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Argon Plasma Coagulation: Clinical Applications in Gastroenterology

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Argon Plasma Coagulation: Clinical Applications in Gastroenterology ANNALS OF GASTROENTEROLOGY 2003, 16(2):131-137 Review Argon plasma coagulation: Clinical applications in Gastroenterology J. Robotis, P. Sechopoulos, Th. Rokkas SUMMARY sue and most importantly in a non-conduct mode. APC has revealed a remarkable spectrum of clinical applica- Argon plasma coagulation (APC) is a method of non-con- tions, raising questions as to whether it should replace tact endoscopic thermal coagulation. According to recent laser in clinical practice. The more gastroenterologists data, it can safely be used in clinical practice and there are familiarize themselves with this technique, the more they indications that APC is undoubtedly preferable to laser appreciate its usefulness. Among its many advantages, treatment in some cases. So, hemostasis of diffuse superfi- the following should be borne in mind: effective and safe cial vascular lesions, such as angiodysplasia, gastric an- coagulation, non-contact mode of action, marked desic- tral vascular ectasias, radiation proctitis, bleeding ulcers cation, no destruction of metal stents, little smoke or and obstructed stents are some of these clinical indications. vapor, easily handled device, lower cost compared to There is a lack of published experience of APC and abla- laser, and finally, no extended safety precautions. tion therapy, such as large villous adenomas, rectal and However, to date, no formal cost-effectiveness study has stomach cancer thus further studies are necessary to de- been published. In this review we summarize the main fine the results and technical details of the procedure. indications of APC in gastrointestinal diseases. We also describe basic physical principles, equipment and tech- Key words: Argon plasma coagulation, clinical indications, nique. hemostasis, tumour ablation Physical principles Equipment INTRODUCTION Basically, APC applies high frequency (HF) current to a prelocated tissue in a non-contact mode, despite Interventional endoscopy is a well-established break- other thermal coagulation methods. According to this through in the endoscopy of the digestive tract and Ar- method, argon gas is substituted for the usual electrical gon Plasma Coagulation (APC) is a new technique re- current. The whole device includes an argon source, an cently included in the endoscopic armamentarium. This HF current source and the appropriate applying cathe- device is intended for thermal coagulation of tissues and ter. The APC catheter contains an electrode. A second originally APC developed as a thermal method, alterna- neutral electrode patch is placed at the hip of the patient. tive to laser in open and laparoscopic surgery.1 APC was As soon as sufficient HF voltage is generated between adapted for use in flexible endoscopy in the early 90s.2 the first electrode and the tissue, argon gas flows out of Through a device, argon gas is delivered via a flexible the catheter and becomes ionised in the high voltage elec- catheter through the endoscopic biopsy channel to tis- tric field that has been created. Thus, argon gas is trans- formed to plasma beams and HF current completes the electrical circuit via the second neutral electrode patch. First Gastroenterology Department, Henry Dunant Hospital, Athens, The heat which is generated devitalises, coagulates, des- Greece iccates and ultimately shrinks the tissue. A desiccated tissue loses electric conductivity because of its higher elec- Author for correspondence: trical resistance.3,4 Therefore the APC beam moves to Theodore Rokkas, MD, PhD (UK), FACG, First Gastroenterolo- the next viable area. In this way, the whole area is uni- gy Department, Henry Dunant Hospital, 107 Mesogeion Ave., 115 26 Athens, Greece, Tel.: 210 6972944, Fax: 210 6984388, formly desiccated and, most importantly, at the same e-mail: [email protected] depth. The depth is limited to 3 mm at most, depending 132 J. ROBOTIS, et al upon the application time.1 The automatically limited argon gas and clear the smoke from the visual field. When depth, as well as the absence of tissue vaporisation, are treating tissue in contact with metal implants such as safety guards against thin wall perforations. Consequently, stents, settings should be reduced. Although there is het- APC can hardly remove bulky tumour masses. erogeneity in study designs, indications and definition of complications that limit the interpretation of safety There are two APC systems available on the market, data, complication rates vary from 0% to 24%.7 the ERBE Elektromedizin, Tubingen, Germany; and Conmed, Utica, N.Y. The ERBE type includes an elec- When combustible gas, such as methane, remains in trosurgical unit that generates a high frequency electri- the organ where APC is to be applied there is a danger cal current, an argon gas cylinder and a gas flow meter. of explosion within the organ. The colon must therefore The whole APC apparatus is accompanied by a foot be carefully cleansed before the session. Stenotic areas switch to activate both HF current source and gas. There in the colon should first be dilated with bougienage or are two types of probe catheters to deliver the argon ballooning so that possible explosive gases entrapped may plasma beam parallel or perpendicular to the catheter be evacuated.8 In summary, complications that have been axis. These catheters are covered with teflon material and reported are gaseous distension, pneumatosis intestina- are disposable. There are two sizes available; 2.3 mm in lis, pneumomediastinum and pneumoperitoneum, sub- diameter 2.2m length and 3.2 mm-2.2 m. According to cutaneous emphysema, pain, chronic ulceration, stric- the manufacturers manual the ERBE argon flow varies ture, bleeding, transmural burn syndrome, perforation from 0.1 L/min to 9 L/min. and death. It is therefore highly recommended that APC applications should follow the 10 rules of APC use Procedure (Table 1). Another interesting recommendation is the The appropriate device settings vary between manu- power limit and single-shot duration of APC, according facturers, indications and protocols. There is a step-up to various indications (Table 2). concept of power and flow settings so that superficial vascular lesions are treated with settings of 40 to 50 W and 0.8 L/min. Tissue ablation is achieved with settings Table 1. Practical points of APC use. of up to 70-90 W and 1 L/min.5 Higher settings result in 1. Do not confuse APC with argon laser. They are completely intralumimal gaseous distension and patient discomfort. different in physics, application, and effect. APC is a non-contact technique providing an opera- 2. Always check argon gas flow as well as plasma beam out- tive distance from probe to tissue from 2 to 8 mm.6 If the side the endoscope before inserting the probe into the endoscopist holds the probe too far from the tissue there working channel. will be no argon plasma beam at low power settings. On 3. Advance the APC probe far enough, so that the first black the other hand, tissue contact with the probe results in ring is clearly visible in the endoscopic field. the untoward effect of tissue-probe sticking and thermal 4. Always perform APC under continuous visual control. injury. Deep thermal injury allows argon gas to flow into 5. Be sure that the APC probe neither touches the target tis- the submucosa, producing pneumatosis and even sue nor is too far away during performance. extraintestinal gas. So tissue contact with the probe should 6. Never press the activated probe against the organ wall or be avoided. There must be no intermediate liquid, (in- into tissue for this may result in emphysema or wall dam- cluded blood) between the argon probe and the tissue sur- age or perforation. face, otherwise a coagulation film develops and the un- 7. Do not touch metal stents directly with the APC probe; derlying tissue surface remains inadequately treated. This keep the appropriate distance. has an immediate impact on active bleeding. Thus, sur- 8. Avoid overinflation by checking for abdominal distention; face fluids should be rinsed or sucked out as indicated.7 deflate repeatedly as indicated. 9. Set the power limit of the electrosurgical unit and the APC is performed by applications of 0.5 to 2 seconds duration of the APC supply as indicated by the affected duration.2 The probe tip is directed in a paintbrush-like organ (e.g. upper limit of max. 50 Watt in the right colon manner on extended confluent or linear areas. Direct or cecum, but higher for tumor ablation). vision of the probe tip is essential, throughout the appli- 10. Many short duration applications are more effective than cation. Misdirection of the plasma beam to the endo- a few long-duration ones. Control the penetration depth scope tip may result in video chip damage.7 Frequent by altering the duration rather than lowering the settings. suctions are needed to decompress the intraluminal Adapted from8 Argon plasma coagulation: Clinical applications in Gastroenterology 133 Table 2. Power limit and single shot duration in APC application. Power limit Single shot duration (Watts) (seconds) Normal settings for esophagus, stomach, small intestine and rectum 60-80 1-3 Stomach 70-99 1-3 Stent in-over growth conditioning of fistula 60 1-3 Large tumours (over 1.5 cm) 99 3-10 Medium size (from 0.5-1.5) 80 3-5 Small tumours 60 0.5-5 Right colon 40-50 0.1-0.5-1 Remaining colon 40-60 1-2 Adapted from8 Indications and efficacy 27 In the above studies, various definitions of response Basically, there are two main axes of APC use in clin- to treatment were applied. Thus, clinical success var- ical practice; hemostasis and ablation. The best results ies from 90% to 94%, while complete disappearance are expected to be found in hemorrhagic lesions. How- of bleeding from 81% to 86%. Despite angiectasias, ever, ablation still remains a fascinating practice for the side-effects are more common during treatment for 25 endoscopist and quite helpful to patients, at least as a post-radiation proctopathy, rising to 14%.
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