Argon plasma coagulation for the endoscopic treatment of gastrointestinal tumor bleeding: A retrospective comparison with a non-treated historical cohort.

BACKGROUND: The endoscopic use of argon plasma coagulation (APC) to achieve hemostasis for upper gastrointestinal tumor bleeding (UGITB) has not been adequately evaluated in controlled trials. This study aimed to evaluate the efficacy of APC for the treatment of upper gastrointestinal bleeding from malignant lesions. METHODS: Between January and September 2011, all patients with UGITB underwent high-potency APC therapy (up to 70 Watts). This group was compared with a historical cohort of patients admitted between January and December 2010, when the endoscopic treatment of bleeding malignancies was not routinely performed. Patients were stratified into two categories, grouping the Eastern Cooperative Oncology Group (ECOG) performance status scale: Category I (ECOG 0-2) patients with a good clinical status and Category II (ECOG 3-4) patients with a poor clinical status. RESULTS: Our study had 25 patients with UGITB whom underwent APC treatment and 28 patients whom received no endoscopic therapy. The clinical characteristics of the groups were similar, except for endoscopic active bleeding, which was more frequently detected in APC group. We had 15 patients in the APC group whom had active bleeding, and initial hemostasis was obtained in 11 of them (73.3%). In the control group, four patients had active bleeding. There were no differences in 30-day re-bleeding (33.3% in the APC group versus 14.3% in the control group; p = 0.104) and 30-day mortality rates (20.8% in the APC group, versus 42.9% in the control group; p = 0.091). When patients were categorized according to their ECOG status, we found that APC therapy had no impact in re-bleeding and mortality rates (Group I: APC versus no endoscopic treatment: re-bleeding p = 0.412, mortality p = 0.669; Group II: APC versus no endoscopic treatment: re-bleeding p = 0.505, mortality p = 0.580). Hematemesis and site of bleeding located at the esophagus or duodenum were associated with a higher 30-day mortality. CONCLUSIONS: Endoscopic hemostasis of UGITB with APC has no significant impact on 30-day re-bleeding and mortality rates, irrespective of patient performance status.

Histology assessment of bipolar coagulation and argon plasma coagulation on digestive tract.

AIM: To analyze the effect of bipolar electrocoagulation and argon plasma coagulation on fresh specimens of gastrointestinal tract. METHODS: An experimental evaluation was performed at Hospital das Clinicas of the University of São Paulo, on 31 fresh surgical specimens using argon plasma coagulation and bipolar electrocoagulation at different time intervals. The depth of tissue damage was histopathologically analyzed by single senior pathologist unaware of the coagulation method and power setting applied. To analyze the results, the mucosa was divided in superficial mucosa (epithelial layer of the esophagus and superficial portion of the glandular layer of the stomach and colon) intermediate mucosa (until the lamina propria of the esophagus and until the bottom of the glandular layer of the stomach and colon) and muscularis mucosa. Necrosis involvement of the layers was compared in several combinations of power and time interval. RESULTS: Involvement of the intermediate mucosa of the stomach and of the muscularis mucosa of the three organs was more frequent when higher amounts of energy were used with argon plasma. In the esophagus and in the colon, injury of the intermediate mucosa was frequent, even when small amounts of energy were used. The use of bipolar electrocoagulation resulted in more frequent involvement of the intermediate mucosa and of the muscularis mucosa of the esophagus and of the colon when higher amounts of energy were used. In the stomach, these involvements were rare. The risk of injury of the muscularis propria was significant only in the colon when argon plasma coagulation was employed. CONCLUSION: Tissue damage after argon plasma coagulation is deeper than bipolar electrocoagulation. Both of them depend on the amount of energy used.

Endoscopic treatment of large pancreatic fluid collections (PFC) using self-expanding metallic stents (SEMS) - a two-center experience.

UNLABELLED: Background/study aim: During the last several years, endoscopic ultrasound (EUS)-guided pancreatic fluid collections' (PFC) drainage has evolved into the preferred drainage technique. Recently, self-expanding metallic stents (SEMS) have been used as an alternative to double pigtail stents, with the advantage of providing a larger diameter fistula, thereby decreasing the risk of early obstruction and also allowing for direct endoscopic exploration of the cavity. The aim of this study was to evaluate the technical and clinical success, safety, and outcome of patients undergoing EUS-guided drainage of complex PFC using SEMS. PATIENTS/MATERIALS AND METHODS: The study was conducted at two tertiary hospitals from January 2010 to January 2013. All patients with PFC referred for endoscopic drainage were enrolled in a prospective database. The inclusion criteria were: (1) patients with pseudocysts or walled-off necrosis based on the revised Atlanta classification; (2) symptomatic patients with thick PFC; (3) PFC that persisted more than 6 weeks; and (4) large PFC diameter (≥ 9 cm). The exclusion criteria consisted of coagulation disorders, PFC bleeding or infection, and failure-to-inform written consent. RESULTS: A total of 16 patients (9 females, 7 males; mean age 52.6, range 20 - 82) underwent EUS drainage with SEMS. There were 14 cases of pseudocysts and 2 cases of walled-off necrosis. The etiologies of the PFC were mainly gallstones (8 of 16 patients, 50 %) and alcohol (5 of 16 patients, 31 %). Technical success was achieved in 100 % of the cases. All patients had a complete resolution of the PFC. CONCLUSION: Transmural EUS-guided drainage of complex PFC using SEMS is feasible, appears safe, and is efficacious. However, the exchange of the UC (uncovered)-SEMS for plastic stents is mandatory within 1 week. Future prospective studies, preferably multicenter studies, comparing SEMS versus traditional plastic stents for the drainage of PFC are warranted.

Endoscopic ultrasound-guided choledochoduodenostomy and duodenal stenting in patients with unresectable periampullary cancer: one-step procedure by using linear echoendoscope.

OBJECTIVE: Describe a case series of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD) associated with duodenal self-expandable metal stents (SEMS) placement using solely the linear echoendoscope in seven patients with obstructive jaundice and duodenal obstruction due to unresectable periampullary cancer. MATERIAL AND METHODS: EUS-CD in the first portion of the duodenum, associated with duodenal SEMS placement was performed in seven patients with unresectable periampullary cancer with obstructive jaundice and invasive duodenal obstruction. Laboratory tests and clinical follow-up were performed until patient's death. The procedure was performed by an experienced endoscopist under conscious sedation. The puncture position was chosen based on EUS evaluation, at the common bile duct (CBD) above the tumor, through the distal part of the duodenal bulb. After that, the needle was withdrawn and a wire-guided needle knife was used to enlarge the site puncture in the duodenal wall. Then, a partially covered SEMS was passed over the guide, through the choledochoduodenal fistula. Duodenal SEMS placement was performed during the same endoscopic procedure. RESULTS: The procedure was performed in seven patients, ranging between 34 and 86 years. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Duodenal SEMS placement was effective in 100% of the cases that remained alive after a follow-up of 7 and 30 days. CONCLUSION: The results suggest therapeutic EUS one-step procedure drainage as an alternative for these patients, with good clinical success, feasible technique and safety.