Endoscopic therapy for radiation proctitis-induced hemorrhage in patients with prostatic carcinoma using argon plasma coagulator application

Therapeutics in Radiation-induced Proctopathy: A Systematic Review

Malignant neoplasms are increasingly prevalent in the daily clinical practice. Up to 61% of patients with pelvic malignancies undergo pelvic radiotherapy in different doses, which may cause intestinal damage, and the rectum is the segment most frequently affected due to its fixed position in the pelvis. Currently, there are several strategies to minimize the effects of radiation on the tissues surrounding the neoplastic site; despite those strategies, radiotherapy can still result in serious damage to organs and structures, and these injuries accompany patients throughout their lives. One of the most common damages resulting from pelvic radiotherapy is acute proctitis.The diagnosis is confirmed by visualizing the rectal mucosa through rigid or flexible rectosigmoidoscopy and colonoscopy. The objective of the present study was to review the forms of radiation-induced proctopathytherapy, and to evaluate the results of each method to propose a standardization for the treatment of this pathology. Despite the prevalence of radiation-induced proctopathy, there is no definitive standardized treatment strategy so far. The first approach can be tried with local agents, such as mesalazine and formalin. For refractory cases, control can usually be achieved with argon plasma coagulation, hyperbaric oxygen, and radiofrequency ablation therapies. Regarding the study of radiation-induced proctopathy, there is a lack of robust studies with large samples and standardized therapies to be compared. There is a lack of double-blinded, randomized controlled studies to determine a definitive standard treatment algorithm.

Critical Evaluation of the Interaction of Reactive Oxygen and Nitrogen Species with Blood to Inform the Clinical Translation of Nonthermal Plasma Therapy

Non-thermal plasma (NTP), an ionized gas generated at ambient pressure and temperature, has been an emerging technology for medical applications. Through controlled delivery of reactive oxygen and nitrogen species (ROS/RNS), NTP can elicit hormetic cellular responses, thus stimulating broad therapeutic effects. To enable clinical translation of the promising preclinical research into NTP therapy, a deeper understanding of NTP interactions with clinical substrates is profoundly needed. Since NTP-generated ROS/RNS will inevitably interact with blood in several clinical contexts, understanding their stability in this system is crucial. In this study, two medically relevant NTP delivery modalities were used to assess the stability of NTP-generated ROS/RNS in three aqueous solutions with increasing organic complexities: phosphate-buffered saline (PBS), blood plasma (BP), and processed whole blood. NTP-generated RNS collectively (NO2 -, ONOO-), H2O2, and ONOO- exclusively were analyzed over time. We demonstrated that NTP-generated RNS and H2O2 were stable in PBS but scavenged by different components of the blood. While RNS remained stable in BP after initial scavenging effects, it was completely reduced in processed whole blood. On the other hand, H2O2 was completely scavenged in both liquids over time. Our previously developed luminescent probe europium(III) was used for precision measurement of ONOO- concentration. NTP-generated ONOO- was detected in all three liquids for up to at least 30 seconds, thus highlighting its therapeutic potential. Based on our results, we discussed the necessary considerations to choose the most optimal NTP modality for delivery of ROS/RNS to and via blood in the clinical context.

ASGE guideline on the role of endoscopy for bleeding from chronic radiation proctopathy

Chronic radiation proctopathy is a common sequela of radiation therapy for malignancies in the pelvic region. A variety of medical and endoscopic therapies have been used for the management of bleeding from chronic radiation proctopathy. In this guideline, we reviewed the results of a systematic search of the literature from 1946 to 2017 to formulate clinical questions and recommendations on the role of endoscopy for bleeding from chronic radiation proctopathy. The following endoscopic modalities are discussed in our document: argon plasma coagulation, bipolar electrocoagulation, heater probe, radiofrequency ablation, and cryoablation. Most studies were small observational studies, and the evidence for effectiveness of endoscopic therapy for chronic radiation proctopathy was limited because of a lack of controlled trials and comparative studies. Despite this limitation, our systematic review found that argon plasma coagulation, bipolar electrocoagulation, heater probe, and radiofrequency ablation were effective in the treatment of rectal bleeding from chronic radiation proctopathy.

Argon plasma coagulation is an effective treatment for chronic radiation proctitis in gynaecological malignancy: an observational study

AIM

Chronic radiation proctitis (CRP) develops in 5-15% of patients after pelvic radiation therapy, with rectal bleeding being the main symptom. Reports suggest that argon plasma coagulation (APC) can be an effective therapy for CRP following radiotherapy for prostate cancer, but there is less information about how useful it is after radiotherapy for gynaecological malignancy. The aim of this work therefore was to study the efficacy of APC for CRP after radiotherapy for gynaecological malignancy.

METHOD

This was a prospective study of consecutive patients with CRP following radiotherapy for gynaecological malignancy at IPGME&R, SDLD, Kolkata, India; symptoms included rectal bleeding grade (RBG) ≥ 2. APC was performed at monthly intervals to a maximum of four treatment sessions. Severity of disease at baseline was graded (endoscopically) by the total colonoscopic severity score (TCSS) and treatment response was assessed by reduction in RBG from ≥ 2 to ≤ 1 measured at > 6 months after cessation of APC.

RESULTS

Seventy patients [90% with cervical cancer, 10% with endometrial cancer; mean age 51.93 ± 9.15 years; median RBG 3 (range 2-4)] received APC. Seven patients died due to underlying malignancy and seven patients were lost to follow-up. Fifty-six (85.7%) patients responded to therapy after a median of 2 (range 1-4) treatment sessions. Multivariate analysis demonstrated that a lower haemoglobin at the start of treatment predicted failure of therapy (P < 0.05).

CONCLUSION

APC is an effective management option for CRP in female patients with gynaecological malignancy. However, the more anaemic the patient the less likely it is to be successful.

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

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

Chronic radiation proctitis: tricks to prevent and treat

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Growth hormone used to control intractable bleeding caused by radiation-induced gastritis

Intractable bleeding caused by radiation-induced gastritis is rare. We describe a 69-year-old man with intractable hemorrhagic gastritis induced by postoperative radiotherapy for the treatment of esophageal carcinoma. Although anti-secretory therapy with or without octreotide was initiated for hemostasis over three months, melena still occurred off and on, and the patient required blood transfusions to maintain stable hemoglobin. Finally growth hormone was used in the treatment of hemorrhage for two weeks, and hemostasis was successfully achieved. This is the first report that growth hormone has been used to control intractable bleeding caused by radiation-induced gastritis.

Cold atmospheric plasma devices for medical issues

Cold atmospheric plasma science is an innovative upcoming technology for the medical sector. The plasma composition and subsequent effects on cells, tissues and pathogens can vary enormously depending on the plasma source, the plasma settings and the ambient conditions. Cold atmospheric plasmas consist of a highly reactive mix of ions and electrons, reactive molecules, excited species, electric fields and to some extent also UV radiation. In the last year, this partly ionized gas has been demonstrated to have a broad antimicrobial activity, while resistance and resistance development are unlikely. Furthermore, recent research has indicated that plasmas also have a strong influence on various cell lines and cell functions, including anticancer properties. This review summarizes the major plasma designs available and their main benefits, as well as assessing possible risks of this new technology.

Trans-anal rectoscopic ball diathermy (TARD) for radiotherapy-induced haemorrhagic telangiectasia: a safe and effective treatment

AIM

Rectal bleeding may occur late after radiotherapy for prostate or bladder cancer, particularly when given by external beam, due to radiotherapy-induced haemorrhagic telangiectasia (RIHT). We present the results of trans-anal rectoscopic ball diathermy (TARD) for RIHT.

METHOD

Data were collected from patients who received TARD for RIHT. The diagnosis was made during endoscopic examination. Treatment involved discretely spaced spot monopolar diathermy coagulation of the rectal mucosa to the affected areas.

RESULTS

Thirteen patients [median age 76 (69-80) years] underwent TARD for RIHT between 2005 and 2008. All presented late with rectal bleeding following radiotherapy for prostate or bladder cancer. Eight were treated as a day case, four remained in hospital for one night and one was hospitalized for 2 days. There was no mortality. Eleven patients achieved excellent symptomatic control requiring no further treatment at a median follow-up of 20 (3-36) months. One patient underwent further TARD for recurrence. One patient complained of severe anorectal pain of no obvious cause and one developed constipation.

CONCLUSION

Trans-anal rectoscopic ball diathermy (TARD) is a safe and effective treatment for patients with rectal bleeding due to RIHT.

Treatment of radiation-induced hemorrhagic gastritis with prednisolone: A case report

Radiation-induced gastritis is an infrequent cause of gastrointestinal bleeding. It is a serious complication arising from radiation therapy, and the standard treatment method has not been established. The initial injury is characteristically acute inflammation of gastric mucosa. We presented a 46-year-old male patient with hemorrhagic gastritis induced by external radiotherapy for metastatic retroperitoneal lymph node of hepatocellular carcinoma. The endoscopic examination showed diffuse edematous hyperemicmucosa with telangiectasias in the whole muscosa of the stomach and duodenal bulb. Multiple hemorrhagic patches with active oozing were found over the antrum. Anti-secretary therapy was initiated for hemostasis, but melena still occurred off and on. Finally, he was successfully treated by prednisolone therapy. We therefore strongly argue in favor of perdnisolone therapy to effectively treat patients with radiation-induced hemorrhagic gastritis.

Endoscopic and medical therapy for chronic radiation proctopathy: a systematic review

BACKGROUND

Chronic radiation proctopathy is associated with significant morbidity. The effectiveness of endoscopic and medical therapies has not been evaluated.

OBJECTIVES

The aim of this study was to conduct a systematic review of the effectiveness of endoscopic and comparative medical therapies for chronic radiation proctopathy.

DATA SOURCES

A comprehensive search Medline and PubMed was performed.

STUDY SELECTION

A comprehensive literature search was performed for studies of endoscopic and medical therapy for clinical and endoscopic improvement in chronic radiation proctopathy from January 1990 until December 2010. The quality of the overall evidence was rated according to the Grading of Recommendations, Assessment, Development, and Evaluation Working Group.

SETTING

Patients in both inpatient and outpatient settings were assessed.

PATIENTS

Patients experiencing chronic radiation proctopathy were included.

INTERVENTIONS

Patients had undergone medical or endoscopic treatments for chronic radiation proctopathy.

MAIN OUTCOME MEASUREMENTS

The primary outcomes measured were the resolution or improvement in symptoms.

RESULTS

A total of 39 studies were found, of which 27 evaluated endoscopic therapy and 12 evaluated medical therapy chronic radiation proctopathy. Overall, there is low-level evidence for the effectiveness of endoscopic therapy with argon plasma coagulation in reducing short-term (≤6 weeks) symptoms of chronic radiation proctopathy and insufficient evidence for long-term improvement. There is moderate-level evidence for the use of sucralfate enemas and low-level evidence for use of short-chain fatty acid enemas and hyperbaric oxygen. There is insufficient evidence for other agents: topical formalin, 5-aminosalicylic acid compounds, sulfasalazine, vitamin A, and pentoxifylline.

LIMITATIONS

Individual authors were not contacted, and the search was limited to English language journals only.

CONCLUSION

Endoscopic treatment with argon plasma coagulation appears effective in the short-term outcome of chronic radiation proctopathy. There is a moderate level of evidence for the use of sucralfate enemas. Large, randomized, placebo-controlled studies evaluating endoscopic and medical therapies for chronic radiation proctopathy are needed.

Endoscopic management of chronic radiation proctitis

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

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Endoclipping treatment of life-threatening rectal bleeding after prostate biopsy

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound (TRUS)-guided multiple biopsy of the prostate, but is usually mild and stops spontaneously. We report what is believed to be the first case of life-threatening rectal bleeding following this procedure, which was successfully treated by endoscopic intervention through placement of three clips on the sites of bleeding. This case emphasizes endoscopic intervention associated with endoclipping as a safe and effective method to achieve hemostasis in massive rectal bleeding after prostate biopsy. Additionally, current data on the complications of the TRUS-guided multiple biopsy of the prostate and the options for treating fulminant rectal bleeding, a consequence of this procedure, are described.

[Nonsurgical treatment of chronic radiation-induced hemorrhagic proctitis]

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

Therapeutic endoscopy for nonvariceal gastrointestinal bleeding

The evaluation and management of acute gastrointestinal bleeding in infants, children, and adolescents is a reason for emergency consultation frequently cited by pediatric gastroenterologists. After stabilization of the patient's condition, endoscopic evaluation remains the most rapid and accurate method to identify the origin of acute bleeding in the majority of lesions in the pediatric age group. Several endoscopic techniques may be applied to bleeding lesions to achieve hemostasis. Familiarity with the various techniques and with the specifics of their use is essential for the pediatric endoscopist. This review focuses on the endoscopic management of acute nonvariceal bleeding in infants and children.

Prospective evaluation of a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy

OBJECTIVE

The aim of this study was to prospectively evaluate a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal (GI) endoscopy.

MATERIAL AND METHODS

From February to June 2005, 216 patients (167 M (77.3%), mean age 66 years) underwent treatment with hp-APC in a total of 275 sessions. Main indications were additive ablation therapy in Barrett's esophagus, palliative treatment of esophageal cancer, gastric polyps/carcinomas, angiodysplasias, Zenker's diverticula, and duodenal adenomas. The new hp-APC device (VIO 300 D with APC 2) was used (15-120 W) in upper GI endoscopy, push-enteroscopy, and double-balloon enteroscopy.

RESULTS

The mean number of treatment sessions required was 1.7 (1-5). For palliative tumor ablation in the esophagus, the number of sessions was 2.3 (1-5). Minor complications (pain, dysphagia, neuromuscular irritation, asymptomatic gas accumulation in the intestinal wall) were observed in 29/216 patients (13.4%). Major complications (perforation, stenosis occurred) in 2 patients (0.9%).

CONCLUSIONS

Hp-APC appears to be safe and effective in the treatment of various GI condition using different types of endoscopes including double-balloon enteroscopy. Because of the low number of treatment sessions required, hp-APC could be used as an alternative to Nd:YAG laser treatment in tumor debulking.

Argon plasma coagulation therapy for a hemorrhagic radiation-induced gastritis in patient with pancreatic cancer

Radiation-induced gastritis is a serious complication of radiation therapy for pancreatic cancer which is difficult to manage. A 79-year-old man had been diagnosed as having inoperable pancreatic cancer (stage IVa). We encountered this patient with hemorrhagic gastritis induced by external radiotherapy for pancreatic cancer that was well-treated using argon plasma coagulation (APC). After endoscopic treatment using APC, anemia associated with hemorrhagic radiation gastritis improved and required no further blood transfusion.

Treatment of a radiation-induced rectal ulcer with hyperbaric oxygen therapy in a man with prostate cancer

Late radiation proctopathy is a painful and vexing complication of prostate radiation. We report a case of a 55-year-old man with prostate cancer, and complaints of tenesmus and severe rectal pain after radiation therapy. The patient was diagnosed with a locally advanced Gleason score 8 prostate cancer and an increased prostate-specific antigen of 42.3 ng/ml. His past medical history was notable for a history of bilateral lymph node dissection complicated by Clostridium difficile colitis. He subsequently received 3-dimensional conformal radiation therapy. Seven months after completing therapy, minor rectal bleeding and significant pain developed, requiring increasing doses of opioid analgesics. Fourteen months after 3-dimensional conformal radiation therapy, sigmoidoscopy revealed a single chronic deep ulcer at the anorectal junction. As an alternative to diverting colostomy, the patient underwent a course of hyperbaric oxygen. Within 1 month of completing hyperbaric oxygen treatment, his symptoms completely resolved. Nine months from completion of hyperbaric oxygen therapy, he has had no recurrence of symptoms. Hyperbaric oxygen therapy can be considered a treatment option after failure of standard treatments in patients with severe radiation proctopathy.

Endoscopic treatment of chronic radiation proctopathy

PURPOSE OF REVIEW

Chronic radiation proctopathy is a complication of pelvic radiation therapy. The acute phase of radiation injury to the rectum occurs during or up to 3 months following radiation. Acute radiation injury can continue into a chronic phase or chronic radiation proctopathy may develop after a latent period of several months or years. Symptoms associated with the condition include diarrhea, rectal pain, bleeding, tenesmus, and stricture formation. Of the various symptoms, only bleeding from radiation-induced telangiectasias is amenable to endoscopic therapy. This paper summarizes the findings of experts in the field on endoscopic treatment of bleeding from chronic radiation proctopathy.

RECENT FINDINGS

Medical management is generally ineffective in controlling bleeding from chronic radiation proctopathy. Surgical intervention has a high incidence of morbidity. Promising advances have been made in endoscopic therapy, including formalin, neodymium/yttrium aluminum garnet, argon and potassium titanyl phosphate laser treatments, as well as argon plasma coagulation. Argon plasma coagulation presents an effective, efficient, inexpensive and reasonably safe noncontact method for destruction of radiation telangiectasias.

SUMMARY

Based on currently available data and trends, argon plasma coagulation is the favored treatment for bleeding from chronic radiation proctopathy.

A new minimally invasive technique for treating radiation cystitis: the argon-beam coagulator

OBJECTIVE

To assess the effectiveness of the argon-beam coagulator used endoscopically for treating radiation cystitis, as radiotherapy is commonly used for treating pelvic tumours of urological origin, but intractable bleeding related to radiation cystitis remains a serious complication and requires a difficult long-term follow-up, for which cystoscopic methods of management have traditionally had limited success.

PATIENTS AND METHODS

We assessed seven patients with radiation cystitis; they were treated with argon-beam coagulation after a cystoscopic evaluation.

RESULTS

With a mean follow-up of 15 months, one treatment was used in six patients, with a second treatment required in one.

CONCLUSION

The argon-beam coagulator appears to be a safe, well tolerated and minimally invasive treatment in patients with radiation cystitis.

Late genitourinary and gastrointestinal toxicity after magnetic resonance image-guided prostate brachytherapy with or without neoadjuvant external beam radiation therapy

BACKGROUND

This study was designed to estimate the rates of late genitourinary (GU) and rectal toxicity after magnetic resonance image (MRI)-guided prostate brachytherapy exclusively or in conjunction with external beam radiation therapy (EBRT).

METHODS

Between November 1997 and April 2002, 201 patients with category T1C prostate carcinoma (according to the 2002 American Joint Committee on Cancer staging criteria), prostate specific antigen levels < 10 ng/mL, and biopsy Gleason score 3 + 4 disease were treated with MRI-guided brachytherapy exclusively or in conjunction with EBRT. The MRI-guided technique was designed to spare the urethra based on delivery of the prescription dose to the peripheral zone exclusively. The Kaplan-Meier method was used to estimate rates of freedom from late GU and rectal toxicity. Comparisons were made using a log-rank test.

RESULTS

At a median follow-up of 2.8 years (range, 0.5-5.0 years), the 4-year estimates of rectal bleeding requiring coagulation for patients who underwent implantation therapy, compared with patients who received combined-modality therapy, were 8% versus 30%, respectively (log-rank P value = 0.0001). Although erectile dysfunction was common (range, 82-93%), with the use of sildenafil citrate (Viagra), it was estimated that at least two-thirds of patients had erectile function comparable to or superior to baseline function, independent of whether they received monotherapy or combined-modality therapy (P = 0.46). The 4-year estimate of freedom from radiation cystitis was 100% versus 95% (P = 0.01) for patients who received monotherapy and patients who received combined-modality therapy, respectively. No urethral strictures were observed, and no patients underwent postimplantation transurethral resection of the prostate.

CONCLUSIONS

In the current study, rectal bleeding after MRI-guided prostate brachymonotherapy was infrequent, and urethral and bladder toxicity is reported to be rare and may be attributed to the urethral-sparing technique of the MRI-guided approach.

Haemorrhagic radiation proctitis: endoscopic severity may be useful to guide therapy

BACKGROUND AND AIMS

Management of haemorrhagic radiation proctitis remains controversial. Both endoscopically delivered argon plasma coagulation and rectal administration of formalin have been recommended. We evaluated the efficacy of argon plasma coagulation according to endoscopic severity of radiation proctitis.

PATIENTS AND METHODS

Fourteen patients treated with argon plasma coagulation for rectal bleeding due to radiation proctitis were reviewed. Patients were classified with a new endoscopic score for haemorrhagic radiation proctitis, comprising three factors: telangiectasia distribution, surface area involved, and presence of fresh blood. Seven patients were categorised as having grade A (mild), four grade B (moderate), and three grade C (severe) radiation proctitis. Rectal bleeding was assessed pre- and post-treatment using a five-point bleeding scale.

RESULTS

All patients with grade A and B radiation proctitis were treated successfully by argon plasma coagulation (mean 1.5 sessions). In one patient with grade C radiation proctitis argon plasma coagulation was successful after four sessions, but in the other two patients bleeding could not be controlled; a subsequent single formalin administration was successful in both. Overall in 12 patients (85.7%) bleeding ceased or improved significantly. The mean rectal bleeding scale reduced significantly from 2.6 to 0.9. One patient treated with argon plasma coagulation developed an asymptomatic rectosigmoid stenosis.

CONCLUSION

Argon plasma coagulation is a simple, safe and efficacious therapy for mild/moderate radiation proctitis. In patients with severe radiation proctitis several sessions are usually necessary, and success is not certain; in these cases, topical formalin administration may be more effective. Endoscopic severity of haemorrhagic radiation proctitis may be useful to guide appropriate therapy.

Endoscopic Therapy for Inflammatory Bowel Disease

Endoscopic therapy can be employed and may be useful in inflammatory bowel disease patients with dysplastic polyps, inflammatory strictures (enteric and biliary), bleeding, and for treatment of some complications of continent ileostomies. Dysplastic polyps can be removed endoscopically safely and effectively without resorting to colectomy, as long as there is no other detectable dysplasia in flat mucosa and complete removal can be assured (by biopsy of adjacent mucosa and close follow-up). Some colonic strictures in Crohn's disease can be dilated using endoscopes of graded caliber or with through-the-scope balloons, with or without stent placement. Endoscopy is most useful in dilating anastomotic strictures and less useful for long strictures in active inflammatory disease. Strictures in ulcerative colitis are suspicious for neoplasia and, if dilated at all, should be biopsied extensively and followed closely. We prefer colectomy to endoscopic dilatation for strictures in ulcerative colitis. Biliary endoscopy can be used to dilate strictures in primary sclerosing cholangitis and to sample these areas for malignancy. Although dilatation may improve morbidity and prolong survival, it may not prevent progression to cirrhosis. In cholangiocarcinomas, endoscopic dilatation with or without stents can offer palliation and perhaps be used to deliver photodynamic therapy. Injection and sclerotherapy can be employed in Crohn's disease bleeding from a discrete site. In obstructed continent ileostomies (both Kock pouches and pelvic ileoanal reservoirs), endoscopy can be employed effectively to both determine the cause of the obstruction and re-establish patency. We do not advocate endoscopic treatment of toxic megacolon because of the heightened risk of perforation. Endoscopic therapy of Crohn's fistulas is a possible emerging technology, but it has not been used in large cohorts of patients.