Argon Plasma Coagulation for the Treatment of Hemorrhagic Radiation Proctitis

• Abstract in French
• Introduction
• Patients and Methods
• Results
• Discussion
• References

Background and Study Aims: Chronic radiation proctitis is a complication of radiotherapy for malignant pelvic diseases. 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.

Patients and Methods: The charts of 16 patients with chronic radiation proctitis were analyzed retrospectively. Their average age was 73.5 (range 62 - 80). Fifteen patients had prostate cancer, and one had uterine cancer. The average time to onset of symptoms after radiotherapy was 15 months (range 6 - 36 months). All patients had intermittent or daily rectal bleeding, and three patients needed blood transfusions. The severity of bleeding was graded from 0 to 4. APC treatment was administered every month; the argon gas flow was set at 0.6 l/min with an electrical power setting of 40 W.

Results: All patients were improved with APC treatment. A mean of 3.7 sessions was necessary to relieve symptoms. APC therapy resulted in a reduction in the mean severity score from 2.4 to 0.6. Seven patients had no recurrent rectal bleeding, and the bleeding was significantly reduced to occasional and negligible spotting (less than one bleeding episode per week) in nine patients. None of the patients required transfusions after treatment. During the follow-up period (average 10.7 months, range 8 - 28 months), one patient had a recurrence of rectal bleeding that required two repeat sessions. The tolerance was good, with no long-term treatment-related complications.

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.

Abstract in French

Buts: Le traitement des formes hémorragiques des rectites radiques chroniques est difficile. La coagulation au plasma argon (APC) est un traitement hémostatique efficace en endoscopie digestive thérapeutique et est à ce titre, une alternative au traitement par laser. Le but de notre travail était d'évaluer l'efficacité et la tolérance de l'APC pour le traitement des rectites radiques chroniques hémorragiques.

Patients et Méthodes: Les observations de 16 patients traités par APC pour une rectite radique chronique hémorragique résistante aux traitements usuels ont été étudiées de facžon rétrospective. L'âge moyen était de 73,5 ans (extrêmes 62 à 80 ans), 15 patients avaient eu un cancer de la prostate et 1 patiente avait eu un cancer utérin. Le délai moyen entre le début de la radiothérapie et l'apparition des symptômes était de 15 mois (extrêmes 6 à 36 mois). Tous les patients avaient des rectorragies intermittentes ou quotidiennes et 3 patients nécessitaient des transfusions sanguines. La sévérité des rectorragies était graduée de 0 à 4. Le traitement par APC était effectué à la puissance de 40 Watts avec un débit Argon de 0,6 l/min au rythme d'une séance par mois.

Résultats: Tous les patients ont été améliorés. En moyenne, 3,7 séances étaient effectuées. Le traitement entraînait une baisse du score de gravité hémorragique de 2,4 à 0,56; 7 patients ont eu une cessation complète des rectorragies et 9 patients ne présentaient plus que des rectorragies minimes (moins d'un épisode par semaine en moyenne). Les 3 patients ayant des besoins transfusionnels n'ont pas été transfusés depuis le début du traitement. Au cours du suivi (moyenne 10,7 mois, extrêmes 8 à 28 mois), un patient présentait une récidive de rectorragies nécessitant 2 séances supplémentaires. La tolérance du traitement était bonne sans complications à long terme.

Conclusions: L'APC est un traitement efficace et bien toléré des rectites radiques chroniques hémorragiques. L'APC pourrait être proposé de première intention dans cette indication.

Introduction

Chronic radiation proctitis occurs in 5 - 20 % of patients receiving pelvic radiation [1]. The location of the rectum makes it particularly susceptible to radiation injury. Radiation injury to the rectal wall can cause connective tissue fibrosis and obliterative endarteritis, with tissue ischemia and the development of neovascular mucosal lesions. Short-term consequences of radiation include transitory diarrhea and tenesmus. However, symptoms can persist and progress to chronic bleeding, strictures, or fistula formation. Bleeding occurs months to years after irradiation, and the sequelae range from chronic blood loss to massive hematochezia.

Medical treatment of chronic radiation proctitis is often unsatisfactory [1] [2] [3] . Medical therapy with corticosteroids and nonsteroidal anti-inflammatory enemas is ineffective, and surgical management is associated with frequent mortality and morbidity [1] [2] . Sucralfate enemas [4] [5] , formalin irrigation [6], laser treatment, and electrocoagulation have been tried with good results [7] [8] [9] . Argon plasma coagulation (APC) is an innovative electrocoagulation method [10] in which high-frequency alternating current can be delivered to the tissue using a no-touch technique. APC appears to be an effective and low-cost alternative to laser therapy in gastrointestinal endoscopy [11]. The aim of this study was to evaluate the efficacy of APC therapy, and patients' tolerance of the procedure, in bleeding chronic radiation proctitis.

Patients and Methods

The charts for patients treated with APC for chronic rectal bleeding due to chronic radiation proctitis were analyzed retrospectively. Between January 1997 and May 1999, 16 patients (mean age 73.5 years; range 62 - 80) were treated for daily hematochezia with varying degrees of blood loss. Treatment sessions were performed at the Endoscopic Unit in the University Hospital of Angers. Fifteen patients had prostate cancer, and one had uterine cancer. All of the patients had been unsuccessfully treated with steroid or salicylate enemas. The symptoms occurred within an average of 15 months (range 6 - 36 months) after radiation therapy. All patients had intermittent or daily rectal bleeding (two to eight bleeding episodes per week), and three patients required blood transfusions. The severity of rectal bleeding before and after treatment was graded from 0 to 4, according to the criteria of Chutkan et al. [12]: 0, no blood; 1, blood on toilet paper or stools; 2, blood in toilet bowl; 3, heavy bleeding with clots; 4, bleeding requiring blood transfusions. The initial evaluation was carried out with colonoscopy. In all patients, telangiectasia was present, extending proximally 5 - 30 cm from the anal verge. The telangiectasia was localized in seven patients and diffuse in nine. Five patients were receiving oral anticoagulant treatment (acenocoumarol or fluindione). APC treatment was administered using a single-channel flexible sigmoidoscope (Olympus P10-S). Patients undergoing rectosigmoidoscopy first received 4 l of polyethylene glycol solution or two tap water enemas. No premedication was given. The APC probe (Erbe Medical, France) has an external diameter of 2 mm and an internal diameter of 1.5 mm, and was inserted through the working channel of the endoscope. APC was delivered using the spotting technique, with short applications at 40 W power with a gas flow of 0.6 l/min. Treatment with APC was performed every month until improvement of rectal bleeding occurred, based on the patient's opinion. No systematic endoscopic follow-up was carried out after the rectal bleeding improved. Between APC applications, the patients received no other treatment (such as steroid or salicylate enemas). The average follow-up period was 10.7 months (range 8 - 28 months). Follow-up information was obtained by telephone contact with the patients.

Results

A total of 58 treatment sessions were performed, and the mean number of APC sessions was 3.7 (range 2 - 8). All patients had a marked reduction in rectal bleeding. Reduced rectal bleeding was observed in all patients after a mean of 2.2 sessions (range 1 - 4). Four patients reported an improvement in rectal bleeding after the first treatment session. Endoscopic APC therapy resulted in a decrease in the mean bleeding severity score from 2.4 to 0.6. No recurrence of hematochezia was observed in seven patients; minor rectal bleeding persisted in the nine other patients, but was reduced to occasional and negligible spotting (less than one bleeding episode per week). Three months later, only one patient had a recurrence of rectal bleeding, requiring two repeat sessions; four months later, the patient had not experienced any further recurrences. No patients required blood transfusions after APC treatment. Clinical improvement correlated clearly with endoscopic eradication of telangiectasia (Figure [1]). The efficacy of the treatment was similar in patients with localized or diffuse telangiectasia. In patients receiving oral anticoagulant treatment, a mean of 4.2 sessions was required to achieve a similar efficacy, compared to 3.3 sessions in patients not on anticoagulants. All sessions were well tolerated, but four patients noted a transitory and minimal dysenteric syndrome. No delayed complications such as fistulas, ulcers, or strictures were observed.

Discussion

Medical treatment for chronic radiation proctitis is often unsatisfactory; symptoms may persist and progress to complications requiring surgery [1] [2] . Results with topical therapies such as 5-acetylsalicylic acid and topical corticosteroids have been disappointing. Local irrigation with formalin, sucralfate irrigation, laser therapy, and electrocoagulation are effective treatments [1] [2] [3] [4] [5] [6] [7] [8] [9] . Laser therapy and electrocoagulation are considered to be the most effective methods of treating this condition [1] [2] [3] [7] [8] [9] . The disadvantages of conventional unipolar and bipolar electrocoagulation techniques are adhesion of the probe to tissue and the difficulty of assessing the depth of the thermal effect. Laser therapy has the advantage of being a precise technique that does not involve tissue contact and is well tolerated. However, disadvantages of laser therapy include its high cost and the inability to control the depth of coagulation, resulting in a risk of perforation of the gastrointestinal tract.

APC is an innovative noncontact electrocoagulation technique in which high-frequency alternating current is delivered to the tissue through ionized argon gas [10]. The no-touch application of the coagulation energy via ionized argon prevents the probe from sticking to the tissue. The limited depth of coagulation (2 - 3 mm) explains the low risk of perforation. A further advantage of this technique is the possibility of axial or tangential application of the electrothermic current without significant reduction in effectiveness. Thus, APC is an effective and relatively low-cost alternative to laser therapy in gastrointestinal endoscopy. APC is a well-established treatment for various conditions, such as oozing hemorrhage from angiodysplastic lesions or polypectomy sites [11] [13] [14] [15] . To our knowledge, this is the second largest report to have appeared on the use of APC in the treatment of radiation-induced proctitis. For this indication, APC has been reported in only two previous published studies [16] [17] and in a few abstracts [12] [18] . In 1999, Fantin et al. [16] reported the efficacy of APC in the treatment of radiation-induced proctitis in seven patients. APC was delivered at a power of 60 W, with a gas flow of 3.0 l/min. After two to four sessions of APC, all patients obtained complete relief from symptoms, did not require maintenance therapy, and had no complications. In 1999, Silva et al. [17] reported the efficacy of APC in 28 patients. APC was delivered at a power of 50 W, with a gas flow of 1.5 l/min. In 1997, Chutkan et al. [12] treated 12 patients suffering from refractory radiation proctitis. Five of the 12 patients had complete resolution of bleeding, and 11 of the 12 patients experienced improvement. All patients reported improvement after one session, except those who were receiving warfarin therapy; no complications were noted. In 1999, Saurin et al. [18] reported their experience with APC in the treatment of radiation-induced proctitis in nine patients. APC was delivered at a power of 70 W, with a gas flow of 2.0 l/min. The efficacy was good (six patients reported improvement after one session), but the authors noted a risk of rectal stricture in three patients, who required further investigation.

The results of the present study thus provide further confirmation of the efficacy of APC in the treatment of chronic proctitis. Unlike Saurin et al. [18], we did not observe long-term complications such as strictures or ulcers; however, we used lower gas flow and power levels for treatment (40 W, 0.6 l/min). Radiation proctitis is a chronic disease; symptoms may reappear and can require repeat sessions, as in this study. The present study demonstrates for the first time that the efficacy of treatment can be the same in localized and diffuse telangiectasias. In addition, the effectiveness of APC was not impaired by anticoagulant treatment. Finally, it was found that bowel preparation (for the first sessions) with oral polyethylene glycol solution is preferable to administering rectal enemas, which can damage the mucosa and increase rectal bleeding.

In conclusion, this retrospective study indicates that APC is an effective, safe, and well-tolerated treatment for hemorrhagic radiation proctitis. APC appears to be an effective and low-cost alternative to laser treatment, and should be considered as a first-line therapy for radiation proctitis. Further studies comparing APC with other treatments such as sucralfate or laser will be needed to confirm the efficacy of APC as a first-line therapy for this disease.

References

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M.D. J. Boyer,

Gastroenterology Unit University Hospital

4, rue Larrey

49033 Angers

France

Phone: + 33-2-41 35 38 57

Email: Jeboyer@chu.angers.fr

References

• 1 Babb RR. Radiation proctitis: a review.  Am J Gastroenterol. 1996;  91 1309-1311
  PubMedSearch in Google Scholar
• 2 Swaroop VS, Goustout GJ. Endoscopic treatment of chronic radiation proctopathy.  J Clin Gastroenterol. 1998;  27 36-40
  CrossrefPubMedSearch in Google Scholar
• 3 De Parades V, Bauer P, Girodet J, et al. Traitement nonchirurgical des rectites radiques chroniques.  Gastroenterol Clin Biol. 1998;  22 688-696
  PubMedSearch in Google Scholar
• 4 Kochhar R, Patel F, Dhar A, et al. Radiation-induced proctosigmoiditis: prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate.  Dig Dis Sci. 1991;  36 103-107
  CrossrefPubMedSearch in Google Scholar
• 5 Kochhar R, Sriram PVJ, Sharma SC, et al. Natural history of late radiation proctosigmoiditis treated with topical sucralfate suspension.  Dig Dis Sci. 1999;  44 973-978
  CrossrefPubMedSearch in Google Scholar
• 6 Furs S, Isaacs K, Bozymski E, et al. Endoluminal formalin therapy for refractory radiation-induced hemorrhagic proctitis.  Gastrointest Endosc. 1997;  15 107
  PubMedSearch in Google Scholar
• 7 Taylor JG, Di Sario JA, Buchi KN. Argon laser therapy for hemorrhagic radiation proctitis: long-term results.  Gastrointest Endosc. 1993;  39 641-644
  PubMedSearch in Google Scholar
• 8 Carbatzas C, Spencer GM, Thorpe M, et al. Nd:YAG laser treatment for bleeding from radiation proctitis.  Endoscopy. 1996;  28 497-500
  Thieme ConnectPubMedSearch in Google Scholar
• 9 Jensen DM, Machicado GA, Cheng S, et al. A randomized prospective study of endoscopic bipolar electrocoagulation and heater probe treatment of chronic rectal bleeding from radiation telangiectasia.  Gastrointest Endosc. 1997;  45 20-25
  PubMedSearch in Google Scholar
• 10 Grund KE. Argon plasma coagulation (APC): ballyhoo or breakthrough?.  Endoscopy. 1997;  29 196-198
  PubMedSearch in Google Scholar
• 11 Johanns W, Luis W, Jansen J, et al. Argon plasma coagulation (APC) in gastroenterology: experimental and clinical experiences.  Eur J Gastroenterol Hepatol. 1997;  9 581-587
  PubMedSearch in Google Scholar
• 12 Chutkan R, Lipp A, Waye J. The plasma argon coagulator: a new and effective modality for treatment of radiation proctitis.  Gatrointest Endosc. 1997;  45 27
  PubMedSearch in Google Scholar
• 13 Canard JM, Fontaine H, Védrenne B. Electrocoagulation par plasma argon: première expérience française rapportée.  Gastroenterol Clin Biol. 1997;  21 36
  PubMedSearch in Google Scholar
• 14 Prelician M, Boyer J. Traitement par électrocoagulation par plasma argon des tumeurs et malformation vasculaires digestives.  Gastroenterol Clin Biol. 1998;  22 65
  PubMedSearch in Google Scholar
• 15 Wahab PJ, Mulder CJJ, Den Hartog G, et al. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences.  Endoscopy. 1997;  29 176-181
  Thieme ConnectPubMedSearch in Google Scholar
• 16 Frantin AC, Binek J, Suter WR, et al. Argon beam coagulation for treatment of symptomatic radiation-induced proctitis.  Gastrointest Endosc. 1999;  49 515-518
  PubMedSearch in Google Scholar
• 17 Silva RA, Correira AJ, Moreira Dias L, et al. Argon plasma coagulation therapy for hemorrhagic radiation proctosigmoiditis.  Gastrointest Endosc. 1999;  50 221-224
  CrossrefPubMedSearch in Google Scholar
• 18 Saurin JC, Coelho J, Leprêtre J, et al. Rectites radiques ou ectasies vasculaires antrales: effets de la coagulation au plasma argon.  Gastroenterol Clin Biol. 1999;  23 54
  PubMedSearch in Google Scholar

M.D. J. Boyer,

Gastroenterology Unit University Hospital

4, rue Larrey

49033 Angers

France

Phone: + 33-2-41 35 38 57

Email: Jeboyer@chu.angers.fr