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.

Endoscopic ablation of Barrett's esophagus using the second generation argon plasma coagulation:a prospective randomized controlled trail

Objective：To investigate the efficacy and safety of the second generation argon plasma coagulation（VIO APC） in the ablation of Barrett＇ s Esophagus. Methods：A total of 35 patients with uncomplicated Barrett＇ s esophagus entered into a prospective, randomized, unblinded study comparing the treatment VIO APC combined with a proton pump inhibiter with a proton pump inhibiter administered alone. VIO APC was performed at a power setting of 40W, and argon gas flow at 1.5-2.0 L/min, and＂ forced＂ mode. Ablative treatment was repeated until either no Barrett＇ s epithelium remained or a maximum of 5 treatment sessions occurred. Results：In the ablation group, macroscopic complete ablation was achieved in 14 of 18 patients, and complete ablation confirmed by histology in 12 of 18 patients （P 〈 0.01）. Buried glands were observed in 2 patients who had achieved macroscopic ablation. The Barrett＇s mucosa averaged a reduction of 65%（range 50-75%） in the remaining 4 patients. In the control group, only 2 patients had partial regression, median 30%（range 20-40%）. In the ablation group, post-treatment 4 patients had transient retrosternal pain, and 3 patients had mild epigastric discomfort. One patient had a small hemorrhage during the procedure, which ceased after norepinephrine and thrombosin were administered through the endoscope biopsy channel. No adverse events were observed in the control group. During 11.8（4-15） months follow-up, patients who had achieved the complete ablation have no evidence of relapse of Barrett＇ s esophagus. Conclusion：VIO APC with a relatively low power setting can effectively ablate the Barrett＇ s mucosa. No severe adverse events were observed. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium.

Ablation of Barrett’s esophagus using the second-generation argon plasma coagulation

Objective To investigate the efficacy and safety of the second-generation argon plasma coagulation (VIO APC) in ablation of Barrett’s esophagus. Methods Eighteen patients with Barrett’s esophagus (12 males, median age of 55 years, median length of 2.1 cm,1 low-grade dysplasia, 13 cases of short segment Barrett’s esophagus) received VIO APC, which was performed at a power setting of 40W and argon gas flow at 1.5-2.0 L/min, "forced" mode, in 1-3 sessions (mean 1.3). All the patients received treatment with high-dose proton pump inhibitors. The main complaints before ablation were upper abdominal pain in 12 patients (66%), sour regurgitation in 14 patients (77%), and dysphagia or odynophagia in 7 patients (38%). Two patients (11%) had esophageal hiatal hernia. Results The percentage of patients in whom ablation was endoscopically achieved proximal to the gastroesophageal junction was 77.8% (14/18), and histologically achieved in 66.7% (12/18). Berried glands were observed in 2 patients who had achieved endoscopic ablation, the areas of Barrett’s mucosa were reduced by more than 60% in the other 4 patients. After treatment, 4 patients had transient retrosternal pain and 3 patients had mild epigastric discomfort. One patient had small amounts of hemorrhage during the process, and it ceased after norepinephrine and thrombosin were administered through endoscope biopsy channel. No esophageal stricture or other severe adverse events was observed. During 11.8 (4-15) months’ follow-up, the patients who had achieved the complete ablation had no evidence of relapse of Barrett’s esophagus. Conclusion VIO APC with a relatively low power setting can effectively ablate the Barrett’s mucosa with special intestinal metaplasia when standard APC has been done. No severe adverse events were observed. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium.

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.

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.

Esophageal squamous papillomas with focal dermal hypoplasia and eosinophilic esophagitis

Focal dermal hypoplasia(FDH) is a rare disorder of the mesodermal and ectodermal tissues. Here we present an eight-year-old female known to have FDH who presents with poor weight gain and dysphagia. She was diagnosed with multiple esophageal papillomas and eosinophilic esophagitis. She was successfully treated with argon plasma coagulation and ingested fluticasone propionate, which has not been described previously in a child.

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.

In vitro study of safety and co-efficiency of the transbronchial coagulation techniques

Background The usual transbronchial coagulation techniques include microwave, argon plasma coagulation （APC）, electrocautery and cryotherapy. However, there are serious clinical problems in the safety of each. By analyzing the experimental data and clinical observations, we observed the variable effects of different coagulation techniques via bronchofibroscopy, to look for an optimal interventional management of luminal bronchus diseases, and evaluate the safety and the equivalent point. Methods Four kinds of coagulation techniques under bronchoscopy were performed on the fresh bronchus of healthy sheep, and the pathologic changes in all groups were observed under the microscope. The different treatment parameters were as follows： microwave 60 Wxl second, 3 seconds, 5 seconds and 40 W×1 second, 3 seconds, 5 seconds; APC 40 W×1 second, 3 seconds, 5 seconds; electrocautery 40 W×1 second, 3 seconds, 5 seconds; cryotherapy 100 Ω×60 seconds, 120 seconds. Results After treatment, ovine bronchial mucosa in all groups showed pathologic changes such as local necrosis and amotio of the mucosa lining epithelium, local submucosa coagulative necrosis or tissue defects, while inflammation in the surrounding tissue was not obvious. Under the same output power and action time, different methods had different outcomes. The damage by APC was the most superficial, microwave was the second, and electrocautery caused the worst damage. The study also found that effects of electrocautery at 40 W×3 seconds, microwave at 40 W×5 seconds or 60 W×3 seconds, APC at 40 W×5 seconds and cryotherapy at 100 Ω×120 seconds were the equivalent point conditions. The appearance included mucosa absence, partial submucosa absence, and collagen fiber coagulation in treatment areas. Conclusions Each coagulation technique has its own characteristic. It is very important to choose the appropriate power and action time of the suitable method according to the therapy requirement.