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Endoscopic argon plasma coagulation (APC) for radiation proctopathy
AJG – September, 2000
Abstracts
decline in the mean platelet count, which failed to improve on discontinuation of Ribavirin. 389 Acute liver failure due to mushroom poisoning: a clinical series. Guilherme Macedo, MD, FACG, Jose´ Costa Maia, MD, Abilio Gomes, MD, Susana Lopes, MD, Fa´tima Carneiro, Ph.D., Ana Mota, MD, Araujo Teixeira, Ph.D., Tome´ Ribeiro, Ph.D. Gastroenterology and Liver Transplant Unit, H.S. Joa˜o, Porto, Portugal. Mushroom poisoning, mycetismus, is a well recognized medical emergency, that may lead to fulminant hepatic failure, with significant mortality, specially if associated with renal failure and cerebral lesions. Timing for liver transplantation is particularly difficult in this setting because progressive organ damage may evolve unrecognized and rapidly. Two groups of toxins induce different symptoms, in a sequential form: phalloidin, at first, which would be responsible for gastrointestinal upset; alpha-amanitin afterwards inducing subclinical deterioration, and acute liver failure (ALF), with encephalopathy and bleeding diathesis. We present 3 cases of ALF due to Amanita Phalloides ingestion, with different clinical courses, in whom timing for transplantation was evaluated and eventually performed. These were 2 men (aged 28 and 66) and a 38 years old caucasian woman, from 3 nonrelated families, that were admitted in different seasons, after consuming wild mushrooms with other family members, who had transient gastrointestinal symptoms. We describe the clinical evolution, time lag between ingestion and ALF, blood chemistries, Clichy’s and King’s College criteria for liver transplant and treatment. To patients progressed to grade 3 encephalopathy and were proposed for urgent liver transplant, successfully performed in one, and not done in the older patient, who died after 72 h in a national urgent waiting list. The younger patient had an uneventful total recovery after intensive care. We conclude that mushroom poisoning may have a fatal outcome, that clinical evolution may be variable, and that intensive therapy should be proposed in an institution able to perform liver transplantation.
COLON 390 Endoscopic argon plasma coagulation (APC) for radiation proctopathy KW Adkisson, MD, Stanley J Rogers, MD, John P Cello, MD. Departments of Medicine and Surgery, San Francisco General Hospital and the University of California, San Francisco. Radiation therapy for pelvic neoplasia is widely employed for both curative and palliative intent. Although safe and effective, 5–10% patients experience the undesirable complication of radiation proctitis (more properly called proctopathy). The rectal bleeding is typically intermittent but rarely presents as acute lower GI bleeding. Endoscopic evaluation reveals scattered vascular ectasias throughout the rectum/distal sigmoid. The vascular ectasias are felt to arise from neoangiogenesis resultant from vascular wall fibrosis induced by radiation. Many modalities for treatment have been employed including topical application of various agents (formaldehyde, short-chain fatty acids, sulfasalazine, 5-ASA), endoscopic use of Nd:YAG laser, bipolar cautery and various surgical interventions. APC is a new endoscopic coagulation modality employing pressurized ionized argon gas delivered via polyethylene catheter to achieve superficial cauterization. Five patients diagnosed with symptomatic radiation proctopathy and anemia underwent APC at our institution within the past 18 months. One patient had been treated previously with YAG laser. During each endoscopic treatment session a flexible sigmoidoscopy was performed followed by ablation of rectal ectasias by APC. Routine APC application consisted of multiple, brief pulses from the APC device (ERBE) set at 60 – 65 watts applied by mucosal “painting” over focal areas of visible ectasias. Patients received a mean of 4.6 (range 2–7) treatment sessions (approx. one session
2525
every 3 wks). Hematocrit (Hct) values immediately preceding APC therapy and packed red blood cell transfusions (PRBC) during a 6 month interval prior to APC were compared to Hct and PRBC requirements during APC therapy. Hct values remained stable or improved while the need for PRBC was either eliminated or substantially decreased in all patients. Statistical significance was not achieved due to the limited sample size. All patients tolerated the procedure well with no complications noted. Conclusion: APC is a reliable and acceptable endoscopic treatment option for ectasias associated with radiation proctopathy and may be superior to other forms of coagulation therapy in ablating vascular ectasias.
391 Side-viewing colonoscopy for the evaluation and treatment of difficult colonic lesions. Aziz Ahmad, MD, Paul S Berg, MD, Matthew McKinley, MD, FACG. North Shore University Hospital, Manhasset, NY and ProHEALTH Care Associates, Lake success, NY. Objective: To investigate the use of side-viewing technology in colonoscopy. Background: Endoscopy has transformed and improved our approach to digestive diseases. Despite great advances, there are technical limitations to currently available endoscopes. Studies examining the inherent polyp miss rate of colonoscopy, using methodology such as same day repeat exams, often site the angle of visualization as a limiting factor. This is particularly problematic in lesions located on the proximal aspects of valves or haustrae. It is for this reason that wide-angle colonoscopy is being investigated. Until such technology is perfected, endoscopists need to utilize all available tools. We describe the role of the side-viewing enterscope in the evaluation and treatment of three difficult colonic lesions. Methods and Results: Three cases of colonic neoplasia were addressed with the standard forward viewing technique. Anatomic parameters limited visualization and attempts at therapy. Two lesions were on the proximal aspect of folds (rectum and sigmoid) and one in the splenic flexure. A side-viewing enteroscope (Olympus TJF-130) was gently introduced by carefully extending the scope tip and then advancing in small “blind” movements in a neutral tip position. Using this technique, improved visualization was easily achieved. Polypectomy and biopsy was technically possible only with the side-viewing instrument in these patients. The presence of an elevator on the enteroscope assisted manipulation of accessories. Conclusion: In the hands of endoscopists familiar and comfortable with the side-viewing enteroscope, it can be a useful tool in the evaluation and treatment of colonic lesions not amenable to standard therapy. Benefits will need to be compared to any increased risks, especially in patients with anatomic conditions such as diverticulosis.
392 Rectal resection and coloanal anastamosis: a retrospective study Robert Akbari, MD, Philip F Caushaj, MD, FACG*, Devora E Hathaway, RN, William McDougall, MD. The Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, United States Purpose: Surgical treatment of rectal carcinoma has changed over the years. The abdominoperineal resection (APR) is the gold standard. More recently sphincter preservation via coloanal anastamosis has gained popularity. This retrospective study was done by reviewing one surgeon’s results with coloanal anastamosis in order to reiterate the benefits of this newer operation. Methods: In a retrospective fashion, all rectal resections and coloanal anastamosis done by one surgeon between 1986 to 1999 were analyzed. This included 38 patients. Various surgical indications included rectal adenocarcinoma (23), villous adenoma (5), Hartman/Diverticulitis (5), proctitis (2), and miscellaneous (3). Various preoperative studies were used. Most patients with adenocarcinoma had either T2 or T3 lesions by
Abstracts
decline in the mean platelet count, which failed to improve on discontinuation of Ribavirin. 389 Acute liver failure due to mushroom poisoning: a clinical series. Guilherme Macedo, MD, FACG, Jose´ Costa Maia, MD, Abilio Gomes, MD, Susana Lopes, MD, Fa´tima Carneiro, Ph.D., Ana Mota, MD, Araujo Teixeira, Ph.D., Tome´ Ribeiro, Ph.D. Gastroenterology and Liver Transplant Unit, H.S. Joa˜o, Porto, Portugal. Mushroom poisoning, mycetismus, is a well recognized medical emergency, that may lead to fulminant hepatic failure, with significant mortality, specially if associated with renal failure and cerebral lesions. Timing for liver transplantation is particularly difficult in this setting because progressive organ damage may evolve unrecognized and rapidly. Two groups of toxins induce different symptoms, in a sequential form: phalloidin, at first, which would be responsible for gastrointestinal upset; alpha-amanitin afterwards inducing subclinical deterioration, and acute liver failure (ALF), with encephalopathy and bleeding diathesis. We present 3 cases of ALF due to Amanita Phalloides ingestion, with different clinical courses, in whom timing for transplantation was evaluated and eventually performed. These were 2 men (aged 28 and 66) and a 38 years old caucasian woman, from 3 nonrelated families, that were admitted in different seasons, after consuming wild mushrooms with other family members, who had transient gastrointestinal symptoms. We describe the clinical evolution, time lag between ingestion and ALF, blood chemistries, Clichy’s and King’s College criteria for liver transplant and treatment. To patients progressed to grade 3 encephalopathy and were proposed for urgent liver transplant, successfully performed in one, and not done in the older patient, who died after 72 h in a national urgent waiting list. The younger patient had an uneventful total recovery after intensive care. We conclude that mushroom poisoning may have a fatal outcome, that clinical evolution may be variable, and that intensive therapy should be proposed in an institution able to perform liver transplantation.
COLON 390 Endoscopic argon plasma coagulation (APC) for radiation proctopathy KW Adkisson, MD, Stanley J Rogers, MD, John P Cello, MD. Departments of Medicine and Surgery, San Francisco General Hospital and the University of California, San Francisco. Radiation therapy for pelvic neoplasia is widely employed for both curative and palliative intent. Although safe and effective, 5–10% patients experience the undesirable complication of radiation proctitis (more properly called proctopathy). The rectal bleeding is typically intermittent but rarely presents as acute lower GI bleeding. Endoscopic evaluation reveals scattered vascular ectasias throughout the rectum/distal sigmoid. The vascular ectasias are felt to arise from neoangiogenesis resultant from vascular wall fibrosis induced by radiation. Many modalities for treatment have been employed including topical application of various agents (formaldehyde, short-chain fatty acids, sulfasalazine, 5-ASA), endoscopic use of Nd:YAG laser, bipolar cautery and various surgical interventions. APC is a new endoscopic coagulation modality employing pressurized ionized argon gas delivered via polyethylene catheter to achieve superficial cauterization. Five patients diagnosed with symptomatic radiation proctopathy and anemia underwent APC at our institution within the past 18 months. One patient had been treated previously with YAG laser. During each endoscopic treatment session a flexible sigmoidoscopy was performed followed by ablation of rectal ectasias by APC. Routine APC application consisted of multiple, brief pulses from the APC device (ERBE) set at 60 – 65 watts applied by mucosal “painting” over focal areas of visible ectasias. Patients received a mean of 4.6 (range 2–7) treatment sessions (approx. one session
2525
every 3 wks). Hematocrit (Hct) values immediately preceding APC therapy and packed red blood cell transfusions (PRBC) during a 6 month interval prior to APC were compared to Hct and PRBC requirements during APC therapy. Hct values remained stable or improved while the need for PRBC was either eliminated or substantially decreased in all patients. Statistical significance was not achieved due to the limited sample size. All patients tolerated the procedure well with no complications noted. Conclusion: APC is a reliable and acceptable endoscopic treatment option for ectasias associated with radiation proctopathy and may be superior to other forms of coagulation therapy in ablating vascular ectasias.
391 Side-viewing colonoscopy for the evaluation and treatment of difficult colonic lesions. Aziz Ahmad, MD, Paul S Berg, MD, Matthew McKinley, MD, FACG. North Shore University Hospital, Manhasset, NY and ProHEALTH Care Associates, Lake success, NY. Objective: To investigate the use of side-viewing technology in colonoscopy. Background: Endoscopy has transformed and improved our approach to digestive diseases. Despite great advances, there are technical limitations to currently available endoscopes. Studies examining the inherent polyp miss rate of colonoscopy, using methodology such as same day repeat exams, often site the angle of visualization as a limiting factor. This is particularly problematic in lesions located on the proximal aspects of valves or haustrae. It is for this reason that wide-angle colonoscopy is being investigated. Until such technology is perfected, endoscopists need to utilize all available tools. We describe the role of the side-viewing enterscope in the evaluation and treatment of three difficult colonic lesions. Methods and Results: Three cases of colonic neoplasia were addressed with the standard forward viewing technique. Anatomic parameters limited visualization and attempts at therapy. Two lesions were on the proximal aspect of folds (rectum and sigmoid) and one in the splenic flexure. A side-viewing enteroscope (Olympus TJF-130) was gently introduced by carefully extending the scope tip and then advancing in small “blind” movements in a neutral tip position. Using this technique, improved visualization was easily achieved. Polypectomy and biopsy was technically possible only with the side-viewing instrument in these patients. The presence of an elevator on the enteroscope assisted manipulation of accessories. Conclusion: In the hands of endoscopists familiar and comfortable with the side-viewing enteroscope, it can be a useful tool in the evaluation and treatment of colonic lesions not amenable to standard therapy. Benefits will need to be compared to any increased risks, especially in patients with anatomic conditions such as diverticulosis.
392 Rectal resection and coloanal anastamosis: a retrospective study Robert Akbari, MD, Philip F Caushaj, MD, FACG*, Devora E Hathaway, RN, William McDougall, MD. The Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, United States Purpose: Surgical treatment of rectal carcinoma has changed over the years. The abdominoperineal resection (APR) is the gold standard. More recently sphincter preservation via coloanal anastamosis has gained popularity. This retrospective study was done by reviewing one surgeon’s results with coloanal anastamosis in order to reiterate the benefits of this newer operation. Methods: In a retrospective fashion, all rectal resections and coloanal anastamosis done by one surgeon between 1986 to 1999 were analyzed. This included 38 patients. Various surgical indications included rectal adenocarcinoma (23), villous adenoma (5), Hartman/Diverticulitis (5), proctitis (2), and miscellaneous (3). Various preoperative studies were used. Most patients with adenocarcinoma had either T2 or T3 lesions by