First description of oesophageal melanoma in a cat and palliative treatment by endoscopic argon plasma coagulation laser.

Case summary: An 11-year-old castrated male domestic shorthair cat presented with chronic regurgitation and weight loss. Despite a 2-month history of weight loss, regurgitation intensified over 4 weeks, occurring with every food intake, even on a semi-liquid diet. Physical examination revealed thinness and dehydration, and a focal oval mass was noted in the middle mediastinum on thoracic radiography. Oesophagoscopy identified a 6 cm neoformation almost completely obstructing the oesophageal lumen. Biopsies were taken and histopathology, positivity to melanoma triple cocktail and PNL-2 by immunohistochemistry led to the diagnosis of melanocytic neoplasm. Palliative debulking with argon plasma coagulation (APC) was performed, significantly improving the cat's quality of life for 2 months. The cat survived for 107 days after diagnosis. Relevance and novel information: This case report describes the first report of melanocytic neoplasia originating from the oesophageal mucosa in a cat. In cats, melanomas outside the eyes are exceedingly rare and oesophageal neoplasms are exceptionally rare in veterinary medicine, particularly melanomas. The diagnosis relied on positive immunohistochemistry markers aligning with previous research. Treatment with APC emerged as a novel, potentially palliative approach, successfully alleviating regurgitation for 3 months. This underscores APC's potential in feline oesophageal neoplasia palliative care, which deserves further investigation in a broader feline cohort to confirm its efficacy. Overall, this report provides valuable insights into the diagnosis and treatment of oesophageal melanoma in cats.

Anemia Secondary to Gastric Antral Vascular Ectasia Successfully Treated With Antral Gastrectomy.

Gastric antral vascular ectasia (GAVE) is a rare but significant cause of chronic gastrointestinal bleeding and anemia, particularly in elderly patients. We report the case of a 75-year-old female who presented with severe anemia secondary to GAVE. Despite multiple endoscopic interventions with argon plasma coagulation (APC) treatments and endoscopic band ligation (EBL), the patient's condition persisted, necessitating an antral gastrectomy with intraoperative endoscopy to delineate the proximal resection margin. Postoperative outcomes were favorable, with no recurrence of anemia or gastrointestinal bleeding observed during follow-up.

A sheep in wolf's clothing? Herpes-simplex-virus endobronchial pseudotumor.

Central airway obstruction (CAO) is generally defined as airflow limitation due to >50 % occlusion and is most commonly due to malignant etiologies. However, benign etiologies, including herpes-simplex-virus (HSV) endobronchial pseudotumor, can occur. Due to the rarity of HSV causing airway obstruction, an evidence-based approach to the bronchoscopic resection and standardization of therapy after removal are lacking. Herein, we present a case of HSV pseudotumor successfully managed by argon-plasma-coagulation (APC) debulking via bronchoscopy and medical management with intravenous foscarnet due to failed treatment with acyclovir for previous HSV lesions.

Endoscopic Management of Weight Regain After Bariatric Surgery.

Weight regain, also known as recurrent weight gain, is common following bariatric surgeries. While anti-obesity medications and surgical revisions offer effective treatment options, they are not without their challenges and limitations. Over the last few decades, there have been significant advancements in endoscopic interventions to address weight regain following bariatric surgery. These procedures have demonstrated feasibility, safety, efficacy, and durability, offering minimally invasive treatment options for this patient population.

Successful treatment of tracheal stenosis due to a broken uncovered metallic stent placed over 20 years ago in a patient with recurrent polychondritis using argon plasma coagulation and airway ballooning.

A woman in her mid-60s with recurrent polychondritis was admitted to our hospital due to airway stenosis secondary to an uncovered metallic stent. She underwent a bronchoscopic intervention under general anaesthesia. During the procedure, the stent fracture was cauterized using Argon Plasma Coagulation (APC) cauterisation, performed with argon flow at 1 L/min and power set at 70 W. APC cauterisation caused the stent wire to flex circularly, gradually improving the stenosis. Tracheal dilatation was then performed using an airway balloon. Following the ballooning, a thin bronchoscope was easily passed through the lower trachea, and the left and right main bronchi were observed; therefore, the procedure was completed without any complications. APC coagulation and airway ballooning are viable choices for the temporary treatment of airway stenosis due to broken metallic stents.

Treatment of Laryngeal and Tracheal Stenosis: Cooperative Treatment With Our Pulmonary Interventionalist Colleagues.

OBJECTIVES/HYPOTHESIS: We will describe the treatment of patients with subglottic and tracheal stenosis using instruments and techniques utilized by otolaryngologists and interventional pulmonologists (IP), with a focus on IP-favored approaches that may be less familiar to otolaryngologists. We will present two cases that were treated cooperatively by otolaryngology and IP and will highlight the advantages of certain techniques. STUDY DESIGN: Case series METHODS: This is a case-based presentation highlighting procedures done cooperatively by otolaryngology and IP. Instruments and techniques typically utilized by each specialty will be presented, including rigid and flexible bronchoscopy, laser, balloon dilation, medical adjuncts, fiberoptic electrocautery, fiberoptic cryoablation, and fiberoptic argon plasma coagulation. Patient outcomes for these techniques will also be discussed based on the current literature. RESULTS AND CONCLUSIONS: A dichotomy exists in the approaches typically utilized by otolaryngology and IP to address laryngotracheal stenosis. Our IP colleagues utilize techniques via a flexible bronchoscope that are often not considered in a typical otolaryngology practice. We discussed these techniques to educate otolaryngologists who may be looking to contribute to their armamentarium, as current literature suggests promising patient outcomes. Ultimately, a team approach to these often-complex patients can result in excellent outcomes.

Comparative clinical feasibility of antireflux mucosectomy and antireflux mucosal ablation in the management of gastroesophageal reflux disease: Retrospective cohort study.

OBJECTIVES: No definitive treatment has been established for refractory gastroesophageal reflux disease (GERD). Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) using argon plasma coagulation are promising methods. However, no study has compared these two. This study compared the efficacy and safety of the two procedures. METHODS: This multicenter, retrospective, observational study included 274 patients; 96 and 178 patients underwent ARMA and ARMS, respectively. The primary outcome was subjective symptom improvement based on GERD questionnaire (GERDQ) scores. The secondary outcomes included changes in the presence of Barrett's esophagus, Los Angeles grade for reflux esophagitis, flap valve grade, and proton pump inhibitor withdrawal rates. RESULTS: The ARMS group had higher baseline GERDQ scores (10.0 vs. 8.0, P < 0.001) and a greater median postprocedure improvement than the ARMA group (4.0 vs. 2.0, P = 0.002), and even after propensity score matching adjustment, these findings remained. ARMS significantly improved reflux esophagitis compared with ARMA, with notable changes in Los Angeles grade (P < 0.001) and flap valve grade scores (P < 0.001). Improvement in Barrett's esophagus was comparable between the groups (P = 0.337), with resolution rates of 94.7% and 77.8% in the ARMS and ARMA groups, respectively. Compared with the ARMA group, the ARMS group experienced higher bleeding rates (P = 0.034), comparable stricture rates (P = 0.957), and more proton pump inhibitor withdrawals (P = 0.008). CONCLUSIONS: Both ARMS and ARMA showed improvements in GERDQ scores, endoscopic esophagitis, flap valve grade, and the presence of Barrett's esophagus after the procedures. However, ARMS demonstrated better outcomes than ARMA in terms of both subjective and objective indicators.

Gastric Antral Vascular Ectasia: Resolution of Bleeding and Stabilization of Hematocrit Following Orthotopic Liver Transplantation.

Gastric Antral Vascular Ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding and iron deficiency anemia in the geriatric population. It is often associated with cirrhosis of the liver and is hypothesized to result from synthetic liver dysfunction. Treatment options include argon plasma coagulation, endoscopic band ligation, and radiofrequency ablation. An orthotopic liver transplant may be effective for patients with advanced liver disease. In this case report, we describe a 60-year-old woman with a history of cirrhosis secondary to nonalcohol-related steatohepatitis (NASH) and GAVE syndrome who presented with abdominal pain and melena. She had multiple prior episodes of gastrointestinal bleeding, leading to long-term transfusion dependency. An urgent esophagogastroduodenoscopy revealed the presence of GAVE with active bleeding. The patient was supported with blood transfusions and transferred to a transplant center, where she underwent orthotopic liver transplantation. Following the transplantation, her hemoglobin levels improved and remained stable. She was no longer noted to require any further blood transfusions during outpatient follow-up visits. This case report substantiates the role of synthetic liver dysfunction in the development of GAVE. Also, it suggests that patients with advanced cirrhosis and refractory GAVE may benefit from liver transplantation as a potential treatment option.

Hybrid argon plasma coagulation for the treatment of Barrett's esophagus: A prospective, multicenter study.

BACKGROUND: The incidence of Barrett's esophagus (BE) in China is lower compared to the Western populations. Hence, studies conducted in the Chinese population has been limited. The current treatment options available for BE treatment includes argon plasma coagulation (APC), radiofrequency ablation and cryoablation, all with varying degrees of success. AIM: To determine the efficacy and safety of HybridAPC in the treatment of BE. METHODS: The study cohort consisted of patients with BE who underwent HybridAPC ablation treatment. These procedures were performed by seven endoscopists from different tertiary hospitals. The duration of the procedure, curative rate, complications and recurrent rate by 1-year follow-up were recorded. RESULTS: Eighty individuals were enrolled for treatment from July 2017 to June 2020, comprising of 39 males and 41 females with a median age of 54 years (range, 30 to 83 years). The technical success rate of HybridAPC was 100% and the overall curative rate was 98.15%. No severe complications occurred during the operation. BE cases were classified as short-segment BE and long-segment BE. Patients with short-segment BE were all considered cured without complications. Thirty-six patients completed the one-year follow-up without recurrence. Twenty-four percent had mild dysplasia which were all resolved with one post-procedural treatment. The mean duration of the procedure was 10.94 ± 6.52 min. CONCLUSION: Treatment of BE with HybridAPC was found to be a simple and quick procedure that is safe and effective during the short-term follow-up, especially in cases of short-segment BE. This technique could be considered as a feasible alternative ablation therapy for BE.

Efficacy of surgical treatments for the management of solitary rectal ulcer syndrome: a network meta-analysis.

AIM: Solitary rectal ulcer syndrome (SRUS) is a benign and poorly understood disorder with complex management. Typical symptoms include straining during defaecation, rectal bleeding, tenesmus, mucoid secretion, anal pain and a sense of incomplete evacuation. Diagnosis is based on characteristic clinical symptoms and endoscopic/histological findings. Several treatments have been reported in the literature with variable ulcer healing rates. This study aimed to evaluate the efficacy of different treatments for SRUS. MATERIALS AND METHODS: A systematic review and network meta-analysis were performed according to the PRISMA guidelines. Studies in English, French and Spanish languages were included. Papers written in other languages were excluded. Other exclusion criteria were reviews, case reports or clinical series enrolling less than five patients, study duplications, no clinical data of interest and no article available. A systematic literature search was conducted from January 2000 to March 2024 using the following databases: PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus. The biases of the studies were assessed using the Newcastle-Ottawa scale or the Jadad scale when appropriate. Types of treatment and their efficacy for the cure of SRUS were collected and critically assessed. The study's primary outcome was to estimate the rate of patients with ulcer healing. RESULTS: A total of 22 studies with 911 patients (men 361, women 550) diagnosed with SRUS were analysed in the final meta-analysis. The pooled effect estimates of treatment efficacy revealed that surgery showed the highest ulcer healing rate (70.5%; 95% CI 0.57-0.83). Surgery was superior in the cure of ulcers with respect to medical therapies and biofeedback (OR 0.09 and OR 0.14). CONCLUSION: Solitary rectal ulcer syndrome is a challenging clinical entity to manage. Proficient results have been reported with the surgical approach, suggesting its positive role in cases refractory to medical and biofeedback therapy. Further studies in homogeneous populations are required to evaluate the efficacy of surgery in this setting. (PROSPERO registration number CRD42022331422).

Effectiveness and Safety of Argon Plasma Coagulation in Patients with Haemoptysis Caused by an Endobronchial Malignancy.

INTRODUCTION: Patients with central neoplasms and haemoptysis show low survival rates. Symptom control without recurrence 48 h after bronchoscopic interventions may improve the prognosis of these patients. Bronchoscopic argon plasma coagulation (APC) is a useful technique for endobronchial management of haemoptysis in patients with central malignancies. Nevertheless, limited data are available in the literature on its efficacy and safety and the main predictors of success are still unclear. METHODS: An observational, prospective, single-centre cohort study was carried out to assess the efficacy (i.e., immediate bleeding cessation without recurrence during the following 48 h) of bronchoscopic APC in the treatment of patients with haemoptysis caused by endobronchial malignancies and the main predictors of success. RESULTS: A total of 76 patients with median age 75 years (interquartile range: 65-79) were enrolled. 67 (88.2%) patients had bleeding cessation without recurrence 48 h after bronchoscopic APC. A low rate of non-serious adverse events (5.3%) was recorded and a low (7.6%) recurrence rate of haemoptysis at 3.5 months after the procedure was also shown. No clinical, demographic and endoscopic variables related to a successful procedure at 48 h were found. CONCLUSION: This study demonstrates that bronchoscopic APC is an effective procedure in the treatment of patients with haemoptysis caused by endobronchial malignancies, regardless of the clinical characteristics of the patients, the endoscopic and histological features of the neoplasm and the severity of the symptom. Furthermore, it shows a low rate of complications and long-term efficacy in bleeding control.

Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis.

(1) Background: Large colonic polyps during colonoscopy can be managed by Endoscopic mucosal resection (EMR). To decrease the polyp recurrence rate, thermal ablation methods like argon plasma coagulation (APC) and snare tip soft coagulation (STSC) have been introduced. We performed this network meta-analysis to assess the efficacy and safety of these modalities. (2) Methods: We performed a comprehensive literature review, through 5 January 2024, of databases including Embase, PubMed, SciELO, KCI, Cochrane Central, and Web of Science. Using a random effects model, we conducted a frequentist approach network meta-analysis. The risk ratio (RR) with 95% confidence interval (CI) was calculated. Safety and efficacy endpoints including rates of recurrence, bleeding, perforation, and post polypectomy syndrome were compared. (3) Results: Our search yielded a total of 13 studies with 2686 patients. Compared to placebo, both APC (RR: 0.33 CI: 0.20-0.54, p < 0.01) and STSC (RR: 0.27, CI: 0.21-0.34, p < 0.01) showed decreased recurrence rates. On ranking, STSC showed the lowest recurrence rate, followed by APC and placebo. Regarding individual adverse events, there was no statistically significant difference between either of the thermal ablation methods and placebo. (4) Conclusions: We demonstrated the efficacy and safety of thermal ablation after EMR for decreasing recurrence of adenoma.

Comparing the effects of argon plasma coagulation and interferon therapy in patients with vaginal intraepithelial neoplasia: a single-center retrospective study.

PURPOSE: This study aimed to evaluate the clinical efficacy and safety of argon plasma coagulation (APC) therapy and interferon therapy in patients with grade I and II vaginal intraepithelial neoplasia (VaIN). METHODS: A total of 112 patients with VaIN were diagnosed via colposcopy-induced biopsy and classified into the APC group (n = 77) and interferon group (n = 35). Clinical data including age, grade, symptoms, historical or concomitant neoplasia of the lower genital tract, indications for hysterectomy, pregnancy history, cytology, human papillomavirus (HPV) subtype, treatment modalities, and clinical outcomes were analyzed, retrospectively. Complications and clinical outcomes were assessed at 6- and 12-month follow-ups. RESULTS: There was no significant difference in the HPV clearance rate between the APC (53.42%) and interferon (33.33%) groups at 6 months after treatment. However, the 12-month follow-up of the APC group showed a significantly higher HPV clearance rate as compared to the interferon group (87.67% vs. 51.52%, P < 0.05). The APC group exhibited a significantly higher cure rate (79.22% vs. 40.0%) and lower persistence rate (12.99% vs. 37.14%) than the interferon group (P < 0.05). Adverse reaction analysis revealed that the primary reaction in the APC group was vaginal drainage, in contrast to the increased vaginal discharge in the interferon group; though the difference was significant (68.83% vs. 28.57%, P < 0.05), no serious complications were observed. CONCLUSIONS: Treatment with APC is a safe and more effective procedure against VaIN I and II, compared to interferon. APC may serve as a viable alternative to other physiotherapies.

Hot avulsion versus argon plasma coagulation for the management of the non-ensnarable polyp: A multicenter, randomized controlled trial.

Background and Aim: Snare resection of nonlifting colonic lesions often requires supplemental techniques. We compared the success rates of neoplasia eradication using hot avulsion and argon plasma coagulation in colonic polyps when complete snare polypectomy had failed. Methods: Polyps that were not completely resectable by snare polypectomy were randomized to argon plasma coagulation or hot avulsion for completion of resection. Argon plasma coagulation was delivered using a forward shooting catheter, using a nontouch technique (flow 1.2 L, 35 watts). Hot avulsion was performed by grasping the neoplastic tissue with hot biopsy forceps and applying traction away from the bowel wall while using EndoCut I or soft coagulation for avulsion. Surveillance colonoscopies were performed at 6, 12, and 18 months. Results: From November 2013 to July 2017, 59 patients were randomized to argon plasma coagulation (28) or hot avulsion (31). The median age was 69 (60-75), with 46% being female. The median residual tissue size was 10 mm (6-12). The residual adenoma rate at 6 months (hot avulsion 6% vs argon plasma coagulation 21% P = 0.09) and 18 months was not different between the groups (6.6% vs 3.6% P = 0.25). One patient in the argon plasma coagulation arm was diagnosed with metastatic cancer of likely colorectal origin despite benign histology in the original polypectomy specimen, supporting the importance of tissue acquisition. Conclusion: Both hot avulsion and argon plasma coagulation are effective and safe modalities to complete resection of non-ensnarable colonic polyps.

A multidisciplinary approach to identifying and managing heterotopic gastric inlet patches.

INTRODUCTION: Gastric inlet patches are often incidental, but can also be a treatable cause of laryngo-esophageal symptoms. METHODS: We retrospectively reviewed all patients whose gastric inlet patches were diagnosed following assessment for laryngopharyngeal and swallowing symptoms. Improvement following Argon Plasma Coagulation (APC) was assessed using Minimum Clinically-Important Difference methodology combining voice, throat, and swallowing domains. Correlations between APC response and measures of reflux and mucosal barrier integrity, measured during 24-h pH-impedance manometry, were obtained. Proximal and Distal Mean Nocturnal Baseline Impedance (MNBI) values were separately calculated and the novel variable of Mucosal Impedance Gradient was derived as [((Distal MNBI-Proximal MNBI)/((Distal MNBI + Proximal MMBI)/2)) x 100]. KEY RESULTS: Inlet patches were detected in 57 of 651 patients who had Transnasal Panendoscopy (8.7 ± 2.2%). There were 34 males. Mean age was 58 years. Mean duration of symptoms was 2 years. The commonest symptoms were hoarseness (n = 33), throat symptoms (n = 24), and dysphagia (n = 21), respectively. APC was used to ablate patches in 34 patients. Treatment response was 71% at a mean followup of 5.5 months. MIG > - 25% predicted response to APC, with area under the receiver operating characteristic curve of 0.875 (Sensitivity = 81%; Specificity = 100%; p < 0.0001). CONCLUSIONS: Gastric inlet patches are common and under-recognized. They can cause protracted pharyngo-esophageal symptoms. Patch ablation is an effective treatment for carefully selected patients. Optimal patient selection requires multidisciplinary teamwork. Mucosal Impedance Gradient could further refine patient selection.

Esophageal squamous cell carcinoma complicated with varices successfully treated by endoscopic injection sclerotherapy and argon plasma coagulation: A case report.

Treatment guidelines for esophageal squamous cell carcinoma (ESCC) with concomitant esophageal varices (EVs), which increase the risk of bleeding, are unavailable. A 66-year-old man with a history of total gastrectomy was admitted to the hospital owing to hematemesis. Emergency upper gastrointestinal endoscopy revealed variceal bleeding near the anastomosis between the esophagus and jejunum, and endoscopic clipping stopped the bleeding. Upper gastrointestinal endoscopy following hemostasis revealed four EVs and a two-thirds ESCC circumference. The ESCC depth was suspected to be up to the mucosa. The patient underwent intravariceal endoscopic injection sclerotherapy (EIS) for EVs, followed by paravariceal EIS. However, after these treatments, blood flow in the EVs just below the ESCC remained, and endoscopic resection of the ESCC was judged to be difficult to perform. Therefore, we prioritized EV treatment and performed a second EIS on the ESCC, followed by argon plasma coagulation (APC). APC was expected to not only solidify the EVs but also eliminate the ESCC existing in the mucosa. Finally, EVs and ESCC were treated by EIS and APC. EIS followed by APC may be useful for treating concurrent EVs and intramucosal ESCC in patients with liver cirrhosis when embolization of the EVs is ineffective.

Native Aortic Valve Endocarditis Secondary to Gastric Antral Vascular Ectasia Manipulation During Endoscopic Argon Plasma Coagulation.

Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal (GI) bleeds. Due to the high vascularity of the region, transient bacteremia due to manipulation of the GI tract can very rarely cause the translocation of bacteria. We present a rare case in which endoscopic manipulation to treat GAVE led to native valve infective endocarditis (IE). Our patient had a prior history of GAVE and presented with worsening dizziness and shortness of breath (SOB). After an esophagogastroduodenoscopy (EGD) and subsequent argon plasma coagulation (APC) for active preantral bleeding, the patient was noted to have repeated fevers, a new cardiac murmur, and positive blood cultures for Staphylococcus epidermidis, leading to a diagnosis of native infective endocarditis. With high clinical suspicion and early recognition of a new cardiac murmur, a transesophageal echocardiogram (TEE) was key in identifying vegetation. This case highlights the importance of combining history, a physical exam, and diagnostic lab tests and imaging to identify endocarditis. Management included two months of intravenous (IV) vancomycin and repeat TEE for close monitoring of vegetation improvement.

Case report: Successful treatment of advanced colon cancer in an eighty-year-old man with long-term and multi-stage endoscopic minimally invasive therapy.

Background: No previous studies have reported on the use of minimally invasive endoscopic therapy for colon cancer in older patients. Case presentation: An 80-year-old man was admitted to our hospital with haematochezia and diagnosed with advanced colon cancer in 2018. Traditional surgical care was rejected by his family. We successfully treated the patient with multiple minimally invasive endoscopic therapies, such as argon plasma coagulation, from 2018 to 2021. Conclusion: Invasive endoscopic therapy is a feasible way to treat colon cancer in older patients.

Intraductal Papillary Neoplasm of the Bile Duct Treated with Argon Plasma Coagulation via Endoscopic Ultrasound-guided Choledochoduodenostomy.

A 93-year-old man presented to our hospital with a fever, abdominal pain, and jaundice. Computed tomography revealed bilateral bile duct dilation, cystic lesions with bile duct communication, and intraluminal solid nodules arising from the bile duct wall. The patient was diagnosed with intraductal papillary neoplasm of the bile duct. Surgery was not performed, considering the patient's age. It was impossible to control cholangitis using conventional endoscopic therapy. We therefore created an access route to the bile duct using endoscopic ultrasound-guided choledochoduodenostomy and inserted a lumen-apposed metal stent. Thereafter, we performed argon plasma coagulation of the tumor in the bile duct, which successfully prevented cholangitis recurrence.