Argon plasma coagulation treatment in patients with chronic radiation proctitis

 

 Buy Article Permissions and Reprints

We have read with great interest the article by Karamanolis et al. [1] on the role of argon plasma coagulation (APC) treatment in patients with chronic radiation proctitis. Chronic radiation proctitis represents a challenging condition that is seen with increased frequency due to the common use of radiation for the treatment of pelvic cancer, and for which current treatment modalities are unsatisfactory [2]. Rectal bleeding is one of the most feared complications. It can be severe enough to result in significant anemia and transfusion dependency. There is still no consensus for its management, which remains essentially empirical [2] [3].

We have also performed a study (a 5-year retrospective study), in which we have reported the treatment of 41 patients with radiation proctitis (confirmed by endoscopy) who experienced rectal bleeding. All patients had colonoscopy to exclude another source of bleeding.

The severity of the disease was evaluated by the presence or absence of anemia (Hb < 11.0 g/dL) and by the endoscopic distribution of telangiectasias and friability: patients with anemia and/or spontaneous bleeding or friability of the mucosa of the entire rectum (with or without involvement of the sigmoid) were considered to have a severe disease.

All patients (n = 41) were treated with mesalazine or sucralfate enemas. Patients in whom these medical measures failed and all patients with severe disease (n = 30) were also treated with APC (flow rate 1.0 L/minute, electrical power 40 W). Repeat sessions of APC were usually carried out at intervals of 4 weeks.

The features of our patients were similar to those in the study by Karamanolis et al. The mean age was 68.9 years (range 45 – 81 years). All patients had undergone pelvic irradiation for the treatment of pelvic malignancies (prostate cancer [n = 34], rectal cancer [n = 4], cervical cancer [n = 2], and anal cancer [n = 1]) between 4 and 48 months before the diagnosis of radiation proctitis (mean time 12 months). Radiation proctitis was classified as severe in 19 patients (46.3 %). Anemia was present in 17 patients (41.5 %), nine of whom (21.9 %) required blood transfusion.

We achieved successful control of bleeding (i. e. complete cessation of bleeding or occasional loss of blood in the stools, less than once a month, with no development or recurrence of anemia) in 93.3 % (n = 28) of the patients treated with APC. The bleeding stopped completely in 20 patients after the first session and in three patients after more than one session; five patients experienced occasional rectal bleeding. The other two patients were lost to follow-up. A median of 2.5 sessions (range 1 – 6) were performed. In accordance with the authors we also found that patients with severe radiation proctitis required a higher number of sessions to achieve control of bleeding, but we do not think that administration of high-energy doses of APC should be performed in these patients to improve the outcome because of the risk of major ulcerations, fistulization or even perforation. Instead we recommend maintaining the energy dose of 40W but performing more sessions with concomitant use of sucralfate enemas.

All APC sessions were well tolerated and we have had no registered reports of any major complication, such as perforation, stricture or fistulization. We saw no cases of colonic explosion, probably because standard bowel preparation was always required for us to perform the treatment.

Over the mean follow-up period of 19 months (range 12 – 48 months) there was no case of recurrence of bleeding that required a new treatment session.

In disagreement with the data from the authors, which suggest that anticoagulants or aspirin could be a co-factor for rectal bleeding in patients with radiation proctitis, in our study these drugs had no influence on the efficacy of APC treatment and on the recurrence rate of bleeding. This is possibly because only two patients (6.67 %) were treated with warfarin and three (10.0 %) with aspirin or another antiplatelet, and all of these patients had a mild radiation proctitis.

In summary, like Karamanolis et al., we also consider that APC is a safe, highly effective, and long-lasting therapy in patients with hemorrhagic radiation proctitis.

Competing interests: None

References

• 1 Karamanolis G, Triantafyllou K, Tsiamoulos Z. et al . Argon plasma coagulation has a long-lasting therapeutic effect in patients with chronic radiation proctitis.  Endoscopy. 2009;  41 529-531
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Cotti G, Seid V, Araujo S. et al . Conservative therapies for hemorrhagic radiation proctitis: a review.  Rev Hosp Clín Fac Med S Paulo. 2003;  58 284-292
  CrossrefPubMedGoogle Scholar
• 3 Hong J J, Park W, Ehrenpreis E D. Current therapeutic options for radiation proctopathy.  Aliment Pharmacol Ther. 2001;  15 1253-1262
  CrossrefPubMedGoogle Scholar
• 4 Sebastian S, O’Connor H, O’Morain C, Buckley M. Argon plasma coagulation as first-line treatment for chronic radiation proctopathy.  J Gastroenterol Hepatol. 2004;  19 1169-1173
  CrossrefPubMedGoogle Scholar

C. G. RodriguesMD 

Department of Gastroenterology
Professor Fernando Fonseca Hospital

IC19 Venteira Amadora
Lisbon 2720-276
Portugal

Fax: +351-21-4345566

Email: catarinagr@hotmail.com