Original article
Clinical endoscopy
Argon plasma coagulation treatment of hemorrhagic radiation proctopathy: the optimal settings for application and long-term outcome

https://doi.org/10.1016/j.gie.2010.11.015Get rights and content

Background

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.

Objective

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.

Design

Prospective case series.

Setting

University teaching hospital.

Patients

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

Interventions

APC for HRP.

Main Outcome Measurements

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

Results

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.

Limitations

Nonrandomized study.

Conclusions

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

Section snippets

Ex vivo experiments

Standard APC equipment consisting of a high-frequency generator (ICC 200; ERBE Elektromedizin, Tübingen, Germany), an automatically regulated argon source (APC 300; ERBE Elektromedizin), and a flexible axial spot beam APC probe (2.3 mm in diameter, 100-W maximum output, and 2.4-L/min maximum flow rate) was used in this study. Ex vivo experiments were performed to determine the optimal parameters for APC using swine rectal walls, which were obtained within 1 hour after the swine were killed. APC

Patients and methods

Eligible patients had endoscopically confirmed radiation proctopathy with rectal bleeding, had not undergone APC therapy previously, and provided informed consent. Colonoscopy was performed in all patients before treatment to rule out any other cause of the rectal bleeding. Patients undergoing APC received a standard polyethylene glycol preparation. Anticoagulants and aspirin were discontinued 1 week and 3 days before treatment, respectively.

APC was administered by using a single-channel

Ex vivo experiments

We first performed an ex vivo experiment on swine rectal mucosa to determine the ideal parameters for APC for use in the treatment of radiation proctopathy in humans. The experiment was repeated twice by using the rectums from 2 swine. The results of the 2 experiments were almost identical. Figure 1 shows the macroscopic appearance of swine rectal mucosa coagulated at differing parameters.

Coagulation depths at varying parameters based on histological analysis are summarized in Figure 2. The

Discussion

In this study, we first determined the optimal settings for APC with first-generation APC generators by using swine rectum, and we then treated patients with HRP prospectively to assess the efficacy and safety of APC using the same settings.

Most of the previous studies on HRP were retrospective and were limited by small patient numbers. Our patient series represents one of the largest reported to date and also provides longer term follow-up data compared with other studies.14, 28, 29 We

Acknowledgments

We express our deep appreciation to Dr. Ikeda for his valuable advice on hematoxylin and eosin staining and Elastica van Gieson staining.

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

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