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Efficacy and complications of argon plasma coagulation for hematochezia related to radiation proctopathy
Efficacy and complications of argon plasma coagulation for hematochezia related to radiation proctopathy Raphael T. Villavicencio, MD, Douglas K. Rex, MD, Emad Rahmani, MD Indianapolis, Indiana
Background: Endoscopic treatments effectively control bleeding caused by radiation proctopathy. The aims of this study were to determine the efficacy and side effects of argon plasma coagulation in the treatment of this type of bleeding. Methods: Records of 21 consecutive patients in whom argon plasma coagulation was used to treat hemorrhagic radiation proctopathy were reviewed. Results: Pharmacologic measures had been unsuccessful in 12 patients. Endoscopic treatment had been unsuccessful in 5 patients. All patients were anemic and 4 had received blood transfusions. The mean number of treatment sessions was 1.7, and 10 patients were successfully treated in single session. Rectal bleeding resolved within 1 month of the last treatment in 19 patients, usually on the day of the last procedure. Bleeding resolved 2 months after cessation of therapy in another patient. Short-term side effects occurred in 3 (14%) patients (rectal pain, tenesmus, and/or abdominal distention); long-term complications (rectal pain, tenesmus, diarrhea) developed in 4 patients (19%). Conclusions: Hematochezia caused by radiation proctopathy is effectively controlled by argon plasma coagulation, in some cases after a single treatment session. Treatment may result in protracted bowel symptoms. (Gastrointest Endosc 2002;55:70-4.)
Various therapies ranging from topical medications to surgery have been used to control bleeding caused by radiation proctopathy. Pharmacologic agents used for this purpose include sulfasalazine,1 5-aminosalicylic-acid,2 corticosteroids,3 sucralfate enemas,4 and dilute formalin.5 Endoscopic devices used to coagulate bleeding points have included the heat probe,6 argon laser,7 multipolar probes,8 and the Nd:YAG9 and KTP lasers.10 Argon plasma coagulation (APC) has been used endoscopically in the GI tract for various purposes including palliation of stenosing esophageal carcinoma,11 destruction of mucosal esophageal cancer,12 and coagulation of iatrogenic gastric mucosal injury,13 hemorrhagic radiation gastritis,14 vascular malformations, and residual flat adenoma after polypectomy.15 There are also recently published reports on the use of APC for radiation-induced proctopathy,16,17 as well as preliminary reports.18-22 The APC probe can be applied both en face and tangentially. APC is also a noncontact form of therReceived November 14, 2000. For revision January 31, 2001. Accepted April 12, 2001. From the Department of Medicine and Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana. Reprint requests: Douglas K. Rex, MD, 550 North University Blvd., Indiana University Hospital, Suite 2300, Indianapolis, IN 46202-5121. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/1/119877 doi:10.1067/mge.2002.119877 70
GASTROINTESTINAL ENDOSCOPY
apy. Compared with an Nd:YAG laser, an argon plasma coagulator is less expensive. Moreover, there is no risk of damage to the endoscope when the APC probe is used with the instrument retroflexed, as is often necessary during treatment of patients with radiation-induced proctopathy. This is a description of our experience with APC in the treatment of hematochezia caused by radiation proctopathy. Because APC produces ulceration of the mucosa, the side effects and complications of this therapy are also described. PATIENTS AND METHODS Patients with chronic hematochezia caused by radiation-induced proctopathy evaluated between February 1998 and August 2000 were identified. Colonoscopy to the cecum was performed in every patient (either at our center or by the referring physician) to determine the proximal extent of the disease and to exclude other potential sources of bleeding. Sixteen patients chose to undergo APC under conscious sedation. The mean duration of the APC sessions was 41 minutes (range 20-125 minutes). All patients were treated with the ERBE Argon Plasma Coagulator ICC 200 (ERBE USA, Marietta, Ga.). The argon gas flow rate used ranged from 1.2 to 2 L/min, the electrical power setting from 45 to 50 W, and probe size from 2.7- to 3.2-mm diameter. An effort was made to treat individual telangiectasias (Fig. 1) and whenever possible to avoid “painting” the rectal wall so as to minimize ulceration. The pulse duration was usually less than 1 second unless telangiectasias were virtually confluent, in which case longer pulse durations were used to allow “painting” of small VOLUME 55, NO. 1, 2002
Argon plasma coagulation for radiation proctopathy
R Villavicencio, D Rex, E Rahmani
A
B
Figure 1. A, Endoscopic view of typical telangiectasias in radiation-proctopathy. B, Endoscopic appearance at conclusion of first APC session showing that areas of coagulation are not confluent.
Table 1. Patient and APC treatment details
No./gender/age 1/M/73 2/F/75 3/M/71 4/F/74 5/M/72 6/F/78 7/M/77 8/F/82 9/M/58 10/F/70 11/M/70 12/M/75 13/M/67 14/M/65 15/M/78 16/M/74 17/M/86 18/M/71 19/M/76 20/F/62 21/M/72
Malignancy Prostate Endometrial Prostate Endometrial Prostate Endometrial Prostate Sacral chondroma Prostate Endometrial Prostate Prostate Prostate Prostate Prostate Prostate Prostate Prostate Prostate Cervical Prostate
Time since radiation (y)
No. of APC treatments and total time period
Immediate APC complications
Duration of longterm APC complications (mo)
1 1 1 2 3 1 1 1 2 7 2 1 1 2 1 2 1 1 2 2 1
3 over 12 wk 1 4 over 20 wk 2 over 7 wk 3 over 18 wk 2 over 8 wk 1 1 2 over 10 wk 1 1 2 over 5 wk 1 1 1 2 over 8 wk 1 1 2 over 8 wk 2 over 84 wk 2 over 8 wk
0 0 Rectal pain* 0 0 0 0 0 Bloating 0 0 Tenesmus 0 0 0 0 0 0 0 0 0
None None None T/R 3 mo None None None R 10 mo D/T 1 mo None None B/T 2 mo None None None None None None None None None
B, Bleeding-rectal; D, diarrhea; R, rectal pain; T, tenesmus. *One episode of rectal pain after 2 separate APC sessions.
areas. All lesions were treated in a single session whenever possible. Telangiectasias in the skin of the anal canal were not treated, but the area coagulated was extended to the dentate line when necessary. Double channel upper endoscopes were generally used initially so that argon gas could be suctioned from the lumen. If the rectum was narrow, a standard 9.8-mm single channel upper endoscope was frequently needed to achieve adequate retroflexion. In all cases, telangiectatic lesions were treated first on forward view until no further lesions were visible and then the VOLUME 55, NO. 1, 2002
instrument was retroflexed and treatment continued. Retroflexion, performed in all patients, usually showed telangiectasias that were not seen on forward viewing. In addition to providing access to the most distal segment of the rectum, retroflexion sometimes made it easier to treat lesions on the proximal side of the first rectal valve. All patients were treated on an outpatient basis except for one who had been hospitalized for a blood transfusion. After APC, patients were treated with a stool softener, dietary fiber supplementation, and laxatives or an antiGASTROINTESTINAL ENDOSCOPY
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Argon plasma coagulation for radiation proctopathy
A
B
C
D
Figure 2. Patient treated in 2 sessions of APC. A, Endoscopic appearance before initial treatment. B, Appearance at the conclusion of first treatment. C, Endoscopic view 2 months later, immediately before second session, showing scars and residual telangiectasias. D, Appearance at end of second session. motility agent as needed. Patients in whom it appeared endoscopically that all telangiectatic lesions had been treated in one session were asked to return only if bleeding persisted. Follow-up was by review of medical records and by telephone interviews. Patients were asked to estimate as a percentage the reduction in bleeding in response to treatment as compared with bleeding before treatment. Resolution of bleeding was defined as a 90% or greater reduction in bleeding as estimated by the patients. Side effects and complications were defined as shortterm if they appeared within 24 hours of the APC procedure and persisted for less than 1 month. Those that persisted for longer than 1 month after the last APC session were considered long-term complications. Patients were asked (yes or no) whether they were satisfied overall with the treatment.
RESULTS Twenty-one consecutive patients (15 men, 6 women; median age 72.6 years; range 58 to 86 years) 72
GASTROINTESTINAL ENDOSCOPY
underwent APC for hemorrhagic radiation proctopathy (Table 1). All patients had chronic hematochezia. Twelve had been treated unsuccessfully with various pharmacologic agents including orally (n = 4) and rectally (n = 5) administered mesalamine and rectally administered corticosteroids (n = 8). Various forms of endoscopic treatment (APC, laser photocoagulation, multipolar coagulation) had been performed in 5 (24%) patients, all without achieving control of bleeding. All patients were anemic and 4 (19%) had received blood transfusion. All patients had rectal telangiectasias; in 3 the distal sigmoid colon was also involved. The median number of treatment sessions was 1.7 (range 1-4) (Fig. 2). There was no resultant endoscope damage when telangiectasias near the insertion tube of the retroflexed instrument were treated. Median followup was 10.5 months (range 1 to 29 months). VOLUME 55, NO. 1, 2002
Argon plasma coagulation for radiation proctopathy
Rectal bleeding resolved within 1 month of the last APC session in 19 patients (90%), usually on the day of the last procedure (Table 1). Fourteen patients reported a 100% reduction (total resolution) in bleeding. None of those with residual minor bleeding (≥90% reduction) felt that additional therapy was warranted. Ten patients were successfully treated with a single session. For the patients who returned for further therapy, the average interval between sessions was 13 weeks (range 5-84 weeks). Hematochezia resolved after a single session of APC in the 4 patients who received transfusions before APC. Hematochezia persisted for 1 month or longer after APC in 2 patients (patient 3, 8 months; patient 12, 2 months). Patient 3 experienced a reduction of only 30% in bleeding after 4 treatment sessions despite endoscopically apparent coagulation of all telangiectasias. This patient had hemorrhoids for which he declined therapy, and further evaluation for another source of bleeding was negative. Patient 12 stated his bleeding stopped for 2 days, then resumed. After 2 months, his bleeding ceased. After completion of APC treatment(s), no patient underwent further endoscopic or surgical intervention to control rectal bleeding or received a transfusion because of anemia caused by rectal bleeding. Thus APC was successful in resolving bleeding in 20 of 21 patients (95%). All 21 patients reported resolution of their anemia. Short-term side effects developed in 3 patients (19%) (Table 1). Patient 3 developed rectal pain immediately after 2 separate APC sessions, which resolved in both instances by the following day. Patient 9 reported excessive bloating, probably secondary to luminal distention with argon gas, a known side effect of APC.13 Patient 12 had severe tenesmus after APC. In each case, these short-term side effects of APC resolved within 24 hours of treatment. Long-term complications occurred after APC in 4 patients (19%) (Table 1). Patient 4 had tenesmus and rectal pain that persisted for 3 months after APC. Patient 8 reported dark stools and rectal pain that persisted 10 months. Patient 9 had diarrhea and tenesmus develop that lasted over 1 month. Patient 12 had tenesmus for 2 months. Twenty of 21 patients were satisfied with treatment, including 3 of the 4 with long-term symptoms and the single patient with persistent bleeding. Patient 8 was not satisfied because of the persistent dark stools, which she perceived as bleeding. Her hematochezia resolved after treatment. Before APC her hemoglobin was 6.8 gm/dL, and she was transfused 3 units of packed red blood cells. After APC the hemoglobin rose to 14.6 gm/dL, no further transfusions were given, and stool tested negative for occult VOLUME 55, NO. 1, 2002
R Villavicencio, D Rex, E Rahmani
A
B Figure 3. A, Endoscopic view of rectum 12 days after APC of confluent lesions on one wall showing extensive ulceration. The patient had persistent bleeding from incompletely treated lesions in the proximal rectum and distal sigmoid colon. B, Endoscopic view 1 month later showing persistent ulceration. Bleeding had stopped.
blood. Despite being presented these facts, she remained dissatisfied. DISCUSSION The results in this series confirm that APC is highly effective in controlling hematochezia and improving anemia in patients with radiation proctopathy. Only 1 patient had persistent bleeding, possibly related to hemorrhoids. The mean number of treatment sessions required in our patients was 1.7, and 10 of 21 patients were effectively treated in single session. This mean number of sessions is slightly lower than that in other series.16-21 Whether this reflects our specific effort to treat all telangiectatic lesions in a single session is uncertain. GASTROINTESTINAL ENDOSCOPY
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No significant complications occurred in patients with radiation-induced proctopathy treated by APC in the series of Fantin et al.16 and that of Silva et al.17 In the present series, some patients had persistent symptoms develop of rectal pain or altered bowel habit. Whether this is a result of more extensive treatment during a single session in the present series is uncertain. However, it would be reasonable to evaluate treatment over multiple sessions as a way to reduce complications. In a preliminary report, Saurin et al.21 described mild to moderate rectal pain in 4 of 9 patients and rectal stenoses in 3 of 9 patients treated with APC at 60 to 80 W. Rectal stenosis was not noted in any patient in the present series, but follow-up examinations were not performed in all patients. However, power settings of 45 to 50 W effectively eliminated the vascular lesions of radiation proctopathy in patients in the present series; therefore, lower power settings (4550 W) should be used. Further, because extensive ulceration may develop after APC (Fig. 3), brief pulses should be used and individual vascular lesions be targeted rather than “painting” the rectal wall. Further studies are needed to determine optimal power settings and method of delivery and whether the surface area treated per session should be limited. Complications have also been described after Nd:YAG laser photocoagulation for radiationinduced proctopathy.23 Despite the development of new symptoms after APC in a few patients, nearly all patients in the present series were satisfied with the results of their treatment. REFERENCES 1. Gilinsky NH, Khoury J, Thorton JJ. Treatment of chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids. Am J Gastroenterol 1979;70:62-5. 2. Baum CA, Biddle WL, Miner PB. Failure of 5-aminosalicylic acid enemas to improve chronic radiation proctitis. Dig Dis Sci 1989;654:758-60. 3. Goldstein F, Khoury J, Thornton JJ. Treatment of chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids: a pilot study. Am J Gastroenterol 1976;65:201-8. 4. Kochhar R, Sharma SC, Gupta BB, Mehta SK. Rectal sucralfate in radiation proctitis. Lancet 1988;2:400. 5. Seow-Choen F, Gos HS, Eu KW, Ho YH, Tay SK. A simple and effective treatment for hemorrhagic radiation proctitis using formalin. Dis Colon Rectum 1993;36:135-8. 6. Fuentes D, Monserat R, Isern AM, Salazar J, Bronstein M, Gumina C, et al. Colitis due to radiation: endoscopic management with heater probe [in Spanish with English abstract]. G E N 1993;47:165-7.
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Argon plasma coagulation for radiation proctopathy
7. Taylor JG, Disario JA, Buchi KN. Argon laser therapy for hemorrhagic radiation proctitis long-term results. Gastrointest Endosc 1993;39:641-4. 8. Maunoury V, Brunetaud JM, Cortot A. Bipolar electrocoagulation treatment for hemorrhagic radiation injury of the lower digestive tract. Gastrointest Endosc 1991;37:492-3. 9. Viggiano TR, Zighelboim J, Ahlquist DA, Gostout CJ, Wang KK, Larson MV. Endoscopic Nd:YAG laser coagulation of bleeding from radiation proctopathy. Gastrointest Endosc 1993;39:513-7. 10. Taylor JG, DiSario JA, Bjorkman DJ. KTP laser therapy for bleeding from chronic radiation proctopathy. Gastrointest Endosc 2000;52:353-7. 11. Robertson GS, Thomas M, Jamieson J, Veitch PS, Dennison AR. Palliation of esophageal carcinoma using the argon beam coagulator. Brit J Surg 1996;83:1769-71. 12. May A, Gossner L, Gunter E, Stolte M, Ell C. Local treatment of early cancer in short Barrett’s esophagus by means of argon plasma coagulation: initial experience. Endoscopy 1999;31:497-500. 13. Kihara S, Mizutani T, Shimizu T, Toyooka H. Bleeding from a tear in the gastric mucosa caused by transoesophageal echocardiography during cardiac surgery: effective hemostasis by endoscopic argon plasma coagulation. Br J Anesth 1999;82:948-50. 14. Morrow JB, Dumot JA, Vargo JJ. Radiation-induced hemorrhagic carditis treated with argon plasma coagulator. Gastrointest Endosc 2000;51:498-9. 15. Wahab PJ, Mulder CJ, den Hartog G, Thies JE. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences. Endoscopy 1997;29:176-81. 16. Fantin AC, Binek J, Suter WR, Meyenberger C. Argon beam coagulation for treatment of symptomatic radiation-induced proctitis. Gastrointest Endosc 1999;49:515-8. 17. Silva RA, Correia AJ, Dias LM, Viana HL, Viana RL. Argon plasma coagulation therapy for hemorrhagic radiation proctosigmoiditis. Gastrointest Endosc 1999;50:221-4. 18. Lee JH, Johannes RS, Van Dam J, Taielbaum G, Piper J, CarrLocke DL, et al. Argon plasma coagulation in endoscopic therapy [abstract]. Gastrointest Endosc 2000;51:AB264. 19. Kaassis M, Oberti F, Burtin P, Boyer J. Argon plasma coagulation is an effective and well tolerated treatment for rectal bleeding due to chronic radiation proctitis [abstract]. Gastrointest Endosc 2000;51:AB147. 20. Taieb S, Rolachon A, Cenni JC, Bouvoisin S, Fournet J, Gerard JP, et al. Argon plasma coagulation therapy for management of refractory hemorrhagic radiation proctitis [abstract]. Gastrointest Endosc 2000;51:AB144. 21. Saurin JC, Cohelo J, Lepretre J, Chavaillon A, Systchenko R, Ponchon T, et al. Argon plasma coagulation (APC) efficiently controls bleeding in patients with watermelon stomach or radiation proctitis [abstract]. Gastrointest Endosc 1999;49: AB169. 22. Davila AD, Koch J, Cello JP. Management of chronic radiation proctitis [abstract]. Gastrointest Endosc 1996;43:365. 23. Alexander TJ, Dwyer RM. Endoscopic Nd:YAG laser treatment of severe radiation injury of the lower gastrointestinal tract: long-term follow-up. Gastrointest Endosc 1988;34:40711.
VOLUME 55, NO. 1, 2002
Background: Endoscopic treatments effectively control bleeding caused by radiation proctopathy. The aims of this study were to determine the efficacy and side effects of argon plasma coagulation in the treatment of this type of bleeding. Methods: Records of 21 consecutive patients in whom argon plasma coagulation was used to treat hemorrhagic radiation proctopathy were reviewed. Results: Pharmacologic measures had been unsuccessful in 12 patients. Endoscopic treatment had been unsuccessful in 5 patients. All patients were anemic and 4 had received blood transfusions. The mean number of treatment sessions was 1.7, and 10 patients were successfully treated in single session. Rectal bleeding resolved within 1 month of the last treatment in 19 patients, usually on the day of the last procedure. Bleeding resolved 2 months after cessation of therapy in another patient. Short-term side effects occurred in 3 (14%) patients (rectal pain, tenesmus, and/or abdominal distention); long-term complications (rectal pain, tenesmus, diarrhea) developed in 4 patients (19%). Conclusions: Hematochezia caused by radiation proctopathy is effectively controlled by argon plasma coagulation, in some cases after a single treatment session. Treatment may result in protracted bowel symptoms. (Gastrointest Endosc 2002;55:70-4.)
Various therapies ranging from topical medications to surgery have been used to control bleeding caused by radiation proctopathy. Pharmacologic agents used for this purpose include sulfasalazine,1 5-aminosalicylic-acid,2 corticosteroids,3 sucralfate enemas,4 and dilute formalin.5 Endoscopic devices used to coagulate bleeding points have included the heat probe,6 argon laser,7 multipolar probes,8 and the Nd:YAG9 and KTP lasers.10 Argon plasma coagulation (APC) has been used endoscopically in the GI tract for various purposes including palliation of stenosing esophageal carcinoma,11 destruction of mucosal esophageal cancer,12 and coagulation of iatrogenic gastric mucosal injury,13 hemorrhagic radiation gastritis,14 vascular malformations, and residual flat adenoma after polypectomy.15 There are also recently published reports on the use of APC for radiation-induced proctopathy,16,17 as well as preliminary reports.18-22 The APC probe can be applied both en face and tangentially. APC is also a noncontact form of therReceived November 14, 2000. For revision January 31, 2001. Accepted April 12, 2001. From the Department of Medicine and Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana. Reprint requests: Douglas K. Rex, MD, 550 North University Blvd., Indiana University Hospital, Suite 2300, Indianapolis, IN 46202-5121. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/1/119877 doi:10.1067/mge.2002.119877 70
GASTROINTESTINAL ENDOSCOPY
apy. Compared with an Nd:YAG laser, an argon plasma coagulator is less expensive. Moreover, there is no risk of damage to the endoscope when the APC probe is used with the instrument retroflexed, as is often necessary during treatment of patients with radiation-induced proctopathy. This is a description of our experience with APC in the treatment of hematochezia caused by radiation proctopathy. Because APC produces ulceration of the mucosa, the side effects and complications of this therapy are also described. PATIENTS AND METHODS Patients with chronic hematochezia caused by radiation-induced proctopathy evaluated between February 1998 and August 2000 were identified. Colonoscopy to the cecum was performed in every patient (either at our center or by the referring physician) to determine the proximal extent of the disease and to exclude other potential sources of bleeding. Sixteen patients chose to undergo APC under conscious sedation. The mean duration of the APC sessions was 41 minutes (range 20-125 minutes). All patients were treated with the ERBE Argon Plasma Coagulator ICC 200 (ERBE USA, Marietta, Ga.). The argon gas flow rate used ranged from 1.2 to 2 L/min, the electrical power setting from 45 to 50 W, and probe size from 2.7- to 3.2-mm diameter. An effort was made to treat individual telangiectasias (Fig. 1) and whenever possible to avoid “painting” the rectal wall so as to minimize ulceration. The pulse duration was usually less than 1 second unless telangiectasias were virtually confluent, in which case longer pulse durations were used to allow “painting” of small VOLUME 55, NO. 1, 2002
Argon plasma coagulation for radiation proctopathy
R Villavicencio, D Rex, E Rahmani
A
B
Figure 1. A, Endoscopic view of typical telangiectasias in radiation-proctopathy. B, Endoscopic appearance at conclusion of first APC session showing that areas of coagulation are not confluent.
Table 1. Patient and APC treatment details
No./gender/age 1/M/73 2/F/75 3/M/71 4/F/74 5/M/72 6/F/78 7/M/77 8/F/82 9/M/58 10/F/70 11/M/70 12/M/75 13/M/67 14/M/65 15/M/78 16/M/74 17/M/86 18/M/71 19/M/76 20/F/62 21/M/72
Malignancy Prostate Endometrial Prostate Endometrial Prostate Endometrial Prostate Sacral chondroma Prostate Endometrial Prostate Prostate Prostate Prostate Prostate Prostate Prostate Prostate Prostate Cervical Prostate
Time since radiation (y)
No. of APC treatments and total time period
Immediate APC complications
Duration of longterm APC complications (mo)
1 1 1 2 3 1 1 1 2 7 2 1 1 2 1 2 1 1 2 2 1
3 over 12 wk 1 4 over 20 wk 2 over 7 wk 3 over 18 wk 2 over 8 wk 1 1 2 over 10 wk 1 1 2 over 5 wk 1 1 1 2 over 8 wk 1 1 2 over 8 wk 2 over 84 wk 2 over 8 wk
0 0 Rectal pain* 0 0 0 0 0 Bloating 0 0 Tenesmus 0 0 0 0 0 0 0 0 0
None None None T/R 3 mo None None None R 10 mo D/T 1 mo None None B/T 2 mo None None None None None None None None None
B, Bleeding-rectal; D, diarrhea; R, rectal pain; T, tenesmus. *One episode of rectal pain after 2 separate APC sessions.
areas. All lesions were treated in a single session whenever possible. Telangiectasias in the skin of the anal canal were not treated, but the area coagulated was extended to the dentate line when necessary. Double channel upper endoscopes were generally used initially so that argon gas could be suctioned from the lumen. If the rectum was narrow, a standard 9.8-mm single channel upper endoscope was frequently needed to achieve adequate retroflexion. In all cases, telangiectatic lesions were treated first on forward view until no further lesions were visible and then the VOLUME 55, NO. 1, 2002
instrument was retroflexed and treatment continued. Retroflexion, performed in all patients, usually showed telangiectasias that were not seen on forward viewing. In addition to providing access to the most distal segment of the rectum, retroflexion sometimes made it easier to treat lesions on the proximal side of the first rectal valve. All patients were treated on an outpatient basis except for one who had been hospitalized for a blood transfusion. After APC, patients were treated with a stool softener, dietary fiber supplementation, and laxatives or an antiGASTROINTESTINAL ENDOSCOPY
71
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Argon plasma coagulation for radiation proctopathy
A
B
C
D
Figure 2. Patient treated in 2 sessions of APC. A, Endoscopic appearance before initial treatment. B, Appearance at the conclusion of first treatment. C, Endoscopic view 2 months later, immediately before second session, showing scars and residual telangiectasias. D, Appearance at end of second session. motility agent as needed. Patients in whom it appeared endoscopically that all telangiectatic lesions had been treated in one session were asked to return only if bleeding persisted. Follow-up was by review of medical records and by telephone interviews. Patients were asked to estimate as a percentage the reduction in bleeding in response to treatment as compared with bleeding before treatment. Resolution of bleeding was defined as a 90% or greater reduction in bleeding as estimated by the patients. Side effects and complications were defined as shortterm if they appeared within 24 hours of the APC procedure and persisted for less than 1 month. Those that persisted for longer than 1 month after the last APC session were considered long-term complications. Patients were asked (yes or no) whether they were satisfied overall with the treatment.
RESULTS Twenty-one consecutive patients (15 men, 6 women; median age 72.6 years; range 58 to 86 years) 72
GASTROINTESTINAL ENDOSCOPY
underwent APC for hemorrhagic radiation proctopathy (Table 1). All patients had chronic hematochezia. Twelve had been treated unsuccessfully with various pharmacologic agents including orally (n = 4) and rectally (n = 5) administered mesalamine and rectally administered corticosteroids (n = 8). Various forms of endoscopic treatment (APC, laser photocoagulation, multipolar coagulation) had been performed in 5 (24%) patients, all without achieving control of bleeding. All patients were anemic and 4 (19%) had received blood transfusion. All patients had rectal telangiectasias; in 3 the distal sigmoid colon was also involved. The median number of treatment sessions was 1.7 (range 1-4) (Fig. 2). There was no resultant endoscope damage when telangiectasias near the insertion tube of the retroflexed instrument were treated. Median followup was 10.5 months (range 1 to 29 months). VOLUME 55, NO. 1, 2002
Argon plasma coagulation for radiation proctopathy
Rectal bleeding resolved within 1 month of the last APC session in 19 patients (90%), usually on the day of the last procedure (Table 1). Fourteen patients reported a 100% reduction (total resolution) in bleeding. None of those with residual minor bleeding (≥90% reduction) felt that additional therapy was warranted. Ten patients were successfully treated with a single session. For the patients who returned for further therapy, the average interval between sessions was 13 weeks (range 5-84 weeks). Hematochezia resolved after a single session of APC in the 4 patients who received transfusions before APC. Hematochezia persisted for 1 month or longer after APC in 2 patients (patient 3, 8 months; patient 12, 2 months). Patient 3 experienced a reduction of only 30% in bleeding after 4 treatment sessions despite endoscopically apparent coagulation of all telangiectasias. This patient had hemorrhoids for which he declined therapy, and further evaluation for another source of bleeding was negative. Patient 12 stated his bleeding stopped for 2 days, then resumed. After 2 months, his bleeding ceased. After completion of APC treatment(s), no patient underwent further endoscopic or surgical intervention to control rectal bleeding or received a transfusion because of anemia caused by rectal bleeding. Thus APC was successful in resolving bleeding in 20 of 21 patients (95%). All 21 patients reported resolution of their anemia. Short-term side effects developed in 3 patients (19%) (Table 1). Patient 3 developed rectal pain immediately after 2 separate APC sessions, which resolved in both instances by the following day. Patient 9 reported excessive bloating, probably secondary to luminal distention with argon gas, a known side effect of APC.13 Patient 12 had severe tenesmus after APC. In each case, these short-term side effects of APC resolved within 24 hours of treatment. Long-term complications occurred after APC in 4 patients (19%) (Table 1). Patient 4 had tenesmus and rectal pain that persisted for 3 months after APC. Patient 8 reported dark stools and rectal pain that persisted 10 months. Patient 9 had diarrhea and tenesmus develop that lasted over 1 month. Patient 12 had tenesmus for 2 months. Twenty of 21 patients were satisfied with treatment, including 3 of the 4 with long-term symptoms and the single patient with persistent bleeding. Patient 8 was not satisfied because of the persistent dark stools, which she perceived as bleeding. Her hematochezia resolved after treatment. Before APC her hemoglobin was 6.8 gm/dL, and she was transfused 3 units of packed red blood cells. After APC the hemoglobin rose to 14.6 gm/dL, no further transfusions were given, and stool tested negative for occult VOLUME 55, NO. 1, 2002
R Villavicencio, D Rex, E Rahmani
A
B Figure 3. A, Endoscopic view of rectum 12 days after APC of confluent lesions on one wall showing extensive ulceration. The patient had persistent bleeding from incompletely treated lesions in the proximal rectum and distal sigmoid colon. B, Endoscopic view 1 month later showing persistent ulceration. Bleeding had stopped.
blood. Despite being presented these facts, she remained dissatisfied. DISCUSSION The results in this series confirm that APC is highly effective in controlling hematochezia and improving anemia in patients with radiation proctopathy. Only 1 patient had persistent bleeding, possibly related to hemorrhoids. The mean number of treatment sessions required in our patients was 1.7, and 10 of 21 patients were effectively treated in single session. This mean number of sessions is slightly lower than that in other series.16-21 Whether this reflects our specific effort to treat all telangiectatic lesions in a single session is uncertain. GASTROINTESTINAL ENDOSCOPY
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No significant complications occurred in patients with radiation-induced proctopathy treated by APC in the series of Fantin et al.16 and that of Silva et al.17 In the present series, some patients had persistent symptoms develop of rectal pain or altered bowel habit. Whether this is a result of more extensive treatment during a single session in the present series is uncertain. However, it would be reasonable to evaluate treatment over multiple sessions as a way to reduce complications. In a preliminary report, Saurin et al.21 described mild to moderate rectal pain in 4 of 9 patients and rectal stenoses in 3 of 9 patients treated with APC at 60 to 80 W. Rectal stenosis was not noted in any patient in the present series, but follow-up examinations were not performed in all patients. However, power settings of 45 to 50 W effectively eliminated the vascular lesions of radiation proctopathy in patients in the present series; therefore, lower power settings (4550 W) should be used. Further, because extensive ulceration may develop after APC (Fig. 3), brief pulses should be used and individual vascular lesions be targeted rather than “painting” the rectal wall. Further studies are needed to determine optimal power settings and method of delivery and whether the surface area treated per session should be limited. Complications have also been described after Nd:YAG laser photocoagulation for radiationinduced proctopathy.23 Despite the development of new symptoms after APC in a few patients, nearly all patients in the present series were satisfied with the results of their treatment. REFERENCES 1. Gilinsky NH, Khoury J, Thorton JJ. Treatment of chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids. Am J Gastroenterol 1979;70:62-5. 2. Baum CA, Biddle WL, Miner PB. Failure of 5-aminosalicylic acid enemas to improve chronic radiation proctitis. Dig Dis Sci 1989;654:758-60. 3. Goldstein F, Khoury J, Thornton JJ. Treatment of chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids: a pilot study. Am J Gastroenterol 1976;65:201-8. 4. Kochhar R, Sharma SC, Gupta BB, Mehta SK. Rectal sucralfate in radiation proctitis. Lancet 1988;2:400. 5. Seow-Choen F, Gos HS, Eu KW, Ho YH, Tay SK. A simple and effective treatment for hemorrhagic radiation proctitis using formalin. Dis Colon Rectum 1993;36:135-8. 6. Fuentes D, Monserat R, Isern AM, Salazar J, Bronstein M, Gumina C, et al. Colitis due to radiation: endoscopic management with heater probe [in Spanish with English abstract]. G E N 1993;47:165-7.
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7. Taylor JG, Disario JA, Buchi KN. Argon laser therapy for hemorrhagic radiation proctitis long-term results. Gastrointest Endosc 1993;39:641-4. 8. Maunoury V, Brunetaud JM, Cortot A. Bipolar electrocoagulation treatment for hemorrhagic radiation injury of the lower digestive tract. Gastrointest Endosc 1991;37:492-3. 9. Viggiano TR, Zighelboim J, Ahlquist DA, Gostout CJ, Wang KK, Larson MV. Endoscopic Nd:YAG laser coagulation of bleeding from radiation proctopathy. Gastrointest Endosc 1993;39:513-7. 10. Taylor JG, DiSario JA, Bjorkman DJ. KTP laser therapy for bleeding from chronic radiation proctopathy. Gastrointest Endosc 2000;52:353-7. 11. Robertson GS, Thomas M, Jamieson J, Veitch PS, Dennison AR. Palliation of esophageal carcinoma using the argon beam coagulator. Brit J Surg 1996;83:1769-71. 12. May A, Gossner L, Gunter E, Stolte M, Ell C. Local treatment of early cancer in short Barrett’s esophagus by means of argon plasma coagulation: initial experience. Endoscopy 1999;31:497-500. 13. Kihara S, Mizutani T, Shimizu T, Toyooka H. Bleeding from a tear in the gastric mucosa caused by transoesophageal echocardiography during cardiac surgery: effective hemostasis by endoscopic argon plasma coagulation. Br J Anesth 1999;82:948-50. 14. Morrow JB, Dumot JA, Vargo JJ. Radiation-induced hemorrhagic carditis treated with argon plasma coagulator. Gastrointest Endosc 2000;51:498-9. 15. Wahab PJ, Mulder CJ, den Hartog G, Thies JE. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences. Endoscopy 1997;29:176-81. 16. Fantin AC, Binek J, Suter WR, Meyenberger C. Argon beam coagulation for treatment of symptomatic radiation-induced proctitis. Gastrointest Endosc 1999;49:515-8. 17. Silva RA, Correia AJ, Dias LM, Viana HL, Viana RL. Argon plasma coagulation therapy for hemorrhagic radiation proctosigmoiditis. Gastrointest Endosc 1999;50:221-4. 18. Lee JH, Johannes RS, Van Dam J, Taielbaum G, Piper J, CarrLocke DL, et al. Argon plasma coagulation in endoscopic therapy [abstract]. Gastrointest Endosc 2000;51:AB264. 19. Kaassis M, Oberti F, Burtin P, Boyer J. Argon plasma coagulation is an effective and well tolerated treatment for rectal bleeding due to chronic radiation proctitis [abstract]. Gastrointest Endosc 2000;51:AB147. 20. Taieb S, Rolachon A, Cenni JC, Bouvoisin S, Fournet J, Gerard JP, et al. Argon plasma coagulation therapy for management of refractory hemorrhagic radiation proctitis [abstract]. Gastrointest Endosc 2000;51:AB144. 21. Saurin JC, Cohelo J, Lepretre J, Chavaillon A, Systchenko R, Ponchon T, et al. Argon plasma coagulation (APC) efficiently controls bleeding in patients with watermelon stomach or radiation proctitis [abstract]. Gastrointest Endosc 1999;49: AB169. 22. Davila AD, Koch J, Cello JP. Management of chronic radiation proctitis [abstract]. Gastrointest Endosc 1996;43:365. 23. Alexander TJ, Dwyer RM. Endoscopic Nd:YAG laser treatment of severe radiation injury of the lower gastrointestinal tract: long-term follow-up. Gastrointest Endosc 1988;34:40711.
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