treatment, we believe the results support the conclusion that HBO2 results in healing or clinically significant improvement in over 75% of patients with severe chronic radiation enteritis.
Background: Data to guide the clinician as to the choice between colonoscopy or flexible sigmoidoscopy is lacking in patients with isolated rectal bleeding (IRB). This may pose the greatest difficulty in younger patients with IRB, where the risk of neoplastic disease is slight but not absent and other diseases may exist. Aim: To determine the burden of disease in the right colon (proximal to splenic, Right) in patients presenting with IRB. Methods: We performed a one year retrospective analysis of 853 patients with IRB who had a colonoscopy. Types of pathology (path) identified included mucosal inflammation, polyps, tumour, diverticular disease (DD) and haemorrhoids (h’oids). Results: See table. Caecal intubation rate was 96% while terminal ileum was 52.4%. The median age of patients (pts) with exclusive right sided pathology was 58 years (range 36-90) compared to 63 years (range 18-93) for those who had only left sided pathology. In pts. with IRB, left sided disease is nine times more likely than right sided disease. Equal numbers of young and old pts had lone right sided pathology. Pts. less than 50 yrs with IRB were three times more likely than patients over 50yr to have lone right colon inflammation. Isolated right colon pathology in pts.over 50 yrs was equaly divided between inflammation, neoplasia and diverticular disease. 34 colonoscopies needed to be performed to find one patient less than 50 yrs with significant right sided disease. In patients over 50 years of age, this figure was 24. Conclusions: Very few cancers would be missed if colonoscopy was reserved for older patients with IRB. However, significant and treatable disease will be missed if young patients with IRB are not colonoscoped.
*W1620 Usefulness of Angiography in Patients with Undiagnosed Lower Gastrointestinal Bleeding Carmen Abadia, Ana Adet, Saperas Esteve, Faust Feu, J.R. Armengol, Juan Malagelada, Pique Jose M Colonoscopy is considered the most effective first test in the evaluation of patients with significant lower gastrointestinal bleeding (LGB). However, if colonoscopy can not identify a definite bleeding source, the optimal approach remains uncertain. Aims of the study: 1) To assess the effectiveness of colonoscopy as initial diagnostic test for acute LGB, and 2) To determine the diagnostic yield of selective mesenteric angiography in patients with undiagnosed LGB. Patients and methods: patients hospitalized for acute LGB over a 50 month period in two teaching hospitals, who underwent urgent colonoscopy and eventual gastroscopy as initial diagnostic procedures were retrospectively analyzed. By using predetermined criteria, diagnosis were categorized either as definite, when a lesion showed stigmata of recent hemorrhage, or undiagnosed, in the absence of lesions or signs of recent bleeding. Results:162 patients (50% male) with a mean age of 69+/1.6 yrs (75% equal or > 65 yrs) were included. Presentation of hemorrhage was severe with shock in 19%, 67% requiered blood transfusions (mean: 3.4+/0.4 UU) and 60% had comorbidity. Colonoscopy found potential bleeding lesions in 109/162 patients (38% had diverticulosis), but definite diagnosis could be established in only 42/162 (26%) patients. Diverticulosis (7%), cancer and polyps (38%), ischemic colitis (12%) and angiodysplasia (14%) were the main sources of bleeding. Angiography, performed in 69 out of 120 patients with undiagnosed hemorrhage (58%), established a definite diagnosis in 48/69 (70%) patients. Angiodysplasia was the bleeding source in 15 out of 17 (88%) patients with further bleeding during hospitalization, whereas in the 52 patients with self-limited hemorrhage angiodysplasia was found in 31 (60%) patients. Angiography also established the diagnosis in 2 additional patients (1 small bowel tumor and 1 actively bleeding diverticuli). Conclusions: Acute LGB often remains undiagnosed after initial colonoscopy. In this condition, colonic angiodysplasia is the most common cause and mesenteric angiography is a useful procedure, particularly in patients with further bleeding.
VOLUME 59, NO. 5, 2004
*W1622 Comparison of Safety and Outcome Between Two Argon Plasma Coagulation Settings for Radiation Proctopathy in Patients with Prostate Cancer Richard S. Kwon, Clair Beard, Anthony V. D’Amico, David L. Carr-Locke Radiation proctopathy is a late complication of radiation therapy for prostate cancer. Argon plasma coagulation (APC) is an accepted endoscopic therapy, but there is no consensus for power settings and gas flow rate. We describe our experience with two different settings. Methods: Between January, 1997 and June, 2003, 124 patients were referred for endoscopic therapy for radiation proctopathy. The first exam was always a colonoscopy to rule out synchronous lesions. Repeat procedures were sigmoidoscopies. All procedures were performed by one endoscopist using an ERBE APC 300 and ICC 200 generator with end-firing probes. Early in the series, APC settings were 75W and 1.0 L/min. Later, these settings were changed to 40-60W and 1.0 L/min. Successful outcome was defined as cessation of bleeding. Failure was determined as need for surgical or other therapy. Results: 257 procedures were performed on 114 patients (93%) with a history of prostate cancer. The mean age was 71 years (range 51-84). 44 had external beam therapy (EBT, mean dose = 6227 cGy) 6 hormonal blockade (HB), 18 had EBT (mean dose = 6115 cGy) + brachytherapy (BT), and 25 patients had BT 6 HB. Brachytherapy doses were set according to American Association of Physicists in Medicine Task Group #43. 28 patients had an unspecified treatment regime. The mean procedures per patient was 2.2 (range 1-7). 63 patients received at least one APC treatment session at a setting of 75W. 51 patients had APC settings of 4060W. The 75W group required an average of 2.6 procedures (range 2-7) to achieve success as compared to 1.6 procedures (range 1-4) for the 40-60W (p<0.001). Of the 33 patients who required 3 or more treatment sessions, 27 (82%) received APC at 75W for at least one session. This subset averaged 4 treatment sessions per patient and 66.7% of these were at the 75W setting. There were 3 complications (1.2%), all in the 75W group. Two patients had continued bleeding that required admission and transfusion. One of these patients underwent a diverting colostomy. A third patient had an asymptomatic rectal stricture. Conclusions: APC is a safe and effective procedure at a power setting of 60W or less. This study underscores the need for a grading system using endoscopic findings and radiation therapy parameters to most accurately compare treatment responses.
GASTROINTESTINAL ENDOSCOPY
P271
*W1621 The Right and Left Conundrum: Colonoscopy or Flexible Sigmoidoscopy for the Investigation of Isolated Rectal Bleeding (IRB) Maeve M. Skelly, Ramesh Arasaradnam, Mark T. Donnelly
HYPOTHESIS: Hyperbaric oxygen therapy (HBO2) is a useful treatment for chronic radiation enteritis. DESIGN: Retrospective case series of 58 consecutive patients treated with HBO2 for chronic radiation enteritis between July 1991 and December 2002. SETTING: A tertiary community teaching hospital. PATIENTS: 58 patients (33 male, 25 female; mean age 65 years) irradiated for malignant disease were treated with HBO2 for radiation injury to the alimentary tract. INTERVENTIONS: Patients were treated with an initial series of 30 daily treatments, each administering 90 minutes of 100% oxygen at 2.36 atmospheres absolute. Thirty patients with partial symptom response and/or endoscopic evidence of healing received an additional 6 to 30 treatments. MAIN OUTCOME MEASURES: Main outcome measures included resolution of bleeding, pain, weight loss, diarrhea and tenesmus. Endoscopic documentation of healing was used when available. RESULTS: The primary indication for hyperbaric oxygen treatment was bleeding in 49 patients, 15 of whom required transfusions. Additional symptoms were pain, urgency, diarrhea, ulceration, partial bowel obstruction, malabsorption and fistula formation. The mean interval between completion of radiation treatment and beginning HBO2 was 43 months (range = 2-288 months). For all patients, 28 (48%) had a complete response, 17 (29%) a partial response, and 13 (22%) failed to respond. Follow-up ranged from 1 to 60 months. Several patients responded during treatment but relapsed and are included with the failure or partial response groups as appropriate. The partial/ complete response rate for rectal disease was 77% and for all other sites was 80%. The partial/complete response rate for those with bleeding was 80% and for nonbleeding symptoms (eg obstruction, fistula, malabsorption) was 67%. CONCLUSION: The present series represents the largest report of hyperbaric oxygen therapy for radiation injury to the GI tract. Although this study is limited by the subjective nature of presenting symptoms and evaluation of response to treatment, we believe the results support the conclusion that HBO2 results in healing or clinically significant improvement in over 75% of patients with severe chronic radiation enteritis.
Background: Data to guide the clinician as to the choice between colonoscopy or flexible sigmoidoscopy is lacking in patients with isolated rectal bleeding (IRB). This may pose the greatest difficulty in younger patients with IRB, where the risk of neoplastic disease is slight but not absent and other diseases may exist. Aim: To determine the burden of disease in the right colon (proximal to splenic, Right) in patients presenting with IRB. Methods: We performed a one year retrospective analysis of 853 patients with IRB who had a colonoscopy. Types of pathology (path) identified included mucosal inflammation, polyps, tumour, diverticular disease (DD) and haemorrhoids (h’oids). Results: See table. Caecal intubation rate was 96% while terminal ileum was 52.4%. The median age of patients (pts) with exclusive right sided pathology was 58 years (range 36-90) compared to 63 years (range 18-93) for those who had only left sided pathology. In pts. with IRB, left sided disease is nine times more likely than right sided disease. Equal numbers of young and old pts had lone right sided pathology. Pts. less than 50 yrs with IRB were three times more likely than patients over 50yr to have lone right colon inflammation. Isolated right colon pathology in pts.over 50 yrs was equaly divided between inflammation, neoplasia and diverticular disease. 34 colonoscopies needed to be performed to find one patient less than 50 yrs with significant right sided disease. In patients over 50 years of age, this figure was 24. Conclusions: Very few cancers would be missed if colonoscopy was reserved for older patients with IRB. However, significant and treatable disease will be missed if young patients with IRB are not colonoscoped.
*W1620 Usefulness of Angiography in Patients with Undiagnosed Lower Gastrointestinal Bleeding Carmen Abadia, Ana Adet, Saperas Esteve, Faust Feu, J.R. Armengol, Juan Malagelada, Pique Jose M Colonoscopy is considered the most effective first test in the evaluation of patients with significant lower gastrointestinal bleeding (LGB). However, if colonoscopy can not identify a definite bleeding source, the optimal approach remains uncertain. Aims of the study: 1) To assess the effectiveness of colonoscopy as initial diagnostic test for acute LGB, and 2) To determine the diagnostic yield of selective mesenteric angiography in patients with undiagnosed LGB. Patients and methods: patients hospitalized for acute LGB over a 50 month period in two teaching hospitals, who underwent urgent colonoscopy and eventual gastroscopy as initial diagnostic procedures were retrospectively analyzed. By using predetermined criteria, diagnosis were categorized either as definite, when a lesion showed stigmata of recent hemorrhage, or undiagnosed, in the absence of lesions or signs of recent bleeding. Results:162 patients (50% male) with a mean age of 69+/1.6 yrs (75% equal or > 65 yrs) were included. Presentation of hemorrhage was severe with shock in 19%, 67% requiered blood transfusions (mean: 3.4+/0.4 UU) and 60% had comorbidity. Colonoscopy found potential bleeding lesions in 109/162 patients (38% had diverticulosis), but definite diagnosis could be established in only 42/162 (26%) patients. Diverticulosis (7%), cancer and polyps (38%), ischemic colitis (12%) and angiodysplasia (14%) were the main sources of bleeding. Angiography, performed in 69 out of 120 patients with undiagnosed hemorrhage (58%), established a definite diagnosis in 48/69 (70%) patients. Angiodysplasia was the bleeding source in 15 out of 17 (88%) patients with further bleeding during hospitalization, whereas in the 52 patients with self-limited hemorrhage angiodysplasia was found in 31 (60%) patients. Angiography also established the diagnosis in 2 additional patients (1 small bowel tumor and 1 actively bleeding diverticuli). Conclusions: Acute LGB often remains undiagnosed after initial colonoscopy. In this condition, colonic angiodysplasia is the most common cause and mesenteric angiography is a useful procedure, particularly in patients with further bleeding.
VOLUME 59, NO. 5, 2004
*W1622 Comparison of Safety and Outcome Between Two Argon Plasma Coagulation Settings for Radiation Proctopathy in Patients with Prostate Cancer Richard S. Kwon, Clair Beard, Anthony V. D’Amico, David L. Carr-Locke Radiation proctopathy is a late complication of radiation therapy for prostate cancer. Argon plasma coagulation (APC) is an accepted endoscopic therapy, but there is no consensus for power settings and gas flow rate. We describe our experience with two different settings. Methods: Between January, 1997 and June, 2003, 124 patients were referred for endoscopic therapy for radiation proctopathy. The first exam was always a colonoscopy to rule out synchronous lesions. Repeat procedures were sigmoidoscopies. All procedures were performed by one endoscopist using an ERBE APC 300 and ICC 200 generator with end-firing probes. Early in the series, APC settings were 75W and 1.0 L/min. Later, these settings were changed to 40-60W and 1.0 L/min. Successful outcome was defined as cessation of bleeding. Failure was determined as need for surgical or other therapy. Results: 257 procedures were performed on 114 patients (93%) with a history of prostate cancer. The mean age was 71 years (range 51-84). 44 had external beam therapy (EBT, mean dose = 6227 cGy) 6 hormonal blockade (HB), 18 had EBT (mean dose = 6115 cGy) + brachytherapy (BT), and 25 patients had BT 6 HB. Brachytherapy doses were set according to American Association of Physicists in Medicine Task Group #43. 28 patients had an unspecified treatment regime. The mean procedures per patient was 2.2 (range 1-7). 63 patients received at least one APC treatment session at a setting of 75W. 51 patients had APC settings of 4060W. The 75W group required an average of 2.6 procedures (range 2-7) to achieve success as compared to 1.6 procedures (range 1-4) for the 40-60W (p<0.001). Of the 33 patients who required 3 or more treatment sessions, 27 (82%) received APC at 75W for at least one session. This subset averaged 4 treatment sessions per patient and 66.7% of these were at the 75W setting. There were 3 complications (1.2%), all in the 75W group. Two patients had continued bleeding that required admission and transfusion. One of these patients underwent a diverting colostomy. A third patient had an asymptomatic rectal stricture. Conclusions: APC is a safe and effective procedure at a power setting of 60W or less. This study underscores the need for a grading system using endoscopic findings and radiation therapy parameters to most accurately compare treatment responses.
GASTROINTESTINAL ENDOSCOPY
P271