Efficacy and Safety of Argon Plasma Coagulation for the Ablation of Barrett's Esophagus: A Systemic Review and Meta-Analysis

Background/Aims

Argon plasma coagulation (APC) is an alternate ablative method to radiofrequency ablation for the treatment of Barrett's esophagus (BE), and it is preferred due to its lower cost and widespread availability. The present meta-analysis aimed to analyze the safety and efficacy of APC for the management of BE.

Methods

A literature search from January 2000 to November 2022 was done for studies analyzing the outcome of APC in BE. The primary outcomes were clearance rate of intestinal metaplasia and adverse events (AE). Pooled event rates were expressed with summative statistics.

Results

A total of 38 studies were included in the final analysis. The pooled event rate for clearance rate of intestinal metaplasia with APC in BE was 86.8% (95% confidence interval [CI], 83.5% to 90.2%), with high-power and hybrid APC having a higher rate compared to standard APC. The pooled incidence of AE with APC in BE was 22.5% (95% CI, 15.3% to 29.7%), without any significant difference between the subgroups, with self-limited chest pain being the commonest AE. The incidence of serious AE was only 0.4% (95% CI, 0.0% to 1.0%), while stricture development was seen only in 1.7% (95% CI, 0.9% to 2.6%) of cases. The pooled recurrence rate of BE was 16.1% (95% CI, 10.7% to 21.6%), with a significantly lower recurrence with high-power APC than standard APC.

Conclusions

High-power and hybrid APC seem to have an advantage over standard APC in terms of clearance rate and recurrence rate. Further studies are required to compare the efficacy and safety of hybrid APC with standard APC and radiofrequency ablation.

Comparing the effects of argon plasma coagulation and interferon therapy in patients with vaginal intraepithelial neoplasia: a single-center retrospective study

PURPOSE

This study aimed to evaluate the clinical efficacy and safety of argon plasma coagulation (APC) therapy and interferon therapy in patients with grade I and II vaginal intraepithelial neoplasia (VaIN).

METHODS

A total of 112 patients with VaIN were diagnosed via colposcopy-induced biopsy and classified into the APC group (n = 77) and interferon group (n = 35). Clinical data including age, grade, symptoms, historical or concomitant neoplasia of the lower genital tract, indications for hysterectomy, pregnancy history, cytology, human papillomavirus (HPV) subtype, treatment modalities, and clinical outcomes were analyzed, retrospectively. Complications and clinical outcomes were assessed at 6- and 12-month follow-ups.

RESULTS

There was no significant difference in the HPV clearance rate between the APC (53.42%) and interferon (33.33%) groups at 6 months after treatment. However, the 12-month follow-up of the APC group showed a significantly higher HPV clearance rate as compared to the interferon group (87.67% vs. 51.52%, P < 0.05). The APC group exhibited a significantly higher cure rate (79.22% vs. 40.0%) and lower persistence rate (12.99% vs. 37.14%) than the interferon group (P < 0.05). Adverse reaction analysis revealed that the primary reaction in the APC group was vaginal drainage, in contrast to the increased vaginal discharge in the interferon group; though the difference was significant (68.83% vs. 28.57%, P < 0.05), no serious complications were observed.

CONCLUSIONS

Treatment with APC is a safe and more effective procedure against VaIN I and II, compared to interferon. APC may serve as a viable alternative to other physiotherapies.

A multidisciplinary approach to identifying and managing heterotopic gastric inlet patches

INTRODUCTION

Gastric inlet patches are often incidental, but can also be a treatable cause of laryngo-esophageal symptoms.

METHODS

We retrospectively reviewed all patients whose gastric inlet patches were diagnosed following assessment for laryngopharyngeal and swallowing symptoms. Improvement following Argon Plasma Coagulation (APC) was assessed using Minimum Clinically-Important Difference methodology combining voice, throat, and swallowing domains. Correlations between APC response and measures of reflux and mucosal barrier integrity, measured during 24-h pH-impedance manometry, were obtained. Proximal and Distal Mean Nocturnal Baseline Impedance (MNBI) values were separately calculated and the novel variable of Mucosal Impedance Gradient was derived as [((Distal MNBI-Proximal MNBI)/((Distal MNBI + Proximal MMBI)/2)) x 100].

KEY RESULTS

Inlet patches were detected in 57 of 651 patients who had Transnasal Panendoscopy (8.7 ± 2.2%). There were 34 males. Mean age was 58 years. Mean duration of symptoms was 2 years. The commonest symptoms were hoarseness (n = 33), throat symptoms (n = 24), and dysphagia (n = 21), respectively. APC was used to ablate patches in 34 patients. Treatment response was 71% at a mean followup of 5.5 months. MIG > - 25% predicted response to APC, with area under the receiver operating characteristic curve of 0.875 (Sensitivity = 81%; Specificity = 100%; p < 0.0001).

CONCLUSIONS

Gastric inlet patches are common and under-recognized. They can cause protracted pharyngo-esophageal symptoms. Patch ablation is an effective treatment for carefully selected patients. Optimal patient selection requires multidisciplinary teamwork. Mucosal Impedance Gradient could further refine patient selection.

Endoscopic Management of Tumor Bleeding: Techniques and Strategies

Endoscopic management of gastrointestinal (GI) tumor-related bleeding is challenging for many reasons including high rebleeding rates, poor tissue response to endoscopic therapies, altered wound healing and underlying coagulopathy. However, endoscopic treatment may help reduce transfusion requirements, avoid surgery, and provide a temporary bridge to oncologic therapy. This article explores various endoscopic techniques in managing tumor bleeding from more traditional approaches of using thermal or mechanical therapy with injection therapy to newer topical agents.

Thermoablative Techniques to Treat Excessive Central Airway Collapse

Excessive central airway collapse (ECAC) is a condition characterized by the excessive narrowing of the trachea and mainstem bronchi during expiration, which can be caused by Tracheobronchomalacia (TBM) or Excessive Dynamic Airway Collapse (EDAC). The initial standard of care for central airway collapse is to address any underlying conditions such as asthma, COPD, and gastro-esophageal reflux. In severe cases, when medical treatment fails, a stent-trial is offered to determine if surgical correction is a viable option, and tracheobronchoplasty is suggested as a definitive treatment approach. Thermoablative bronchoscopic treatments, such as Argon plasma coagulation (APC) and laser techniques (potassium-titanyl-phosphate [KTP], holmium and yttrium aluminum pevroskyte [YAP]) are a promising alternative to traditional surgery. However, further research is needed to assess their safety and effectiveness in humans before being widely used.

Electrosurgical unit in GI endoscopy: the proper settings for practice

INTRODUCTION

Electrosurgical unit (ESU) is integral to the endoscopy unit. The proper knowledge of the Mode with setting is essential for good therapeutic outcomes and the safety of the patients.

AREAS COVERED

ESU generates high-frequency electric current, which could perform cutting and coagulation for various therapeutic interventions. We review the proper settings for common endoscopic interventions like hemostasis, polypectomy, sphincterotomy, and advanced procedures like endoscopic ultrasound-guided cysto-gastrostomy, bile duct drainage, and endoscopic Ampullectomy. We review the various waveforms of ESU in practice in endoscopy, including special conditions like patients with pacemakers.

EXPERT OPINION

Knowledge of the waveforms' duty cycle and crest factor is necessary. A high-duty cycle and lower crest factor lead to a good cutting effect on the tissue. Endocut is the most commonly used Mode in ESU in endoscopic practices like sphincterotomy and polypectomy. Endocut I mode (effect 1-2, duration 3, interval 3) is used for endoscopic sphincterotomy, while Forced Coag mode (Effect 2, 60 W) controls post-sphincterotomy bleeding. Endocut Q mode (Effect 2-3, duration 1, interval 3) is used for cutting the polyp, while Forced Coag mode (Effect 2, 60 W) is used before cutting for pre-coagulation of the stalk.

Argon plasma coagulation therapy in hemorrhagic radiation proctitis following pelvic radiation in gynecological malignancies

Introduction

Chronic radiation proctitis is a common chronic complication of malignant pelvic diseases after pelvic radiation therapy. Although, the incidence has decreased after advent of intensity-modulated radiotherapy due to better control of radiation dose to rectum. In the era of conventional two-field radiotherapy to pelvis, this was a common complication usually presenting after 1-2 years of treatment completion. Rectal bleeding caused by radiation proctitis is difficult to manage. Argon plasma coagulation (APC) is an electrocoagulation technique that appears to be an effective and low-cost alternative to the use of lasers in gastrointestinal endoscopy. The aim of this study was to evaluate the efficacy of APC, as well as patients' tolerance of the procedure, in the treatment of bleeding radiation-induced proctitis.

Materials and Methods

Between January 2015 and August 2017, 29 patients of cancer cervix treated with definite radiotherapy both external and brachytherapy who suffered from rectal bleeding due to radiation proctitis were included for treatment with argon plasma laser (APC). Twenty-three patients suffered from anemia, 16 of whom required blood transfusion. APC was performed, applying the no-touch spotting technique at an electrical power of 40 Watt and an argon gas flow of 1.5-2.0 l/min. Pulse duration was <0.5 s. Treatment sessions were carried out at intervals of 3 weeks. Subjects received 2-4 treatment sessions.

Results

Twenty-eight out of 29 patients were accessible for effects and results. APC led to persistent clinical and endoscopic remission of rectal bleeding after a median of three sessions. No adverse effects were encountered after initial treatment. All the patients were in complete remission.

Conclusions

APC is an effective, safe, and well-tolerated treatment for rectal bleeding caused by chronic radiation proctitis. It should be considered as a first-line therapy for radiation proctitis.

Prospective Meta-analysis of Weight Loss Regained and Success Rate of Argon Plasma Coagulation to Suture and Surgery Procedures Post-bariatric Surgery: Status of the Art of Endoscopic Treatment

BACKGROUND

This study performed a meta-analysis to compare the safety and efficacy of argon plasma coagulation (APC) concerning suture (SUT) and surgery (SUR).

METHODS

The One-Way tests were applied, with p <0.05 significant. The value of R2 was analyzed (heterogeneity), and the risk of bias of articles was evaluated.

RESULTS

A total of 34 studies were found, eight about APC, twenty about SUT, and six about SUR. For the percentage of Weight Loss Regained (%WLR), the means for APC, SUT, and SUR were 19.39 ± 10.94, 26.06 ± 16.71, and 17.05 ± 9.85, and for success rate (%SR), the means were 89.75 ± 16.75, 86.80 ± 11.44, and 76.00 ± 21.57, respectively with p >0.05, with R2 ≥ 50%.

CONCLUSION

The APC proved to be efficient and safe like the other techniques.

Clinical course and treatment of radiation-induced hemorrhagic gastritis: a case series study

Radiation-induced hemorrhagic gastritis is a relatively uncommon complication of irradiation that can be severe. However, appropriate treatment guidelines have not yet been established because of the small number of known cases. At our hospital, we encountered nine cases of radiation-induced hemorrhagic gastritis between July 2005 and July 2018. All patients initially underwent argon plasma coagulation (APC) for hemostasis. The treatment was highly effective, and hemostasis was successfully achieved in eight of the cases. Hemostasis could not be achieved in one case treated with APC; therefore, surgical resection was required. This patient had risk factors, such as liver cirrhosis and a history of abdominal surgery. Our case series suggests that APC is an effective hemostatic method that should be considered as the initial treatment option for radiation-induced hemorrhagic gastritis; however, surgical resection may be considered when the patient is at high risk for rebleeding.

Blue rubber bleb nevus syndrome complicated with disseminated intravascular coagulation and intestinal obstruction: A case report

BACKGROUND

Blue rubber bleb nevus syndrome is a rare vascular malformation syndrome with unclear etiopathogenesis and noncurative treatments. It is characterized by multiple vascular malformations of the skin, gastrointestinal tract, and other visceral organs. The most common symptoms are intermittent gastrointestinal bleeding and secondary iron deficiency anemia, thus requiring repeated blood transfusions and hospitalizations. It is easily missed and misdiagnosed, and there is no specific treatment.

CASE SUMMARY

We report a case of blue rubber bleb nevus syndrome combined with disseminated intravascular coagulation and efficacy of treatment with argon plasma coagulation under enteroscopy and sirolimus. A 56-year-old female patient was admitted to the hospital with 3-year history of fatigue and dizziness that had aggravated over the past 10 d with melena. The patient had a history of repeated melena and multiple venous hemangiomas from childhood. After treatment with argon plasma coagulation combined with sirolimus for nearly 8 wk, the patient’s serum hemoglobin increased to 100 g/L. At the 12-mo follow-up, the patient was well with stable hemoglobin (102 g/L) and no recurrent intestinal bleeding.

CONCLUSION

Argon plasma coagulation and sirolimus may be an efficacious and safe treatment for blue rubber bleb nevus syndrome, which currently has no recommended treatments.

Argon Plasma Coagulation of Gastric Inlet Patches of the Cervical Esophagus Relieves Vocal and Respiratory Symptoms in Selected Patients

OBJECTIVES

Argon plasma coagulation (APC) of gastric inlet patches of the cervical esophagus (GIP) has been shown to relieve the globus sensation. This study aimed to investigate the long-term effects of APC therapy on a variety of laryngopharyngeal symptoms.

METHODS

Patients with laryngopharyngeal symptoms who had undergone endoscopic GIP eradication via APC therapy were eligible for a retrospective observational cohort study. Symptom relief was assessed by a five-grade scale during a structured interview. Statistical analysis included ANOVA, the chi-squared and t-test.

RESULTS

A total of 45 patients (61.0 (52.0; 69.0) years, 26 (57.8%) female) were included after a follow-up time of 85.0 (55.3; 111.0) months. Symptoms included dysphagia (56.0%), dysphonia (51.0%), hoarseness (76.0%), the necessity of throat clearing (73.0%), globus sensation (56.0%) and heartburn (71.0%). Complete GIP eradication was achieved after one session in 25 (55.6%), repetitive sessions were needed in the remaining cases. Fourteen patients (31.1%) reported a very strong, 11 (24.4%) a strong and 8 patients (17.8%) an intermediate improvement; five patients did not benefit. The most apparent improvement was seen regarding hoarseness (from 2.6 ± 1.7 to 1.2 ± 1.3), the necessity of throat clearing (from 2.6 ± 1.7 to 1.1 ± 1.3), globus sensation (from 2.0 ± 1.9 to 0.9 ± 1.3) and heartburn (from 2.5 ± 1.8 to 1.4 ± 1.6). Adverse events included post-endoscopic pain (n = 6, 13.3%) and purulent pharyngitis (n = 2, 4.4%).

CONCLUSIONS

The APC therapy of GIP is safe and leads to long-term relief of laryngopharyngeal symptoms in carefully selected patients.

Anesthetic Management of Gas Embolism During Rigid Bronchoscopy with Argon Plasma Coagulation: A Case Report

Gas embolism is a procedure-related complication and has been reported during endoscopy, surgical procedures, intravenous catheterization, positive pressure ventilation, and a multitude of scenarios. Recognizing the potential for gas embolus and a high level of suspicion are paramount to timely intervention to prevent significant morbidity and mortality. There is such rapid decompensation that only clinical suspicion can guide timely intervention; it is not uncommon for gas embolus to be diagnosed postmortem. It then must be determined whether the gas embolus has a venous or systemic entry point. Overall management is similar for both forms of gas emboli with focus on hemodynamic support and preservation of organ function. This case report discusses an occurrence of presumed systemic gas embolus from argon plasma coagulation and management of a patient under general anesthesia during rigid bronchoscopy.

Influences of etiology and endoscopic appearance on the long-term outcomes of gastric antral vascular ectasia

BACKGROUND

Gastric antral vascular ectasia (GAVE) has diverse associations and presumed causes, which include liver cirrhosis, chronic kidney disease, and autoimmune disease. This heterogeneity of underlying disorders suggests that the pathogenesis of GAVE may be variable.

AIM

To compare the clinical features and long-term outcomes of GAVE according to endoscopic patterns and etiologies.

METHODS

The medical records and endoscopic images of 23 consecutive patients diagnosed with GAVE by endoscopy at Yeungnam University Hospital from January 2006 to December 2020 were retrospectively reviewed. Patients were allocated to cirrhosis (16 patients) and non-cirrhosis groups (7 patients). GAVE subtypes, as determined by endoscopy, were categorized as punctate (a diffuse, honeycomb-like appearance, 17 patients) or striped (a linear, watermelon-like appearance, 6 patients).

RESULTS

All GAVE patients with cirrhosis (16/16, 100%) had a punctate pattern by endoscopy, whereas the majority of patients (6/7, 85.7%) without cirrhosis had a striped pattern (P < 0.001). Overt GAVE bleeding (10/23, 43%) was significantly more common in the non-cirrhosis group than in the cirrhosis group (6/7, 85.7% vs 4/16, 25.0%; P = 0.019), and more common in the striped group than in the punctate group (5/6, 83.3% vs 5/17, 29.4%; P = 0.052). However, mean numbers of admissions due to GAVE bleeding and argon plasma coagulation (APC) sessions to address overt bleeding were similar in the cirrhosis and non-cirrhosis groups and in the punctate and striped groups. All patients with GAVE bleeding were successfully treated by APC, and no patient died from GAVE-related blood loss during a median follow-up of 24 mo.

CONCLUSION

Punctate-type GAVE is strongly associated with liver cirrhosis, and GAVE patients without cirrhosis tend to be more prone to overt bleeding. However, the presence of cirrhosis and endoscopic patterns did not influence long-term clinical courses or outcomes in cases of overt bleeding.

Tracheal myoepithelioma resected by using rigid bronchoscopy: a case report and review of the literature

Background

Endotracheal tumors are rare in the respiratory system. Myoepitheliomas are benign tumors, which are rarely reported in the respiratory system. Herein, we report a rare case of endotracheal myoepithelioma, which was resected by rigid bronchoscopy.

Case presentation

A 36-year-old man, presenting with chest pain, dyspnea, stridor, and hemoptysis, was referred to our center with radiological features of near-total tracheal obstruction due to mass. Fiberoptic bronchoscopy with argon plasma coagulation and rigid bronchoscopy with grasper forceps was utilized to resect the mass. Pathological evaluation of the mass demonstrated myoepithelioma. The patient was discharged in good condition. Now, after 6 months, the patient is symptom-free with no evidence of tumor recurrence or re-growth.

Conclusions

Despite being extremely rare, myoepithelioma should be considered a possible differential diagnosis for endotracheal tumors. Fiberoptic and rigid bronchoscopy management is an effective method for the resection of endotracheal tumors.

Percutaneous or Endoscopic Treatment of Peripheral Bile Duct Leaks: Initial Experience with an Innovative Approach of Microcatheter-Delivered Argon Plasma Coagulation

PURPOSE

Biliary 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.

RESULTS

The 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.

Application of Argon Plasma Coagulation for Gastrointestinal Angiodysplasia in Children- Experience From a Tertiary Center

BACKGROUND

Argon plasma coagulation (APC) has been applied in adults to treat various diseases, including vascular lesions in the gastrointestinal (GI) tract. However, angiodysplasia (AD) is an uncommon cause of pediatric GI bleeding, while the experience of treating AD with APC was rarely reported.

METHODS

Five children with AD in the GI tract successfully treated with APC were reviewed.

RESULTS

Three of the five patients were girls, and the age at diagnosis ranged from 1.5 months to 10.5 years of age. One patient with gastric AD manifested with tarry stool, and the rest had colonic AD, which caused various degrees of bloody stool. Three patients had evident anemia. All patients received an endoscopic diagnosis, and two had compatible findings in radiographic exams. Each patient underwent one APC treatment session, and none encountered procedure-related complications or re-bleeding.

CONCLUSION

AD can be an etiology of GI bleeding even in neonates. APC is an effective and safe therapy for symptomatic AD in children.

Fluid cushion protects against thermal damage during argon plasma coagulation

Background

Thermal damage to the muscle layer during mucosal application of argon plasma coagulation (APC) may be avoided by creating a fluid cushion within the submucosal layer, but the minimum injection volume needed or the ideal injection fluid are yet to be established. We conducted a systematic ex vivo study with this aim.

Methods

All experiments were performed in an ex vivo porcine gastrointestinal tract model. Five different fluids (saline, Glyceol, Gelafundin, Voluven, and Eleview) of different volumes were injected into the submucosa of different parts of the gastrointestinal tract. APC was applied to the mucosa at different power settings. Immediately after APC treatment, the temperature was measured through a thermocouple placed inside the fluid cushion, just on top of the muscle layer. The minimum volume of fluid needed to protect the muscle layer from thermal damage was determined.

Results

There was no difference in the temperature measured among the different injection fluids at the surface of the muscle, in all the locations, at equal injection volumes and power settings. The minimum amounts of fluid needed to protect the muscle layer were 2 and 3 mL for power settings of 30-90 W and 90-120 W, respectively.

Conclusions

Normal saline and 4 commercially available submucosal injection fluids possess similar thermal protective effects. To reduce the likelihood of thermal damage to deeper layers when APC is applied, a minimum injection volume of 3 mL is recommended if less than 90 W power will be utilized over 3 sec.

Good Clinical Practices on Argon Plasma Coagulation Treatment for Weight Regain Associated with Dilated Gastrojejunostomy Following Roux-en-Y Gastric Bypass: a Brazilian-Modified Delphi Consensus

Introduction

Argon plasma coagulation (APC) alone is effective and safe at treating weight regain following Roux-en-Y gastric bypass (RYGB). However, technical details of the treatment vary widely among studies. Therefore, we aimed to create good clinical practice guidelines through a modified Delphi consensus, including experts from the collaborative Bariatric Endoscopy Brazilian group.

Methods

Forty-one locally renowned experts were invited to the consensus by email. Experiences of > 150 APC-treated cases or authorship of relevant articles were the eligibility criteria. An initial questionnaire with short-answer questions was distributed to the experts. The organizing committee converted the responses into statements for an online 2-day voting webinar. Consensus was defined as more than 67% of positive answers. Three consecutive voting rounds were planned with discussion and statement refinements between rounds.

Results

Thirty-seven experts fulfilled eligibility criteria and attended the live webinar voting. The total number of patients treated by the panel was 12,349. By the third round, all 79 statements reached consensus. The recommendations include the definition of dilated gastrojejunal anastomosis as ≥ 15 mm, minimum regain of 20% of the lost weight to indicate the APC therapy, 6 to 8 weeks as the ideal interval between ablation sessions, and stopping treatment when the stoma reaches < 12 mm of breadth.

Conclusions

This consensus provides several recommendations based on a highly experienced panel of endoscopists. Although it covers most aspects of the treatment, the level of evidence is low for the majority of the statements. Therefore, bariatric endoscopists should be constantly attentive to new evidence on APC treatment.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05795-y.

Hereditary hemorrhagic telangiectasia with liver cirrhosis: a case report

BACKGROUND

Hereditary hemorrhagic telangiectasia is an autosomal dominant hereditary hemorrhagic disease. Its main feature is an abnormal structure of the blood vessel wall. Cirrhosis of the liver is a common chronic progressive disease with one or more causes in which diffuse liver damage occurs after long-term or repeated injury. Liver cirrhosis can cause dilation of gastrointestinal capillaries. Many patients with hereditary hemorrhagic telangiectasia accompanied by gastrointestinal vascular malformations and liver cirrhosis may be diagnosed only with liver cirrhosis if the clinician does not pay attention to physical examination findings and family history. Moreover, general treatment measures, such as blood transfusion, iron supplementation, and application of hemostatic drugs, are less effective for bleeding in patients with hereditary hemorrhagic telangiectasia than in those with liver cirrhosis alone.

CASE PRESENTATION

Here, we report the rare case of a 75-year-old Chinese man who was admitted to the hospital with repeated melena and epistaxis. He was diagnosed with unexplained liver cirrhosis, which was later confirmed as hereditary hemorrhagic telangiectasia. Subsequently, we implemented the treatment intervention of oral thalidomide combined with gastrointestinal argon plasma coagulation. A follow-up of more than 8 months showed that the treatment effect was excellent.

CONCLUSIONS

If patients with liver cirrhosis and gastrointestinal vascular malformations also have a family history of epistaxis, special attention should be paid to targeted physical examination results, and the possibility of hereditary hemorrhagic telangiectasia should be considered. Moreover, for patients with hereditary hemorrhagic telangiectasia and both gastrointestinal bleeding caused by gastrointestinal capillaries and repeated epistaxis, when other general treatment measures are ineffective, thalidomide combined with gastrointestinal argon plasma coagulation may be an effective intervention.

Hereditary hemorrhagic telangiectasia with liver cirrhosis: a case report

Background

Hereditary hemorrhagic telangiectasia is an autosomal dominant hereditary hemorrhagic disease. Its main feature is an abnormal structure of the blood vessel wall. Cirrhosis of the liver is a common chronic progressive disease with one or more causes in which diffuse liver damage occurs after long-term or repeated injury. Liver cirrhosis can cause dilation of gastrointestinal capillaries. Many patients with hereditary hemorrhagic telangiectasia accompanied by gastrointestinal vascular malformations and liver cirrhosis may be diagnosed only with liver cirrhosis if the clinician does not pay attention to physical examination findings and family history. Moreover, general treatment measures, such as blood transfusion, iron supplementation, and application of hemostatic drugs, are less effective for bleeding in patients with hereditary hemorrhagic telangiectasia than in those with liver cirrhosis alone.

Case presentation

Here, we report the rare case of a 75-year-old Chinese man who was admitted to the hospital with repeated melena and epistaxis. He was diagnosed with unexplained liver cirrhosis, which was later confirmed as hereditary hemorrhagic telangiectasia. Subsequently, we implemented the treatment intervention of oral thalidomide combined with gastrointestinal argon plasma coagulation. A follow-up of more than 8 months showed that the treatment effect was excellent.

Conclusions

If patients with liver cirrhosis and gastrointestinal vascular malformations also have a family history of epistaxis, special attention should be paid to targeted physical examination results, and the possibility of hereditary hemorrhagic telangiectasia should be considered. Moreover, for patients with hereditary hemorrhagic telangiectasia and both gastrointestinal bleeding caused by gastrointestinal capillaries and repeated epistaxis, when other general treatment measures are ineffective, thalidomide combined with gastrointestinal argon plasma coagulation may be an effective intervention.

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.

Effect of Antithrombotic Therapy on Bleeding after Argon Plasma Coagulation for Gastric Neoplasms

Background/Aims

Postprocedural bleeding is known to be relatively low after argon plasma coagulation (APC) for gastric neoplasms; however, there are few studies proving the effect of antithrombotic agents. This study aimed to analyze the incidence of delayed bleeding (DB) based on antithrombotic agents administered and to identify the risk factors for DB in APC for gastric tumors.

Methods

A total of 785 patients with 824 lesions underwent APC for single gastric neoplasm between January 2011 and January 2018. After exclusion, 719 and 102 lesions were classified as belonging to the non-antithrombotics (non-AT) and AT groups, respectively. The clinical outcomes were compared between the two groups, and we determined the risk factors for DB in gastric APC.

Results

Of the total 821 cases, DB occurred in 20 cases (2.4%) 17 cases in the non-AT group and three cases in the AT group (2.4% vs 2.9%, p=0.728). Multivariate analysis of the risk factors for DB confirmed the following significant, independent risk factors male sex (odds ratio, 7.66; 95% confidence interval, 1.02 to 57.69; p=0.048) and chronic kidney disease (odds ratio, 4.51; 95% confidence interval, 1.57 to 13.02; p=0.005). Thromboembolic events and perforation were not observed in all patients regardless of whether they took AT agents.

Conclusions

AT therapy is acceptably safe in gastric APC because it does not significantly increase the incidence of DB. However, patients with chronic kidney disease or male sex need to receive careful follow-up on the incidence of post-APC bleeding.

The Efficacy of Argon Plasma Coagulation versus Carvedilol for Treatment of Portal Hypertensive Gastropathy

BACKGROUND/AIM

Several treatment options have been developed for portal hypertensive gastropathy (PHG); medications and endoscopic management. The aim of this study was to evaluate the efficacy and safety of argon plasma coagulation (APC) versus Carvedilol in treatment of a cohort of Egyptian patients with severe PHG.

METHODS

A total of 130 patients with severe PHG were enrolled; 10 patients were excluded due to death and failure to complete the treatment sessions accordingly, 120 patients were included. Patients were divided into 2 groups: Group A (n = 52) treated with APC; Group B (n = 68) treated with oral Carvedilol. Success was defined as stabilization of hemoglobin (Hb) over 100 g/dL or Hb increase >10% from pretreatment level and reduction of blood transfusion requirements over the following 3 months after the start of therapy. Upper gastrointestinal endoscopy was performed to assess the degree and site of PHG. APC was conducted to areas with mucosal ectatic vascular lesions.

RESULTS

PHG was mostly fundic (36.35%) in APC group and (36.76%) in Carvedilol group (p = 0.56). Throughout follow-up period, there was significant increase in Hb level, serum iron, and serum ferritin with a significant decrease in total iron-binding capacity (TIBC) in APC group as compared to Carvedilol group (p < 0.001). Additionally, there was gradual increase in the mean Hb, serum iron, and serum ferritin and gradual decrease of TIBC in Carvedilol group. Accordingly, there was an overall improvement of iron deficiency anemia (IDA) in both groups; however, it was significantly better in APC group than in Carvedilol group. No major adverse events were detected in both the groups.

CONCLUSION

APC significantly improves IDA and decreases transfusion requirements in patients with severe PHG as compared to oral Carvedilol with small risk of adverse events. Furthermore, the combination of APC and Carvedilol unless contraindicated could have a synergistic effect in controlling severe PHG.

Persistent Peristomal Leakage from Percutaneous Endoscopic Gastrostomy Successfully Treated with Argon Plasma Coagulation

Introduction

Percutaneous endoscopic gastrostomy is a safe and effective technique and its use is widely spread. Peristomal leakage may occur within the first few days after gastrostomy tube placement and also in the mature gastrostomy tract. The initial treatment involves conservative measures. If the leakage does not resolve, different endoscopic interventions could be necessary with consequent impairing of enteral nutrition and, in some cases, the need of creating a new gastro-cutaneous fistula.

Case Report

We present 4 consecutive cases complicated with late peristomal leakage and medical treatment failure. These patients underwent upper digestive endoscopy, and circumferential fulguration of the mucosa surrounding the tube with pulsed argon plasma coagulation (APC) at 50 W and 1 L/min flow rate was performed. Additional long through-the-scope clips were applied in 2 cases, since the inner orifice remained enlarged, in order to obtain a better closure. Complete leakage and skin changes resolution occurred between 2 and 6 weeks after the procedure (mean 3.5 weeks). The overall mean follow-up was 19 months after the endoscopic procedure (maximum 30 months, minimum 10 months). There was no recurrence of leakage.

Conclusion

The use of APC alone or combined with long through-the-scope clips in large internal stoma orifice resolved persistent leakage from percutaneous endoscopic gastrostomy in all 4 presented cases without complications. In our case series, this technique appeared to be an effective, safe, and relatively low-cost alternative to the treatment of persistent peristomal leakage of the mature gastrostomy tract.

Endoscopic Band Ligation Versus Argon Plasma Coagulation in the Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims

Argon plasma coagulation (APC) is the most commonly used endoscopic treatment for gastric antral vascular ectasia (GAVE). Endoscopic band ligation (EBL) has emerged as an alternative therapy. Our goal was to evaluate the feasibility, efficacy, and safety of APC and EBL for the treatment of GAVE. This is the first systematic review that included only randomized controlled trials (RCTs) on this topic.

Methods

A comprehensive search was performed using electronic databases to identify RCTs comparing APC and EBL for the treatment of GAVE following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Results

Four RCTs were included, with a total of 204 patients. EBL was related to higher endoscopic eradication rates risk difference [RD], 0.29; 95% confidence interval [CI] [0.14, 0.44]; I²=0%) and less bleeding recurrence than APC (RD, 0.29; 95% CI [0.15, 0.44]; I²=0%). Patients treated with EBL required fewer blood transfusions (mean difference [MD], 1.49; 95% CI [0.28, 2.71]; I²=96%) and hospitalizations (MD, 0.29; 95% CI [0.19, 0.39]; I²=0%). The number of sessions required for the obliteration of lesions was higher with APC. There was no difference in the incidence of adverse events.

Conclusions

EBL is superior to APC in the treatment of GAVE in terms of endoscopic eradication rates, recurrence of bleeding, and transfusion requirements.

Argon Plasma Coagulation: Elucidation of the Mechanism of Gas Embolism

BACKGROUND

Argon plasma coagulation (APC) is a tool used in the management of tracheobronchial obstruction or bleeding. Complications include gas embolism which can cause devastating effects including hemodynamic instability, cardiac arrest, and stroke. Multiple theories as to how gas embolism occurs with APC have been postulated; however, none have identified the exact mechanism.

OBJECTIVES

To identify the mechanism by which APC causes gas embolism in the tracheobronchial tree.

METHODS

Using an explanted porcine tracheobronchial tree with lung parenchyma, the APC catheter was applied through noncontact and direct contact to the endobronchial airway mucosa via flexible bronchoscopy. This was done at multiple gas flow settings and pulse durations. Visual changes in the mucosa were photographed, videoed, and described.

RESULTS

Gross evidence of submucosal gas transfer occurred when the APC catheter was in direct contact with the mucosa at all gas flow settings in all applications, despite using shorter pulse durations. Whenever the catheter was not in contact with the mucosa, there was no transfer of gas at any gas flow setting or pulse duration.

CONCLUSIONS

Direct mucosal contact with the APC probe leads to submucosal gas deposition and is a likely mechanism for gas entry into the intravascular space. In reported cases of APC-associated gas embolism, presence of a vascularized endobronchial tumor may have increased the risk of gas tracking into the intravascular space. Care should be taken when applying APC during brisk bleeding or limited vision, as inadvertent mucosal contact may occur and could increase the risk of gas embolism.

Can prophylactic argon plasma coagulation reduce delayed post-papillectomy bleeding? A prospective multicenter trial

BACKGROUND AND AIM

Endoscopic post-papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy.

METHODS

In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post-papillectomy bleeding rate and the tumor persistence rate.

RESULTS

The delayed post-papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non-APC group (P = 0.434). The post-procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure-related mortalities or serious complications.

CONCLUSION

Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration-cris.nih.go.kr; KCT0001955).

Argon plasma coagulation-an effective treatment for solitary rectal ulcer syndrome: A single-center experience from western India

BACKGROUND AND AIM

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign disorder of defecation. Management of ulcers is usually unsatisfactory with conventional treatment (laxatives, behavioral therapy, biofeedback, topical treatments, and surgery). Studies on the effectiveness of argon plasma coagulation (APC) for SRUS refractory to conventional treatment is lacking. The aim of the study was to examine the effect of APC with conventional therapy in controlling bleeding and healing of refractory SRUS.

METHODS

Fourteen patients of refractory SRUS diagnosed on clinical, colonoscopic, and histological findings, refractory to conventional therapy, were offered multiple sessions of APC in addition to conventional treatment. All patients were followed up to determine bleeding control and ulcer healing.

RESULTS

Fourteen patients with a mean duration of symptoms of 9.21 ± 6.94 months were included. All the patients were advised to have a high intake of fluids and laxatives and to undergo biofeedback in addition to the APC. Lesions were located anteriorly (66%), circumferentially (25%), and posteriorly (9%). Mean follow-up duration was 7 months (3 to 12 months). APC enabled bleeding control in all the patients (100%), complete healing of ulcer in 71% (10 patients), and reduction in ulcer size to less than 50% of the initial size in the remaining 29% patients. None of the patients had any procedure-related complications like bowel perforation, infections, or fistula formation.

CONCLUSIONS

APC with conventional therapy is effective in controlling bleeding and healing in SRUS refractory to conventional treatment.

Role of argon plasma coagulation in treatment of esophageal varices

With the development of endoscopic therapy, argon plasma coagulation (APC) has been widely used by endoscopists. It has many advantages, such as simple to operate, low cost, and minimal invasiveness. Because of its capability of lesion ablation and hemostasis, APC has several indications in the gastrointestinal tract. One of them is esophageal varices. The aim of this review is to summarize the research on APC in this field to provide a reference for clinical practice.

Is Endoscopic Band Ligation a Superior Treatment Modality for Gastric Antral Vascular Ectasia Compared to Argon Plasma Coagulation?

BACKGROUND/AIMS

Gastric antral vascular ectasia (GAVE) is a rare acquired vascular lesion of the gastric antrum. The most frequent presentation of GAVE is iron deficiency anemia. Endoscopic therapy is the mainstay of treatment. However, there is no consensus regarding the optimal treatment modality.

METHODS

A retrospective cohort study was performed on patients with GAVE, including patients receiving endoscopic therapy. Treatment was with either argon plasma coagulation (APC) or endoscopic band ligation (EBL). Basic demographic data, indication for index procedure, number of sessions, and pre- and post-hemoglobin levels were collected. The aim of the study was to compare outcomes across the two treatment modalities.

RESULTS

One hundred and seventeen diagnoses of GAVE were made. Sixty-two patients (53%) required endoscopic treatment for symptomatic GAVE (female, n=38, 61%; mean age of 74.4 years). Two hundred and eighteen procedures were performed during the study period. APC was performed (n=161, 74%) more frequently than EBL (n=57, 26%). Patients treated with APC at index required a median 5 subsequent therapeutic interventions (APC or EBL), while those treated with EBL at index required a further 2.9 treatments (EBL only) (p<0.05).

CONCLUSION

APC was the most common treatment modality employed. We demonstrate an increasing incidence of EBL. Patients treated with EBL at index treatment required fewer subsequent treatment sessions and had a greater mean rise in hemoglobin. This suggests a more effective endoscopic response with EBL.

Endobronchial treatment of benign endobronchial neoplasms: Our 10 years of experience

Background

The aim of the study was to assess the safety, efficacy, complications, and long-term outcomes of endobronchial treatment for benign endobronchial tumors.

Methods

A total of 53 patients (39 males, 14 females; mean age: 53.7 years; range, 12 to 83 years) with the diagnosis of benign endobronchial neoplasms in our center between November 2010 and September 2019 were retrospectively analyzed. Data including demographic and clinical characteristics of the patients and treatment outcomes were examined.

Results

Tumors regressed in all patients with argon plasma coagulation, diode laser and electrocautery, which was combined with cryotherapy in some cases. Complications were observed in five (9%) patients. Major complications were atrial fibrillation in two patients and respiratory failure requiring mechanical ventilation in one patient. Minor complications were minimal bleeding in two patients. The response was very good in 39 (74%) patients and good in 12 (23%) patients. There was no significant difference in the residual tissue formation requiring cryotherapy among the endobronchial treatment modalities (p>0.05). The five-year survival rate was 94%. No endobronchial treatment-related mortality was observed in any of the patients.

Conclusion

Endobronchial treatment modalities including diode laser, electrocautery, and argon plasma coagulation combined with or without cryotherapy are effective and safe in the treatment of benign endobronchial tumors.

Endoscopic mucosal ablation - an alternative treatment for colonic polyps: Three case reports

BACKGROUND

Endoscopic resection of non-invasive lesions is now the standard of care for lesions in the GI tract. However, resection techniques require extensive training, are not available in all endoscopy centers and are prone to complications. Endoscopic mucosal ablation (EMA) is a combination of resection and ablation techniques and it may offer an alternative in the management of such lesions.

CASE SUMMARY

In this case series we report the successful treatment of three flat colonic polyps using the EMA technique. Two lesions were treatment naïve and 1 was a recurrence after an endoscopic mucosal resection. The sizes ranged from 2 to 4 cm. All three polyps were ablated successfully with no immediate or delayed complications. The recurrence rate at 1 year of follow up was 0%.

CONCLUSION

Based on this initial experience, we conclude that EMA is a safe and effective technique for the treatment of non-invasive colonic polyps when endoscopic resection techniques are not available.

Management of Remnant or Recurrent Lesions after Endoscopic Papillectomy

Endoscopic papillectomy (EP) for ampullary adenomas achieves cure rates ranging from 76% to 90%, and recurrence rates are as high as 33%. If remnant or recurrent lesions after prior EP are endoscopically visible and are not suspected of intraductal extension into the biliary or pancreatic duct, repeated snaring and cutting can be performed until all visible lesions are completely resected. However, endoscopic ablative therapies, particularly argon plasma coagulation, can be attempted for tiny or uncertain remnant and recurrent lesions. In addition, intraductal radiofrequency ablation has recently been attempted for residual intraductal lesions after EP at several institutions. Although still under investigation, it has shown some promise. It might be offered as an alternative to surgery, particularly in patients who are unfit for surgery or those who refuse to undergo surgery.

Gastric bypass with weight regain - Biliary limb distalization plus endoscopic transjejunal A.P.C. pouch therapy in one step: Case report

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Weight regain is a common problem within Bariatric Surgery and about 20% of patients who undergo Roux-en-Y gastric bypass patients may experience weight regain.

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Among the arsenal of alternatives to treat weight regain we have endoscopic therapies and surgical modifications of the primary technique, among others.

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This case represents the first report in which endoscopic therapy via transjejunal is used in conjunction with distalization of the biliopancreatic limb.

Introduction

In recent years there has been a significant growth in the percentage of patients with weight regain after Roux-en-Y gastric bypass (RYGB). Approximately 20% RYGB patients may experience weight regain 24 months after the intervention.

Presentation of case

A 53 yr male patient who underwent RYGB in 2011 with an initial weight of 140 kg and BMI of 44.19 kg/m who consults in 2019 for a weight regain of 45.9%. Transoperative endoscopy assessment revealed a gastric pouch and gastrojejunal anastomosis with a diameter of 7 cm and 2.5 cm respectively. During the procedure we found a common channel of 725 cm, it is decided to shorten it through the distalization of the biliopancreatic limb. Afterward using the same laparoscopic ports to introduce the endoscope through jejunal cane to realize the APC therapy. He was discharged on the 2nd-day, without any complaint.

Discussion

The purpose of this case report is to expose the viability to perform a combined surgical technique such as the distalization of the biliopancreatic limb with endoscopic techniques of argon plasma coagulation (APC) via transjejunal in the same operative course. Using this combined technique we can increase hypoabsortive and restrictive components that would represent a secure and efficient weight loss in our patient.

Conclusions

This innovative technique can represent a viable alternative that is secure and reproducible in revisional surgery for weight regain context.

Argon plasma coagulation for superficial squamous cell carcinoma in the residual esophagus after esophagectomy

BACKGROUND

Patients after esophagectomy for esophageal squamous cell carcinoma (SCC) occasionally develop metachronous SCC in the residual esophagus. Although most of these second primary lesions are detected as superficial cancer at follow-up endoscopy, it is often difficult to perform endoscopic resection for these lesions near the site of anastomosis.

METHODS

The objective of this study was to evaluate the effectiveness of argon plasma coagulation (APC) for superficial SCC in the residual esophagus after esophagectomy. Twelve patients (involving 15 s primary lesions) received APC for superficial SCC in the residual esophagus after esophagectomy. These lesions were difficult to perform endoscopic resection and they were treated using APC.

RESULTS

There was no treatment-related complication. Complete remission (CR) was achieved in 13 (86.6%) of the 15 lesions: CR was achieved in 11 lesions (73.3%) after the first APC course, and in another 2 lesions (13.3%) after two or more APC courses. Of the 2 patients with persisting residual tumor, 1 patient received 12 times repeated-APC courses over 6 years, and eventually achieved local control without metastasis, the other patient received radiotherapy and cervical esophagectomy after treatment failure with APC. All patients survived except for one patient who died of old age and another patient who died of tongue cancer.

CONCLUSIONS

APC was a safe treatment that was easy to perform. APC was concluded to be an effective treatment for superficial SCC in the residual esophagus after esophagectomy when endoscopic resection was difficult.

Long-term survival after palliative argon plasma coagulation for intraductal papillary mucinous neoplasm of the bile duct

Intraductal papillary mucinous neoplasm of the bile duct (IPNB) is an epithelial tumor that can cause obstructive jaundice and cholangitis due to mucin production. Although the effectiveness of argon plasma coagulation in IPNB treatment has been demonstrated, the long-term effect of the therapy is largely unknown. Here, we have presented a patient with IPNB who underwent argon plasma coagulation with a follow-up period of more than 2 years. A 74-year-old woman was referred to our department for treatment of obstructive jaundice. Endoscopic retrograde cholangiopancreatography revealed marked dilation of intrahepatic and extrahepatic bile ducts and thick mucin drainage from the ampulla of Vater. IPNB was diagnosed pathologically from biopsy specimens. Surgery was not recommended because of the extensive intrahepatic spread of the lesion. Endoscopic sphincterotomy, endoscopic papillary large balloon dilation, and insertion of a metallic stent could not resolve the obstructive jaundice. Finally, argon plasma coagulation with percutaneous cholangioscopy was performed 3 times over 1 month. After treatment, obstructive jaundice was resolved and the patient's clinical condition has been stable for more than 2 years, except for a single episode of transient cholangitis. In conclusion, argon plasma coagulation may be an alternative to surgery for the palliation of jaundice with IPNB.

Comparison Between Redo Endoscopic Treatment and Surgery in Patients with Locally Recurrent Gastric Neoplasms

BACKGROUND

Treatment of locally recurrent gastric neoplasms after endoscopic resection remains challenging. We investigated the efficacy and safety of treatment options for recurrent gastric neoplasms localized to the scar of previous endoscopic submucosal dissection (ESD).

METHODS

The clinicopathological characteristics and treatment outcomes of patients who underwent endoscopic treatment or surgery for recurrent gastric neoplasms between June 2010 and May 2017 were retrospectively reviewed.

RESULTS

Of the 92 patients included, 74 underwent endoscopic treatment (51 redo ESD, 23 argon plasma coagulation [APC] ablation) and 18 underwent surgery. The redo ESD procedure time was significantly longer than that of the primary ESD (31.0 versus 22.0 min, p = 0.018). Overall, adverse events occurred in 11 patients (12.0%), with the incidence being significantly higher in the surgery group (27.8% versus 8.1% in the endoscopic treatment group, p = 0.036). Local recurrence-free survival rates were 81.1% for the endoscopic treatment group (86.3% and 69.6% for redo ESD and APC groups, respectively) and 100% for the surgery group (log rank p = 0.033). Logistic regression analysis showed that tumor size > 12.5 mm (odds ratio [OR] 5.14, 95% confidence interval [CI] 1.25-26.9, p = 0.032) and tumors located in the upper two-thirds of the stomach (OR 4.43, 95% CI 1.27-16.8, p = 0.023) were associated with non-curative resection after redo ESD.

CONCLUSIONS

Endoscopic treatment could be an effective and safe alternative to surgery for selected patients with gastric neoplasms recurring at the scar of previous ESD. Especially, patients having small lesions located in the distal part of the stomach could be a good candidate for redo ESD.

Clinical Outcomes following Endoscopic Treatment for Sporadic Nonampullary Duodenal Adenoma

BACKGROUND AND AIMS

Endoscopic treatment for duodenal neoplasms is associated with a high risk of perforation. This study aimed to determine the feasibility of endoscopic treatment for sporadic nonampullary duodenal adenoma (SNDA).

METHODS

Consecutive patients undergoing endoscopic treatment for SNDA between January 2005 and December 2015 were included in the study. Clinical characteristics and endoscopic outcomes were analyzed using medical records. Long-term outcome was assessed in patients whose follow-up period was >12 months >1 year.

RESULTS

A total of 95 lesions (92 patients) were treated with argon plasma coagulation (APC) ablation (n = 25), endoscopic mucosal resection (EMR, n = 59), or endoscopic submucosal dissection (ESD, n= 11). The median age was 54.9 years, and 63% were male. In patients who underwent EMR and ESD, the en bloc resection rate was 83.1 and 90.0% (p > 0.99); and the complete resection rate was 81.4 and 80% (p > 0.99), respectively. Perforation occurred in 8 patients (8.7%), 4 of whom required surgery. The ESD group showed a significantly higher perforation rate than APC or EMR group (45.5 vs. 0 and 5.1%; p < 0.001). During the median follow-up period of 19 months (range 12-137 months), one patient in the APC ablation group experienced recurrence; no recurrences were seen among EMR and ESD groups.

CONCLUSIONS

Favorable long-term outcomes indicate that endoscopic treatment is an effective approach for the treatment of SNDA. Considering the high risk of perforation associated with ESD, APC, or EMR may be an acceptable alternative.

Argon plasma coagulation for successful treatment of bile leakage after subtotal cholecystectomy

Background

Subtotal cholecystectomy is an effective surgical method to decrease the risk of complications for gallbladders that are difficult to remove. However, there is a risk for postoperative refractory bile leakage through the gallbladder stump. Here, we report a new management technique involving the use of argon plasma coagulation (APC) to stop bile leakage after a subtotal cholecystectomy.

Case presentation

A 74-year-old man was referred to our hospital for abdominal pain and fever. Contrast-enhanced computed tomography of the abdomen showed fluid collection, such as an abscess, surrounding the gallbladder and hepatic flexure colon. The patient was diagnosed with colonic perforative peritonitis, and he underwent emergency surgery. On laparotomy, the abscess was observed outside of the hepatic flexure colon and gallbladder necrosis was detected. The neck of the gallbladder and the area close to the hepatoduodenal ligament was severely inflamed prohibiting dissection. The hepatic flexure colon was part of the abscess wall, and resection was needed. A subtotal cholecystectomy and right hemicolectomy confirmed peritonitis caused by cholecystic perforation. The mucous membrane of the gallbladder neck that remained was necrotic or detached. Therefore, the stump of the gallbladder was closed by primary sutures without cauterization of the mucosa. On postoperative day 6, bile leakage from the gallbladder stump was revealed. Percutaneous and endoscopic retrograde cholangiography drainage were performed. However, the liquid, which seemed to be secreted from the mucosa of the remnant gallbladder, was continuously obtained. We used APC to cauterize the gallbladder mucosa through the fistula of the abdominal drainage tube. Bile leakage and mucus discharge were improved after three rounds of APC cauterization.

Conclusions

APC effectively treated refractory bile leakage from a gallbladder stump after subtotal cholecystectomy for severe cholecystitis.

Management of Barrett’s esophagus with dysplasia refractory to radiofrequency ablation

Radiofrequency ablation (RFA) is very effective for eradication of flat Barrett’s mucosa in dysplastic Barrett’s esophagus after endoscopic resection of raised lesions. However, in a minority of the time, RFA may be ineffective at eradication of the Barrett’s mucosa. Achieving complete eradication of intestinal metaplasia can be challenging in these patients. This review article focuses on the management of patients with dysplastic Barrett’s esophagus refractory to RFA therapy. Management strategies discussed in this review include optimizing the RFA procedure, optimizing acid suppression (with medical, endoscopic, and surgical management), cryotherapy, hybrid argon plasma coagulation, and EndoRotor resection.

Argon gas knife combined with cryotherapy for amyloidosis leading to severe airway stenosis

Objective

This case report shows that bronchoscopy is an important method to treat severe airway stenosis caused by bronchial amyloidosis. Bronchoscopic forceps were used to incise the intra-tracheal lump repeatedly. The incision was frozen with a cryosurgery probe, argon knife was used to stop the bleeding until the airway lumen stenosis was reduced to approximately 40%, after which, it continued to enter the lumen. We used bronchoscopic biopsy forceps to repeatedly clamp the lumps in the tracheal carina and left and right main bronchial tumors until the lumen was completely unobstructed.

Results

The symptoms of severe dyspnea and wheezing were significantly improved after two interventions with the bronchoscope.

Efficacy of Utilizing Argon Plasma Coagulation for Weight Regain in Roux-en-Y Gastric Bypass Patients: a Multi-center Study

BACKGROUND

Endoscopic approaches exist for targeting weight regain after Roux-en-Y gastric bypass (RYGB), including endoscopic suturing, clipping, and sclerotherapy. Argon plasma coagulation (APC) is a noncontact electrocoagulation method, and when used in RYGB patients, it has shown reduction in the diameter of the gastrojejunal anastomosis.

OBJECTIVES

To study the effectiveness of APC for weight regain in terms of weight loss for RYGB patients, from eight bariatric centers.

METHODS

A retrospective chart review was performed for 558 patients at eight bariatric centers in the USA (1) and Brazil (7) who underwent APC procedure between 31st July 2009 and 29th March 2017. APC was performed on patients who regained weight after RYGB procedure.

RESULTS

Upon exploratory analysis of the individual BMI data, the mean BMI decreased slightly during the first 24 months and increased slightly afterwards following the APC intervention. The mean weight was 94.5 ± 18.6 kg and the mean BMI was 34.0 kg/m² at APC. Where data were available, the mean of lowest weight was 67.0 ± 23.0 kg and the mean of lowest BMI was 24.1 kg/m² following gastric bypass. The mean weight loss was 6.5, 7.7, and 8.3 kg at 6, 12, and 24 months, respectively, and the changes in weight over time was statistically significant (p < 0.0001). Multi-level for change model showed the low body mass index (BMI) group (BMI < 30 kg/m²) to have greater TWL than the high BMI (BMI ≥ 30 kg/m²) group at 6, 12, and 24 months. In the low BMI group, the mean TWL was 4.7, 6.1, 6.9, and 2.4%, at 6, 12, and 24 months, respectively. In the high BMI group, the mean TWL was 7.5, 10.4, 13.4, and 3.7%, at 6, 12, 24, and 36 months, respectively. Of the 333 patients in four centers who provided complication information, complications after APC included stenosis (n = 9), GJ ulcer (n = 3), vomiting (n = 3), GJ leakage (n = 2), and melena (n = 1).

CONCLUSION

APC can be useful in reducing the regained weight after RYGB, and patients showed 6-10% total weight loss at 12 months. Randomized trials would be needed to validate the findings.

Clinical efficacy of argon plasma coagulation combined with cryotherapy for central airway stenosis caused by lung cancer

BACKGROUND

This study aimed to study the clinical efficacy of argon plasma coagulation plus cryotherapy for central airway stenosis caused by lung cancer.

METHODS

The clinical data of 177 patients with central airway stenosis caused by lung cancer received surgery from June, 2017 to July 2018 were retrospectively analyzed. According to different treatments, 43 patients received cryotherapy were included in the control group, while 134 patients received argon plasma coagulation plus cryotherapy were in the observation group. After propensity score matching, patients in the two groups were in a 1:1 ratio. The Karnofsky score, partial pressure of oxygen (PaO₂), arterial oxygen saturation (SaO₂), partial pressure of arterial carbon dioxide (PaCO₂) and adverse reactions in patients were analyzed one week before and after treatment. Besides, the survival rates of the two groups were compared.

RESULTS

After propensity score matching, the baseline data were not significantly different between the two groups. The post-treatment Karnofsky scores in the two groups were significantly higher than those of before treatment, and the post-treatment score of the observation group was higher than that of the control group (all P < 0.05). The post-treatment PaO₂ and SaO₂ in the observation group were both higher than those of the control group; while the PaCO₂ in the observation group was significantly lower than that of the control group (all P < 0.05). In the observation group, the levels of PaO₂ and SaO₂ were significantly higher, and the level of PaCO₂ was significantly lower after treatment than those of before treatment (all P < 0.05). The rates of completely effective and mild effective in the observation group were significantly higher than those in the control group (both P < 0.05). The incidences of bleeding, arrhythmia and fever in the observation group were significantly lower than those in the control group (all P < 0.05). The survival rate was significantly higher in the observation group (72.09%) than in the control group (51.16%).

CONCLUSIONS

Argon plasma coagulation combined with cryotherapy can significantly alleviate the central airway stenosis caused by lung cancer, reduce the incidence of adverse reactions, and improve prognosis in patients.

The Effect of Hemostasis Powder® on Treatment of Bleeding from Benign Ulcers of Upper Gastrointestinal Tract; A Pilot Study

BACKGROUND

Gastrointestinal (GI) bleeding is one of the most prevalent internal medical emergencies. Despite using several methods of treatment, effective treatment cannot be achieved in some patients. Hemostasis powder® is a mineral-herbal product. This emulsion was able to coagulate blood in, in vitro studies and also was effective in the treatment of mucosal and cutaneous bleeding in animal studies, without any toxicity. We decided to compare its effect on the treatment of human GI bleeding with the other common method for treatment of GI bleeding "argon plasma coagulation plus epinephrine injection" in a pilot randomized clinical trial.

METHODS

The patients with GI bleeding who were admitted to the emergency wards of Ghaem and Imam-Reza Hospitals in Mashhad were randomized to treatment with Hemostasis powder® or "argon plasma coagulation plus epinephrine injection" method, with randomized doctors, after complete testimonial sheet. The patients underwent re-endoscopy to evaluate the ulcers 3 days later, and were under observation for 3 months. After achieving the number of patients that was planned (20 patients), all data were entered to SPSS software version 20 and were analyzed with parametric and non-parametric tests.

RESULTS

The treatment success was 95% in both groups. There was no complication after treatment of GI bleeding in the two groups after 3 months. No rebreeding was reported in Hemostasis powder® group but 10 % was reported in "argon plasma coagulation plus epinephrine injection" group.

CONCLUSION

It seems that if the successful results occur in the future complimentary studies, Hemostasis powder® can be used as a new, effective, available, and inexpensive measure in the treatment of GI bleeding and also in the GI bleedings that cannot be treated with common available methods.

Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis (GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation (APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.

CASE SUMMARY

A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA. Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel. Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.

CONCLUSION

APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.

Gastric antral vascular ectasia in portal hypertensive children: Endoscopic band ligation versus argon plasma coagulation

BACKGROUND/PURPOSE

Gastric antral vascular ectasia (GAVE) can cause recurrent bleeding and chronic anemia in children with portal hypertension (PHT). We aimed to evaluate the efficacy of EBL in comparison to argon plasma coagulation (APC) in children with PHT, bleeding from GAVE.

METHODS

This prospective comparative study included 40 children with PHT who presented with nonvariceal GIT bleeding from GAVE. Patients were divided into 2 groups, each including 20 cases: one group was managed with APC and the other with EBL. Endoscopy was repeated every 3-4 weeks until complete ablation of GAVE. Patients were reevaluated earlier in the event of recurrence of bleeding or in case of severe anemia necessitating blood transfusion. A follow-up endoscopy was done 6 months after the last APC or EBL session.

RESULTS

The ages ranged between 2 and 16 years. The EBL group required a significantly lower number of sessions for complete obliteration of the lesions (1.85 ± 0.81) as compared to APC group (4.15 ± 1.22), p < 0.05. EBL was superior to APC as regards shorter procedure time (p = 0.001), lower blood transfusion requirement (p < 0.05), less hospitalization (p < 0.05) and significantly lower recurrence rate of GAVE after 6 months of follow up (p = 0.01) CONCLUSIONS: EBL is more effective and time saving when compared to APC in treatment of bleeding from GAVE in children.

LEVELS OF EVIDENCE

Treatment study, Level II (prospective comparative study).

Clinical outcomes of endoscopic treatment for gastric epithelial neoplasm in remnant stomach after distal gastrectomy

BACKGROUNDS/AIM

We aimed to evaluate the feasibility of endoscopic treatment for gastric epithelial neoplasm in the remnant stomach after distal gastrectomy and compared the clinical outcomes by tumor location and endoscopic treatment modality.

METHODS

We reviewed the data of patients who underwent endoscopic treatment for gastric epithelial neoplasms in the remnant stomach after distal gastrectomy between January 1996 and August 2013. The treatments included endoscopic resection or argon plasma coagulation.

RESULTS

Herein, 107 patients (median age, 65.1 years; 92 men) encompassing 117 cases of gastric neoplasms in the remnant stomach after distal gastrectomy were endoscopically treated. Forty of these lesions were located at anastomotic sites; they were treated with endoscopic resection in 29 cases (72.5%) and argon plasma coagulation in 11 cases (27.5%). For 77 lesions located on the non-anastomotic site, endoscopic resection was performed in 68 cases (88.4%) and argon plasma coagulation was performed in nine cases (11.7%; p = 0.031). The mean endoscopic resection duration was significantly longer in the anastomotic site group than in the non-anastomotic site group (43.6 vs. 26.3 min, p = 0.018). Recurrence was observed in five (12.8%) patients in the former and in one (1.3%) in the latter (p = 0.015); all the patients were successfully retreated with endoscopic resection or APC.

CONCLUSIONS

Endoscopic treatment for gastric epithelial neoplasm in a remnant stomach after distal gastrectomy is effective and safe. However, closely monitoring for recurrence should be conducted, particularly when the tumor is located at the anastomotic site.

Efficacy and complications of argon plasma coagulation for hemorrhagic chronic radiation proctitis

BACKGROUND

Chronic radiation proctitis (CRP) is a complication which occurs in 1%-5% of patients who undergo radiotherapy for pelvic malignancies. Although a wide range of therapeutic modalities are available, there is no literature to date showing any particularly appropriate therapeutic modality for each disease stage. Argon plasma coagulation (APC) is currently recommended as the first-choice treatment for hemorrhagic CRP, however, its indication based on long-term follow-up is still unclear. On the hypothesis that the long-term efficacy and safety of APC are not fully understood, we reviewed APC treatment for patients with hemorrhagic CRP from a single center.

AIM

To assess the long-term efficacy and safety of APC for hemorrhagic CRP.

METHODS

This is a retrospective study of consecutive patients treated with APC for hemorrhagic CRP from January 2013 to October 2017. Demographics, clinical variables, and typical endoscopic features were recorded independently. Success was defined as either cessation of bleeding or only occasional traces of bloody stools with no further treatments for at least 12 mo after the last APC treatment. We performed univariate and multivariate analyses to identify factors associated with success and risk factors for fistulas.

RESULTS

Forty-five patients with a median follow-up period of 24 mo (range: 12-67 mo) were enrolled. Fifteen (33.3%) patients required blood transfusion before APC. Successful treatment with APC was achieved in 31 (68.9%) patients. The mean number of APC sessions was 1.3 (1-3). Multivariate analysis showed that APC failure was independently associated with telangiectasias present on more than 50% of the surface area [odds ratio (OR) = 6.53, 95% confidence interval (CI): 1.09-39.19, P = 0.04] and ulcerated area greater than 1 cm² (OR = 8.15, 95%CI: 1.63-40.88, P = 0.01). Six (13.3%) patients had severe complications involving rectal fistulation. The only factor significantly associated with severe complications was ulcerated area greater than 1 cm² (P = 0.035).

CONCLUSION

The long-term efficacy of APC for hemorrhagic CRP is uncertain in patients with telangiectasias present on > 50% of the surface area and ulceration > 1 cm².