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Argon plasma coagulation and the future applications for dual-mode endoscopic probes

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Abstract

Argon plasma coagulation (APC) is a thermoablative technique increasingly being used in endoscopy. Since its introduction, the flexible APC probe has been employed by endoscopists throughout the world. APC has helped change the endoscopic management of many gastrointestinal (GI) diseases, including hemorrhagic proctitis, watermelon stomach, bleeding peptic ulcer, and colonic varices. Endoscopists and surgeons are creatively combining standard and new electrosurgical techniques with APC. For instance,. APC used in combination with piecemeal polypectomy, endoscopic mucosal resection, balloon dilatation for strictures, and plasma welding of bleeding vessels after sclerotherapy injection are among the recent innovative techniques reported. Other emerging innovations using APC that are being considered include endoscopic en bloc resection of mucosal and submucosal tumors of the GI tract, endoscopic mucosal resection supplemented with APC for high-grade dysplasia and early GI cancers, endoscopic repair of anastomotic strictures, and welding GI fistula tracts. As such, endoscopists require more efficient and cost-effective multifunctional thermoablative probes. This review discusses the development and the potential application of dual-mode plasma endoscopic probes in fulfilling these emerging needs.

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... [1][2][3][4][5] Common gastrointestinal (GI) diseases treated by APC include radiation proctitis, Barrett's esophagus, and gastric antral vascular ectasia (GAVE). [6][7][8][9][10][11][12][13] APC is a preferable treatment method because it conducts electrical current without direct contact. mitigate the risk of bleeding at the targeted site and the surrounding tissue. ...
... The produced heat denatures the proteins and evaporates the intracellular and extracellular water, resulting in tissue destruction and coagulation. 2,3,6 The tissue's response to thermal heating is directly dependent on the amount of power applied. The applied power ranges from 20 to 90 W based on the type of treatment. ...
Article
The coagulation properties of the argon plasma coagulation (APC) technique present tremendous potential for a wide range of endoscopic applications. Although several studies have explored the endoscopic application of this technique, there has been no previous research about the relevant argon plasma properties during coagulation. We have investigated the role of power in the interactions between plasma and biological tissue, and have reported on the dielectric properties of the APC treated samples. The data revealed that at a resistance of 1 kΩ, the applied power was within 10% to 15% of the power setting, and the average resistance of the animal samples was between 0.8 and 3.7 kΩ. The data also suggested that the amount of power applied could be adjusted according to the expected tissue resistance range. Additionally, it was determined that the burned surface caused by the APC treatment was on average two to three times less conductive than the untreated surface. The data also revealed that 60%–80% of the power produced by the electrosurgical generator was delivered into the biological tissue, and the plasma channel consumed the remaining 20%–40%. This study establishes a guide for the investigation of optimal argon thermal plasma properties for biological tissue application.
... The latter serves as a mechanism for the implementation of plasma-induced apoptosis (in some cases, with prolonged exposure to the action of the necrosis factor). Additionally, these shifts in the membrane state can significantly change the adhesive properties of the cell and affect its migration [90][91][92]. ...
Article
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Currently, plasma medicine is a synthetic direction that unites the efforts of specialists of various profiles. For the successful formation of plasma medicine, it is necessary to solve a large complex of problems, including creating equipment for generating cold plasma, revealing the biological effects of this effect, as well as identifying and justifying the most promising areas of its application. It is known that these biological effects include antibacterial and antiviral activity, the ability to stimulate hemocoagulation, pro-regenerative properties, etc. The possibility of using the factor in tissue engineering and implantology is also shown. Based on this, the purpose of this review was to form a unified understanding of the biological effects and biomedical applications of argon cold plasma. The review shows that cold plasma, like any other physical and chemical factors, has dose dependence, and the variable parameter in this case is the exposure of its application. One of the significant characteristics determining the specificity of the cold plasma effect is the carrier gas selection. This gas carrier is not just an ionized medium but modulates the response of biosystems to it. Finally, the perception of cold plasma by cellular structures can be carried out by activating a special molecular biosensor, the functioning of which significantly depends on the parameters of the medium (in the field of plasma generation and the cell itself). Further research in this area can open up new prospects for the effective use of cold plasma.
... 4 APC is being used to cut tissue and, in particular in endoscopic applications. 5 Stoffels et al. 6 studied the plasma needle device and demonstrated the promising potential of the cold plasma in biomedical applications. They demonstrated that the cold plasma can interact with organic materials without causing thermal/electric damage to the surface. ...
Article
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Recent progress in atmospheric plasmas has led to the creation of cold plasmas with ion temperature close to room temperature. This paper outlines recent progress in understanding of cold plasma physics as well as application of cold atmospheric plasma (CAP) in cancer therapy. Varieties of novel plasma diagnostic techniques were developed recently in a quest to understand physics of CAP. It was established that the streamer head charge is about 108 electrons, the electrical field in the head vicinity is about 107 V/m, and the electron density of the streamer column is about 1019 m−3. Both in-vitro and in-vivo studies of CAP action on cancer were performed. It was shown that the cold plasma application selectively eradicates cancer cells in-vitro without damaging normal cells and significantly reduces tumor size in-vivo. Studies indicate that the mechanism of action of cold plasma on cancer cells is related to generation of reactive oxygen species with possible induction of the apoptosis pathway. It is also shown that the cancer cells are more susceptible to the effects of CAP because a greater percentage of cells are in the S phase of the cell cycle.
... Argon plasma coagulation (APC) is a noncontact method for plasma coagulation that allows controlled electrocoagulation [12] The basic mechanism of APC involves the use of a jet of gas (i.e., Argon) that has been previously ionized, and therefore provides electrical conductivity to the tissue where it is applied, typically via an endoscope, to promote coagulation. This thermoablative technique has been used with increasing frequency in endoscopy (typically with direct vision via an endoscope) and has advanced the endoscopic management of many gastrointestinal diseases including hemorrhagic proctitis, watermelon stomach, bleeding peptic ulcer, colonic varices, and gastrointestinal polyps [13]. However, this technique has not been used for occlusion of BDL. ...
Article
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PurposeBiliary ductal injuries are challenging to treat, and often lead to severe morbidity and mortality. The first-line approach involves endoscopic retrograde cholangiopancreatography with sphincterotomy and, in case of refractory leakage, long-lasting percutaneous transhepatic biliary drainage, endoscopic or percutaneous injection of sclerosing agents and/or coiling can be used. We describe a treatment procedure using microcatheter-mediated percutaneous or endoscopic argon plasma coagulation (APC).Materials and Methods Three patients (7-year-old male, 14-year-old male, 81-year-old female) with refractory postsurgical and/or post-traumatic bile leaks underwent percutaneous (n = 2) or endoscopic (n = 1) APC through a detachable microcatheter.ResultsThe procedure was technically feasible in all patients. Postoperative imaging showed complete occlusion of biliary leakage. The technique was uneventful intraoperatively with no adverse events occurring during recovery or follow-up.Conclusion Our initial experience demonstrates that refractory bile duct leaks may be successfully treated with microcatheter-mediated APC endoscopically or percutaneously. Further research is needed to confirm the safety, efficacy, and clinical indications for this innovative technique.
... Marketed gas plasma systems in Europe comply with the guidelines set out by the medical device regulations, are operated at body temperature and atmospheric pressure, and are usually classified as medical devices class IIa [42]. Medical plasma applications are established for a long time in the field of electro surgery, where techniques like argon plasma coagulation (APC) rely on precisely targeted thermal necrotization of tissue to achieve hemostasis (cauterization) or to cut or remove tissue [43,44]. The technical availability of setups for stable and reproducible plasma generation at low temperature under atmospheric conditions, so-called cold atmospheric plasmas (CAP), opened up the new field of plasma medicine, meaning the direct application of physical plasma on or in the human (or animal) body to apply therapeutic effects. ...
Article
Full-text available
Defective wound healing poses a significant burden on patients and healthcare systems. In recent years, a novel reactive oxygen and nitrogen species (ROS/RNS) based therapy has received considerable attention among dermatologists for targeting chronic wounds. The multifaceted ROS/RNS are generated using gas plasma technology, a partially ionized gas operated at body temperature. This review integrates preclinical and clinical evidence into a set of working hypotheses mainly based on redox processes aiding in elucidating the mechanisms of action and optimizing gas plasmas for therapeutic purposes. These hypotheses include increased wound tissue oxygenation and vascularization, amplified apoptosis of senescent cells, redox signaling, and augmented microbial inactivation. Instead of a dominant role of a single effector, it is proposed that all mechanisms act in concert in gas plasma-stimulated healing, rationalizing the use of this technology in therapy-resistant wounds. Finally, addressable current challenges and future concepts are outlined, which may further promote the clinical utilization, efficacy, and safety of gas plasma technology in wound care in the future.
... 4 APC is being used to cut tissue and, in particular in endoscopic applications. 5 Stoffels et al. 6 studied the plasma needle device and demonstrated the promising potential of the cold plasma in biomedical applications. They demonstrated that the cold plasma can interact with organic materials without causing thermal/electric damage to the surface. ...
Article
Full-text available
Plasma is an ionized gas that is typically generated in high-temperature laboratory conditions. Recent progress in atmospheric plasmas led to the creation of cold plasmas with ion temperature close to room temperature. Areas of potential application of cold atmospheric plasmas (CAP) include dentistry, drug delivery, dermatology, cosmetics, wound healing, cellular modifications, and cancer treatment. Various diagnostic tools have been developed for characterization of CAP including intensified charge-coupled device cameras, optical emission spectroscopy and electrical measurements of the discharge propertied. Recently a new method for temporally resolved measurements of absolute values of plasma density in the plasma column of small-size atmospheric plasma jet utilizing Rayleigh microwave scattering was proposed [1,2]. In this talk we overview state of the art of CAP diagnostics and understanding of the mechanism of plasma action of biological objects. The efficacy of cold plasma in a pre-clinical model of various cancer types (long, bladder, and skin) was recently demonstrated [3]. Both in-vitro and in-vivo studies revealed that cold plasmas selectively kill cancer cells. We showed that: (a) cold plasma application selectively eradicates cancer cells in vitro without damaging normal cells. For instance a strong selective effect was observed; the resulting 60--70% of lung cancer cells were detached from the plate in the zone treated with plasma, whereas no detachment was observed in the treated zone for the normal lung cells under the same treatment conditions. (b) Significantly reduced tumor size in vivo. Cold plasma treatment led to tumor ablation with neighbouring tumors unaffected. These experiments were performed on more than 10 mice with the same outcome. We found that tumors of about 5mm in diameter were ablated after 2 min of single time plasma treatment. The two best known cold plasma effects, plasma-induced apoptosis and the decrease of cell migration velocity can have important implications in cancer treatment by localizing the affected area of the tissue and by decreasing metastasic development. In addition, cold plasma treatment has affected the cell cycle of cancer cells. In particular, cold plasma induces a 2-fold increase in cells at the G2/M-checkpoint in both papilloma and carcinoma cells at about 24 hours after treatment, while normal epithelial cells (WTK) did not show significant differences. It was shown that reactive oxygen species metabolism and oxidative stress responsive genes are deregulated. We investigated the production of reactive oxygen species (ROS) with cold plasma treatment as a potential mechanism for the tumor ablation observed. [4pt] [1] Shashurin A., Shneider M.N., Dogariu A., Miles R.B. and Keidar M. Appl. Phys. Lett. (2010) 96, 171502.[0pt] [2] Shashurin A., Shneider M.N., Keidar M. Plasma Sources Sci. Technol. 21 (2012) 034006.[0pt] [3]. M. Keidar, R. Walk, A. Shashurin, P. Srinivasan, A. Sandler, S. Dasgupta , R. Ravi, R. Guerrero-Preston, B. Trink, British Journal of Cancer, 105, 1295-1301, 2011
... Medical treatment techniques using such plasmas have been firmly established for a long time in the field of electro surgery, even if they were not explicitly referred to as plasma medicine at the time. Such techniques, like argon plasma coagulation (APC), rely on precisely targeted thermal necrotization of tissue to achieve hemostasis (cauterization), or to cut or remove tissue (16,17). Furthermore, several plasma-based devices in cosmetics, e.g. for wrinkle removal and skin regeneration, also rely on thermal plasma effects (18,19). ...
Article
Plasma medicine comprises the application of physical plasma directly on or in the human body for therapeutic purposes. Three most important basic plasma effects are relevant for medical applications: i) inactivation of a broad spectrum of microorganisms, including multidrug-resistant pathogens, ii) stimulation of cell proliferation and angiogenesis with lower plasma treatment intensity, and iii) inactivation of cells by initialization of cell death with higher plasma treatment intensity, above all in cancer cells. Based on own published results as well as on monitoring of relevant literature the aim of this topical review is to summarize the state of the art in plasma medicine and connect it to redox biology. One of the most important results of basic research in plasma medicine is the insight that biological plasma effects are mainly mediated via reactive oxygen and nitrogen species influencing cellular redox-regulated processes. Plasma medicine can be considered a field of applied redox biology.
... One of the successful applications of thermal plasma is the argon plasma coagulation (APC) in which highly conductive plasma allows passing a current through the tissue. APC has been used to cut tissue and, in particular, in endoscopic applications [9]. ...
Article
Full-text available
Electric discharge utilized for electrosurgery is studied by means of a recently developed method for the diagnostics of small-size atmospheric plasma objects based on Rayleigh scattering of microwaves on the plasma volume. Evolution of the plasma parameters in the near-electrode sheaths and in the positive column is measured and analyzed. It is found that the electrosurgical system produces a glow discharge of alternating current with strongly contracted positive column with current densities reaching 10(3) A/cm(2). The plasma electron density and electrical conductivities in the channel were found be 10(16) cm(-3) and (1-2) Ohm(-1)cm(-1), respectively. The discharge interrupts every instance when the discharge-driving AC voltage crosses zero and re-ignites again every next half-wave at the moment when the instant voltage exceeds the breakdown threshold.
Chapter
This chapter covers the Plasma medicine, which is an emerging field combining plasma physics, medicine, bioengineering and engineering to use plasmas for therapeutic applications. One example of such plasmas is cold atmospheric plasma (CAP). CAP has tremendous applications in bioengineering and medicine. Physics of CAP and various plasma diagnostics are covered. Various effects related to interaction of the CAP with cells (cell migration, apoptosis, integrins activation etc) are considered. The therapeutic potential of CAP with a focus on selective tumor cell eradication capabilities and signaling pathway deregulation is described.
Article
Background and aim: Endoscopic snare papillectomy (ESP) is an effective treatment for ampullary adenoma. Argon plasma coagulation (APC) is widely used as an additional method to control bleeding or ablate the residual tumor. However, the efficacy of this procedure has not yet been fully evaluated. This study aimed to evaluate the usefulness of APC as an additional method to ESP. Methods: The patients who underwent ESP for ampullary adenoma between September 2005 and September 2015 were retrospectively reviewed. Using propensity score matching, we compared short- and long-term outcomes between ESP with additional APC group and ESP only group. Primary outcome was early post-ESP adverse events (AEs), and secondary outcome were late AEs and recurrence. Results: Among 109 patients, additional APC was performed in 59 (54.1%) patients. After matching, 41 patients were included in both groups, respectively. Bleeding rate was significantly lower in ESP+APC group than ESP only group (7.3% vs. 31.7%, odds ratio = 0.180, P<0.01). However, there were no significant differences in other procedure-related early AEs such as pancreatitis (12.2% vs. 19.5%, P = 0.365), cholangitis (2.4% vs. 9.8%, P = 0.198), and perforation (2.4% vs. 2.4%, P = 1.000) between ESP+APC group and ESP only group. During the follow-up period (mean 904±868 days), papillary stricture (9.8% vs. 4.9%, P = 0.405) and recurrence rates (24.4% vs. 24.4%, P = 0.797) were not significantly different between ESP+APC group and ESP only group. Conclusions: Additional APC during ESP may have beneficial effect by decreasing bleeding rate without harmful effect. This article is protected by copyright. All rights reserved.
Article
Electrosurgical cutting is a well-known technique for creating incisions often used for the removal of benign and malignant tumors. The proposed mathematical model suggests that incisions are created due to the localized heating of the tissue. The model estimates a volume of tissue heating in the order of 2 10⁻⁴ mm³. This relatively small predicted volume explains why the heat generated from the very tip of the scalpel is unable to cause extensive damage to the tissue adjacent to the incision site. The scalpel exposes the target region to an RF field in 60 ms pulses until a temperature of around 100 °C is reached. This process leads to desiccation where the tissue is characterized by a significantly low electrical conductivity, which prevents further heating and charring. Subsequently, the incision is created from the mechanical scraping process that follows.
Chapter
Upper gastrointestinal bleeding (UGIB) represents a significant entity for all clinicians. Despite advances in Helicobacter pylori detection and eradication, education on the effects of nonsteroidal antiinflammatory drugs (NSAID) use, and the use of proton pump inhibitors (PPIs), peptic ulcer disease (PUD) remains the most common cause of nonvariceal UGIB. The initial evaluation and risk assessment of the patient are the most important steps in the management of acute gastrointestinal bleeding. Endoscopy remains the gold standard for the diagnostic evaluation of an UGIB. Endoscopy usually offers a direct visualization of the source, immediate implementation of appropriate therapies, and assessment of further management needs. The majority of supporting evidence for the performance of a second look endoscopy is based on multiple trials carried out prior to current practice that includes avoidance of single epinephrine injection therapy for high-risk stigmata bleeds, and the use of high dose PPI therapy after endoscopic hemostasis.
Chapter
Plasma medicine is on its way to clinical practice to become a successful part of modern medicine. Plasma medicine is focused on the therapeutic application of cold atmospheric plasma (CAP) whose efficacy is predominantly based on the action of reactive oxygen and nitrogen species (ROS, RNS). One of the strengths of plasma medicine is that its initial clinical success is based on a sound scientific fundament. This successful course should not be stopped or delayed by devices, which are inappropriately prepared and tested. Therefore, even if all general demands of medical device regulations were met, some specific basic characterizations of CAP devices for medical applications are recommended. This chapter will give some landmarks to estimate the reliability of a plasma device for medical application. It is necessary to differentiate between reliable and well-characterized CAP devices, and other strongly promoted products whose performance characteristics are disclosed inadequately. Any references of “esoteric” plasma applications to the results of scientific plasma medicine have to be rejected rigorously.
Article
Plasma medicine is an innovative research field combining plasma physics, life science, and clinical medicine. It is mainly focused on the application cold atmospheric plasma (CAP) in therapeutic settings. Based on its ability to inactivate microorganisms but also to stimulate tissue regeneration, current medical applications are focused on the treatment of wounds and skin diseases. Since CAP is also able to inactivate cancer cells, its use in cancer therapy is expected to be the next field of clinical plasma application. Other promising applications are expected in oral medicine and ophthalmology. It is the current state of knowledge that biological CAP effects are mainly based on the action of reactive oxygen and nitrogen species supported by electrical fields and UV radiation. However, continuing basic research is not only essential to improve, optimize, and enlarge the spectrum of medical CAP applications and their safety, but it is also the basis for identification and definition of a single parameter or set of parameters to monitor and control plasma treatment and its effects. In the field of CAP plasma devices, research and application are currently dominated by two basic types: dielectric barrier discharges and plasma jets. Its individual adaptation to specific medical needs, including its combination with technical units for continuous and real-time monitoring of both plasma performance and the target that is treated, will lead to a new generation of CAP-based therapeutic systems.
Chapter
A textbook is imparting application-based knowledge. It is intended to serve doctors and nurses in the field of clinical plasma medicine with practical instructions. However, scientists and engineers gain a profit as well by learning about the practitioners´ point of view. This chapter of the textbook is advisable for an overview of good clinical practice in plasma medicine.At present medical devices generating cold physical atmospheric pressure plasma (CAP) are approved for badly healing wounds and infected skin. This includes in particular chronic and infected wounds, suppurative focuses, acute wounds at high risk of infection or serious progression, non-healing wounds by other reasons, and skin, including mucosa with certain local infections.There are a few plasma devices available with a background of detailed preclinical and clinical investigations to prove efficacy and with comprehensive physical and biological characterization: kINPen MED (neoplas tools GmbH, Greifswald, Germany), PlasmaDerm Flex and Dress (CINOGY GmbH, Duderstadt, Germany), SteriPlas (ADTEC, Hounslow, UK) and Plasma care (terraplasma medical GmbH, Garching, Germany).From a clinical point of view, the direct combination of wound antisepsis with a stimulating effect on tissue regeneration is a unique selling proposition of CAP in comparison to conventional and established wound care measures.KeywordsGood clinical practiceProblem pathologiesCurative indicationPalliative indicationAt-risk patientEvidence-based medicineInformed consentDebriefing of therapy
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Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease-the most common etiology of UGIB-endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.
Article
Argon plasma coagulation is a new method of non-contact hemostasis in which thermal energy is delivered to a target lesion via a spray of ionized argon gas. The 2.3 mm diameter Argon plasma probe (ERBE, USA) is positioned within 1 cm of the target lesion. The ionized gas which is then released grounds itself in the nearest tissue, with resultant coagulation at a penetration depth of 2-3 mm. This allows for the tangential coagulation of hard to reach lesions for which direct contact is difficult. From June to December 1995, we have used argon plasma to coagulate angiomata on 44 occasions involving 32 patients. These included 9 patients with watermelon stomach, 4 with OWR, 4 with radiation (XRT) proctitis, and 15 with other angiomata. In all cases, argon plasma was easy to use and immediate hemostasis was achieved. This facilitated the rapid treatment of multiple lesions. One patient had a 2 unit rebleed within 24 hours of the procedure. Two patients experienced mild abdominal pain for 1 day. 25 of the patients treated with argon plasma coagulation have been followed for at least 1 month (mean 3.3 months; range 1-5.5). 17 of these patients (68%) had evidence of improvement documented by either a ≥20% rise in hemoglobin (Hgb) concentration, a decrease in transfusion requirements, or resolution of lesions at repeat endoscopy when performed. 6 patients had no appreciable change and 2 were worse by these criteria. ANGIOMATA: AVM Watermelon OWR XRT proctitis No further bleeding 7/11 9/9 2/3 1/2 ≥ 20% Hgb rise 5/11 7/9 2/3 1/2 Decreased transfusions 5/11 4/9 2/3 1/2 Endoscopic resolution 0/1 5/8 1/1 1/1 Conclusion: Argon plasma coagulation is an effective, safe, and simple technique for treating GI angiomata. It provides rapid, non-contact coagulation with less cost and fewer safety concerns than with laser devices.
Article
Radiation proctitis presents an extremely difficult management problem, as most existing therapies are either ineffective or plagued with an unacceptably high complication rate. The argon plasma coagulator (APC) utilizes ionized argon gas to conduct high-frequency alternating current to tissues without direct contact, and has been used for hemostasis in the operating room with excellent results. A flexible probe developed by ERBE, Inc. permits this application to be used through the channel of any flexible endoscope. It is inexpensive, requires no protective gear, and provides a controllable and predictable depth of tissue penetration (1-4 mm). We treated 12 patients with refractory radiation proctitis with the APC. All patients had received prior treatment with a variety of topical agents with poor results. 10 of the patients had received standard radiotherapy for prostate cancer and 2 had been treated with radiation for uterine cancer. Vascular telangiectasias with stigmata of recent hemorrhage were seen in the rectum in all patients. The 2 female pts also had evidence of disease in the sigmoid. The average age was 72 years (range 64-85), and the mean interval between radiation and APC therapy was 26.4 months (range 12-51). We obtained a mean follow-up of 6.6 months (range 3-13). Results : We used an integer scale to grade the extent of bleeding before and after APC therapy: 0=no blood; 1=blood on toilet paper or stool; 2=blood in toilet bowl; 3=heavy bleeding with clots; 4= bleeding requiring transfusions. Patient 1 2 3 4 5 6 7 8 9 10 11 12 Pre APC 3 4 3 3 3 4 1 2 3 1 4 2 Post APC 1 1 1 0 0 3 0 1 2 0 4 0 The average score decreased from 2.75 to 1.08 after APC therapy. All but one patient (# 11) dropped at least one point on the integer scale. This pt had less bleeding after APC but still required transfusions. 5 of the 12 pts had complete resolution of bleeding after APC therapy. All pts responded with a single APC session except pt # 8 who was on coumadin and required 2 sessions. None of the pts reported any significant pain, discomfort, or complications after therapy. Conclusion : The argon plasma coagulator is an effective therapy for achieving hemostasis in radiation proctitis and its efficacy, cost, and safety profile offer advantages over previous treatment modalities. The encouraging results obtained in our series indicate that the APC represents a major advance in the therapy of bleeding from radiation proctitis.
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In a prospective study, 37 consecutive patients with radiation-induced proctosigmoiditis were randomized to receive a four-week course of either 3.0 g oral sulfasalazine plus 20 mg twice daily rectal prednisolone enemas (group I,N=18) or 2.0 g twice daily rectal sucralfate enemas plus oral placebo (group II,N=19). The two groups were comparable with respect to demographic features, duration of symptoms, and clinical and endoscopic staging of the disease. Fifteen patients in group I and 17 in group II completed the trial. At four weeks, both groups showed significant clinical improvement (PPPPPP>0.05). We conclude that both treatment regimens are effective in the management of radiation proctitis. Sucralfate enemas give a better clinical response, are tolerated better, and because of the lower cost should be the preferred mode of short-term treatment.
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Three patients who bled from curious vascular lesions of the gastric antrum are described. Each presented with an iron-deficiency anemial. Histological examination in two of the patients demonstrated numerous ectatic submucosal vessels in the antrum, the appearances being somewhat similar to angiodysplasia of the colon. The gastric lesions were not shown by barium meal examination or angiography but gave characteristic appearances on endoscopy. We believe that Billroth I partial gatrectomy is the treatment of choice for this condition.
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Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In the more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Eight patients (seven females and one male) with hemorrhagic radiation proctitis were Treated over a six-month period with endoluminal formalin. The technique used ensured minimal contact with formalin. The median age of the patients was 68 years (range, 42–73 years). Seven patients had had cancer of the uterine cervix, and one patient had had cancer of the prostate treated with radiotherapy at a median time of 30 months (range, 9–46 months) previously. The median duration of time of symptomatic rectal hemorrhage before formalin therapy was eight months (range, 1–12 months). The median number of units of blood transfused previously per patient was four (range, 2–32). The time taken for formalin therapy was 20 minutes (range, 10–70 minutes). One patient required repeat formalin application at two weeks. Bleeding ceased immediately in seven patients after formalin treatment. No further bleeding was noted, nor was any blood transfusion needed, at follow-up at four months (range, 1–6 months). Formalin therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis.
Article
Radiation therapy directed at the abdomen may damage the digestive tract, the type and extent of injury depending on the dose of the radiation and the radiation sensitivity of the gut. Characteristic early changes are manifest in the mucosa of the gut: for later ulceration, changes in the collagen tissues and particularly in the vascular channels occur. This paper describes and characterizes injuries to the esophagus, stomach, small intestine and colon. It emphasizes the importance of recognizing radiation-induced damage to the gut which may occur early or late after radiation.
Article
Endoscopic electrocoagulation was performed on 40 occasions for 38 patients with bleeding gastrointestinal lesions. Cessation of bleeding was achieved in 95%. Fifteen gastric ulcers, 14 duodenal ulcers, six Mallory-Weiss tears, one gastric varix, one hemorrhagic antral gastritis, and one esophageal ulcer were successfully electrocoagulated. Three duodenal and three gastric ulcers rebled. One duodenal ulcer and one gastric ulcer were successfully reelectrocoagulated. Failure to stop bleeding by electrocoagulation occurred in one Mallory-Weiss tear and one duodenal ulcer. There was no morbidity nor mortality attributed to endoscopic electrocoagulation. A retrospective cost analysis showed that the cost of hospitalization was less in patients treated by electrocoagulation. Patients so treated were hospitalized for a shorter duration. (JAMA 236:2076-2079, 1976)
Article
The watermelon stomach is an uncommon but treatable cause of chronic gastrointestinal bleeding. We report our experience with the clinical and endoscopic features of 45 consecutive patients treated by endoscopic Nd:YAG laser coagulation. The prototypic patient was a woman (71%) with an average age of 73 years (range of 53-89 years) who presented with occult (89%) transfusion-dependent (62%) gastrointestinal bleeding over a median period of 2 years (range of 1 month to > 20 years). Autoimmune connective tissue disorders were present in 28 patients (62%), especially Raynaud's phenomena (31%) and sclerodactyly (20%). Atrophic gastritis occurred in 19 of 19 (100%) patients, with hypergastrinemia in 25 (76%) of 33 patients tested. Antral endoscopic appearances included raised or flat stripes of ectatic vascular tissue (89%) or diffusely scattered lesions (11%). Proximal gastric involvement was present in 12 patients (27%), typically in the presence of a diaphragmatic hernia. Endoscopic laser therapy after a median of one treatment (range of 1-4) resulted in complete resolution of visible disease in four patients (13%) and resolution of > 90% in 24 patients (80%). Hemoglobin levels normalized in 87% of patients over a median follow-up period of 2 years (range of 1 month to 6 years) with no major complications. Blood transfusions were not necessary after laser therapy in 86% of 28 initially transfusion-dependent patients. The characteristic clinical, laboratory, and endoscopic features allow for a confident diagnosis that can lead to successful endoscopic treatment.
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Although the hot biopsy technique is widely used to treat diminutive colon polyps, there is concern over its efficacy and safety. Our study involved 39 patients undergoing routine colonoscopy in whom 62 diminutive polyps were found in the rectosigmoid. These lesions were treated with hot biopsy forceps in the standard manner. Flexible sigmoidoscopy was repeated 1 and 2 weeks later with the original treatment sites being identified. Eleven of the 62 sites (17%) revealed persistent viable polyp remnants, indicating incomplete treatment. In terms of safety, there were no clinical complications in this small study and most post-biopsy ulcers were healed by 2 weeks. This study shows that the hot biopsy technique may be unreliable in eradicating diminutive colon polyps.
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Short communication.
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Survival of ovarian adenocarcinoma patients depends on the size of the largest residual nodule at the end of debulking surgery. The argon beam coagulator (ABC) delivers radiofrequency current traveling in a beam of argon gas which facilitates tumor destruction and hemostasis. We used the ABC as an aid to cytoreduction in seven consecutive patients with stage III/IV ovarian cancer. Despite extensive disease, optimal debulking was achieved in all seven patients: four (57%) had no gross residual cancer; three had residual nodules of 2-3 mm. The ABC facilitated tumor destruction on the diaphragm, bowel wall and mesentery, presacral space, ureters, vagina, and iliac vessels. In addition, the ABC was used to "sterilize" surgical margins such as the vaginal cuff and rectosigmoid colon anastomoses. Five patients are currently alive, four disease free, with mean survival of 33 months since diagnosis. The ABC enables debulking of ovarian cancer in sites inaccessible to conventional resection.
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Large polyps are sessile or pedunculated lesions that are larger than or equal to 3 cm in size. Sixty-six colonoscopic piecemeal excisions of large pedunculated and sessile polyps (75 percent of 88 recognized large polyps) were performed over eight years. The macroscopic feature of the lesions and the result of an extensive snare biopsy were the deciding factors for endoscopic as opposed to surgical removal. Only three complications (4.5 percent) were recorded (two hemorrhages and one colonic wall burn syndrome), none of which required surgery. Fifty patients with 52 adenomatous lesions had colonoscopic follow-up (range, 3 to 85 months). Of 36 sessile adenomas, two cases of residual (5.5 percent) and four of recurrent disease (11 percent) were observed. Colonoscopic removal is an alternative to local surgical excision of large benign colorectal polyps, and often can be an alternative method to elective colectomy in elderly and high-risk patients.
Article
Ten patients with severe chronic irradiation injury to the rectum were treated by mucosal proctectomy and colo-anal sleeve anastomosis. The indications were: recurrent rectal bleeding (five), stricture (three), fistula (one) and intractable pain (one). Overall follow-up has ranged from 8 to 77 months (mean 40 months). In the present survivors (n = 7) the follow-up ranges from 18 to 77 months (mean 52 months). Six patients have been followed up for more than 3 years and four for more than 5 years. There was no operative mortality. Three anastomotic strictures occurred but the protecting stoma could be closed in all but one patient. Continence was acceptable although urgency and frequency of defaecation were troublesome symptoms. The operation is recommended for life-threatening, haemorrhagic chronic irradiation injury to the rectum.
Article
This study analyzes 28 consecutive patients with large sessile polyps snared piecemeal from the colon and rectum. The sections were examined to determine the adequacy of orientation and margin of excision. Orientation was judged excellent in five, good in 12, fair in six, and poor in five cases. The margin of excision was judged adequate in 23 of 28 cases. Five of eight patients with invasive carcinoma underwent bowel resection, and no residual tumor was found in the resected specimens. Of the remaining 20 patients without carcinoma, five had residual tumor or recurrences, with follow-up from 6 months to 6 years (average, 18 months). All of them underwent rebiopsies and electrocoagulation. None of the residual tumor or recurrences showed evidence of malignancy. Piecemeal snare excision of large sessile polyps of the large bowel appears to be an adequate procedure for most patients. A close follow-up with colonoscopy or proctoscopy is essential because residual tumor or recurrences are common.
Article
The author analyses the results of endoscopic removal of 136 villous tumors of the colon in 125 patients. The tumors ranged from 2 cm to over 6 cm in size. In the article emphasis is placed on the fact that multi-stage interventions are mainly practiced in the removal of villous tumors. A study of the histological structure has shown that malignancy in the group of villous tumors is considerably more rarely encountered than in the group of combined papillary adenomas, despite the fact that villous tumors are larger than glandular-villous adenomas. Dynamic supervision over a period of up to 7 years shows that in 68 out of 95 men there were no signs of recurrence, in 16 men the so-called "growth recurrence" was seen, and in 5 men continued growth of the primary tumor; in 2 cases new villous tumors were detected, and in 4 carcinomas were detected at the sites at which villous tumors had been previously removed. Endoscopic removal of villous tumors should rightfully be considered the procedure of choice in dealing with nodal and spreading tumors of the colon, especially in elderly patients suffering from severe accompanying diseases.
Article
One hundred four patients, 80 women and 24 men, with radiation injury of the rectum following treatment for gynecologic and urologic malignancy were studied. In 50 patients, the rectal injury was treated surgically; 54 patients were treated conservatively. The age and sex distributions were the same in each group. In 63 patients, symptoms developed one month to one year after radiotherapy. The longest latent interval was 17 years. Of the 50 surgical patients, 23 had associated small bowel injury. The indications for surgery for the rectal injury were 1) proctitis unresponsive to conservative measures in 14 patients, 2) rectal stricture or fistula or both in 32, and 3) rectosigmoid perforation in four. Forty-one patients had external diversions. Eleven had intestinal continuity restored; six of the 11 had required the stoma for proctitis unresponsive to medical measures. Nineteen patients did not undergo colostomy closure, although symptoms wer greatly improved. Diversion alone was insufficient treatment in the remaining 11 patients. Twenty-six patients died. The 12 deaths in the surgical group comprised four due to residual malignancy, four from postoperative complications, and four from unrelated causes. Of the 14 deaths in the nonsurgical group, 11 died of the primary malignancy and three of unrelated causes. Diversion is considered the safest form of treatment for rectovaginal fistulae, rectal strictures, and proctitis unresponsive to medical measures. Intestinal resection resulted in sharp rise in the morbidity and mortality rates.
Article
This prospective study was carried out in order to compare endoscopic laser therapy with injection-assisted piecemeal polypectomy for treatment of sessile rectal adenomas. We randomized 94 patients with rectal sessile adenomas to either of the two treatments. The adenomas were classified according to size as extensive or intermediate. Of the patients with extensive adenomas, a complete ablation was achieved in 63.6% with laser versus 33.3% with piecemeal snaring (p < .01). For the intermediate adenomas, the rates of permanent ablation were 81.2% with laser versus 86.6% with piecemeal snaring polypectomy (difference not statistically significant). The complication rates were acceptable in both the laser and piecemeal snaring groups. (One case of perforation and one case of stenosis were observed in the laser group, both probably related to prior electroresection.) Our study suggests that the specific indication for laser therapy should be extensive lesions; with intermediate adenomas, laser therapy and injection-assisted piecemeal polypectomy are equally efficacious for achieving complete ablation. However, the duration of initial treatment differs: 6.3 weeks for laser therapy versus 2.4 weeks for piecemeal polypectomy; moreover, about 70% of the intermediate adenomas were eradicated with a single session of piecemeal polypectomy.
Article
Monopolar hot biopsy forceps (HBF), bipolar HBF, and cold biopsy forceps (CBF) followed by bipolar electrocoagulation are used clinically to simultaneously perform a biopsy and coagulate diminutive colon polyps and angiomata. Our purpose was to conduct a randomized, controlled study to evaluate the safety of these different techniques in the canine right colon. After right colotomy in 8 mongrel dogs, colonic mucosa was grasped en face, tented, and biopsy performed in randomized order. The dogs were sacrificed after nine days and the biopsy sites were identified and histologically examined. Monopolar HBF caused an overall mean rate of acute serosal whitening of 29% compared with 0% for bipolar HBF and CBF and 6% for CBF/bipolar probe. Histologically confirmed transmural injury 9 days after biopsy occurred in 44% of monopolar HBF compared with 5% of bipolar HBF, 0% of CBF, and 50% of CBF/bipolar probe. Monopolar HBF had significantly higher rates of acute serosal whitening and histologic transmural damage than bipolar HBF or cold biopsy alone. On the basis of these results, monopolar HBF should be avoided for coagulation of small or flat right colon lesions such as diminutive polyps or angiomata.
Article
A common perception among purchasers is that academic medical centers are inefficient and overutilize technology; however, little empirical information exists. The aim of this study was to compare treatment and outcomes of patients with upper gastrointestinal hemorrhage admitted to major teaching hospitals and other hospitals in a large metropolitan area. Data on 3801 consecutive eligible patients admitted to five major teaching hospitals and 25 other hospitals from 1991 to 1993 were obtained by review of medical records. Admission severity of illness was measured using validated multivariable models. Rates of upper endoscopy were somewhat lower among the 1004 patients discharged from fellowship hospitals, compared with the other 2797 patients (82.9% vs. 85.6%; P < 0.05), and the use of other procedures was similar. Although patients admitted to fellowship hospitals tended to have a higher severity of illness, both unadjusted (6.3 +/- 9.0 vs. 7.1 +/- 7.5 days; P < 0.01) and risk-adjusted length of stay were somewhat shorter. Mortality rates were similar between hospitals, and patients admitted to fellowship hospitals were somewhat less likely to be transfused. In patients with upper gastrointestinal hemorrhage, teaching hospitals do not appear to provide inefficient care or overutilize expensive treatments when compared with community facilities. These findings are noteworthy at a time when viability of academic centers and fellowship training is threatened.
Article
In argon plasma coagulation (APC), high-frequency energy is transmitted to tissue by ionized gas, thus reducing contact with the tissue to a minimum. Successful endoscopic APC was initially reported in the palliative treatment of gastrointestinal neoplasms. The main objectives in this pilot study were to evaluate the treatment indications, efficacy and safety of the use of APC. Between September 1994 and January 1996, APC was used to treat 125 patients with various forms of gastrointestinal pathology. For local palliative treatment, APC was successfully used alongside snare loop coagulation, dilation, stenting and/or radiotherapy to treat the following conditions: carcinoma of the esophagus: 15 patients, mean number of treatment sessions (MTS) 3.3; gastric carcinoma: 10 patients, MTS 4.9; rectosigmoid carcinoma: seven patients, MTS 2.7; carcinoma of the papilla of Vater: two patients, MTS 1.5. Repeated treatment was also effective for tubulovillous adenoma of the rectum (20 patients, MTS 2.5), stomach (three patients, MTS 2.0), duodenum (two patients, MTS 1.5) and papilla of Vater (two patients, MTS 3.0). In addition, APC proved helpful in coagulating the remaining tissue and achieving hemostasis after polypectomy in the colon (18 patients, MTS 1.2) and in endoscopic treatment of Zenker's diverticulum, for coagulation of the tissue bridge and hemostasis (31 patients, MTS 2.5). Finally, APC was helpful in coagulation of multiple gastric polyps (one patient, one session), hemostasis in superficial ulceration of the duodenal bulb (one patient, one session), after dilation of benign stenoses of anastomoses in the esophagus (one patient, one session) and colon (one patient, one session) and for vascular malformations in the colon (three patients, MTS 1.3), duodenum (one patient, one session), antrum (one patient, two sessions), and watermelon stomach (six patients, MTS 2.8). We recognized signs of perforation in six patients after treatment of Zenker's diverticulum (n = 3), polypectomy in the colon (n = 2) and coagulation of angiodysplasia in the cecum. Laparotomy was carried out in two patients; in one, a perforation was sutured, and in the other no focus of leakage was seen. All six patients recovered without further complications. No complications were observed in any other patients. These initial experiences indicate that APC seems to be effective in a number of indications, and relatively safe. Objective evaluation, a longer follow-up period, and comparative trials with other treatment modalities should follow.
Article
Argon plasma coagulator was prospectively compared with heater probe in patients with bleeding peptic ulcers. Forty-one patients with major stigmata of ulcer hemorrhage were randomly assigned to receive either heater probe (n = 20) or argon plasma coagulation (n = 21) treatment; 40% had active bleeding and 60% had a nonbleeding visible vessel in the ulcer crater. The two groups were similar with respect to all background variables. Episodes of recurrent bleeding were retreated with the same modality as used previously. Patients in whom treatment or retreatment failed underwent emergency surgery. Initial hemostasis (95% vs. 95.2%), recurrent bleeding (21% vs. 15%), 30-day mortality (5% vs. 4.7%), and emergency surgery (15% vs. 9.5%) were comparable in the heater probe and argon plasma coagulation groups, respectively. Argon plasma coagulation provided faster hemostasis (mean 60 +/- 19 vs. 115 +/- 28 seconds, p < 0.05). Argon plasma coagulation is safe and effective. Larger studies in patients with bleeding peptic ulcers are needed to confirm these promising results.
Article
Radiation proctitis is a complication of radiotherapy for malignant pelvic disease. Argon beam coagulation is a new and rapidly evolving technology that permits a "no-touch" electrocoagulation of diseased tissue. We analyzed retrospectively the records of 7 patients with prostatic and endometrial cancers treated with irrradiation (median radiation dose was 6840 cGy, range 2400 to 7200 cGy). The median time to onset of symptoms after the conclusion of radiotherapy was 20 months (range 16 to 48 months); symptoms consisted of rectal bleeding and tenesmus in all patients. The patients underwent argon beam coagulation after colonoscopic evaluation. The usual treatment interval was 3 weeks (range 1 to 3 weeks). A median of 2 treatment sessions (range 2 to 4) was necessary for complete symptom relief. All interventions were well tolerated without complications. During follow-up (median 24 months, range 18 to 24 months), there was no recurrence of symptoms (bleeding, tenesmus). Argon beam coagulation is a safe, well tolerated, and effective treatment option in symptomatic radiation proctitis.
Article
Rectal bleeding due to radiation proctosigmoiditis is often difficult to manage. We had earlier shown the efficacy of short-term therapy with topical sucralfate in controlling bleeding in the radiation proctosigmoiditis. We now report our long-term results with this form of therapy. The study comprised 26 patients with radiation proctosigmoiditis. Sigmoidoscopically, 9 (34.6%) patients had severe changes, 15 (57.69%) had moderate, and 2 (7.69%) had mild changes. Severity of bleeding was graded as severe (> 15 episodes per week), moderate (8-14 episodes per week), mild (2-7 episodes per week), negligible (< or = 1 episode per week), or nil (no bleeding). Ten patients had moderate rectal bleeding, while 16 had severe bleeding. All patients were treated with 20 ml of 10% rectal sucralfate suspension enemas twice a day until bleeding per rectum ceased or failure of therapy was acknowledged. Response to therapy was considered good whenever the severity of bleeding showed improvement by a change of two grades. Rectally administered sucralfate achieved good response in 20 (76.9%) patients at 4 weeks, 22 (84.6%) patients at 8 weeks, and 24 (92.3%) patients at 16 weeks. This change was significant by Wilcoxon matched-pairs signed-ranks test. Two patients required surgery due to poor response. Over a median follow-up of 45.5 months (range 5-73 months) after cessation of bleeding, 17 (70.8%) patients had no further bleeding while 7 (22.2%) had recurrence of bleeding. All recurrences responded to short-term reinstitution of therapy. No treatment-related complications were observed. Ten patients had other associated late toxicity due to pelvic irradiation in the form of asymptomatic rectal stricture (N = 3), rectovaginal fistula (N = 1), intestinal stricture (N = 1), vaginal stenosis (N = 1), and hematuria (N = 6). Three patients had progression of the primary disease in the form of pelvic recurrence (N = 2) and hepatic metastases (N = 1). We conclude that topical sucralfate induces a lasting remission in a majority of patients with moderate to severe rectal bleeding due to radiation proctosigmoiditis.
Article
Residual adenoma is frequently found at the site of endoscopically resected large sessile adenomas on follow-up examination. We evaluated the efficacy of a thermal energy source, the argon plasma coagulator, to destroy visible residual adenoma after piecemeal resection of sessile polyps. Seventy-seven piecemeal polypectomies with or without the use of argon plasma coagulator were analyzed retrospectively. All polyps were sessile, 20 mm or greater in size. The results from three groups of patients were compared. The study group was composed of patients who had visible residual adenoma after piecemeal polypectomy and had the base of the polypectomy site treated with the argon plasma coagulator. The first comparison group consisted of patients who underwent standard piecemeal polypectomy in whom the colonoscopist thought that all adenomatous tissue was removed and no further treatment was necessary. The second comparison group included patients in whom visible residual adenoma was left at the base after piecemeal resection of large adenomas. Follow-up colonoscopy was performed approximately 6 months after the initial procedure to check for recurrent/residual adenomatous tissue. The argon plasma coagulator was used after 30 piecemeal polypectomies in an attempt to eradicate visible residual adenomatous tissue; at follow-up, 50% of these cases had complete eradication of adenoma. The group in whom all visible tumor was removed by piecemeal polypectomy alone had an adenoma eradication rate of 54% on follow-up colonoscopy. In the patients in whom visible residual adenoma was left at the site the recurrence rate was 100% on the follow-up examination. Bleeding necessitating endoscopic therapy occurred once (3.3%) in the argon plasma coagulator group; there were four (12.5%) bleeding episodes and one (3.1%) confined retroperitoneal perforation in the complete piecemeal polypectomy group and no complications in the group in which polypectomy was incomplete. Argon plasma coagulator ablation of residual adenomatous tissue at the polypectomy base is safe and useful. It helps to complete the eradication of large sessile polyps when there is visible evidence of residual polyp.
Article
Thermoablation is being used to eliminate the metaplastic epithelium of Barrett's esophagus and allow its reversal into squamous epithelium in an acid-controlled environment. This study assessed the efficacy and safety of a new thermoablation technique, argon plasma coagulation. Patients with circumferential Barrett's esophagus 2 to 5 cm long were enrolled. Acid suppression was accomplished with lansoprazole. One-half the circumference of Barrett's mucosa was treated with argon plasma coagulation, and the other half served as an internal control. After macroscopic squamous re-epithelialization occurred, biopsy specimens were obtained from both areas systematically. Nine patients, all men with a mean age of 51.1 years, completed the study. During 24-hour esophageal pH monitoring a pH less than 4 occurred on average 2.8% of the time with a mean dose of lansoprazole of 70 mg/day. Squamous re-epithelialization developed in treated areas in all 9 patients. Biopsy showed that 7 of 9 patients (77.8%) had squamous re-epithelialization without intestinal metaplasia. Biopsy showed that 2 of 9 patients (22.2%) had squamous re-epithelialization with evidence of underlying intestinal metaplasia. There were no serious complications. Argon plasma coagulation in an acid-controlled environment was both efficacious and safe in the treatment of Barrett's esophagus. However, the reappearance of squamous epithelium after therapy did not exclude the presence of underlying intestinal metaplasia.
Article
Radiation-induced proctosigmoiditis is a serious complication of pelvic radiation therapy. Rectal bleeding occurs among 6% to 8% of these patients and is extremely difficult to manage. Pharmacotherapy is generally ineffective, whereas surgical treatment is associated with high morbidity and mortality. Argon plasma coagulation is a new method of noncontact electrocoagulation well suited for hemostasis of large bleeding areas. From December 1996 through March 1998, we used argon plasma coagulation to treat 28 patients with hemorrhagic radiation-induced proctosigmoiditis. Indications for treatment were anemia (n = 18) and persistent bleeding despite pharmacotherapy (n = 10). Argon flow and electrical power were set at 1.5 L/min and 50 W. The severity of rectal bleeding was graded from 0 to 4 (highest), and hemoglobin levels were recorded before and after treatment. Eighty-two therapeutic sessions were performed (median 2.9 sessions per patient). The severity score for rectal bleeding dropped at least 1 point for all but 2 patients, and the mean value decreased from 2.96 to 0.68. Average hemoglobin level increased 1.2 gm/dL (1.9 gm/dL among anemic patients). No serious complications were observed. Argon plasma coagulation appears to be a simple, safe, and effective technique in the management of hemorrhagic radiation-induced proctosigmoiditis.
Article
Because endoscopic en bloc resection of large, sessile colorectal polyps is technically difficult, they are usually resected piecemeal. However, piecemeal resection makes it difficult to evaluate the completeness of the resection histopathologically. In this study the efficacy of endoscopic piecemeal resection of large, sessile colorectal polyps was investigated after follow-up greater than 1 year. We removed 56 sessile colorectal polyps 2 cm or greater in diameter in 56 patients by using an endoscopic submucosal saline injection technique. Endoscopic examinations were repeated at 3, 6, and 12 months and longer after initial endoscopic resection. If no residual tumor was found endoscopically and histologically, the patient was considered to be "cured." Of the 56 polyps, 14 (25%) were resected en bloc, and 42 (75%) were resected piecemeal. Of the 42 patients treated with piecemeal resection, 23 (55%) required additional endoscopic or surgical interventions. In patients followed 1 year or longer after initial treatment, the cure rate by en bloc resection was 100% (14 of 14) and that by piecemeal resection was 83% (35 of 42). Arterial bleeding occurred in 4 patients (7%) during or after endoscopic resection. In 3 of them, bleeding was stopped by endoscopic clipping, but 1 patient required emergent laparotomy. Endoscopic piecemeal resection after submucosal saline injection with an intensive follow-up program is a safe and effective treatment for large, sessile colorectal polyps.
Article
Esophagogastric cancer often presents at an advanced stage, or in patients unfit for resection. These patients may benefit from local ablation to provide both symptom and disease control. A series of 48 consecutive patients with esophagogastric cancer were treated with endoscopic argon beam plasma coagulation (ABPC) at a specialist unit. Of 16 unfit patients who presented with early cancers, four are disease-free and all are asymptomatic at a median of 21 months after treatment. In 13 of 14 patients with occluded esophageal stents, the esophageal lumen was restored. In 18 patients with advanced cancers, ABPC was employed to debulk two gastric outlet and eight esophageal tumors. Argon was employed successfully to control bleeding in three of five patients. In advanced disease, dysphagia was relieved in only one of three patients. Endoscopic ABPC controls symptoms and may control early esophageal and gastric cancers in unfit patients. ABPC allows restoration of the lumen in stent overgrowth and control of bleeding from advanced gastric neoplasms; however, its role in debulking large tumors is less clear.
Article
We report our recent experience of using argon plasma to endoscopically cut biliary Wallstent prostheses in these patients. The first patient had a bleeding duodenal ulceration caused by the impaction of the prosthesis meshes whereas the second patient had an ill-positioned biliary stent with impaction into the opposite duodenal wall. Both prostheses were shortened using argon plasma. In the third patient, the lower extremity of a obstructed biliary Wallstent was positioned in the third duodenum preventing its endoscopic catheterization. After shortening using argon plasma, a new plastic stent could be inserted to allow drainage. The outcomes in these cases demonstrate the feasibility of endoscopically shortening metallic Wallstents after release using argon plasma.
Article
Esophageal varices are treated by endoscopic ligation with or without sclerotherapy. Here we used argon plasma coagulation (APC) to promote mucosal fibrosis and compared the efficacy of ligation plus APC with ligation alone in the treatment of esophageal varices. Our prospective study included 30 patients with esophageal varices randomly assigned to receive APC after ligation (combined group) and 30 patients assigned to receive ligation only (ligation group). Endoscopic ligation was performed until the varix shrank to F1 without red color sign or smaller. This was followed by induction of fibrosis of the distal esophageal mucosa using APC in the combined group. APC was performed using an argon gas at a flow rate of 1.5-2 l/min and a high frequency arc output of 50-60 W. Treatment outcome and complications were compared between the two groups. The mean follow-up time was 18.5+/-6.8 and 15.8+/-7.7 months (+/- SD) for the combined and ligation groups, respectively. The number of treatment sessions was slightly lower in the ligation group (2.9+/-0.6 vs. 2.5+/-0.6, P<0.05). The number of ligation bands used was not different between the two groups (13.4+/-3.1 vs. 14.9+/-2.4). The cumulative recurrence-free rate at 24 months after treatment in the combined group was significantly higher than in the ligation group (74.2% vs. 49.6%, P < 0.05). A significantly higher incidence of pyrexia was encountered in the combined group (P <0.05), but the incidences of other complications were similar in both groups. Our results indicate that endoscopic ligation of esophageal varices combined with APC is superior to ligation alone. Since APC is theoretically well suited for mucosal fibrosis therapy, it can be used for the complete elimination of esophageal varices and for fibrosis of the distal esophageal mucosa.
Article
We report on 17 patients with GAVE-syndrome (gastric antral vascular ectasia) treated by means of endoscopic argon plasma coagulation (APC). 16 of 17 patients presented with iron deficiency anemia; transfusion-dependent anemia was noted in 11 patients (65%). Resolution of the gastric angiectasia could be achieved in all patients by endoscopic APC after 1-4 treatment sessions. Endoscopic follow-up revealed recurrence of GAVE in 5 patients (requiring further treatment sessions). Mean pretreatment hemoglobin level of 78 g/l improved to 115 g/l after treatment. Only one patient needed post-treatment transfusions; she had refused further endoscopy. The mean follow-up was 30.4 months (range 1-65). In one case circumferential scarring of the antrum led to asymptomatic stenosis 6 months after APC; at the same time early recurrence of extensive angiectasia occurred. Billroth I resection was performed. No other complications were observed. Our results show that argon plasma coagulation is an effective and safe treatment for gastrointestinal blood loss due to GAVE syndrome (watermelon stomach). Control endoscopies are indicated in order to recognize and treat recurrence of angiectasia on time.
Article
Chronic radiation proctitis complicating pelvic radiotherapy can be debilitating. It commonly presents with rectal bleeding, which can be difficult to control. Medical management of hemorrhagic radiation proctitis is not very successful, although surgery carries high risks. Thus, endoscopic treatments are preferred. The aim of this study is to assess the efficacy of argon plasma coagulation applied endoscopically to treat hemorrhagic radiation proctitis that has been refractory to topical formalin therapy. Twelve patients who had ongoing bleeding from radiation proctitis, after previously failed formalin therapy, underwent endoscopic treatment using argon plasma coagulation. The efficacy of treatment was assessed by grading the frequency and severity of bleeding (0-4, 0 being no bleeding), hemoglobin level, and transfusion requirements. At a median follow-up of 11 months, ten patients (83 percent) had a significant reduction in the severity and frequency of bleeding, with complete cessation in six (50 percent). The presence of coexistent radiation-induced sigmoiditis in two patients was associated with reduced but persistent bleeding, because of difficulty in targeting the bleeding sites in the sigmoid colon. The median number of treatment sessions per patient was two (range, 1-3), with the number of sessions correlated with the extent of the proctitis. All patients had an improvement in their hemoglobin level, with the mean increasing from 11.2 to 12.3 g/dl. In the six months before starting therapy, all patients had been taking iron supplements, and four had required blood transfusions (median 3 units, range, 2-6). Iron supplements were ceased four weeks after the completion of therapy in all cases, and no further transfusions were required during the study period. None of the patients experienced any significant side effects or complications. Argon plasma coagulation is an effective and safe treatment for hemorrhagic radiation proctitis that has been refractory to topical formalin therapy.
Article
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. Records of 21 consecutive patients in whom argon plasma coagulation was used to treat hemorrhagic radiation proctopathy were reviewed. 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%). 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.
Article
Recurrence is frequent after piecemeal snare resection of large sessile colorectal polyps. The aim of this study was to evaluate the safety and efficacy of argon plasma coagulation (APC) in preventing recurrence when applied to the edge and base of the polypectomy site after apparently complete piecemeal resection. Patients with large (>1.5 cm) sessile polyps removed by piecemeal snare cautery were placed into 2 groups. The first consisted of patients with polyps believed by the endoscopist to be completely excised. These patients were randomized to either no further therapy (control) or to APC of the rim and any residual mucosal or submucosal tissue in the base of the polypectomy site. The second group comprised patients in whom polyps, as judged by the endoscopist, were incompletely excised by snare polypectomy; APC was routinely applied without randomization to all visible remaining adenomatous tissue. Follow-up colonoscopy was performed within 3 months and 1 year; biopsy specimens were taken routinely from the resection site and further polypectomy was performed as indicated. There were fewer recurrences after APC in the randomized group (1/10 APC, 7/11 no APC; p = 0.02). In the group with initial incomplete snare polypectomy, recurrence was detected at 3 months in 6 of 13 despite APC. One patient was hospitalized with abdominal pain and minor rectal bleeding but required no intervention. There were no other episodes of significant late bleeding caused by piecemeal polypectomy. One patient was referred for surgery after unsuccessful endoscopic management. In patients with apparent complete endoscopic snare resection of large adenomas, postpolypectomy application of APC reduces adenomatous recurrence.
Article
Recurrent hemorrhage in patients with severe radiation proctitis is very common. It is often refractory to medical therapy. Endoscopic and surgical treatment may be required when conservative medical therapy fails. The aim of this study was to assess the therapeutic results of the Argon Plasma Coagulator (APC) (ERBE USA, Inc., Marietta, GA, USA) application in patients with radiation proctitis-induced hemorrhage. Forty patients with radiation-induced proctitis causing severe bleeding, who had failed conservative medical management were treated endoscopically. Twenty-one patients in this group required blood transfusions. APC application was used in 40 patients with only one failure. The failed patient underwent formalin application using 4% formalin solution with resolution of the bleeding. Argon plasma coagulation application is a safe, well-tolerated treatment option and, historically, has been superior to Nd:YAG laser ablation.
Article
Submucosal saline solution injection may limit the depth of thermal injury to the gut wall by acting as a heat-sink and by increasing the distance between burn and serosa. The aim of this study was to determine the effect of submucosal saline solution injection on depth of colonic thermal injury produced by commonly used endoscopic thermal modalities. Longitudinal colotomy incisions were made on the antimesenteric colonic border of anesthetized swine. Lesions were made by using a bipolar device (20 W, 2 seconds), heat probe (30 J); monopolar contact with hot biopsy forceps (20 W, 2 seconds), and monopolar noncontact with argon plasma coagulation (45 W, 3 seconds). Ten or more lesions were created with each device. Lesions were made with or without prior submucosal injection of 2 mL of normal saline solution. After 24 hours the lesions were excised for histologic analysis. Injury was assessed in relation to the severity of damage to the deep (longitudinal) muscle layer. The proportions of control lesions (without submucosal saline solution injection) in which deep injury was evident were as follows: argon plasma coagulation, 86%; hot biopsy forceps, 64%; heat probe, 50%; bipolar device, 18%. Submucosal saline solution injection significantly reduced the proportions of lesions with deep injury for argon plasma coagulation (p = 0.009) and heat probe (p = 0.03), but not hot biopsy forceps or bipolar device (argon plasma coagulation, 86% to 21%; heat probe, 50% to 0%; hot biopsy forceps, 64% to 50%; bipolar device, 18% to 9%). At equivalent energy outputs, the bipolar device results in less deep injury than the monopolar or heat probe. Submucosal saline solution injection reduced injury to the muscularis propria caused by both heat probe and argon plasma coagulation, but not hot biopsy forceps. Despite submucosal saline solution injection, caution should be exercised when using prolonged monopolar cautery.
Article
Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence in small uncontrolled series. The aim of this study was to determine whether argon plasma coagulation is effective in reducing variceal recurrence after endoscopic variceal ligation. Thirty patients with cirrhosis, a history of acute esophageal variceal bleeding, and eradication of varices by endoscopic variceal ligation were randomized to argon plasma coagulation (16 patients) or observation (14 patients). The 2 groups were similar with respect to all background variables including age, Child-Pugh score, presence of gastric varices, and degree of portal hypertensive gastropathy. In the argon plasma coagulation group, the entire esophageal mucosa 4 to 5 cm proximal to the esophagogastric junction was thermocoagulated circumferentially with argon plasma coagulation in 1 to 3 sessions performed at weekly intervals. Endoscopy was performed every 3 months to check for recurrence of varices in both groups. During the course of the study, no serious complication was noted. After argon plasma coagulation, transient fever occurred in 13 patients and 8 complained of dysphagia or retrosternal pain/discomfort. Mean follow-up for all patients was 16 months (range 9-28 months). No recurrence of varices or variceal hemorrhage was observed in the argon plasma coagulation group, whereas varices recurred in 42.8% (6/14) of the patients in the control group (p < 0.04) and bleeding recurred in 7.2% (1/14). Argon plasma coagulation of the distal esophageal mucosa after eradication of esophageal varices by endoscopic variceal ligation is safe and effective for reducing the rate of variceal recurrence.
Article
Barrett's esopagus (BE) is considered a risk factor for the development of esophageal carcinoma. Recently, partial restoration of squamous mucosa after ablation of BE with endoscopic techniques has been described. From November 1996 to November 1999, 23 patients with histologically proven BE have been treated by endoscopic argon plasma coagulation (APC) following suppression of gastro-esophageal reflux by laparoscopic fundoplication. Histological follow-up after completed ablation ranged from 16 to 45 months (mean, 31.9 months). Histologically, complete squamous reepithelialization was observed in 20/23 patients, whereas a regrowth of a mixed squamous and gastric type mucosa was observed in 1 patient. Small islands of intestinal metaplasia were observed under the neosquamous epithelium in two patients (9%) during follow-up. The success rate of APC ablation following laparoscopic antireflux surgery in our series may be as high as 91%. Nevertheless, small islands of intestinal metaplasia under the new squamous epithelium may persist in some patients. In these circumstances, the authors recommend that endoscopic ablation of BE should be confined to controlled clinical trials.
Article
The aim of this study was to evaluate prospectively the long-term outcomes of using argon plasma coagulation (APC) as an adjunct to piecemeal polypectomy of large sessile colorectal adenomas. A total of 77 patients with 82 sessile colorectal adenomas (median size 2.9 cm, range 1.5 - 8.0 cm) underwent snare piecemeal polypectomy. Patients in whom polypectomy was complete received no further treatment (polypectomy group; n = 14). When polypectomy was incomplete, additional treatment with APC was started either immediately or 1 - 3 months after the last polypectomy session (polypectomy + APC group; n = 63). Patients were followed (by endoscopy and biopsy) at regular intervals. Histologically proven adenoma eradication was achieved in 100 % of patients (14/14) in the polypectomy group and in 90 % of patients (57/63) in the polypectomy + APC group (two patients died of unrelated causes before adenoma was eradicated, two underwent operation because cancer was detected in the polyp treated, and two underwent operation because of endoscopic treatment failure). The adenoma recurrence rate was 14 % in both the polypectomy and polypectomy + APC groups. All recurrences except one occurred during the first year of follow-up and all were successfully re-treated endoscopically. A total of 69 patients in whom long-term follow-up data are available are free from adenoma at a median follow-up of 37 months (range 12 - 80). No major complications of endoscopic treatment occurred. In seven cases (9 %) the polyp was eventually shown to be malignant; in two of these patients the diagnosis of cancer was delayed as a result of unsuccessful endoscopic treatment. APC used in combination with piecemeal polypectomy of large colorectal adenomas is an effective and safe method of therapy, provided patient selection is careful and follow-up close.
Article
Epinephrine injection with heat probe coagulation is an effective treatment for bleeding peptic ulcer. Few studies have investigated the efficacy of dual therapy with epinephrine injection plus either heat probe or argon plasma coagulation for high-risk bleeding peptic ulcers. This study compared epinephrine injection plus heat probe coagulation to epinephrine injection plus argon plasma coagulation for the treatment of high-risk bleeding peptic ulcers. The study design was prospective, randomized, and controlled. Patients with actively bleeding peptic ulcers, ulcers with adherent clots, or ulcers with nonbleeding visible vessels were randomly assigned to epinephrine injection plus heat probe coagulation or epinephrine injection plus argon plasma coagulation. Patients with previous gastric surgery, malignant ulcers, and unidentifiable ulcers because of torrential bleeding were excluded. The primary outcome measure was recurrence of bleeding. Secondary outcome measures were initial hemostasis, endoscopic procedure duration, number of patients requiring surgery, mortality within 30 days, and ulcer status at 8 week follow-up endoscopy. One hundred ninety-two patients were enrolled; 7 with malignant ulcers were excluded after randomization. One hundred eighty-five cases were analyzed, 97 in the heat probe group and 88 in the argon plasma coagulation group. Patient demographics and ulcer characteristics were comparable between the groups. There was no significant difference in terms of initial hemostasis (95.9% vs. 97.7%), frequency of recurrent bleeding (21.6% vs. 17.0%), requirement for emergency surgery (9.3% vs. 4.5%), mean number of units of blood transfused (2.4 vs. 1.7 units), mean hospital stay (8.2 vs. 7.0 days), and hospital mortality (6.2% vs. 5.7%). Sixty (61.8%) patients in the heat probe group and 52 (52.9%) in the argon plasma coagulation group underwent endoscopy at 8 weeks. There was no significant difference between these groups in the relative frequency of nonhealing ulcer at 8 weeks. Epinephrine injection plus argon plasma coagulation is as safe and effective as epinephrine injection plus heat probe coagulation in the treatment of patients with high-risk bleeding peptic ulcers.
Article
Polypectomy techniques vary in clinical practice. The aim of this study was to determine patterns of polypectomy practices in a random sample of gastroenterologists. A total of 300 gastroenterologists were selected randomly from the membership directory of a professional society. They were asked to complete a standardized survey by telephone, electronic mail, or facsimile. The offices of 285 physicians were contacted successfully. A total of 189 (63%) chose to participate. 152 (80%) of these physicians were in private practice, and 37 (20%) were in academic practice. The mean number of years in practice was 15.5 (range 1-46 years). Forceps techniques (cold or hot) dominated other polypectomy methods for polyps 1 to 3 mm in size ( p < 0.0001), whereas electrosurgical snare resection was dominate for polyps 7 to 9 mm in diameter ( p < 0.0001). No method of polypectomy was significantly more likely to be used for polyps 4 to 6 mm in size. The proportion of physicians who had used dye spraying was 8.5%; detachable snares, 20.1%; clips, 20.1%; and submucosal saline solution injection, 82%. Of those who had used submucosal saline solution injection, 29.7% had no rules for its use, and, in the remainder, there was marked variation regarding the criteria. For polyp stalks greater than 1 cm in diameter, 69% used no method to prevent bleeding. Of those who did use preventive techniques, 76% used epinephrine injection. The electrosurgical current used for polypectomy was pure coagulation in 46%, blend in 46%, and pure-cut in 3%; 4% varied the current. At present, polypectomy technique among clinical gastroenterologists is highly variable. Some newer ancillary techniques have had extremely limited use thus far.
Article
The aim of this study was to assess the feasibility and efficiency of plasma argon trimming of gastrointestinal and biliary metallic stents. A total of 31 patients underwent plasma argon trimming of their metallic stents (14 women, 17 men; mean +/- SD age 73 +/- 12.2 years, range 46 - 96 years). Of these 31 patients, 24 had had covered or noncovered Unistep Wallstents placed in the biliary tract (13 patients with pancreatic neoplasms, five patients with Vater ampulloma, five patients with biliary tract carcinoma and one patient with chronic calcifiying pancreatitis); three patients had noncovered Enteral Unistep Wallstents (pyloroduodenal); two patients with obstructive colorectal carcinoma had a noncovered Bard Memotherm stent inserted; and two patients had noncovered Ultraflex stents placed for esophageal carcinoma. Endoscopic trimming of the stents was performed under propofol-induced general anesthesia, with the power set at 70 - 80 watts and an argon flow of 0.8 liters/minute. Complete and satisfactory trimming of the stents was possible, without complications (mean follow-up 15.8 months), in all patients except one, a patient with a covered biliary Wallstent. In 13 patients with biliary or Enteral Wallstents the trimming procedure was preventive. In eight patients with ulceration and/or hemorrhage (duodenal or rectal), healing was achieved after stent trimming and epinephrine (adrenaline) injection followed by electrocoagulation. Stent trimming restored patency of the duodenal lumen in six patients and of the esophageal lumen in two patients, and was done to allow insertion of a biliary stent in one patient whose duodenal stent was covering the papilla. In one patient with rectal tenesmus, stent shortening resulted in complete resolution of symptoms. Endsocopic plasma argon trimming of metallic stents is an efficient procedure which allows easy, reproducible and well-tolerated correction of complications that arise due to these prostheses.