1. science
2. medicine
3. surgery

TECHNIQUE REVIEW
Argon Plasma Coagulation
and the Future Applications
for Dual-Mode Endoscopic Probes
Jerome Canady, MD,* Kimberly Wiley, MD,* Biagio Ravo, MD†
*Jerome Canady Institute for Advanced Biological & Technical Sciences, Hampton, VA; †Rome American
Hospital, Rome, Italy
Argon plasma coagulation (APC) is a thermoablative technique increasingly
being used in endoscopy. Since its introduction, the flexible APC probe has
been employed by endoscopists throughout the world. APC has helped change
the endoscopic management of many gastrointestinal (GI) diseases, including
hemorrhagic proctitis, watermelon stomach, bleeding peptic ulcer, and colonic
varices. Endoscopists and surgeons are creatively combining standard and
new electrosurgical techniques with APC. For instance, APC used in
combination with piecemeal polypectomy, endoscopic mucosal resection,
balloon dilatation for strictures, and plasma welding of bleeding vessels after
sclerotherapy injection are among the recent innovative techniques reported.
Other emerging innovations using APC that are being considered include
endoscopic en bloc resection of mucosal and submucosal tumors of the GI
tract, endoscopic mucosal resection supplemented with APC for high-grade
dysplasia and early GI cancers, endoscopic repair of anastomotic strictures,
and welding GI fistula tracts. As such, endoscopists require more efficient
and cost-effective multifunctional thermoablative probes. This review
discusses the development and the potential application of dual-mode
plasma endoscopic probes in fulfilling these emerging needs.
[Rev Gastroenterol Disord. 2006;6(1):1-12]
© 2006 MedReviews, LLC
Key words: Electrocautery • Argon plasma coagulation • Polyps • Endoscopic probes •
Radiation proctitis • Watermelon stomach • GI bleeding
emostasis and tissue destruction are of critical importance when removing abnormal tissue during therapeutic endoscopy. Papp1 described 3
modes of high-frequency electrocoagulation during surgical procedures:
monopolar, bipolar, and fulguration. Monopolar and bipolar electrocoagulation
H
VOL. 6 NO. 1 2006
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
1
Argon Plasma Coagulation continued
are the 2 primary modes of high
frequency energy used today during
endoscopic therapy. In the monopolar
mode, the active electrode is in direct
and permanent contact with the patient via an electrode or plate used to
collect current over a large area to
prevent tissue burns. In the bipolar
mode, a pair of active electrodes is
attached to the generator, and is
connected to the jaws of the forceps,
and the tissue between the jaws is
coagulated.
The development of a plasma
scalpel was introduced in Western
medicine 30 years ago.2 Argon
plasma coagulation (APC) is a
monopolar thermoablative method of
electrocoagulation that has been
widely used in general surgery3 for
the last 20 years, and in the specialized fields of laparoscopy,4 thoracoscopy,5 and gynecological6 surgery
for more than 10 years. Since
Canady’s7 development of the flexible
catheter that allowed the use of APC
in endoscopy, numerous applications
of APC8 have been demonstrated in
therapeutic endoscopy.
APC has been used to treat many
gastrointestinal (GI) diseases (ie,
radiation
proctitis,9-11
Barrett’s
12-14
esophagus,
gastric antral vascular
ectasia [GAVE], and treatment of
Figure 1. Single-mode probe.
arteriovenous malformations [AVM]16
throughout the GI tract). Recently,
there have been reports of using APC as
an adjunct in the endoscopic management of sessile polyps during mucosal
resection of neoplastic tissue, and during the management of GI bleeding.
However, an optimal single-use device
for these complex procedures has not
been available before now.
At the present time, 3 single-mode
flexible endoscopic APC probes are
available in the United States
(CANADY TECHNOLOGY, Hampton,
VA; CONMED Corporation, Utica, NY;
and ERBE Elektromedizin GmbH,
Tubingen, Germany). The singlemode flexible endoscopic probes are
composed of a handle (proximal connection to the connecting cable),
Teflon tubing, a fixed inner tungsten
wire within the tube, and with or
without a ceramic nozzle tip at the
end of the tube. APC probes are available in 3 diameters: 2.3 mm, 3.2 mm,
and 1.5 mm.
The APC probes are attached to a
high-frequency monopolar electrosurgical generator that delivers an
output ranging between 5000 and
6500 V. Gas flow and power range are
adjusted between 1.0 L/min to 7 L/
min and 0 to 155 W, respectively. APC
is activated by a foot switch that synchronizes current with the transfer of
an ionized plasma gas across the field
to the target tissue (Figure 1).
Dual-mode flexible endoscopic
plasma probes are composed of a handle, Teflon tubing, a movable tungsten
wire within the tube, and sometimes a
ceramic nozzle tip depending on the
application. Dual-mode plasma probes
are developed to be multifunctional
and consist of an APC polypectomy
snare, APC sclerosing needle, APC
endoscopic mucosal resector, and APC
biopsy forceps. The probes allow the
endoscopist to combine standard
monopolar electrocautery with plasma
for thermoablation in a polypectomy
snare, varix injection, mucosal resection, or biopsy of diminutive polyps as
required (Figures 2-7).
Figure 2. A. Handles for dualmode probes: Canady plasma
polypectomy snare, Canady
plasma biopsy forceps, Canady
plasma sclerosing needle B.
Canady plasma dual-mode
probes.
A
2
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REVIEWS IN GASTROENTEROLOGICAL DISORDERS
B
Argon Plasma Coagulation
Table 1
Noble Gases
He
Xe
• From Greek helios for “sun”
• Second most abundant gas in the known universe
Ne
• First noble gas to be discovered by Janssen and
Lockyear in 1868
Kr
• From Greek xenos for “strange”
Ar
• Fourth most abundant element in known universe
• From Greek kryptos for “hidden”
• Sixth in abundance in the Earth’s atmosphere
• Used in various kinds of lights from flashlights to
airport runway lights
• Rarest of the stable noble gases in the air
• Widely used commercially in headlights and
lightbulbs
• From Greek neos for “new”
• Radioactive noble gas
Rn
• Potential health hazard
• From Greek argos for “inactive”
• Third most abundant gas in the earth’s atmosphere
What Is Plasma?
Plasma is not a human invention. It is
the most common form of matter in the
universe (Figure 8). Plasma is considered the fourth state of matter and consists of a collection of freely moving
electrically charged particles of electrons and radicals. However, to appre-
of matter, the plasma state (Figure 9).
Known plasma gases in the earth’s
atmosphere are He (helium), Xe
(xenon), Ar (argon), Ne (neon), Kr
(krypton), and Ra (radon). These are
shown in Table 1.
Electrical conduction of the gas
occurs when additional energy is
When argon plasma coagulation, a form of cold plasma technology, is used
in endoscopic surgery, tissue destruction is greatly reduced.
ciate the configuration of this fourth
state, there must be a basic understanding of the other 3 states of matter:
solid, liquid, and gaseous states.
The first state of matter is the solid
state. It is configured in a chemical
structure of strong, fixed bonds between hydrogen and oxygen molecules. By gradual increases in temperature, the structural bonds between
these molecules begin to weaken, separate, and finally free hydrogen and
oxygen molecules. These molecular
changes cause the transformation of
solids (ice) into the second state of
matter, the liquid state (water); then
the third state, the gaseous state
(steam); and finally, the fourth state
supplied, despite the preservation of
electrical neutrality. This process
occurs when the electrons gain sufficient energy to separate from the gas
atoms or molecules. Plasmas are
functionally different depending on
whether or not they are in a thermal
equilibrium. Thermal equilibrium
plasmas are typically present in stars,
in contrast to nonequilibrium plasmas
that do not produce heat overload
(low-temperature plasmas).
Low-temperature plasmas are ubiquitous throughout our daily lives. This
technology is indispensable in modern material science, microelectronics,
nanotechnology, and semiconductor
technology. Low-temperature plasma
VOL. 6 NO. 1 2006
(cold plasma) technology has vast and
remarkable biomedical applications.
This plasma technology will replace
conventional modes of medical treatment in surgery and medicine.
Characteristics of Argon Plasma
Coagulation in Clinical Medicine
APC has been demonstrated to be
effective in the coagulation of blood
vessels and human tissue during
surgery. A form of cold plasma
technology that is superior to conventional modes of electrosurgery
because tissue destruction is greatly
reduced, APC is a technological
advance compared with radio-frequency (RF) electrosurgery.
APC uses a beam of high purity
(99.999%) ionized argon gas to conduct current to the tissue. The argon
stream is colorless, odorless, and conducts electrical current to the tissue
and vessel walls. Argon, one of the
safest gases known, is a noble, inert
gas, which will not react with other
elements. It will not support combustion and it clears the body in 1 respiratory cycle.
APC functions in a noncontact manner. The electrical current is initiated
only when the tip of the handpiece or
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
3
Argon Plasma Coagulation continued
Table 2
Depth of Tissue Injuiry
Tissue
Depth of Injury
Kidney
2-4 mm
Skin flap
(Breast tissue)
0.23-0.78 mm
Stomach
1.0-1.55 mm
Data from Teimourian B et al.17
catheter is within 1 cm of the target
tissue and produces a homogenous
1 mm to 2 mm well-delineated eschar.
This is more effective than standard
electrocautery because APC distributes
the arc tunnels in a more even pattern,
resulting in a uniform depth of penetration to the target tissue.
Depth of tissue injury ranges between 0.23 mm and 4 mm (Table 2).17
Tissue coagulation depths with APC
are dependent on the duration of
application, power generator output,
and distance from the target tissue.
The eschar remains firmly attached to
the tissue, in contrast to other coagulation modalities where there is an
overlying charred layer of coagulated
blood. Argon gas is used in this system because it will not oxidize the
electrode. Because of the cooling
effect of argon gas and because no
further conduction of radio-frequency
energy into tissue occurs once an
eschar forms, the temperature in the
tissue being cauterized never exceeds
110°F. This process is thought to minimize tissue destruction and necrosis.
In contrast to APC, electrosurgery
and lasers use electrical current or
light energy to localize heat and
thereby achieve hemostasis. Electrocautery and laser technology function
by temperature-dependent mechanisms. Tissue temperature increases to
200°F with electrocautery. This results
in the boiling of cellular water, the
subsequent rupture of cell membranes,
and photoevaporation of tissue.
With lasers, tissue temperature rises
even higher to 300°F to 400°F, at
which point carbonization occurs,
and 500°F, when combustion occurs
(Table 3). This heat is distributed in an
uneven fashion and may lead to the
damage of adjacent tissue and an
unknown depth of tissue injury.
Clinical Application of
Dual-Mode Plasma
Endoscopic Probes
Large Sessile Polyps
The standard treatment for colorectal
polyps is endoscopic polypectomy
snare removal. Over the last 2 decades
the endoscopic approach of even
large sessile adenomas has been established as an alternate option to
surgery. The endoscopic technique for
large sessile polyps is piecemeal
resection; however, recurrence is
among the risks.18-26
Laser photoablation27 and hot
biopsy forceps28 have been used to
Table 3
Physiological Effects Due to Temperature Changes
Temperature (°C)
4
Physiological Process
Argon Plasma Coagulation 100-110
Coagulation
Electrocautery
200
Rupture of cell membrane,
photoevaporation of tissue
Laser
300-400
500
Carbonization
Combustion
VOL. 6 NO. 1 2006
A
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
B
Figure 3. A. 4-cm sessile polyp of transverse colon; B.
Polypectomy site after successful plasma resection
with Canady polypectomy snare.
eradicate remnant adenomatous tissue after piecemeal polypectomy in
an attempt to completely ablate any
remaining neoplastic tissue. Drawbacks to lasers are their cost and the
potential of full-thickness injury and
perforation. Hot biopsy forceps are
inadequate to treat large mucosal
areas and the depth of tissue injury
can be excessive.
Argon Plasma Coagulation
Figure 4. A. Plasma polypectomy snare around polyp;
B and C. Gastric polyp removed with plasma polypectomy
snare; D. Residual site after plasma ablation.
Figure 5. A. Circumferential lesion of duodenum; B.
Piecemeal resection of the duodenal lesion with plasma
polypectomy snare; C. Plasma ablation of the duodenal lesion; D. Residual site after plasma ablation and piecemeal
resection.
VOL. 6 NO. 1 2006
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
5
Argon Plasma Coagulation continued
A
B
C
Figure 6. A. Flat colonic polyp; B. Plasma polypectomy snare is now around colonic polyp; C. Residual site after plasma ablation.
B
A
C
Figure 7. A. Sigmoid colonic polyp; B. Biopsy site with plasma forceps; C. Residual site after plasma ablation.
Argon plasma coagulation is a
monopolar thermoablative technique
that is suitable to treat large mucosal
areas with a predictable depth of
tissue injury.29-31 Recently, adjunct
use of APC after piecemeal polyp
resection has been reported to be safe
and efficacious. Wahab and colleagues15 reported that the combination of polypectomy snare resection
and APC was effective and safe in the
ablation of residual adenomatous tissue throughout the GI tract. Eradication of residual adenomatous tissue
after polypectomy with adjunct APC
was subsequently reported by Zlatanic,32 Regula,33 and Brooker and
colleagues.34 Despite the success of
this combination therapy, the use of 2
or separate probes remains costly and
6
VOL. 6 NO. 1 2006
a single-use device is intuitively
attractive.
Flat Polyps
Early endoscopic treatment of
diminutive polyps is not standardized
among gastroenterologists. The routine approach to flat small colorectal
polyps has been cold and hot forceps,
but polypectomy technique is not
consistent. A recent survey35 by the
American College of Gastroenterology
(ACG) revealed that the method of
polypectomy for small polyps (1 to
3 mm) was cold forceps (50.3%) and
hot forceps (33.3%).
The major disadvantage to the hot
and cold biopsy techniques is the
residual remnant of the polyp after
the procedure.36-38 Larger polyps in-
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
crease the incidence of residual polyp
when using cold forceps. Piecemeal
resection is often required with the
cold forceps. In 16% to 18% of
polypectomies using hot biopsy forceps, residual neoplastic tissue was
identified in the central portion of the
polyp site.
Argon has proven to be safe and
efficacious in colon polyp eradication. Wahab and colleagues15 described the coagulation of multiple
gastric polyps. Garcia and colleagues39 reported the first uncontrolled trial of APC ablation in 22
consecutive patients with colorectal
flat or sessile adenomas. In previous
reported results of adjunct APC, the
authors treated only large sessile
polyps.
Argon Plasma Coagulation
In Garcia’s report, 11 patients were
treated with piecemeal polypectomy
and supplemented with APC ablation
of residual adenomatous tissue. The
other 11 patients with flat adenomas
were only treated with APC. The rectum (50%) and cecum (23%) were the
most frequent location of the adenomas, with adenomatous tissue size
ranging from 20 mm to 40 mm. Com-
acids,54 corticosteroids,55 sucralfate
enemas, 55,56 and 5-aminosalicylicacid (5-ASA).57 Surgical approaches
have resulted in significant mortality
and morbidity.58,59 Endoscopic methods using neodymium:yttrium aluminum garnet (Nd:YAG),60 laser61
and argon lasers, or bipolar electrocoagulation62 have been used successfully to arrest rectal bleeding.
A
As a treatment for radiation proctitis, APC was quite effective after failed
therapy by Nd:YAG laser, electrocoagulation, heater probe, and endoscopic
formalin therapy.
B
C
D
Figure 8. Plasma in nature. A. Solar system; B. Lightning; C. Sun; D. Northern lights.
plete ablation was obtained in 90.9%,
with a recurrence rate of 20% (4) after
a mean follow-up period of 16.3
months. Recurrence was not related to
previous piecemeal polypectomy.
There were no major complications.
Radiation Proctitis
Radiation proctitis is a well-described
complication after pelvic radiation.40-42 The incidence of chronic
radiation proctitis lies in the range
between 2% to 20%,42,43 and 30% of
patients with acute radiation-induced
bowel injury develop this condition.44
Connective tissue fibrosis, obliterative
endarteritis with tissue ischemia, and
neovascular mucosal lesions are welldescribed histopathological changes
after radiation injury. Early clinical
symptoms45-47 include tenesmus, and
diarrhea with resolution in 2 to
6 months. However, chronic progression of radiation injury results in late
complications, which include ulcerations, chronic bleeding, strictures, and
fistula formations.42,48-50
Various nonsurgical treatment
modalities have been used with
different levels of success. These
modalities include topical treatment
with formalin solution, 51,52 sulfasalazine, 53
short-chain
fatty
VOL. 6 NO. 1 2006
Many authors9-11,63-69 have reported
favorable outcomes in the use of APC
for the treatment of radiation proctitis. In the above-mentioned case
studies, 210 patients were treated for
radiation proctitis by APC. Power setting and gas flow ranged between 40
to 70 W and 0.6 to 3.0 L/min, respectively. Outcome data revealed significant symptomatic relief resulting in
decreased transfusion dependency,
and improvement in anemia after 2
treatment sessions. APC was also
quite effective after failed therapy by
Nd:YAG laser, electrocoagulation,
heater probe, and endoscopic formalin therapy.
Complications included short-term
symptoms like tenesmus, anisimus,
and abdominal distension. Long-term
complications such as rectal strictures
requiring dilation,63 and rectovaginal
fistula11 were documented in this
series. Two patients with a myelodysplastic syndrome63 developed gramnegative bacteremia. Both patients
were regarded as immunocompromised and responded to an appropriate antibiotic regimen. Overall, APC
appears to be a safe, effective, coagulative modality for hemorrhagic proctitis and a low-cost alternative to
laser therapy.
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7
Argon Plasma Coagulation continued
Hydrogen atom
Oxygen atom
Strong bond
A
Weak bond
B
Free H
Free H
No bond
between molecules
Free O
Free H
Free H
O-H
Free H
Free O
D
C
Figure 9. Molecular development of plasma state. A. Solid state; B. Liquid state; C. Steam state; D. Plasma.
Vascular Ectasias
GAVE or watermelon stomach is an
uncommon but well-described cause
of occult GI bleeding. The majority
of patients present with iron deficiency anemia. Rider and colleagues70 were the first to describe
this disorder. In 1979, Wheeler and
colleagues71 reported a bleeding vascular lesion of the antrum and in
1984, Jabbari and colleagues 72
termed the phenomenon “water-
8
VOL. 6 NO. 1 2006
melon stomach.” He described the
endoscopic appearance as longitudinal column vessels traversing the
antrum and going across the pylorus.
Gostout and colleagues73 reported
that 89% of cases with vascular ectasia present with stripes of ecstatic
vascular tissue, and the remaining
11% have diffuse scattered lesions.
Various modalities for treating
watermelon stomach are used. In
1979, Wheeler and colleagues71 be-
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
lieved that partial gastrectomy was
the procedure of choice. Several endoscopic treatment options (eg,
Nd:YAG laser,74 bipolar electrocoagulation75 sclerotherapy,76 elastic band
ligation77) have proven to be effective.
Initial reports78-80 stated that APC
was effective in the treatment of
watermelon stomach. Further noncomparative studies15,81,82 revealed
that after 2 to 3 sessions, APC mini-
Argon Plasma Coagulation
mized transfusion requirements and
significantly improved hemoglobin
levels. GAVE was resolved in all
patients. A 40% recurrence rate was
observed after a mean follow-up of
20 months, but APC was still effective
in the recurrence group. Overall APC
is effective in controlling bleeding
due to watermelon stomach in the
majority of patients with low complication rates.
APC has been equally effective in
the treatment of AVM of the stomach,
small bowel, and colon.16 Despite
the success described in this report,
there was a 8% recurrence rate over a
6-month follow-up period. Submucosal argon gas and cecal perforation
at the treatment site has been
reported.15,83 Perhaps submucosal
saline solution cushion should be
implemented prior to APC therapy to
prevent deep tissue injury. Norton
and colleagues demonstrated this
technique in a porcine model.84 An
innovative technique of combining
1% polidocanol and APC to ablate
gastric AVM in a patient with
Rendu-Osler-Weber disease has been
reported.85
Bleeding Peptic Ulcer, Recurrent
Esophageal Varices
Upper GI bleeding has a prevalence of
approximately 170 cases per 100,000
per year.86 Peptic ulcer disease represents 50% to 70% of acute nonva-
riceal upper GI bleeding.87,88 Mortality
rate89,90 (3.5% to 7%) has remained
the same despite innovative technology and advanced training of
gastroenterologists.
Recent analysis by the Nonvariceal
Upper GI Bleeding Consensus Conference Group91 recommended that no
single method of endoscopic thermal
coaptive therapy is superior to another. The consensus group reported
that individual randomized studies
showed no difference in rebleeding
rates, surgery, and mortality among
thermoablative therapy with heater
probe, multipolar electrocoagulation,
or Nd:YAG laser when compared with
injection therapy.
In a randomized prospective trial,
Cipolletta and colleagues92 reported
the comparison of APC with heater
probe in 41 patients with bleeding
peptic ulcers, initial rate of hemostasis, recurrent bleeding, 30-day mortality rate, and emergency surgery.
Argon plasma coagulation provided
faster hemostasis. However, because
of the small sample size, the statistical
power of the study was insufficient to
conclude a significant P value. In a
separate randomized controlled trial,
Cipoletta and colleagues93 evaluated
APC use in the prevention of recurrent
esophageal varices after endoscopic
band ligation.
An interim report showed that patients receiving APC exhibited a
lower recurrence rate. The sample
size, however, was small again, leaving open the question of an adequate
statistical evaluation. Nakamura and
colleagues94 evaluated a randomized
group of patients (n 60) to endoscopic variceal ligation (EVL), or EVL
followed by APC. Recurrence free rate
of variceal formation was significantly higher than the patients
receiving EVL monotherapy (74.2%
vs 49.6%).
Post-treatment fever was significantly greater in the combination
group versus monotherapy group
(63.3% vs 33.3%). A prospective
randomized trial was performed by
Chau and colleagues95 comparing
patients with actively bleeding ulcers,
ulcers with clots, and ulcers with nonbleeding visible vessels. Patients were
randomly assigned to epinephrine
injection plus heat probe coagulation
or epinephrine injection plus APC.
They concluded that there was no difference between injection plus heater
probe versus epinephrine plus APC.
APC Ablation of Barrett’s
Esophagus
Endoscopic thermoablation for Barrett’s epithelium still remains controversial. APC has also been used to
treat Barrett’s esophagus. Mutiple
variables are involved to ascertain the
success rate in the treatment of
Barrett’s esophagus. For instance,
Main Points
• Argon plasma coagulation (APC) is a monopolar thermoablative method of electrocoagulation that has been widely used in general
surgery for the last 20 years, and in the fields of laparoscopy, thoracoscopy, and gynecological surgery for more than 10 years.
• APC is thought to minimize tissue destruction and necrosis because of the cooling effect of argon gas and because no further
conduction of radio-frequency energy into tissue occurs once an eschar forms.
• The development of a flexible catheter has allowed the use of APC in numerous applications of therapeutic endoscopy. It has been
used as a treatment in many gastrointestinal (GI) diseases, including radiation proctitis, Barrett’s esophagus, gastric antral vascular ectasia, and treatment of arteriovenous malformations throughout the GI tract.
• APC also has been reported as an effective adjunct in the endoscopic management of sessile polyps during mucosal resection of
neoplastic tissue, and during the management of GI bleeding.
VOL. 6 NO. 1 2006
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
9
Argon Plasma Coagulation continued
Barrett’s segment length, antisecretory regimen used, APC setting,
treatment pattern, and surveillance
post-treatment all may affect outcome. Van Laethem and colleagues14
reported a complete eradication of
Barrett’s in 61%, whereas Byrne and
colleagues96 reported a success rate of
59.2% using APC. However, microscopic foci of Barrett’s epithelium was
identified in up to 50% of the
patients.
Morino and colleagues97 reported
an 87% complete macroscopic clearance, whereas 9% of the patients
revealed microscopic foci after laparoscopic Nissen fundoplication
followed by APC therapy. Variable
data are published on the outcome of
APC in the treatment of Barrett’s
esophagus with high-grade dysplasia
or carcinoma in situ. Pereira-Lima
and colleagues98 reported no microscopic recurrence of dysplasia or
advancement of malignancy after
10.6 months of follow-up.
strated that APC is safe and effective
in GAVE, radiation proctitis, angiodysplasia, ablation of colorectal
polyps, ablation of residual tissue
after polypectomy and mucosectomy,
bleeding peptic ulcer and ulcers with
high risk of rebleeding, eradication of
Barrett’s esophagus, trimming of
stents, and for use in opening obstructing GI malignancies.
The expanded use of APC is inevitable because of its ease in learning, mobile apparatus, and low cost.
The introduction of dual-mode APC
catheters will greatly expand the use
of APC beyond its current use.
1.
2.
3.
4.
Combination of APC with other
treatment modalities has proved to
be a sufficient device for the treatment of GI malignancies. Wahab and
colleagues15 reported using APC in
various settings in concert with multiple devices. APC was used in combination with monopolar polypectomy snare in 34 patients who
presented with esophageal or gastric
cardia malignancies. Savory dilation
also was used in some cases. Akhtar
and colleagues99 reported using APC
on 83 patients with malignant strictures of the esophagus and gastric
cardia. APC also has been used for
trimming of biliary and GI metallic
stents.100,101
5.
Summary
12.
Use of APC via flexible endoscopes
is well established throughout the
world. Published reports have demon-
13.
VOL. 6 NO. 1 2006
15.
16.
17.
18.
19.
References
APC in Other GI Neoplasias
10
14.
6.
7.
8.
9.
10.
11.
Papp J. Endoscopic electrocoagulation of upper
gastrointestinal hemorrhage. JAMA. 1976;236:
2076-2079.
Morrison CF, Jr. Electrosurgical method and
apparatus for initiating an electrical discharge in
an inert gas flow. US patent 4 040 426. August 9,
1977.
Dunham M, Cornwell E III, Brathwaite EM, et al.
Experience with the argon beam coagulator in
critically injured patients. Panamerican J
Trauma. 1989;1:81-85.
Croce E, Azzola M, Russo R, et al. Laparoscopic
liver tumour resection with the Argon beam. Endosc Surg Allied Technol. 1994;2:186-188.
Rusch V, Schmidt R, Shoij Y, et al. Use of the
argon beam electrocoagulator for performing
pulmonary wedge resections. Ann Thorac Surg.
1990;49:287-291.
Brand E, Pearlman N. Electrosurgical debulking
of ovarian cancer: a new technique using the
argon beam coagulator. Gynecol Oncol. 1990;39:
115-118.
Canady J. Surgical coagulation device. US application patent 5 207 675. July 15, 1991. Patent
issue. May 4, 1993.
Farin G, Grund KE. Technology of argon plasma
coagulation with particular regard to endoscopic
applications. Endosc Surg. 1994;2:71-77.
Kaassis M, Oberti F, Burtin P, Boyer J. Argon
plasma coagulation for the treatment of radiation proctitis. Endoscopy. 2000;32:673-676.
Fantin AC, Binek J, Suter WR, Meyenberger C.
Argon beam coagulation for treatment of symptomatic radiation-induced proctitis. Gastrointest
Endosc. 1999;49:515-518.
Silva RA, Correia AJ, Dias LM, et al. Argon
plasma coagulation therapy for hemorrhagic
radiation proctosigmoiditis. Gastrointest Endosc.
1999;50:221-224.
Grade AJ, Shah IA, Medlin SM, Ramirez FC. The
efficacy and safety of argon plasma coagulation
therapy in Barrett’s esophagus. Gastrointest
Endosc. 1999;50:18-22.
Pereira-Lima JC, Busnello JV, Saul C, et al. High
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
power setting argon plasma coagulation for the
eradication of Barrett’s esophagus. Am J Gastroenterol. 2000;95:1661-1668.
Van Laethem JL, Jagodzinski R, Peny MO, et al.
Argon plasma coagulation in the treatment of
Barrett’s high-grade dysplasia and in situ adenocarcinoma. Endoscopy. 2001;33:257-261.
Wahab PJ, Mulder CJ, den Hartog G, Thies JE.
Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences. Endoscopy. 1997;29:176-181.
Rolachon A, Papillon E, Fournet J. Is argon
plasma coagulation an efficient treatment for
digestive system vascular malformations and
radiation proctitis? Gastroenterol Clin Bio. 2000;
24:1205-1210.
Teimourian B, Duda G, Nikodem A, et al. Application of the argon beam coagulator in plastic
surgery. Perspect Plast Surg. 1991;5:91-98.
Christie JP. Colonoscopic excision of large sessile
polyps. Am J Gastroenterol. 1977;67:430-438.
Strekalovsky VP. Results of endoscopic removal
of villous tumours of the colon. Endoscopy.
1983;15:49-52.
Nivatvongs S, Snover DC, Fang DT. Piecemeal
snare excision of large sessile colon and rectal
polyps: Is it adequate? Gastrointest Endosc.
1984;30:18-20.
Bedogni G, Bertoni G, Ricci E, et al. Colonoscopic excision of large and giant colorectal
polyps. Technical implications and results over
eight years. Dis Colon Rectum. 1986;29:
831-835.
De Palma GD, Caiazzo C, Di Matteo E, et al.
Endoscopic treatment of sessile rectal adenomas:
comparison of Nd:YAG laser therapy and injection-assisted piecemeal polypectomy. Gastrointest Endosc. 1995;41:553-556.
Binmoeller KF, Bohnacker S, Seifert H, et al.
Endoscopic snare excision of “giant” colorectal
polyps. Gastrointest Endosc. 1996;43:183-188.
Kanamori T, Itoh M, Yokoyama Y, Tsuchida K.
Injection-incision-assisted snare resection of
large sessile colorectal polyps. Gastrointest
Endosc. 1996;43:189-195.
Iishi H, Tatsuta M, Iseki K, et al. Endoscopic
piecemeal resection with submucosal saline
injection of large sessile colorectal polyps. Gastrointest Endosc. 2000;51:697-700.
Morson B. Genesis of colorectal cancer. Clin
Gastroenterol. 1976;5:505-525.
Hunter JG, Burt RW, Becker JM, et al. Quantitation of colonic injury from argon laser,
neodymium: YAG laser and monopolar electrocautery applied to flat mucosa and small sessile
polyps of the canine colon. Gastrointest Endosc.
1989;25:16-21.
Savides TJ, See JA, Jensen DM, et al. Randomized controlled study of injury in the canine
right colon from simultaneous biopsy and coagulation with different hot biopsy forceps. Gastrointest Endosc. 1995;42:573-578.
Canady J, Jagdeo C, Nicolo E, Fontana F. Argon
beam endoscopic coagulator (ABEC): the first
experimental & clinical report. Abstract presented at the 2nd European Congress of Minimally Invasive Surgery and New Technologies;
Luxembourg, September 10-12, 1992.
Argon Plasma Coagulation
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
Canady J, Jagdeo C, Nicolo E, Fontana F. Argon
beam endoscopic coagulator via colonoscope.
Abstract presented at the International Society
of University Colon and Rectal Surgeons, XIV
Biennial Conference; Crete, Greece; October
1992.
Canady J, Jagdeo C, Nicolo E, Fontana F. In:
Steichen FM, Welter R, eds. The First Experimental and Clinical Report. Minimally Invasive
Surgery & New Technology, Chapter 32, St. Louis,
MO: Quality Medical Publishing; 1994:92-94.
Zlatanic J, Waye JD, Kim PS, et al. Large sessile
colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy.
Gastrointest Endosc. 1999;49:731-735.
Regula J, Wronska E, Polkowski M, et al. Argon
plasma coagulation after piecemeal polypectomy
of sessile colorectal adenomas: long-term
follow-up study. Endoscopy. 2003;35:212-218.
Brooker JC, Saunders BP, Shah SG, et al.
Treatment with argon plasma coagulation
reduces recurrence after piecemeal resection of
large sessile colonic polyps: a randomized trial
and recommendations. Gastrointest Endosc.
2002;55:371-375.
Singh N, Harrison M, Rex D. A survey of colonoscopic polypectomy practices among clinical
gastroenterologists. Gastrointest Endosc. 2004;
60:414-418.
Peluso F, Goldner R. Follow-up of hot biopsy
forceps treatment of diminutive colon polyps.
Gastrointest Endosc. 1991;37:604-606.
Ellis K, Shiel M, Marquis S. Efficacy of hot
biopsy forceps, cold micro-snare and microsnare
with cautery techniques in the removal of
diminutive colonic polyps [abstract]. Gastrointest Endosc. 1997;45:AB107.
Rex D. Colonscopic polypectomy. Rev Gastroenterol Disord. 2005;5:115-125.
Garcia A, Nunez O, Gonzalez-Asanza C, et al.
Safety and efficacy of argon plasma coagulator
ablation therapy for flat colorectal adenomas.
Rev Esp Enferm Dig. 2004;96:315-321.
Babb R. Radiation proctitis: a review. Am J Gastroenterol. 1996;91:1309-1311.
Kinsella J, Bloomer W. Tolerance of the intestine
to radiation therapy. Surg Gynecol Obstet. 1980;
151:273-284.
Gilinsky NH, Burns DG, Barbezat GO, et al. The
natural history of radiation-induced proctosigmoiditis: an analysis of 88 patients. Q J Med.
1983;205:40-53.
Buchi K. Radiation proctitis: therapy and prognosis. JAMA. 1991;265:1180.
Novak J, Collins J, Donowitz M, et al. Effects of
radiation on the human gastrointestinal tract.
J Clin Gastroenterol. 1979;1:9-39.
Pilepich M, Krall J, George F, et al. Treatment
related morbidity in phase 3 RTOG studies in
extended field irradiation for carcinoma of the
prostate. Int J Radiat Oncol Biol Phys. 1984;
10:1861-1867.
Anseline P, Lavery I, Fazio V, et al. Radiation
injury of the rectum: evaluation of surgical
treatment. Ann Surg. 1981;194:716-724.
Nussbaum ML, Campana TJ, Weese JL. Radiation-induced intestinal injury. Clin Plast Surg.
1993;20:573-580.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
Rosen I, Shapiro B. Radiation enteropathy of the
small bowel. Can Med Assoc J. 1964;91:681-688.
Kinsella T, Bloomer W. Tolerance of the intestine
to radiation therapy. Surg Gynecol Obstet. 1980;
151:273-284.
Cho KH, Lee CK, Levitt SH. Proctitis after conventional external radiation therapy for prostate
cancer: importance of minimizing posterior
rectal dose. Radiology. 1995;195:699-703.
Seow-Choen F, Goh HS, Eu KW, et al. A simple
and effective treatment for hemorrhagic radiation proctitis using formalin. Dis Colon Rectum.
1993;36:135-138.
Roche B, Chautems R, Marti MC. Application of
formaldehyde for treatment of hemorrhagic radiation-induced proctitis. World J Surg. 1996;20:
1092-1095.
Goldstein F, Khoury J, Thorton JJ. Treatment of
chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids.
A pilot study. Am J Gastroenterol. 1976;65:
201-208.
al-Sabbagh R, Sinicrope FA, Sellin JH, et al.
Evaluation of short-chain fatty acid enemas:
treatment of radiation proctitis. Am J Gastroenterol. 1995;91:1814-1816.
Kochhar R, Patel F, Dhar A, et al. Radiationinduced proctosigmoiditis: prospective, randomized, double blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal
sucralfate. Dig Dis Sci. 1991;36:103-107.
Kochhar R, Sriam P, Sharma S et al. Natural history of late radiation proctosigmoiditis treated
with topical sucralfate suspension. Dig Dis Sci.
1999;44:973-978.
Baum C, Biddle WL, Miner PB Jr. Failure of
5-aminosalicylic acid enemas to improve
chronic radiation proctitis. Dig Dis Sci. 1989;
654:758-760.
Browning GG, Varma JS, Smith AN, et al. Late
results of mucosal proctectomy and coloanal
sleeve anastomosis for chronic radiation rectal
injury. Br J Surg. 1987;74:31-34.
Fischer L, Kimose H, Spjeldnaes N, Wara P. Late
progress of radiation-induced proctitis. Acta
Chir Scand. 1990;156:801-805.
Barbatzas C, Spencer GM, Thorpe SM, et al.
Nd:YAG laser treatment for bleeding from radiation proctitis. Endoscopy. 1996;28:497-500.
Taylor JG, Disario JA, Buchi KN. Argon laser
therapy for hemorrhagic radiation proctitis:
long-term results. Gastrointest Endosc. 1993;39:
641-644.
Maunoury V, Brunetaud JM, Cortot A. Bipolar
electrocoagulation treatment for hemorrhagic
radiation injury of the lower digestive tract. Gastrointest Endosc. 1991;37:492-493.
Tam W, Moore J, Schoeman M. Treatment of
radiation proctitis with argon plasma coagulation. Endoscopy. 2000;32:667-672.
Villavicencio RT, Rex DK, Rahmani E. Efficacy
and complications of argon plasma coagulation
for hematochezia related to radiation proctopathy. Gastrointest Endosc. 2002;55:70-74.
Tjandra JJ, Sengupta S. Argon plasma coagulation is an effective treatment for refractory
radiation proctitis. Dis Colon Rectum. 2001;44:
1759-1765.
VOL. 6 NO. 1 2006
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
Venkatesh K, Ramanujam P. Endoscopic therapy
for radiation proctitis-induced hemorrhage in
patients with prostatic carcinoma using argon
plasma coagulator application. Surg Endosc.
2002;16:707-710.
Chutkan R, Lipp A, Waye J. The argon plasma
coagulator: a new and effective modality for
treatment of radiation proctitis. Gastrointest
Endosc. 1997;45:AB27.
Saurin J, Coehlo J, Lepretre, et al. [Recitite
radique ou ectaasies vasculaires antrales: effet de
la coagulation au plasma d’argon.] Gastroenterol
Clin Biol. 1999;23:A54.
V’edrenne B, Canard J, Bader R, et al. [Traitement des recitites radiques par la coagulation au
plasma argon (CPA).] Gastroenterol Clin Biol.
2000;24:A2.
Rider JA, Klotz AP, Kirsner JB. Gastritis with
veno-capillary ectasia as a source of massive
gastric hemorrhage. Gastroenterology. 1953;24:
118-123.
Wheeler MH, Smith PM, Cotton PB, et al. Abnormal blood vessels in the gastric antrum. A
cause of upper-gastrointestinal bleeding. Dig Dis
Sci. 1979;24:155-158.
Jabbari M, Cherry R, Lough JO, et al. Gastric
antral vascular ectasia: The watermelon stomach. Gastroenterology. 1984;87:1165-1170.
Gostout CJ, Viggiano TR, Ahlquist DA, et al. The
clinical and endoscopic spectrum of the watermelon stomach. J Clin Gastroenterol. 1992;15:
256-263.
Liberski SM, McGarrity TJ, Hartle RJ, et al. The
watermelon stomach: long-term outcome in
patients treated with Nd:YAG laser therapy. Gastrointest Endosc. 1994;40:584-587.
Binmoeller KF, Katon RM. Bipolar electrocoagulation for watermelon stomach. Gastrointest
Endosc. 1990;36:399-402.
Rose JD. Endoscopic injection of alchohol for
bleeding from gastroduodenal vascular anomalies. Br Med J. 1987;295:93-94.
Campo R, Brullet E. Endoscopic treatment of
gastric angiodysplasia with elastic band ligation.
Gastrointest Endosc. 1996;43:502-504.
Focke G, Seidl C, Grouls V. Treatment of watermelon stomach (GAVE syndrome) with endoscopic argon plasma coagulation (APC). A new
therapy approach [in German]. Leber Magen
Darm. 1996;26:257-259.
Klump B, Schneider GA, Fierlbeck G, et al. Argon
plasma coagulation in endoscopic therapy of
CREST syndrome associated upper gastrointestinal hemorrhage [in German]. Z Gastroenterol.
1997;35:469-476.
Cohen J, Abedi M, Haber G, et al. Argon Plasma
Coagulation: A new effective technique of noncontact thermal coagulation. Experience in 44
cases of GI angiomata [abstract]. Gastrointest
Endosc. 1996;43:293.
Probst A, Schuebel R, Wienbeck M. Treatment of
watermelon stomach (GAVE syndrome) by
means of endoscopic argon plasma coagulation
(APC): long-term outcome. Z Gastroenterol.
2001;39:447-452.
Yussoff I, Brennan F, Ormonde D, Laurence B.
Argon plasma coagulation for treatment of watermelon stomach. Endoscopy. 2002;34:407-410.
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
11
Argon Plasma Coagulation continued
83.
84.
85.
86.
87.
88.
89.
12
Johanns W, Luis W, Janssen J, et al. Argon
plasma coagulation (APC) in gastroenterology:
experimental and clinical experiences. Eur J
Gastroenterol Hepatol. 1997;9:581-587.
Norton ID, Wang L, Levine SA, et al. Efficacy of
colonic submucosal saline solution injection for
the reduction of iatrogenic thermal injury. Gastrointest Endosc. 2002;56:95-99.
Kitamura T, Tanabe S, Koizumi W, et al. RenduOsler-Weber disease successfully treated by
argon plasma coagulation. Gastrointest Endosc.
2001;54:525-527.
Blatchford O, Davidson LA, Murray WR, et al.
Acute upper gastrointestinal haemorrhage in
west of Scotland: case ascertaintment study.
BMJ. 1997;315:510-514.
Marshall JK, Collins SM, Gafni A. Prediction of
resource utilization and case cost for acute nonvariceal upper gastrointestinal hemorrhage at a
Canadian community hospital. Am J Gastroenterol. 1999;94:1841-1846.
Barkun A, Chiba N, Enns R, et al. Use of a national endoscopic database to determine the
adoption of emerging pharmacological and endoscopic technologies in the everyday care of
patients with upper GI bleeding: the RUGBE initiative [abstract]. Am J Gastroenterol. 2001;96:
S261.
Longstreth GF. Epidemiology of hospitalization
VOL. 6 NO. 1 2006
90.
91.
92.
93.
94.
95.
for acute upper gastrointestinal hemorrhage: a
population-based study. Am J Gastroenterol.
1995:90:206-210.
Cooper GS, Chak A, Harper DL, et al. Care of patients with upper gastrointestinal hemorrhage in
academic medical centers: a community-based
comparison.
Gastroenterology.
1996;11:
385-390.
Barkun A, Bardou M, Marshall JK, et al. Consensus recommendations for managing patients
with nonvariceal upper gastrointestinal bleeding.
Ann Intern Med. 2003;139:843-857.
Cipolletta L, Bianco MA, Rotondano G, et al.
Prospective comparison of argon plasma coagulator and heater probe in the endoscopic treatment of major peptic ulcer bleeding. Gastrointest
Endosc. 1998;48:191-195.
Cipolletta L, Bianco MA, Rotondano G, et al.
Argon plasma coagulation prevents variceal
recurrence after band ligation of esophageal
varices; results of a prospective randomized trial.
Gastrointest Endosc. 2002;56:467-471.
Nakamura S, Mitsunaga A, Murata Y, et al. Endoscopic induction of mucosal fibrosis by argon
plasma (APC) for esophageal varices: a prospective randomized trial of ligation plus APC vs.
ligation alone. Endoscopy. 2001;33:210-215.
Chau CH, Siu WT, Law BK, et al. Randomized
controlled trial comparing epinephrine injection
REVIEWS IN GASTROENTEROLOGICAL DISORDERS
plus heat probe coagulation versus epinephrine
injection plus argon plasma coagulation for
bleeding peptic ulcers. Gastrointest Endosc.
2003;57:455-461.
96. Byrne JP, Armstrong GR, Attwood SE.
Restoration of the normal squamous lining in
Barrett’s esophagus by argon beam plasma coagulation. Am J Gastroenterol. 1998;93:1810-1815.
97. Morino M, Rebecchi F, Giaccone C, et al. Endoscopic ablation of Barrett’s esophagus using
argon plasma coagulation (APC) following surgical laparoscopic fundoplication. Surg Endosc.
2003;17:539-542. Epub 2003 Feb 17.
98. Pereira-Lima JC, Busnello JV, Saul C, et al. High
power setting argon plasma coagulation for the
eradication of Barrett’s esophagus. Am J Gastroenterol. 2000;95:1661-1668.
99. Akhtar K, Byrne JP, Bancewicz J, Attwood SE.
Argon beam plasma coagulation in the management of cancers of the esophagus and stomach.
Surg Endosc. 2000;14:1127-1130.
100. Vanbiervliet G, Piche T, Caroli-Bosc FX, et al.
Endoscopic argon plasma trimming of biliary
and gastrointestinal metallic stents. Endoscopy.
2005;37:434-438.
101. Demarquay JF, Dumas R, Peten EP, Rampal P.
Argon plasma endoscopic section of biliary
metallic prostheses. Endoscopy. 2001;33:
289-290.