Argon Plasma Coagulation for the Treatment of Radiation Induced Proctitis
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Transcript of Argon Plasma Coagulation for the Treatment of Radiation Induced Proctitis
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Abstracts
(87%); in 15 patients the bleeding stopped completely, whereas in 11 patientssymptoms improved significantly. All patients with mild and 9/11 (patients withmoderate RP were successfully treated (mean 2.0 sessions). A mean of 3.5 sessionswas required in 2/5 (40%) patients with severe RP in whom APC was provedsuccessful; in one patient bleeding was controlled after 8 sessions. All APC sessionswere well tolerated, and there were no cases of perforation. Conclusions: APC isa safe, effective, and well-tolerated treatment in patients with mild and moderate RP.However, in the presence of severe RP several sessions of APC are usually requiredand less than 50% of patients were treated successfully.
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Evaluation of the Efficiency of Urgent Colonoscopy to Treat
Bleeding from a Colorectal DiverticulumHiroaki Suda, Sayo Itoh, Iruru MaetaniBackground: Bleeding from a colorectal diverticulum is the cause of about half ofhemorrhages. Urgent colonoscopy is sometimes selected for diagnosis andtreatment, but its efficiency is still unclear because it is often unable to detect thebleeding point and because diverticulum bleeding spontaneously stops in about 70percent of cases. Recent improvements in a variety of endoscopic equipment andimproved techniques allow us to detect the bleeding point more than ever, and inour hospital we detect it in about 70 percent of cases. Aim: We evaluated theefficiency of urgent colonoscopy in patients admitted within 24 hours for diagnosisand therapy for diverticulum bleeding. Methods: The study subjects included 37patients with diverticulum bleeding admitted to our hospital between April 2006and September 2007. Group S was defined as the patients diagnosed and treatedsuccessfully by the urgent endoscopy within 24 hours of admission, and Group Uwas defined as the other patients. Group U contained patients in whom thebleeding point was not detected by endoscopy or detected after 24 hours. Group Sconsisted of 11 men and 5 women. Group U consisted of 15 men and 6 women. InGroup S, the bleeding segment was the cecum and ascending colon in 12 patients,the transverses colon in 2 patients, and the sigmoid colon in 2 patients. In Group U,the bleeding segment was the cecum and ascending colon in 14 patients, thetransverses colon in 4 patients, and the sigmoid colon in 3 patients. There were nosignificant differences in age, sex or bleeding segment between the two groups.Data collected included Hb values before and after diverticulum bleeding,minimum Hb value, requirement for transfusions, total units of blood transfused,and period of hospital stay. Results: The median difference in Hb values before andafter diverticulum bleeding was 1.9g/dl in Group S and 4.6g/dl in Group U (p Z0.027). The median minimum Hb value was 12.1g/dl in Group S and 8.3g/dl inGroup U (p Z 0.01). Transfusions were required in 5 patients (31.2%) in Group Sand in 15 patients (71.4%) in Group U (p Z 0.035). The median total units of bloodtransfused was 0 units in Group S and 4 units in Group U (p Z 0.01). The medianperiod of hospital stay was 9 days in Group S and 14 days in Group U. There was nosignificant difference between the groups. Conclusions: If we can find the bleedingpoint of the diverticulum institute treatment by urgent endoscopy in patientsadmitted within 24 hours, the chance of a transfusion being required and the unitsof blood transfused can be decreased.
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The Role of Flexible Sigmoidoscopy in Acute Lower GI BleedingRebecca Mckay, Deirdre McnamaraBackground: Acute lower gastrointestinal (LGI) bleeding is defined as brisk bloodloss from a source distal to the Ligament of Treitz. Flexible sigmoidoscopy remainsthe initial endoscopic investigation of choice in many centres despite suggestionsthat colonoscopy hastens diagnosis. Aims and Methods: This study aimed todetermine the role of flexible sigmoidoscopy as a first line investigation in acute LGIbleeding. All patients admitted to a high dependency bleeding unit between 1stJanuary 2007 and 1st August 2007 with suspected LGI bleeding were included. Aretrospective review of all endoscopy reports was performed. We recorded thebowel preparation, nature of procedure and diagnosis. Subsequent investigationswere documented and findings noted. Results: 133 patients were included. 64patients (49%) were over 70 years of age, 29(22%) being over 80 years. 7 (5%) wereunder 30 years of age. The commonest cause of bleeding was diverticular disease(31%) followed by colitis (9%). 12% had 2 or more diagnostic findings. Flexiblesigmoidoscopy was the first line endoscopic investigation in 86 patients (65%).62 (72%) of these were unprepared examinations. In 11 patients (13%) views wereinadequate due to the presence of blood,9 of which were unprepared tests.A diagnosis was subsequently made at colonoscopy in 8 cases. 5 of the 7 patientsunder the age of 30 had an unprepared flexible sigmoidoscopy, with a diagnosisbeing made in all instances. 31 (36%) patients had further imaging: 25 (80%)proceeded to colonoscopy and 6 (19%) had a barium enema. In the patients whohad both a flexible sigmoidoscopy and a colonoscopy (n Z 25) an additionaldiagnosis was made in 19 patients (76%). Colonoscopy was the first line endoscopicprocedure for 22 patients (17%). 4 of these were performed without preparationalthough 2 subsequently had the procedure repeated with preparation. 23 patientshad no lower GI endoscopic procedures. Of interest, 47 of the 120 patients aged 30-80 years underwent a colonoscopy within 6 months of their admission (39%).Conclusion: Flexible sigmoidoscopy was the investigation of choice for 65% ofpatients in this audit. Of these, 87% were complete studies and just over a thirdrequired further imaging. Of the 25 who had subsequent colonoscopy, only 7 were
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for inadequate views obtained with unprepared sigmoidoscopies. Just 47 patients(35%) underwent colonoscopy. This audit suggests flexible sigmoidoscopy remainsa useful investigation for LGI bleeding, and that age as well as other clinical factorsmay be useful in selecting patients who would benefit from direct colonoscopy.Further prospective studies will be required to assess the benefits of such a model.
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Argon Plasma Coagulation for the Treatment of Radiation
Induced ProctitisMarıa Laura Gonzalez, Marina Cariello, Carlos Alberto MacıAs GoMez,Fernando Van Domselaar, Jorge R. DaVolosIntroduction: Radiation-induced proctitis (RIP) is a relative common complication ofpelvic radiation therapy. Medical treatment generally fails in control bleeding. ArgonPlasma Coagulation (APC) is established as an alternative effective therapeuticmethod. However, APC usefulness and safety have not been studied in our Country.Aims: To asses the usefulness and safety of APC in the management of patients with(RIP). Patients and methods: We analized the clinical records of fourteen patientswith radiation proctitis derived to our Endoscopic Unit for APC treatment from July2004 through March 2007. Indication for radiation therapy, onset of symptoms afterthe procedure, APC related complications and post treatment clinical evolutionwere analyzed retrospectively. Diagnosis of radiation proctitis was made based onendoscopic findings in rectal or sigmoideal mucosa. Such us single or multipletelangiectasias and/or friability or contact bleeding in patients with previous pelvicradiotherapy without any other bleeding source. Clinical outcome was classified ascompletely response: no recurrence of bleeding, partial response: intermittentslight bleeding or no response: without improvement or worsen of bleeding. Weused ERBE (Tubigen, Germany) APC 300 system with a 3,2 mm probe in all patients.The gas flow was 2 l/min. and the power setting used was 40 W in 2 seconds pulses.Results: Fourteen consecutive patients, (M/F: 12/2, mean age 74 (61-84 years) wereretrospectively included. Male patients received RT due to prostate cancer andfemales for uterine cancer. Onset of symptoms after RTwas 23 months (0-108). Thefollow up was 15 months (2-34). All patients had overt bleeding, 6 of them hadanemia (3 were transfused). Only one patient received previous medical treatmentand endoscopic sclerosis. Eleven patients (79%) responded to APC treatment. Six inthe first session and four required two sessions for complete response. One patienthad a partial response and refused a second session. Three patients had noresponse. One underwent only one session, other received palliative managementand the last one died from no related procedure causes. Anemia improved in allpatients, no transfusions were required and no complication occurred. Conclusion:APC was useful and safe in our patients for RIP treatment and should berecommended as an avilable therapeutic tool in our country.
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Colonoscope Position Detecting System’s Impact
On Patient-Based Comfort and Efficiency of Colonoscopy
in Difficult-to-Insert CasesMorio Takahashi, Yasumi Katayama, Hajime KuwayamaA magnetic imaging system of colonoscope (Unit of Position Detection: UPD,Olympus Optical Co., Ltd.) provides a new facility for viewing of the position of thecolonoscope during examination, without exposing patients or medical staff toradiation. We previously compare UPD system with routine colonoscopy and gotthe impression that UPD system is more useful in comparatively difficult cases. Inorder to confirm this, we assigned the patients into three groups according to theinsertion time to the cecum of previously performed colonoscopy with ordinarycolonoscope (First colonoscopy). Then we performed second colonoscopy withUPD colonoscope. We compared the insertion time between the first (ordinarycolonoscope) and second colonoscopy (UPD) in each group. Methods: From Jan.2005 to August 2007, consecutive 3721 patients undergoing colonoscopy withordinary colonoscope were assigned into three groups according to the insertiontime of first colonoscopy, A group; 7 minute or less, B group; 15 minutes or more,and C group; unable to reach the cecum. Patients of insertion time from 8 to 14 minwere excluded. Of these patients, 310 patients underwent second colonoscopy withUPD and were enrolled in the study. One experienced endoscopist (experiencedmore than 10,000 colonoscopies) performed colonoscopy in this study. Parametersused in this study were the insertion time to the cecum, visual analog scale ofpatients discomfort (0 cm, no pain; 10 cm, worst pain of life). Results: 1. Of 310patients enrolled in the study, 200 patients were assigned to be in A group (! 7min.), 98 in B group (O 15 min.) and 12 in C (unable to reach cecum). 2. In groupA, there was no difference in insertion time between first and second colonoscopy(260þ/-88 seconds vs. 248þ/-58). In group B, the insertion time of secondcolonoscopy is significantly shorter than that of first colonoscopy (1266þ/-582 vs.523þ/-123). In group C, the total colonoscopies were performed in 10 out of 12patients (788þ/-235) with UPD. 3. There was no difference in pain of patients ingroup A (1.67þ/-0.97 vs. 1.72þ/-0.93). There is a trend toward less pain in secondcolonoscopy (UPD) in group B (3.02þ/-1.41 vs. 2.65þ/-1.13). There was nodifference in pain of patients in group C (3.32þ/-2.11 vs. 3.17þ/-2.23). Conclusion:These results indicated that UPD system is useful only in difficult cases and totalcolonoscopy to the cecum can be obtained with UPD in cases where it is notobtained with ordinary colonoscope.
lume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB321