Case Studies: Case Reports

Bowel explosion with colonic perforation during argon plasma coagulation for hemorrhagic radiation-induced proctitis☆,☆☆

Chronic gastrointestinal (GI) hemorrhage may be overt or occult. If bleeding is occult, the clinical presentation is anemia, and evidence of occult bleeding is found on testing of the stools. In some patients, chronic hemorrhage may be clinically interspersed with acute episodes. Chronic bleeding from the gut is always significant; in particular, malignant tumors of the gut that are curable may be present. This chapter discusses some of the most frequent causes of occult or unexplained chronic GI bleeding: vascular tumors, vascular anomalies associated with congenital or systemic diseases, and acquired or sporadic vascular lesions such us angiodysplasias, gastric antral vascular ectasia, lesions related to portal hypertension, and radiation-induced vascular ectasias. An early diagnosis of the bleeding site has become possible recently with the development of several endoscopic modalities for assessment of the small bowel that include wireless capsule endoscopy and deep small bowel enteroscopy (double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy). Their introduction into clinical practice has revolutionized the evaluation of obscure gastrointestinal bleeding and unexplained iron deficiency anemia. Therapeutic approach for each condition is discussed, focusing on endoscopic management and tips to get the best results with endoscopic treatment.

In the past, the treatment of iatrogenic gastrointestinal perforations was limited to surgical management or to medical observation. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has paved the way towards the development of reliable endoscopic closure techniques, which can be applicable in accidental perforations of the gastrointestinal tract.

When endoscopic treatment is feasible, hemoclips are preferred in smaller perforations, while over-the-scope-clips or a combination of hemoclips, endoloops, and glue are used in larger ones. Endoscopic stitching is rarely utilized, and endoscopic stapling has been practically abandoned. The use of self-expandable covered stents can be considered in the esophagus and duodenum. Broad spectrum antibiotics are recommended in most cases. Clinical follow-up in a medico-surgical unit is mandatory and surgical intervention should not be delayed more than 24 h if clinical or biological worsening occurs. Imaging with oral contrast medium is advisable before resumption of oral feeding in the case of large perforations.

Technology is constantly changing, and it is important for perioperative nurses to stay current on new products and technologies in the perioperative setting. AORN's “Recommended practices for electrosurgery” addresses safety standards that all perioperative personnel should follow to minimize risks to both patients and staff members during the use of electrosurgical devices. Recommendations include how to select electrosurgical units and accessories for purchase, how to minimize the potential for patient and staff member injuries, what precautions to take during minimally invasive surgery, and how to avoid surgical smoke hazards. The recommendations also address education/competency, documentation, policies and procedures, and quality assurance/performance improvement. Perioperative nurses should consider the use of checklists and safety posters to remind staff members of the dangers of electrosurgery and the steps to take to minimize the risks for injury.

No standard treatment exists for hemorrhagic radiation proctopathy (HRP). Recently it was reported that argon plasma coagulation (APC) is effective for HRP. However, previous studies documented complications such as ulcers, strictures, and perforations in as many as 20% of APC-treated patients.

The aim of this study was to determine the optimal parameters for APC by using swine rectum and to assess the safety and effectiveness of APC in HRP patients.

Prospective case series.

University teaching hospital.

Sixty-five patients with HRP were prospectively enrolled between 2000 and 2010.

APC for HRP.

Optimal APC parameters, number of treatments, success rate, complications, clinical remissions.

APC in swine rectal wall ex vivo was optimal with a 40-W current, 1.2-L/min gas flow rate, and 2-second application, which was sufficient to treat the submucosal telangiectasia but did not adversely affect the muscle layer. Sixty-five patients (46 men, 19 women; median age 72 years) with HRP occurring at a mean of 20 months after radiotherapy were studied. Proctopathy was classified as grade A (mild) in 7 patients (10.8%), grade B (moderate) in 41 (63.1%), and grade C (severe) in 17 (26.2%). The treatment success rate was 98.5% after a median of 2 (range 1-5) APC sessions. The median clinical score for rectal bleeding was significantly decreased after APC (P < .0001), and the hemoglobin level was significantly increased (P < .0001). APC was well tolerated, and no significant side effects or complications occurred. During a mean follow-up of 34.6 months (range 3.6 –121.1 months), 4 patients (6.3%) had minor recurrent rectal bleeding and 60 (93.8%) remained in remission.

Nonrandomized study.

HRP treatment with optimal APC settings yields a high success rate and long-lasting clinical remission with no significant complications.