Frequency and outcomes of rectal ulcers during argon plasma coagulation for chronic radiation-induced proctopathy

Early and Late Readmissions of Radiation Proctitis in the United States: Are We Getting Better?

Background/Aims: Radiation proctitis (RP), a well-known complication of pelvic radiation therapy, may lead to recurrent hospitalizations. We aimed to assess readmissions of RP in the United States. Methods: We analyzed the Nationwide Readmission Database from 2016 to 2020 to identify all 30-, 60-, and 90-day readmissions of RP in the United States. Hospitalization characteristics, predictors, clinical outcomes, and healthcare burdens were assessed. Results: From 2016 to 2020, we noted a declining trend of 30-, 60-, and 90-day readmissions of RP in the US. However, the all-cause 30-, 60-, and 90-day readmission rates of RP were still high at 13.7%, 19.4%, and 23.16%, respectively. On readmission, RP was identified as the admitting diagnosis in only 20.61%, 17.87%, and 15.76% of 30-, 60-, and 90-day readmissions, respectively. The mean age for all readmissions was 70 years with a significant male dominance. Lower endoscopy at index admission reduced the risk of readmissions within 90 days, but this was not statistically significant. However, the Charlson Comorbidity Index (CCI) score was an independent predictor of all readmissions. Furthermore, the mean length of stay was 5.57 (95% CI 5.15-6), 5.50 (95% CI 5.12-5.89), and 5.47 (95% CI 5.07-5.87) days and the mean hospitalization charge was USD 60,451 (95% CI USD 54,728-66,174), USD 62,671 (95% CI USD 57,326-68,015), and USD 62,144 (95% CI USD 57,144-67,144) for 30-, 60-, and 90-day readmissions. The all-cause inpatient mortality for 30-, 60-, and 90-day readmissions was 3.58%, 3.89%, and 3.46%, respectively. Conclusions: RP readmissions are a significant healthcare burden. Further efforts must be directed toward improving management strategies to reduce readmission rates.

Radiation Proctitis and Management Strategies

Radiotherapy (RT) is a treatment modality that uses high-energy rays or radioactive agents to generate ionizing radiation against rapidly dividing cells. The main objective of using radiation in cancer therapy is to impair or halt the division of the tumor cells. Over the past few decades, advancements in technology, the introduction of newer methods of RT, and a better understanding of the pathophysiology of cancers have enabled physicians to deliver doses of radiation that match the exact dimensions of the tumor for greater efficacy, with minimal exposure of the surrounding tissues. However, RT has numerous complications, the most common being radiation proctitis (RP). It is characterized by damage to the rectal epithelium by secondary ionizing radiation. Based on the onset of signs and symptoms, post-radiotherapy RP can be classified as acute or chronic, each with varying levels of severity and complication rates. The treatment options available for RP are limited, with most of the data on treatment available from case reports or small studies. Here, we describe the types of RT used in modern-day medicine and radiation-mediated tissue injury. We have primarily focused on the classification, epidemiology, pathogenesis, clinical features, treatment strategies, complications, and prognosis of RP.

The Effect of Hyperbaric Oxygen Therapy on Rectal Ulcers after Argon Plasma Coagulation

Chronic radiation proctitis usually develops 3 months after therapy. Despite the lack of standard guidelines regarding treatment, argon plasma coagulation is often a safe and effective endoscopic therapy. However, rectal ulcers are a common complication after argon plasma coagulation. Nevertheless, most patients are asymptomatic and do not require additional monitoring or treatment. We report a case of an argon plasma coagulation-induced ulcer with relevant symptoms and refractory to medical treatment. The patient was treated with hyperbaric oxygen therapy and had complete resolution of the rectal ulcer. Hyperbaric oxygen therapy has shown efficacy in severe chronic proctitis and radiation-induced rectal ulcers, but no clinical report has ever been published on using hyperbaric oxygen therapy for ulcers after argon plasma coagulation. In this case, hyperbaric oxygen therapy was an effective alternative option and can be considered in patients with refractory argon plasma coagulation-induced rectal ulcers.

Endorectal formalin instillation or argon plasma coagulation for hemorrhagic radiation proctopathy therapy: a prospective and randomized clinical trial

BACKGROUND AND AIMS

Radiotherapy may cause hemorrhagic radiation proctopathy (HRP). For conservative treatment of refractory HRP, argon plasma coagulation (APC) is the first-choice therapy. Endorectal formalin instillation (EFI), in turn, is an attractive treatment option because of its satisfactory results, great availability, and low cost. Nevertheless, comparative studies between these procedures are rather scarce. This study aims to make a prospective and randomized comparison of the outcomes in 2 HRP patient groups treated with either APC or EFI.

METHODS

Twenty-seven patients (11 women), with a mean age of 67 years (range, 36-83), were randomized to receive either APC (n = 14) or EFI (n = 13). On completion of the treatment, comparisons were made in relation to the baseline for each patient and between groups for endoscopic findings according to the Vienna score and the telangiectasia distribution pattern score (TDP); the impact of radiation proctitis on patients' lives was made according to the modified radiation toxicity score (MRTS) and hemoglobin levels. Number of sessions, duration of therapy, and adverse events were also compared between groups. The endoscopic therapeutic success (ETS) was defined by the absence or only few residual telangiectasias (TDP ≤1) on conclusion.

RESULTS

An ETS of 92.8% was achieved in patients treated with APC and 92.3% for those treated with EFI (P > .05); there was an MRTS improvement of 85.7% in APC patients and 69.2% in EFI patients (P > .05). Mild adverse events occurred, respectively, in 23% and 28.5% in the EFI and APC groups (P > .05).

CONCLUSIONS

The study showed that APC and EFI have similar efficacy and a high safety profile for HRP treatment. (Clinical trial registration number: 3.120.353.).

Endoscopically delivered Purastat for the treatment of severe haemorrhagic radiation proctopathy: a service evaluation of a new endoscopic treatment for a challenging condition

BACKGROUND

A total of 30 000 people are treated with pelvic radiotherapy annually in the UK. Rectal bleeding is common following pelvic radiotherapy and one of the main causes is radiation proctopathy (RP). Six per cent develop severe bleeding from RP, leading to anaemia requiring iron +/- blood transfusion. There are very few safe, effective, evidence-based treatments. Purastat is a haemostatic agent licensed for gastrointestinal bleeding. It is a self-assembling peptide that forms a molecular mesh in contact with blood, thereby sealing blood vessels. There are numerous studies showing its efficacy and safety in various surgical/endoscopic settings. This service evaluation reports the first experience of the use of Purastat in RP.

METHODS

Consecutive patients attending pelvic radiation disease clinic with severe refractory RP were offered treatment with Purastat. This was defined as rectal bleeding into the pan±anaemia with no response to rectal sucralfate. Purastat was applied endoscopically at four weekly intervals up to three times, with more as required. Bleeding severity, endoscopic grade and haemoglobin were recorded.

RESULTS

Twenty-one patients were treated (18 men, median age 76 years) with a median of three treatments. Ten were on antithrombotics, 1 had thrombocytopenia and 13 had anaemia at baseline. Median episodes of bleeding reduced from 4.5 (0-27) to 2 (0-16) in the 7 days prior to the first and third treatment, respectively. Endoscopic grade was improved. Mean haemoglobin increased from 116.0 to 122.7. There were no complications.

CONCLUSION

Even in this cohort of severe refractory RP, there was an improvement in bleeding and endoscopic grade with Purastat. A randomised controlled trial is planned.

Diverting colostomy is an effective procedure for ulcerative chronic radiation proctitis patients after pelvic malignancy radiation

Background

Chronic radiation proctitis (CRP) with rectal ulcer is a common complication after pelvic malignancy radiation, and gradually deteriorating ulcers will result in severe complications such as fistula. The aim of this study was to evaluate effect of colostomy on ulcerative CRP and to identify associated influence factors with effectiveness of colostomy.

Methods

Between November 2011 to February 2019, 811 hospitalized patients were diagnosed with radiation-induced enteritis (RE) in Sun Yat-sen University Sixth Affiliated Hospital, among which 284 patients presented with rectal ulcer, and 61 ulcerative CRP patients were retrospectively collected and analyzed.

Results

The overall effective rate of colostomy on ulcerative CRP was 49.2%, with a highest effective rate of 88.2% within 12 to 24 months after colostomy. 9 (31.1%) CRP patients with ulcers were cured after colostomy and 12 (19.67%) patients restored intestinal continuity, among which including 2 (3.3%) patients ever with rectovaginal fistula. 100% (55/55) patients with rectal bleeding and 91.4% (32/35) patients with anal pain were remarkably alleviated. Additionally, multivariable analysis showed the duration of stoma [OR 1.211, 95% CI (1.060–1.382), P = 0.005] and albumin (ALB) level post-colostomy [OR 1.437, 95% CI (1.102–1.875), P = 0.007] were two independent influence factors for the effectiveness of colostomy on the rectal ulcer of CRP patients.

Conclusions

Colostomy was an effective and safe procedure for treating rectal ulcer of CRP patients, and also a potential strategy for preventing and treating fistula. Duration of stoma for 12–24 months and higher ALB level could significantly improve the effectiveness of colostomy on ulcerative CRP patients.

A huge rectal ulcer due to argon plasma coagulation in a patient with radiation proctitis

Radiation proctitis (RP) is a complication of radiotherapy in patients with pelvic cancer. A 64-year-old male underwent brachytherapy 2 years previously due to prostate cancer. Subsequently, he developed RP which was treated with argon plasma coagulation (APC). He was subsequently hospitalized due to rectal bleeding and underwent a colonoscopy. A large deep ulcer was seen in the anterior rectum wall, in the same place where APC was performed 3 months earlier. A perforated rectal ulcer was seen via pelvic MRI. However, it was contained by the mesorrectum. Rectal ulcers after APC are uncommon, but they can develop as a result of thermal damage to an ischemic mucosa due to radiotherapy. The treatment of choice of large ulcers is surgery, with a temporary colostomy in order to aid re-epithelialization.

Efficacy and safety of radiofrequency ablation for treatment of chronic radiation proctitis: A systematic review and meta-analysis

BACKGROUND AND AIM

Although argon plasma coagulation is the current standard endoscopic treatment for chronic radiation proctitis (CRP), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study is to evaluate the efficacy and safety of RFA for the treatment of CRP.

METHODS

Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2004 through March 2018. Review and data abstraction were performed independently by two authors. Measured outcomes included hemoglobin, transfusion dependence, number of treatment sessions, RFA settings, and serious adverse events.

RESULTS

Six studies (n = 71; mean age 73.41 ± 1.88 years; 90.14% male) were included. Thirty-eight percent of patients failed prior treatment with argon plasma coagulation. Patients underwent a mean of 1.71 ± 0.34 RFA sessions with 24.54 ± 16.47 RFA applications per session. Pooled clinical and endoscopic success of RFA was 99% (95% confidence interval [CI]: 90-100; P < 0.001) and 100% (95% CI: 94-100; P < 0.001), respectively. Serious adverse events were reported in one patient-pooled rate of 0% (95% CI: 0-3; P < 0.001). Mean pre-procedure hemoglobin was 10.38 ± 1.82 g/dL with significant improvement observed post-RFA [weighted mean difference 2.49 g/dL (95% CI: 2.16-2.82; P < 0.001)]. Among transfusion-dependent patients, 85% (95% CI: 68-97; P < 0.001) became transfusion-free post-RFA. Pooled mean follow-up was 19.73 ± 9.72 months.

CONCLUSION

Despite limited long-term data on RFA for CRP, available evidence suggests RFA is an effective and safe treatment.

Arteriovenous malformations respond poorly to argon plasma coagulation in patients with continuous flow left ventricular assist devices

BACKGROUND

Gastrointestinal bleeding in patients with continuous flow left ventricular assist devices (LVADs) causes significant morbidity. Arteriovenous malformations (AVMs) cause 30-60% of bleeds, yet the efficacy of endoscopic interventions and risk factors for rebleeding have not been studied.

PATIENTS AND METHODS

The charts of all LVAD patients undergoing endoscopy for gastrointestinal bleeding at Stanford between January 2010 and December 2017 were reviewed. Cox proportional hazard modeling was used to evaluate risk factors for rebleeding, including the type of endoscopic treatment, patient characteristics, and endoscopic findings.

RESULTS

Of 54 total LVAD patients presenting with gastrointestinal bleeding, 23 (42.6%) had AVMs documented on endoscopy. Treatment with argon plasma coagulation (APC) alone was associated with a higher risk of rebleeding compared to no treatment [hazard ratio (HR)=4.77, P=0.012], and compared with clip±APC (HR=7.47, P=0.012). The 90-day bleed-free rate was 10.9% with APC, 100% with clipping±APC, and 83.3% with no endoscopic treatment. Additional risk factors for rebleeding included the presence of gastric AVMs (HR=3.64, P=0.024), and presence of hematochezia (HR=5.15, P=0.05). In a multiple Cox regression model, only the presence of gastric AVMs (HR=5.50, P=0.029) and APC use (HR=14.3, P=0.008) remained significant predictors of rebleeding.

CONCLUSION

The use of APC alone for the treatment of AVMs in LVAD patients had a high failure rate. The presence of gastric AVMs was a significant risk factor for rebleeding in LVAD patients. Management decisions should take these factors into account.

Management of Radiation Proctitis

Radiation proctitis is radiation-induced rectal mucositis, occurring as a result of radiation therapy for various pelvic malignancies. The management of radiation proctitis is challenging as guidelines are not currently available, and studies of the various treatment modalities are limited. There are various medical, endoscopic, and surgical measures for treating chronic radiation proctitis. Medical options such as anti-inflammatory agents, antioxidants, formalin application, and hyperbaric oxygen may improve bleeding related to chronic radiation proctitis. Endoscopic measures such as argon plasma coagulation are effective and safe. Surgery is considered for refractory or severe cases. A review and discussion of the different treatment modalities is presented.

Mesalazine suppository for the treatment of refractory ulcerative chronic radiation proctitis

The aim of the present study was to investigate the safety and efficacy of mesalazine suppository in the treatment of refractory ulcerative chronic radiation proctitis (CRP). In total, 10 refractory ulcerative CRP patients who did not respond to previous medical treatments were recruited for the present study and were treated with mesalazine suppository (0.5 g) twice daily for 24 weeks. For each patient, the severity of clinical symptoms and endoscopic appearance was assessed before and after the treatment. For symptom scoring, the reductions in the mean total symptom score (pre- vs. post-treatment, 8.20 vs. 0.90; P<0.01), rectal bleeding score (2.40 vs. 0.30; P<0.01), rectal pain score (2.00 vs. 0.50; P<0.01), stool frequency score (2.00 vs. 0.10; P<0.01) and tenesmus score (1.80 vs. 0.00; P<0.01) were all statistically significant. For mucosal damage scoring, there was a reduction in the mean scores for total scores (9.22 vs. 5.22; P<0.01), telangiectasia (2.78 vs. 1.89; P=0.009), edema (2.89 vs. 1.78; P=0.001) and ulceration (2.44 vs. 0.89; P=0.003). However, statistically reductions in the median symptom scores were not observed for stenosis (0.78 vs. 0.67; P=0.347) and necrosis (0.33 vs. 0.00; P=0.081). Furthermore, no adverse events were observed during and after the treatment. The topical mesalazine suppository may be a safe and effective treatment for CRP, particularly for patients with deep ulcers. Adequately randomized controlled trials are required to confirm the results of the present study.

Efficacy and Safety of Argon Plasma Coagulation for Hemorrhagic Chronic Radiation Proctopathy: A Systematic Review

Hemorrhagic chronic radiation proctopathy (CRP) is a common complication after pelvic radiotherapy in patients with prostate or gynecological cancers. This systematic review was conducted to evaluate the efficacy and safety of argon plasma coagulation (APC) in treating hemorrhagic CRP. The databases of PubMed, Embase, and Cochrane Library were searched for related studies from inception to July 2017. Finally, 33 studies were identified with a total of 821 hemorrhagic CRP patients. After APC treatment, hemoglobin levels increased from 7.7–13.4 g/L to 11–14 g/L (including 15 studies). All (n = 33) studies reported an effective rate in rectal bleeding, among which five studies had a rate of 100%. Short-term complications were reported in 31 studies, while long-term complications in 33 studies and no complication in 11 studies. As for the severe complications, perforation was reported by 2 out of 33 studies, and the incidences were 3.3% (1/30) and 3.7% (1/27), respectively. As for APC setting, argon gas flow rate (median 1.5 L/min) and electric power (median 50 W) had no significant influence on complications and hemostasis. In conclusion, current literature indicated that APC therapy was an effective and safe strategy for hemorrhagic CRP, and large-scale prospective studies are needed to warrant our study.

Exploring the Management of Radiation Proctitis in Current Clinical Practice

INTRODUCTION

Radiation proctitis is radiation induced rectal mucositis, occurring as a consequence to radiation therapy of the pelvic organs for various pelvic region malignancies. The management of radiation proctitis is extremely challenging as no recommended guidelines are available and limited number of studies are there in the literature involving the various treatment options.

AIM

The aim of the study is the in-depth review of published literature to see the role of various treatment modalities in the management of radiation proctitis.

MATERIALS AND METHODS

An integrative review was undertaken within PubMed, MEDLINE, PMC, GOOGLE SEARCH databases and articles published upto February 2015 were reviewed and analysed. A total of 54 studies were included.

RESULTS

Literature suggests that non surgical therapies are the first line of treatment and surgery is reserved for advanced or refractory cases. Endoscopic therapies form the mainstay of treatment in managing the patients of radiation proctitis. Argon plasma coagulation and laser therapies are preferred. Radiofrequency ablation, cryoablation and mesenchymal stem cell therapy are the upcoming modalities. Medical therapy can be tried alone or in conjunction to endoscopic therapies. In the resistant or refractory cases, surgery can be looked for in the form of diversion or resection with or without anastamosis.

CONCLUSION

Though, a number of options are available, still a lot can be explored in this field to improve the morbidity in the patients and to confirm the superiority of one treatment over other.

Chronic radiation proctopathy: A practical review of endoscopic treatment

Chronic radiation proctopathy (CRP) is a troublesome complication of pelvic radiotherapy. The most common presentation is rectal bleeding. CRP symptoms interfere with daily activities and decrease quality of life. Rectal bleeding management in patients with CRP represents a conundrum for practitioners. Medical therapy is ineffective in general and surgical approach has a high morbid-mortality. Endoscopy has a role in the diagnosis, staging and treatment of this disease. Currently available endoscopic modalities are formalin, potassium titanyl phosphate laser, neodymium:yttrium-aluminum-garnet laser, argon laser, bipolar electrocoagulation (BiCAP), heater probe, band ligation, cryotherapy, radiofrequency ablation and argon plasma coagulation (APC). Among these options, APC is the most promising.

Chronic radiation proctitis: tricks to prevent and treat

OBJECTIVE

The purpose of this study was to give an overview of the measures used to prevent chronic radiation proctitis (CRP) and to provide an algorithm for the treatment of CRP.

METHODS

Medical literature databases including PubMed and Medline were screened and critically analyzed for relevance in the scope of our purpose.

RESULTS

CRP is a relatively frequent late side effect (5-20%) and mainly dependent on the dose and volume of irradiated rectum. Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. Also, newer techniques like protons and new devices such as rectum spacers and balloons have been developed to spare rectal structures. Biopsies do not contribute to diagnosing CRP and should be avoided because of the risk of severe rectal wall damage, such as necrosis and fistulas. There is no consensus on the optimal treatment of CRP. A variety of possibilities is available and includes topical and oral agents, hyperbaric oxygen therapy, and endoscopic interventions.

CONCLUSIONS

CRP has a natural history of improving over time, even without treatment. This is important to take into account when considering these treatments: first be conservative (topical and oral agents) and be aware that invasive treatments can be very toxic.

Treatment of chronic radiation proctopathy with radiofrequency ablation (with video)

BACKGROUND

Chronic radiation proctopathy (CRP) is a common sequela occurring even many years after pelvic radiation. Current ablative therapies for bleeding ectatic vessels have the potential for deep tissue injury leading to ulcerations, perforation, and fistulas. Radiofrequency ablation (RFA) therapy avoids deep tissue injury and is a promising treatment for CRP.

OBJECTIVE

To assess the long-term safety and efficacy of RFA for the treatment of CRP.

DESIGN

Multicenter, retrospective analysis of a prospectively collected database.

SETTING

Veterans Affairs Boston Healthcare System, Massachusetts; Sarasota Memorial Hospital and Suncoast Endoscopy of Sarasota, Florida.

PATIENTS

A total of 39 consecutive patients with CRP.

INTERVENTIONS

Endoscopic RFA of CRP.

MAIN OUTCOME MEASUREMENTS

The primary endpoint of the study was complete resolution of rectal bleeding. Secondary endpoints included visually scored improvement of CRP on endoscopic follow-up by using a rectal telangiectasia density (RTD) grading score, improvement in hemoglobin level, and adverse events related to the procedure.

RESULTS

A total of 39 male patients (mean [± standard deviation {SD}] age 72.9 ± 6.6 years) were included in the study. The mean number of RFA sessions was 1.49 (median 1, interquartile range [IQR] 1-2, range 1-4), with a mean interval of 18 weeks between sessions. Rectal bleeding stopped completely in all patients during the mean follow-up of 28 months (range 7-53 months). A significant improvement occurred in the mean (± SD) hemoglobin level from 11.8 ± 2 to 13.5 ± 1.6 g % (P < .0001). Endoscopic severity also improved significantly with an improvement in the median RTD score from 3 (IQR 2-3) to 0 (IQR 0-1) (P < .0001). Treatment with RFA led to discontinuation of blood transfusion and iron therapy in 92% and 82% patients, respectively.

LIMITATIONS

Retrospective analysis, lack of control group.

CONCLUSION

RFA therapy led to complete resolution of rectal bleeding in all treated CRP patients, with improvement in clinical and endoscopic indices without any major adverse events. Further controlled studies are needed to establish RFA as the endoscopic therapy of choice for treatment of CRP.

Rectal ulcer: Due to ketoprofen, argon plasma coagulation and prostatic brachytherapy

Prostatic brachytherapy with permanent seed implants is a recent and safe radiation therapy technique associated with radiation-induced digestive disease. Argon plasma coagulation procedure is a validated modality in the management of haemorrhagic radiation proctitis, which is known to occasionally induce chronic rectal ulcers. We report here an original case report of an acute painful rectal ulcer as a consequence of the combination of short-term therapy with non-steroidal anti-inflammatory drugs therapy, prostatic brachytherapy with malposition of seed implants and argon plasma coagulation procedure in a patient with haemorrhagic radiation proctitis. The description of this clinical observation is essential to recommend the discontinuation of non-steroidal anti-inflammatory drugs therapy and the control of the position of seed implants in case of prostatic brachytherapy before argon plasma coagulation for radiation-induced proctitis.

Management of radiation-induced rectal bleeding

Pelvic radiation disease is one of the major complication after radiotherapy for pelvic cancers. The most commonly reported symptom is rectal bleeding which affects patients' quality of life. Therapeutic strategies for rectal bleeding are generally ignored and include medical, endoscopic, and hyperbaric oxygen treatments. Most cases of radiation-induced bleeding are mild and self-limiting, and treatment is normally not indicated. In cases of clinically significant bleeding (i.e. anaemia), medical therapies, including stool softeners, sucralfate enemas, and metronidazole, should be considered as first-line treatment options. In cases of failure, endoscopic therapy, mainly represented by argon plasma coagulation and hyperbaric oxygen treatments, are valid and complementary second-line treatment strategies. Although current treatment options are not always supported by high-quality studies, patients should be reassured that treatment options exist and success is achieved in most cases if the patient is referred to a dedicated centre.

The protective role of antiplatelet treatment against ulcer formation due to argon plasma coagulation in patients treated for chronic radiation proctitis

AIM

Following treatment with argon plasma coagulation (APC), rectal ulceration is seen in approximately 50% of patients with haemorrhagic chronic radiation proctitis (CRP). This study aimed to assess the frequency of rectal ulcers (defined as a mucosal defect of 3 mm or more in diameter) in relation to the use of antiplatelet treatment for concomitant cardiovascular disease.

METHOD

Sixty-two patients with CRP were included in this retrospective study. Patients underwent pelvic irradiation due to prostate cancer (n = 28), cervical cancer (n = 16), endometrial cancer (n = 17) or rectal cancer (n = 1). APC was performed in all patients. Control endoscopies were performed at 8 and 16 weeks after enrolment.

RESULTS

Rectal ulcers were observed after APC in 35 (56%) patients. They were symptomatic in 5 and asymptomatic in 30. The 20 (32%) patients who were on antiplatelet therapy had a significantly lower risk of ulceration after APC (OR = 0.21; 95% CI 0.049-0.91; P = 0.019). The number of symptomatic ulcers (5% vs 10%; P = 1.0) and asymptomatic ulcers alone (30% vs 58%; P = 0.06) was also lower in patients respectively taking and not taking antiplatelet therapy, but these differences did not reach statistical significance.

CONCLUSION

Argon plasma coagulation-related ulceration in patients treated for CRP is less common when concomitant antiplatelet treatment is administered. This preliminary finding suggests that antiplatelet therapy may benefit patients treated with APC for CRP.

Sucralfate or placebo following argon plasma coagulation for chronic radiation proctitis: a randomized double blind trial

AIM

Chronic radiation proctitis is a long-term complication of radiation therapy for pelvic malignancy. The aim of this study was to compare the efficacy and safety of two treatment regimens, sucralfate or placebo, following argon plasma coagulation (APC) for chronic haemorrhagic radiation proctitis.

METHOD

A single-centre, randomized, placebo-controlled, double-blind study was performed on patients with haemorrhagic chronic radiation proctitis after irradiation for prostate, uterine, cervical, rectal or vaginal cancer. All patients received APC, and were then randomized to oral sucralfate (6 g twice a day) or placebo treatment for 4 weeks. APC was repeated every 8 weeks if necessary after the first session. Patients were graded clinically and endoscopically according to the Chutkan and Gilinski scales before and at 8 and 16 weeks after initial APC treatment (1.5-2 l/min, 25-40 W) and after 52 weeks (clinical only).

RESULTS

Of 122 patients, 117 completed the entire protocol, with 57/60 in the sucralfate group and 60/62 in the placebo group. At baseline there were no significant differences between the sucralfate and placebo groups. At 1 year, a significant improvement in the clinical scale in both groups occurred compared with baseline. After 16 weeks, the median overall clinical severity scores fell from 4 to 2 points and the median bleeding score from 2 to 0 in both groups.

CONCLUSION

APC is safe and effective for the management of chronic radiation proctitis. Additional sucralfate treatment did not influence the clinical or endoscopic outcome.

Management of intestinal complications in patients with pelvic radiation disease

Gastrointestinal toxicity after radiotherapy for pelvic cancer is a major complication-the most commonly reported symptoms include rectal bleeding, diarrhea, and fecal incontinence, which substantially impair patients' quality of life. Management of these symptoms can be a challenge, although available treatment strategies generally are ignored or underused. Radiation-induced symptoms have multiple mechanisms of pathogenesis; the first step for the correct management is to identify the mechanism that is causing the symptoms. Optimal management requires close liaisons among physicians, gastroenterologists with specialist interests, radiotherapists, oncologists, dieticians, nurses, and surgeons. Patients should be reassured that treatment options (medical, endoscopic, and surgical) exist and are in most cases successful if patients are referred to experts in pelvic radiation disease. However, although new therapeutic approaches are not yet always supported by high-quality trials, research projects are underway to improve management of patients. Clinicians should focus on using proven treatments correctly and avoiding misuse.

Endoscopic management of chronic radiation proctitis

Chronic radiation proctopathy occurs in 5%-20% of patients following pelvic radiotherapy. Although many cases resolve spontaneously, some lead to chronic symptoms including diarrhea, tenesmus, urgency and persistent rectal bleeding with iron deficiency anemia requiring blood transfusions. Treatments for chronic radiation proctitis remain unsatisfactory and the basis of evidence for various therapies is generally insufficient. There are very few controlled or prospective trials, and comparisons between therapies are limited because of different evaluation methods. Medical treatments, including formalin, topical sucralfate, 5-amino salicylic acid enemas, and short chain fatty acids have been used with limited success. Surgical management is associated with high morbidity and mortality. Endoscopic therapy using modalities such as the heater probe, neodymium:yttrium-aluminium-garnet laser, potassium titanyl phosphate laser and bipolar electrocoagulation has been reported to be of some benefit, but with frequent complications. Argon plasma coagulation is touted to be the preferred endoscopic therapy due to its efficacy and safety profile. Newer methods of endoscopic ablation such as radiofrequency ablation and cryotherapy have been recently described which may afford broader areas of treatment per application, with lower rate of complications. This review will focus on endoscopic ablation therapies, including such newer modalities, for chronic radiation proctitis.

The incidence of bacteraemia after argon plasma coagulation in patients with chronic radiation proctocolitis

AIM

Argon plasma coagulation (APC) is considered a safe treatment for haemorrhagic chronic radiation proctocolitis (CRPC), but bacteraemia is a rare complication. The study aimed to evaluate the frequency of bacteraemia after APC.

METHOD

A prospective study of 21 patients who underwent APC (30 procedures) for CRPC was carried out. Blood cultures (Bactec(®) ) were obtained before and 30 min after the procedure (60 samples total). Patients were monitored for 48 h after the procedure to detect signs of infection.

RESULTS

None of the 21 patients had fever or any sign suggestive of infection after any of the 30 sessions. All baseline blood cultures were negative and two (7%) of the 30-min blood cultures were positive (Staphylococcus hominis n = 1; Streptococcus bovis and Rhodotorula sp n = 1). The first was likely to be a contaminant and the second patient had no evidence of any other colonic disease (neoplasia or polyps) beside CRPC.

CONCLUSION

APC is a low-risk procedure regarding bacteraemia and does not warrant prophylactic antibiotic administration.

[Nonsurgical treatment of chronic radiation-induced hemorrhagic proctitis]

The incidence of radiation-induced chronic hemorrhagic proctitis is less than 10 to 20%. The onset of this proctitis is delayed relative to the radiation therapy and generally develops from 6 to 24 months later. There are numerous predisposing factors, the most important of which is the radiation therapy dose: risk increases exponentially above 40-45 Gy. Its pathophysiology involves progressive obliterating endarteritis and transmural interstitial fibrosis, which induce chronic ischemia that is irreversible and progressive during the years after radiation therapy. Its diagnosis depends most often on the combination of clinical history and typical endoscopic appearance (congestive mucosa and/or telangiectases). Topical administrative of sucralfate or corticosteroids as well as argon plasma coagulation, with formalin treatment if necessary, provides relief for most patients.

Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy

BACKGROUND

Argon plasma coagulation (APC) is a thermal coagulation technique that uses ionized argon for contact-free transmission of high-frequency electrical current to tissue. Prospective data on complications with the new APC-2 (VIO) system are lacking.

METHODS

A prospective trial was conducted with 152 patients treated for various gastrointestinal diseases using three modes of the APC-2. The study aimed to assess complications, focusing on the pain and neuromuscular stimulation (NMS) experienced during and after treatment. Patients reported pain and NMS using a scale ranging from 0 to 10 and were interviewed for symptoms such as tingling, paresthesia, muscle pain, and cramping or twitching. The endoscopists also graded NMS using a separate questionnaire.

RESULTS

A total of 85 males and 67 females (median age, 66 years) were enrolled in the study. All APC therapies were completed successfully. Two peri-interventional perforations were recorded. Of the 152 patients, 26 (17%) reported pain sensation during or after APC. The median pain sensation reported by the patients on the standardized scale was 3.7. The findings showed NMS in 14 (9.2%) of the 152 patients. Significantly more NMS events were seen with pulsed APC than with forced or precise APC. Additional risk factors for NMS were gender (female) and type of sedation (combination midazolam and pethidine). No complications were noted among patients with intracardiac defibrillators or cardiac pacemakers.

CONCLUSIONS

According to the findings, APC may be associated with minor complications such as pain sensation and NMS. These complications were rarely seen, but occurred more often with pulsed APC than with forced or precise APC. Physicians should be aware of these complications.