PULSED APC FOR PROCTOPATHY POST PROSTATIC BRACHYTHERAPY скачать в хорошем качестве

PULSED APC FOR PROCTOPATHY POST PROSTATIC BRACHYTHERAPY

A 64 year old man was diagnosed with prostatic adenocarcinoma 4 years ago. The Gleason score was 3+3=6 and less than 2% of the prostate volume was involved. There was no invasion of the surrounding structures. He was treated with low dose prostate brachytherapy. He now presents with intermittent bright red rectal bleeding thought to be secondary to post brachytherapy proctopathy. The video shows treatment of the proctopathy using APC, which is a slightly controversial technique. --- Permanent radioactive seed implants ("brachytherapy" or "internal radiation therapy”) are a form of radiation therapy for prostate cancer. During the procedure, radioactive (iodine-125 or I-125) seeds are implanted into the prostate gland using ultrasound guidance. The number of seeds and where they are placed is determined by a computer-generated treatment plan tailored for each patient. About 100 seeds are commonly implanted. The implants remain in place permanently, and become biologically inert (inactive) after about 10 months. This technique allows a high dose of radiation to be delivered to the prostate with limited damage to surrounding tissues. Permanent implants are relatively low-energy sources, and therefore have limited tissue penetration. A well-done implant will treat the prostate and the surrounding few millimeters of adjacent tissue. Therefore, the best candidates for this procedure are patients who have a cancer that is contained within or near the prostate. Patients with prostate cancer that is invading nearby structures like the bladder or rectum are not appropriate for this technique. Compared to external radiation, which requires 7 to 7 ½ weeks of daily treatments, convenience is a major advantage of this treatment option because it is a single outpatient procedure. Chronic radiation proctopathy (CRP) affects a significant proportion of patients who undergo radiation treatment for cancer. It manifests in many ways, including pain, diarrhoea and rectal bleeding. Management of rectal bleeding in patients with CRP represents a conundrum for practitioners. Medical therapy is ineffective in general and surgical approach has a high morbidity/mortality. Endoscopy has a role in the diagnosis, staging and treatment of this disease. Currently available endoscopic modalities are formalin, KTP laser, Nd-YAG laser, argon laser, bipolar electrocoagulation (BiCAP), heater probe, band ligation (EBL), cryotherapy, radiofrequency ablation and argon plasma coagulation (APC). Among these options, APC is the most promising, but it can carry risks of ulceration and stricture formation. Laser therapy is an obsolete technology and should be abandoned. Contact methods, especially BiCAP, are very well indicated for patients with pacemakers and other implantable devices. The best way to use formalin is still unknown. More studies with EBL, cryoablation and RFA are still needed. APC has emerged as the front-runner due to its ease of use, affordability, better-defined settings, efficacy and safety. Perhaps in the future, the results of the second generation APC device will improve further. Other options include sucralfate enema and hyperbaric oxygen. The ASGE make the following recommendations: 1. In patients with chronic radiation proctopathy, we suggest APC, bipolar electrocoagulation, heater probe, and RFA for treatment of bleeding from chronic radiation proctopathy. There is insufficient evidence to recommend a specific endoscopic modality over another for treatment of bleeding from chronic proctopathy. 2. In patients with chronic radiation proctopathy, we suggest against the use of 4% formalin compared with APC because of higher adverse event rates compared with APC for treatment of bleeding from chronic radiation proctopathy. 3. In patients with chronic radiation proctopathy, there is insufficient evidence for or against the use of the newer-generation cryoablation systems for treatment of bleeding from chronic radiation proctopathy REFERENCES [1] Lee JK et al, GI Endoscopy, August 2019, 90(2): 171–182, ASGE guideline on the role of endoscopy for bleeding from chronic radiation proctopathy https://www.giejournal.org/issue/S001... [2] Lenz L et al, World J Gastrointest Surg. 2016 Feb 27; 8(2): 151–160. Chronic radiation proctopathy: A practical review of endoscopic treatment https://www.ncbi.nlm.nih.gov/pmc/arti... [3] Zhong Q-H et al World J Gastroenterol. 2019 Apr 7; 25(13): 1618–1627. Efficacy and complications of argon plasma coagulation for hemorrhagic chronic radiation proctitis https://www.ncbi.nlm.nih.gov/pmc/arti...