A Novel Approach to Intractable Rectal Stump Drainage

Dear Editor: A 77-year-old male with recent history of radiation therapy for prostate cancer was referred with symptoms of fresh bleeding per rectum. Radiation proctitis (RP) was previously diagnosed on endoscopy at an outside facility. He had undergone three endoscopic ablation treatments with argon plasma coagulation (APC) but lower GI bleeding persisted, requiring multiple blood transfusions. On flexible sigmoidoscopy, multiple bleeding telangiectatic lesions with erythema and friability extending to 10 cm from the anal verge were noted, consistent with moderate grade radiation proctitis. Radiofrequency ablation (RFA) was offered as a rescue treatment. RFA was performed using the HALO 90 system (Covidien, Sunnyvale, CA), and the scope was rotated circumferentially to target all areas. Energy was delivered at settings of 12–15 J/cm and power density of 40 W/cm. At least two ablation sets were applied to each area. Post ablation, the coagulum was not scraped to promote hemostasis. The patient underwent a total of three RFA sessions at 4to 6-week intervals. His symptoms markedly improved with treatment sessions. On repeat endoscopy, the patient was found to have few spotty telangiectasias that were ablated with APC, 30 W, pulsed at 2 s (Erbe, Tubingen, Germany). On close follow-up, he was asymptomatic and hemoglobin levels were stable from prior. Rectal bleeding can occur from chronic radiation proctitis in up to 20 % of patients as a late complication following radiation therapy for pelvic malignancy. Ablation of the abnormal microvessels with subsequent re-epithelization is beneficial, and APC is currently offered as treatment of choice. However, in refractory cases, endoscopic RFA has recently been proposed as an alternative treatment for RP. RFA confers additional advantages over other modalities such as APC, as illustrated as follows. Firstly, RFA allows simultaneous treatment of broader areas of targeted tissue compared to APC. Also, RFA delivers a consistent amount of energy to the surface causing uniform coagulation of vessels achieving adequate hemostasis. Finally, by the tightly spaced bipolar array, RFA has limited energy penetration, which avoids energy dissipation and further injury to deeper tissue. The technical challenge was to maintain an optimal apposition to the targeted tissue applying torque and rotation of the scope with the electrode attached over the tip in a clockwise fashion, such that circumferential ablation to all areas was feasible. Targeting lesions close to the dentate line may be better using APC. This unique case exhibits a Bdual^ approach to achieve complete resolution of symptoms and bleeding related to chronic RP. In this proposed dual approach, RFA serves to deliver an initial ablative Bhit^ by significantly decreasing the burden of lesions, and APC is used to subsequently target the remaining point lesions. We believe that this combined approach also will prevent ulceration and long-term structuring compared to a single-mode RFA treatment. In conclusion, dual-modal ablation offers an ideal approach to management of RP, especially in refractory cases. * Kevin P. Cowley kcowley@uabmc.edu

Barrett's esophagus: should we burn it all?

Percutaneous osteoid osteoma treatment with combination of radiofrequency and alcohol ablation

Endoscopic Therapy for Barrett's Esophagus

SUMMARY. Radiofrequency ablation (RFA) and endovenous laser coagulation of veins (EVLC) are of priority in the treatment of varicose veins of the lower extremities in outpatient settings. Although the indications for these operations and the technology of their application are defined, the issue of improving their functional results, in particular the involution of collateral veins on the lower leg after ablation of the great saphenous vein, is relevant.
 The aim – to improve the results of the treatment of varicose veins in an outpatient setting by using a combination of radiofrequency and laser vein ablation.
 Material and Methods. Under observation were 154 patients who were operated on with the help of RFA and 111 patients who underwent combined thermal ablation GSV RFA (on the thigh) and EVLС (on the leg).
 To compare the effectiveness of RFA and the combination of RFA with EVLС (hybrid thermoablation of veins), a quantitative and qualitative assessment of their results was carried out. In particular, the quantitative assessment was performed using a number of scales VCSS, VDS, VSDS, VSS. Questionnaires: MOS SF–36 and CIVIQ–20 were used for qualitative assessment. The results of operations were evaluated after 3, 6 months and a year after their implementation.
 Results. The analysis of the results of operations shows that, according to quantitative and qualitative indicators, combined operations with the simultaneous use of RFA and EVLС are more effective than RFA. These indicators were directly influenced by the number of residual veins after 6 months of observation (33.1 % after RFA and 5.4 % after hybrid thermoablation).
 Conclusion. The use of hybrid thermal ablation for the treatment of varicose veins of the lower extremities, in outpatient conditions, is qualitatively and quantitatively more effective than RFA.

Radiofrequency ablation compared with argon plasma coagulation after endoscopic resection of high-grade dysplasia or stage T1 adenocarcinoma in Barrett’s esophagus: a randomized pilot study (BRIDE)

Introduction: Gastric antral vascular ectasia (GAVE) is a rare condition that presents in the distal stomach as dilated longitudinal columns of blood vessels prone to bleeding. Nodular GAVE is an even rarer variant and is often refractory to standard therapy for GAVE. Endoscopic treatment options widely varies and include rubber band ligation, radiofrequency ablation (RFA), argon plasma coagulation (APC), and resection with hot snare. We present a case study of successful treatment of nodular GAVE of a patient who has been refractory to repeated APC with combination therapy of band ligation and sclerotherapy. Case Description/Methods: 63-year-old female with history of alcoholic cirrhosis and pancreatitis who has had persistent iron deficiency anemia thought secondary to chronic blood loss requiring constant transfusions. Initial EGD was performed at age of 60 with evidence of small grade I esophageal varices, portal hypertensive gastropathy, and innumerable gastric polyps in the gastric body and antrum that on biopsy was consistent with nodular GAVE. She then underwent 5 repeat EGDs over a span of 6 months with a combination RFA, APC, snare resection followed by hemostatic clipping, and banding, with continued recurrence of nodular GAVE and transfusion dependent anemia, with total of 17 units of packed red blood cell (pRBC) transfusions required over the same 6 month period. On her seventh EGD, she then underwent combination therapy of sclerotherapy (1% sodium tetradecyl sulfate (STS), 20mL total), which were injected at the base of the nodular areas, along with placement of 12 bands. Her transfusion requirements subsequently subsided after the initial sclerotherapy and band ligation combination session, and the patient received additional 6 EGD sessions with repeat combination therapy over the next 12 months, with notable visual improvement endoscopically subsequent to 2 sclerotherapy plus banding sessions. She only required a total of 3 units of pRBC transfusion over the same period. (Figure) Discussion: We described the first known case of combination sclerotherapy and band ligation therapy for treatment of refractory nodular GAVE. The treatment resulted in significant reduction in transfusion requirements with concomitant improvement of the appearance of nodular GAVE even after just 2 sessions, and may be particularly useful in patients who have failed more conventional treatments. Additional studies will need to be performed to determine the safety and efficacy of this combination treatment modality.Figure 1.: endoscopic images of nodular GAVE before and after serial treatments, along with a timeline of hemoglobin level, transfusions, and endoscopic sessions/therapies over the patient's follow up period of 1.5 years.

Esophageal stents have utility in temporizing esophageal leaks and benign or malignant strictures, but their removal can be complicated by tissue embedment. Special methods for removal include argon plasma coagulation (APC) induction of tissue necrosis and stent-in-stent technique (SIS). APC is a non-contact thermal technology that uses argon gas to deliver plasma of thermal energy to an area adjacent to the probe, and it is widely used as a method to control bleeding. APC can be set at a precise setting to limit necrosis to the superficial layer of the esophageal mucosa. On the other hand, SIS utilizes a second esophageal stent that is placed within the first stent to induce necrosis of embedded tissue, enabling removal of both stents. We present two cases with successful removal of embedded, partially-covered self-expandable esophageal metal stents (SEMS) using APC at a precise setting of 50W. One case showed the flexibility of APC in removal of a migrated SEMS in a 75-year-old female patient with metastatic esophageal cancer. The stent had migrated into the stomach with the distal tip eroding into gastric mucosa with embedment of proximal stent into distal esophagus. Given the positioning, SIS was not possible. APC was used to induce necrosis of embedded tissue. Two days later, repeat APC treatment was performed with removal of the stent with grasping forceps<./p> The second case demonstrated the efficacy of APC in removal of a SEMS placed for an esophageal leak after sleeve gastrectomy in a 44-year-old female patient. A partially-covered SEMS was chosen to minimize migration. After esophageal leak resolution one month later, APC was used to induce tissue necrosis of areas of stent embedment. On repeat endoscopy, the esophageal stent was easily dislodged using blunt dissection with a plastic cap with minimal bleeding. We propose that APC is a superior technique for esophageal stent removal compared to the SIS. APC is more readily available with decreased cost compared to the SIS which requires a second stent. Placing a stent within another can be complicated by incomplete induction of necrosis, severe pain and tracheal compression. APC and SIS both require at least two separate days of endoscopy, but APC in our study has only needed an interval time of 2-4 days versus median time of 9-14 days for SIS. Given the small sample sizes, further investigation is needed to determine the optimal technique for esophageal stent removal.2115_A Figure 1. CT Scan of Abdomen showing esophageal stent migration with erosion into gastric fundus.2115_B Figure 2. #1 shows the migrated esophageal stent. #2 Induction of tissue necrosis with APC.

Purpose: Gastric antral vascular ectasia (GAVE) is an infrequent cause of upper gastrointestinal bleeding, constituting 4% of non-variceal bleeds. Therapeutic options are limited which includes medical, endoscopic, and surgical treatment. We present this case series to evaluate the use of radiofrequency ablation (RFA) as a plausible option. Methods: We conducted a retrospective analysis of patients who underwent RFA for GAVE lesions at our institution. One patient underwent antrectomy 2 days after the first session of RFA and was therefore excluded from this study. One patient received first session of RFA recently and his post-treatment follow-up is not complete. For rest of the patients, their demographics, number of RFA sessions, type of catheter(s) used, total number of ablations and other treatment options used, hemoglobin (Hb) level, total number of blood transfusions required, and total number of days spent in the hospital due to anemia secondary to GAVE lesions before and after therapy were recorded. Results: A total of five (two male, three female) patients were included with a mean age of 81 years. Since one patient does not have complete follow-up after treatment, data pertaining to him is not used to make calculations. Both HALO90 and HALO90 Ultra were used. An average of 1.8 sessions (range 1-4) and 65 ablations (range 17-181) were applied per patient. After the completion of RFA, mean Hb increased from 9.13 gm/dL (range 7.6-11.6 gm/dL) to 11.05 gm/dL (range 9.3-11.75 gm/dL), the mean number of transfusions decreased from 41.25 units/patient (range 0-158) to 8.4 (range 0-10), and none of the patients were admitted to the hospital again with GI bleed or anemia after RFA. Two patients had no previous therapy while the other three had received multiple argon plasma coagulation (APC) sessions (3-13) prior to RFA. Only one patient received APC (two sessions) after RFA. Conclusion: RFA using HALO ablation catheter has been utilized safely in Barrett's Esophagus for ablation of metaplastic epithelium. Its use in GAVE lesions was first shown by Gross et al in 2007. Our case series evaluates the use of RFA in all the patients of GAVE lesions including those not responding to (APC). APC is the most studied and used form of treatment for GAVE, but it has a small surface area of 12 mm2 and hence has a small focal area of coverage. HALO90 and HALO90 Ultra have surface area of 260 mm2 and 520 mm2, respectively, and hence can be used to ablate larger surface areas. In our experience we found that all patients had an improvement in their Hb levels, blood transfusion requirements decreased markedly, and no one was admitted to hospital again with GI bleed or anemia. Our study shows benefits of RFA in GAVE lesions and this must be studied in a randomized controlled trial.

Case. A 74-year-old woman with renal cell carcinoma had an oligometastatic in the vertebra T7 which was treated surgically and adjuvant radiation therapy. Nine months later, the patient reported severe back pain. CT showed a new metastasis of the vertebral body of L1. This lesion was ablated using percutaneous transpedicular radiofrequency ablation (RFA) in combination with the application of bone cement vertebroplasty. Percutaneous transpedicular RFA was considered beneficial, due to being minimally invasive, possible in a daycare setting and lacking the tissue damage as compared to open surgical treatment. This paper describes the perks of RFA as a treatment in spinal metastasis to create awareness for this valuable alternative palliative treatment in a metastasized setting. Conclusion. Percutaneous radiofrequency ablation in combination with the application of vertebroplasty is a potential minimal invasive option to reduce the tumor load, provide pain relief, and stabilization in daycare.

Background and Aims: The aim of this study was to retrospectively analyze use of argon plasma coagulation in lesions of the gastrointestinal tract. Materials and Methods: Data of 92 patients treated with an argon plasma coagulation system in the upper and lower gastrointestinal tract between May 2005 and November 2006, using a VIO argon plasma coagulation device (VIO 300 D with argon plasma coagulation 2; Erbe Elektromedizin, Tubingen, Germany; pulsed argon plasma coagulation, 20?120 W), were reviewed and analyzed. Results: Ninety-two patients were treated with argon plasma coagulation, and the mean age was 61.84 (3-91) years. Fifty of these patients were male (54.3%) and 42 (45.7%) were female. Ninety-two patients were treated in 155 sessions. The mean number of treatment sessions required was 1.68 (1?12). Indications were vascular lesions (24 patients), bleeding peptic ulcers or prevention of bleeding recurrence (19 patients), adjunctive therapy after piecemeal resection of colonic polyps (17 patients), palliative treatment of gastrointestinal tract cancers, treatment of bleeding after polypectomy or biopsy (11 patients), ablation of inlet patch (11 patients), ablation of Barrett?s esophagus (5 patients), radiation proctopathy (4 patients), and metallic stent cut (1 patient). There were no major complications observed. Minor complications were seen in only five patients (bleeding in 2, chest pain in 1, anal pain in 2 patients). Conclusions: Argon plasma coagulation system was an effective and safe method in various gastrointestinal pathologies.

Antitumor Immunity Augmented by Combining Radiofrequency Ablation with Anti–CTLA-4 Therapy in a Subcutaneous Murine Hepatoma Model

Although argon plasma coagulation (APC) is the current standard endoscopic treatment for gastric antral vascular ectasia (GAVE), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study was to perform a systematic review and meta-analysis to evaluate the comparative effectiveness and safety of RFA and APC in the treatment of GAVE. Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases along with major gastroenterology annual meetings were performed through March 2017. Measured outcomes for comparative effectiveness and safety including improvement in hemoglobin levels, transfusion dependence, number of treatment sessions, complications, follow-up, and author-reported endoscopic success were compared among RFA and APC studies. In total, 24 studies (n=508) involving APC and 9 studies (n=104) on RFA were included. Mean age of patients included was comparable in both groups (65.33±7.80 y for APC vs. 66.96±6.23 y for RFA; P=0.98). Pooled mean follow-up was significantly longer for APC compared with RFA (19.52±13.11 vs. 7.43±3.72 mo; P<0.001). In total, 47% of RFA patients were refractory to previous treatment with APC. RFA required fewer mean treatment sessions compared with APC (2.10 vs. 3.39, respectively; P<0.001). RFA resulted in fewer and less severe complications as compared with APC (1.92% vs. 5.12%, respectively; P<0.001). Although the reported endoscopic success was better with RFA compared with APC (97% vs. 66%; P<0.001), the posttreatment pooled hemoglobin increase and reduction in transfusion dependence was higher for APC compared with RFA [weighted mean difference 3.10 g/dL (95% confidence interval, 2.92-3.28) vs. 1.95 g/dL (95% confidence interval, 1.62-2.26); P<0.001; and 88% vs. 66%; P<0.001, for APC and RFA, respectively]. There is limited long-term data on RFA for GAVE; however, available evidence suggests RFA has a comparable efficacy and tolerability compared with APC. In addition, RFA seems to be effective for APC-refractory GAVE patients. Future controlled trials are needed to directly compare treatment efficacy, long-term durability, safety, and cost-effectiveness between these interventions.

Combination Radiofrequency Ablation and Local Injection of the Immunostimulant Bacillus Calmette–Guérin Induces Antitumor Immunity in the Lung and at a Distant VX2 Tumor in a Rabbit Model

Introduction: The inlet patch (IP) is a frequently missed lesion of heterotopic gastric mucosa with varying reported levels of prevalence. Although typically thought to be a benign finding, we have found that there is a link between IPs and patient symptoms of chronic cough, heartburn, and globus after other causes are ruled out by EGD or pH probe. In our study we postulated that ablating the IP will alleviate patients' symptoms. Methods: Patients with histologically confirmed IP on screening EGD between 2017-2019 were selected. Of that cohort patients with chronic cough, heartburn and globus who failed PPI and H2 blocker therapy were offered to have their IP removed either with radiofrequency ablation (RFA), argon plasma coagulation (APC) or biopsy forceps. Patients were followed up afterward to see if there was an improvement of their symptoms. Results: Of 3,269 patients undergoing EGD at our center between 2017-2019, 50 were found to have an IPs. Ages ranged from 24-78 years of age, mean age of 56.4, median age of 51. 10 patients also had Barrett's esophagus. 38% of patients initially had heartburn, 24% dysphagia, 20% chronic cough, 18% throat clearing, 14% globus, 4% nausea. Three patients were asymptomatic. 23 patients underwent RFA or manual removal of IPs. Clearance of IP was confirmed by repeat EGD. Of the 23 who underwent IP removal, 14 (60% of total) had either complete or partial resolution of symptoms. No adverse events reported. Conclusion: Although IPs have been considered clinically irrelevant, we have evidence that they may be the etiology of several common symptoms such as chronic cough, globus or heartburn after other causes were ruled out. Partially this may be due to IPs not being characterized on exam. IPs are either congenital or acquired from chronic acid exposure which later develops the ability to secrete its own acid through oxyntic cells within the patch. These IPs rarely benefit from aggressive acid blocking therapy. In our study we found that symptoms secondary to IPs improved in a vast majority of patients after RFA, APC or manual removal. Some further avenues of research could compare methods of removal as well as determining efficacy of removal when patients have other concomitant GI conditions. Although the study population was small, the magnitude of the number of patients with improvement of symptoms was significant. Our results suggest that further studies are necessary to select which symptomatic individuals could benefit from IP ablation.Figure 1.: A. Single inlet patch, B-C. Inlet patch ablation with APC.Table 1.: Patient list of symptoms and response to treatment. RFA (Radio frequency ablation), APC (Argon plasma coagulation) PPI (Proton pump inhibitors) Bx (Biopsy off), H2 (Histamine-2 blockers).