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Objective: We retrospectively evaluated the efficacy of combining the SpaceOAR (SOAR) hydrogel with prostate brachytherapy, using colonoscopy findings to assess for radiation proctitis., Methods: Among 731 patients undergoing iodine-125 low-dose-rate prostate brachytherapy (LDR-BT), SOAR was utilized in 394 patients (53.9%). Colonoscopy was performed for 97 patients (13.3%) to assess the presence, location, condition, and treatment of radiation proctitis. We also investigated treatment factors associated with the occurrence of radiation proctitis., Results: Radiation proctitis was observed in 57 patients (7.8%) and 17 (2.3%) were treated with argon plasma coagulation (APC). The incidence of radiation proctitis was 12.2% in the non-SOAR and 4.1% in the SOAR group (p < 0.001). In the non-SOAR group, the incidence of radiation proctitis was 6.6% for LDR-BT monotherapy and increased to 22.0% when combined with external beam radiation therapy (EBRT) (p = 0.001). However, in the SOAR group, these rates significantly decreased to 3.3% and 5.7% for monotherapy and combination therapy, respectively (p = 0.035, p < 0.001). With SOAR, inflammation was observed directly above the DL in most patients (87.5%), and only one patient (6.3%) required APC. The absence of SOAR (p < 0.001, HR = 0.29) and the concurrent use of EBRT (p = 0.018, HR = 2.87) were identified as significant risk factors for the occurrence of radiation proctitis., Conclusion: The use of SOAR significantly reduced the incidence of radiation proctitis in patients undergoing LDR-BT monotherapy and combined EBRT. Inflammation primarily occurred directly above the DL; further examination is necessary to clarify its cause., (© 2024 The Japanese Urological Association.)

Background and Aims: Argon plasma coagulation (APC) could be considered a treatment modality for small gastric low-grade dysplasia (LGD) instead of endoscopic resection. Our study investigated the clinical outcomes of APC for treating gastric LGD and associated variables with local recurrence., Methods: This study included 911 patients who underwent APC for gastric neoplasms at the tertiary hospital from July 2007 to March 2022 with a minimal follow-up of 12 months. Of these patients, 112 without any information about Helicobacter pylori infection status, 164 who underwent APC for salvage therapy, 5 with high-grade dysplasia, and 12 with cancer were excluded. Through a retrospective review of medical data, the clinical outcomes and variables associated with the local recurrence were analyzed., Results: A total of 618 patients with LGD (median age, 64 years) were followed up for a median of 30 months, and local recurrence has happened in 21 (3.4%) patients. Multivariate analysis showed that lesion size (hazard ratio, 1.06; 95% confidential interval, 1.01-1.12) was associated with the local recurrence. Among 557 lesions smaller than 10 mm, local recurrence was found in 14 (2.6%) cases, and local recurrence was found in 7 (9.5%) cases of 109 tumors larger than 10 mm (P < .004)., Conclusions: In gastric LGD smaller than 10 mm without scars, APC is a good treatment modality in place of endoscopic resection. However, when a lesion is larger, APC should be selected carefully with close monitoring., Competing Interests: Disclosure All authors disclosed no financial relationships., (Copyright © 2024. Published by Elsevier Inc.)

Competing Interests: Disclosure Supported by Chengdu Science and Technology (2022-YF05-01263-SN), Natural Science Foundation of Sichuan Province (2023NSFSC1622), and China Postdoctoral Science Foundation (2022M712265). All authors disclosed no financial relationships. Commentary Clinical and technical dilemmas as well as adverse events are unwelcomed but inevitable dance partners in interventional endoscopy. More importantly, a thoughtful and timely response with a thorough knowledge of available devices and techniques is essential to quickly map out an exit from the woods. This interesting and dramatic case of a 19-year-old woman with a migrated pancreatic stent is one such example, inasmuch as the endoscopist made the unpleasant discovery of a completely internally migrated pancreatic stent. The endoscopist then must devise an innovative way of solving the problem, as well as a new problem that developed along the way. Although it is not clear what led to the wire being embedded in the pancreatic duct, the careful use of argon plasma coagulation and forceps here was an effective approach. Wisely, a single pigtail pancreatic stent was chosen for subsequent repeated stenting, with apparently good results. Presumably, this 19-year-old woman with severe pancreatic stricturing (to the point of obstruction and severe pancreatolithiasis) will ultimately undergo surgery in her near future. Matthew T. Moyer MD, MS, Division of GI-Hepatology, Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA, USA Amy Tyberg, MD, FASGE, FACG, Associate Editor for Focal Points

Background/aims: Argon plasma coagulation (APC) is an alternate ablative method to radiofrequency ablation for the treatment of Barrett's esophagus (BE), and it is preferred due to its lower cost and widespread availability. The present meta-analysis aimed to analyze the safety and efficacy of APC for the management of BE., Methods: A literature search from January 2000 to November 2022 was done for studies analyzing the outcome of APC in BE. The primary outcomes were clearance rate of intestinal metaplasia and adverse events (AE). Pooled event rates were expressed with summative statistics., Results: A total of 38 studies were included in the final analysis. The pooled event rate for clearance rate of intestinal metaplasia with APC in BE was 86.8% (95% confidence interval [CI], 83.5% to 90.2%), with high-power and hybrid APC having a higher rate compared to standard APC. The pooled incidence of AE with APC in BE was 22.5% (95% CI, 15.3% to 29.7%), without any significant difference between the subgroups, with self-limited chest pain being the commonest AE. The incidence of serious AE was only 0.4% (95% CI, 0.0% to 1.0%), while stricture development was seen only in 1.7% (95% CI, 0.9% to 2.6%) of cases. The pooled recurrence rate of BE was 16.1% (95% CI, 10.7% to 21.6%), with a significantly lower recurrence with high-power APC than standard APC., Conclusions: High-power and hybrid APC seem to have an advantage over standard APC in terms of clearance rate and recurrence rate. Further studies are required to compare the efficacy and safety of hybrid APC with standard APC and radiofrequency ablation.

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., (© 2024 S. Karger AG, Basel.)

Bronchopleural fistula (BPF) is a rare but significant cause of morbidity and mortality in cancer patients undergoing surgical lung resection. The mainstay of treatment for BPF is revision of surgical stump. We describe a case of persistent bronchopleural fistula treated with a novel combination of argon plasma coagulation and fibrin glue.

Case Presentation: A 57-year-old man with a history of polysubstance use presented with shortness of breath, wheezing, productive cough, subjective fever, and chills of 3-day duration. Additionally, he reported worsening shortness of breath for the last 3 months. Of note, the patient was reported to have had, in the previous 6 months, two episodes of pneumonia that was treated with antibiotics and steroids. He was also diagnosed several years prior with adult-onset asthma due to intermittent wheezing and was prescribed an albuterol inhaler. The albuterol did not help relieve his wheezing, and he stopped refilling it., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Endoscopic post-papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy., Methods: In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post-papillectomy bleeding rate and the tumor persistence rate., Results: The delayed post-papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non-APC group (P = 0.434). The post-procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure-related mortalities or serious complications., Conclusion: Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration-cris.nih.go.kr; KCT0001955)., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Rationale: An esophago-bronchial fistula is one of the rare postoperative complications of esophageal cancer. There are various medical treatments, including suturing, endoscopic clip, and fibrin glue. However, these treatments often lead to unsatisfactory results, causing physicians to opt for surgical alternatives. The Over-The-Scope-Clipping (OTSC) system offers an alternative method for fistula closure. It can capture a large amount of tissue and is able to compress the lesion until it has fully healed. However, data indicating the efficacy of OTSC for esophago-bronchial fistula are limited., Patient Concerns: A 64-year-old man presented with an esophago-bronchial fistula after surgery for esophageal cancer. We chose to use a stent as the first line of treatment, but the fistula did not close., Diagnoses: Intractable esophago-bronchial fistula associated with esophageal surgery., Interventions and Outcomes: On the 94th postoperative day, fistula closure with OTSC was performed, and no leakage of the contrast agent was observed during fluoroscopy. We also attempted to close the fistula by combining OTSC and argon plasma coagulation (APC) to burn off the scar tissue from around the fistula. The fistula gradually shrank after a total of 4 rounds of OTSC, and closure of the fistula was achieved on the 185th postoperative day. There were no adverse events during the treatment of this case., Lessons: We demonstrate that OTSC is useful in the management of esophago-bronchial fistulas, and may become a standard procedure for the endoscopic treatment of esophago-bronchial fistulas, replacing the use of stents, clips, or glue., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Aims: To evaluate the efficacy of medical thoracoscopy-assisted argon plasma coagulation in association with autologous blood pleurodesis in spontaneous pneumothorax., Patients and Methods: Three male patients with spontaneous pneumothorax were treated; medical thoracoscopy-assisted argon plasma coagulation combined with autologous blood pleurodesis was conducted for all patients whose duration of the air leak exceeded 7 days. We systematically reviewed all of the relevant literature to analyze and sum up the treatments of secondary spontaneous pneumothorax., Results: The air leaks were all sealed and no recurrence of pneumothorax was reported. No complications of fever, bleeding, or signs of infection were observed during the process., Conclusion: The authors believe that the combination of medical thoracoscopy-assisted argon plasma coagulation and autologous blood pleurodesis is safe and effective. However, due to the number of patients included in this uncontrolled case study, more cases will be collected in the future. The reviews of this paper are available via the supplemental material section.

Background: Patients after esophagectomy for esophageal squamous cell carcinoma (SCC) occasionally develop metachronous SCC in the residual esophagus. Although most of these second primary lesions are detected as superficial cancer at follow-up endoscopy, it is often difficult to perform endoscopic resection for these lesions near the site of anastomosis., Methods: The objective of this study was to evaluate the effectiveness of argon plasma coagulation (APC) for superficial SCC in the residual esophagus after esophagectomy. Twelve patients (involving 15 s primary lesions) received APC for superficial SCC in the residual esophagus after esophagectomy. These lesions were difficult to perform endoscopic resection and they were treated using APC., Results: There was no treatment-related complication. Complete remission (CR) was achieved in 13 (86.6%) of the 15 lesions: CR was achieved in 11 lesions (73.3%) after the first APC course, and in another 2 lesions (13.3%) after two or more APC courses. Of the 2 patients with persisting residual tumor, 1 patient received 12 times repeated-APC courses over 6 years, and eventually achieved local control without metastasis, the other patient received radiotherapy and cervical esophagectomy after treatment failure with APC. All patients survived except for one patient who died of old age and another patient who died of tongue cancer., Conclusions: APC was a safe treatment that was easy to perform. APC was concluded to be an effective treatment for superficial SCC in the residual esophagus after esophagectomy when endoscopic resection was difficult.

Background/aims: Endoscopic resection is the standard treatment for superficial esophageal squamous-cell neoplasia (SESCN). However, we encounter patients in whom endoscopic resection is difficult to perform. We retrospectively studied the usefulness of argon plasma coagulation (APC) in patients with SESCN., Materials and Methods: The study comprised 45 patients with SESCN (81 lesions) who underwent APC in our hospital from March 1999 through August 2016. Clinicopathological characteristics, treatment time, the presence or absence of metastasis and recurrence, adverse events, and outcomes were studied., Results: The median follow-up was 40 months. The median age was 70 years. The tumor diameter was 10 mm or longer in 48 lesions and less than 10 mm in 33 lesions. The median treatment time was 22 minutes. The reasons for selecting APC were as follows: technical difficulty caused by the presence of metachronous multiple lesions in the radiation field after chemoradiotherapy or close proximity to the ulcer scar remaining after endoscopic treatment in 49 lesions (60.4%), and the presence of underlying diseases in 26 lesions (32.0%). Adverse events occurred in 2 patients (4.4%) who had hypoxemia due to over-sedation. Two lesions (2.5%) recurred locally but could be locally controlled by additional APC. No patient had metastasis or recurrence or died of esophageal neoplasia. The 3-year overall survival rate was 87.0%, and the 3-year recurrence-free survival rate was 97.2%., Conclusion: APC can be a useful treatment option for SESCN in patients with a limited life expectancy, poor performance status, or technical difficulty in resection of superficial neoplasms.

Background: Tracheobronchoplasty is the definitive treatment for patients with symptomatic excessive central airway collapse. This procedure is associated with high morbidity and mortality rates. Bronchoscopic techniques are an appealing alternative with less morbidity and the ability to apply it in nonsurgical patients. Although thermoablative methods have been proposed as treatment options to induce fibrosis of the posterior tracheobronchial wall, no studies have compared direct histologic effects of such methods. This study compared the effects of electrocautery, radiofrequency ablation, potassium titanyl phosphate laser, and argon plasma coagulation (APC) in the tracheobronchial tree in an ex vivo animal model., Methods: Four adult sheep cadavers were used for this study. Under flexible bronchoscopy, the posterior tracheal membrane was treated using different power settings on 4 devices. The airways were assessed for the presence of treatment-related histopathologic changes., Results: Histologic changes observed were that of acute thermal injury including: surface epithelium ablation, collagen fiber condensation, smooth muscle cytoplasm condensation, and chondrocyte pyknosis. No distinct histologic differences in the treated areas among different modalities and treatment effects were observed. APC at higher power settings was the only modality that produced consistent and homogenous thermal injury effects across all tissue layers with no evidence of complete erosion., Conclusion: Although electrocautery, radiofrequency ablation, potassium titanyl phosphate laser, and APC all induce thermal injury of the airway wall, only APC at high power settings achieves this effect without complete tissue erosion, favoring potential regeneration and fibrosis. Live animal studies are now plausible.

Traumatic spinal cord injury (TSCI) can cause paralysis and permanent disability. Rehabilitation (RB) is currently the only accepted treatment, although its beneficial effect is limited. The development of biomaterials has provided therapeutic possibilities for TSCI, where our research group previously showed that the plasma-synthesized polypyrrole/iodine (PPy/I), a biopolymer with different physicochemical characteristics than those of the PPy synthesized by conventional methods, promotes recovery of motor function after TSCI. The present study evaluated if the plasma-synthesized PPy/I applied in combination with RB could increase its beneficial effects and the mechanisms involved. Adult rats with TSCI were divided into no treatment (control); biopolymer (PPy/I); mixed RB by swimming and enriched environment (SW/EE); and combined treatment (PPy/I + SW/EE) groups. Eight weeks after TSCI, the general health of the animals that received any of the treatments was better than the control animals. Functional recovery evaluated by two scales was better and was achieved in less time with the PPy/I + SW/EE combination. All treatments significantly increased βIII-tubulin (nerve plasticity) expression, but only PPy/I increased GAP-43 (nerve regeneration) and MBP (myelination) expression when were analyzed by immunohistochemistry. The expression of GFAP (glial scar) decreased in treated groups when determined by histochemistry, while morphometric analysis showed that tissue was better preserved when PPy/I and PPy/I + SW/EE were administered. The application of PPy/I + SW/EE, promotes the preservation of nervous tissue, and the expression of molecules related to plasticity as βIII-tubulin, reduces the glial scar, improves general health and allows the recovery of motor function after TSCI. The implant of the biomaterial polypyrrole/iodine (PPy/I) synthesized by plasma (an unconventional synthesis method), in combination with a mixed rehabilitation scheme with swimming and enriched environment applied after a traumatic spinal cord injury, promotes expression of GAP-43 and βIII-tubulin (molecules related to plasticity and nerve regeneration) and reduces the expression of GFAP (molecule related to the formation of the glial scar). Both effects together allow the formation of nerve fibers, the reconnection of the spinal cord in the area of injury and the recovery of lost motor function. The figure shows the colocalization (yellow) of βIII-tubilin (red) and GAP-43 (green) in fibers crossing the epicenter of the injury (arrowheads) that reconnect the rostral and caudal ends of the injured spinal cord and allowed recovery of motor function.

Objective: This economic evaluation aims to provide a preliminary assessment of the cost-effectiveness of radiofrequency ablation (RFA) compared with argon plasma coagulation (APC) when used to treat APC-refractory gastric antral vascular ectasia (GAVE) in symptomatic patients. Methods: A Markov model was constructed to undertake a cost-utility analysis for adults with persistent symptoms secondary to GAVE refractory to first line endoscopic therapy. The economic evaluation was conducted from a UK NHS and personal social services (PSS) perspective, with a 20-year time horizon, comparing RFA with APC. Patients transfer between health states defined by haemoglobin level. The clinical effectiveness data were sourced from expert opinion, resource use and costs were reflective of the UK NHS and benefits were quantified using Quality Adjusted Life Years (QALYs) with utility weights taken from the literature. The primary output was the Incremental Cost-Effectiveness Ratio (ICER), expressed as cost per QALY gained. Results: Over a lifetime time horizon, the base case ICER was £4840 per QALY gained with an 82.2% chance that RFA was cost-effective at a threshold of £20,000 per QALY gained. The model estimated that implementing RFA would result in reductions in the need for intravenous iron, endoscopic intervention and requirement for blood transfusions by 27.1%, 32.3% and 36.5% respectively. Compared to APC, RFA was associated with an estimated 36.7% fewer procedures. Conclusions: RFA treatment is likely to be cost-effective for patients with ongoing symptoms following failure of first line therapy with APC and could lead to substantive reductions in health care resource.

Radiofrequency ablation (RFA) is very effective for eradication of flat Barrett's mucosa in dysplastic Barrett's esophagus after endoscopic resection of raised lesions. However, in a minority of the time, RFA may be ineffective at eradication of the Barrett's mucosa. Achieving complete eradication of intestinal metaplasia can be challenging in these patients. This review article focuses on the management of patients with dysplastic Barrett's esophagus refractory to RFA therapy. Management strategies discussed in this review include optimizing the RFA procedure, optimizing acid suppression (with medical, endoscopic, and surgical management), cryotherapy, hybrid argon plasma coagulation, and EndoRotor resection., Competing Interests: Conflict-of-interest statement: There is no conflict of interest associated with any of the senior author or other coauthors contributed their efforts in this manuscript., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Central airway obstruction (CAO) is associated with significant morbidity and increased mortality. Bronchoscopic electrosurgical and laser ablative tools have proven to be safe and effective instruments for the treatment of malignant CAO. Although therapeutic modalities such as electrocautery, argon plasma coagulation, and laser have been used for decades, additional tools including radiofrequency ablation catheters continue to be developed for the treatment of CAO. These modalities are considered safe in the hands of experienced operators, although serious complications can occur. This review describes various electrosurgical and laser therapy tools used for the treatment of malignant CAO along with the specific advantages and disadvantages of each device., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Competing Interests: None

Competing Interests: None

Background: This study aimed to study the clinical efficacy of argon plasma coagulation plus cryotherapy for central airway stenosis caused by lung cancer., Methods: The clinical data of 177 patients with central airway stenosis caused by lung cancer received surgery from June, 2017 to July 2018 were retrospectively analyzed. According to different treatments, 43 patients received cryotherapy were included in the control group, while 134 patients received argon plasma coagulation plus cryotherapy were in the observation group. After propensity score matching, patients in the two groups were in a 1:1 ratio. The Karnofsky score, partial pressure of oxygen (PaO 2 ), arterial oxygen saturation (SaO 2 ), partial pressure of arterial carbon dioxide (PaCO 2 ) and adverse reactions in patients were analyzed one week before and after treatment. Besides, the survival rates of the two groups were compared., Results: After propensity score matching, the baseline data were not significantly different between the two groups. The post-treatment Karnofsky scores in the two groups were significantly higher than those of before treatment, and the post-treatment score of the observation group was higher than that of the control group (all P < 0.05). The post-treatment PaO 2 and SaO 2 in the observation group were both higher than those of the control group; while the PaCO 2 in the observation group was significantly lower than that of the control group (all P < 0.05). In the observation group, the levels of PaO 2 and SaO 2 were significantly higher, and the level of PaCO 2 was significantly lower after treatment than those of before treatment (all P < 0.05). The rates of completely effective and mild effective in the observation group were significantly higher than those in the control group (both P < 0.05). The incidences of bleeding, arrhythmia and fever in the observation group were significantly lower than those in the control group (all P < 0.05). The survival rate was significantly higher in the observation group (72.09%) than in the control group (51.16%)., Conclusions: Argon plasma coagulation combined with cryotherapy can significantly alleviate the central airway stenosis caused by lung cancer, reduce the incidence of adverse reactions, and improve prognosis in patients.

Background: Endoscopic full-thickness transoral outlet reduction (efTOR) is a therapeutic option to reduce a dilated gastrojejunal anastomosis (GJA) after Roux-en-Y gastric bypass (RYGB). Mucosal ablation with argon plasma coagulation (APC) is usually performed to achieve tissue adaptation. However, rupture of sutures before scarring can lead to recurrent dilatation of the GJA. Here, we describe efTOR with a semicircumferential endoscopic submucosal dissection (ESD-efTOR) as an alternative to APC-efTOR., Methods: We enrolled 41 patients with comparable baseline characteristics (APC-efTOR 26; ESD-efTOR 15). The main objectives were reduction in the GJA diameter and in ruptured sutures. Technical success, complications, total weight loss (TWL), and percentage of total and excess weight loss (%TWL and %EWL) at 3 and 12 months, were assessed., Results: ESD-efTOR resulted in significantly fewer ruptured sutures (20 % vs. 69 %; P  = 0.004) and a greater reduction in the GJA (major 20 % vs. 0 %; minor 54 % vs. 37 %; no reduction 13 % vs. 58 %; P  = 0.02) after 3 months. Technical efficacy, examination time, and rate of complications were comparable., Conclusions: ESD-efTOR resulted in a significantly greater reduction in the GJA diameter and a lower risk of ruptured sutures compared with APC-efTOR., Competing Interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: None

In patients with advanced esophageal or gastric cancer, it is highly likely that palliation of symptoms will become a focus of treatment. Dysphagia and obstruction are the most common complaints, and many of these patients can be treated with endoscopic interventions to alleviate symptoms. Bleeding, perforation, and nutritional issues are common problems. Attempts at palliation should be guided by thoughtful discussions regarding patients' goals of care. Owing to the high morbidity and mortality in patients with limited life expectancy, a strategy of working from the least invasive to the most invasive interventions should be guided by the patient's goals., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Tonsillectomy is one of the most common otolaryngological procedures. Nonetheless, there is still no universally approved 'gold standard' technique., Objective: To compare the safety and efficacy of argon plasma coagulation and coblation techniques in tonsillectomy., Methods: A multi-institutional, retrospective cohort study was conducted, comprising 283 patients who underwent bilateral tonsillectomies performed by a single surgeon between 2014 and 2017. The outcome measures included: operative time, intra-operative blood loss, post-operative pain and post-operative haemorrhage., Results: In the argon plasma coagulation group, mean operative time and post-operative haemorrhage rate were significantly reduced, p = 0.0006 and p = 0.003 respectively. There was no statistically significant difference between the two groups in terms of post-operative pain and intra-operative blood loss., Conclusion: The argon plasma coagulation technique is easy, safe and efficacious. Argon plasma coagulation tonsillectomy seems cost-effective compared to coblation tonsillectomy: the single-use disposable electrode tip and wand used in this study cost AUD$76.50 and AUD$380 respectively. Argon plasma coagulation appears to be a favourable alternative to current modalities such as coblation.

Background: Mechanisms for weight regain after gastric bypass are not fully understood and the process is likely multifactorial. The initial step in the management of weight regain is a comprehensive evaluation of contributing factors. While lifestyle modification is fundamental, it has limited efficacy which can be enhanced by medications and/or endoscopic revision. Anatomic changes such as larger pouch size and dilation of the gastrojejunal anastomosis (GJA) may contribute to increased postoperative weight gain. Endoluminal revisions offer an effective and less invasive management strategy for this population., Methods: A 55-year-old female with history of RYGB in 2006 presented with weight regain. She was referred to our unit for endoscopic evaluation., Results: During endoscopy, a large GJA (25 mm in diameter) was diagnosed. A novel trans-oral outlet reduction (TORe) was then performed. A modified ESD was first performed on the GJA, followed by argon plasma coagulation of the margins of the ESD. Then a purse-string TORe with suturing was performed, using a 10 mm balloon to size the GJA. On 6-month follow-up, patient lost 20 lb. and 12.26 %TBWL and EGD showed a 10 mm diameter GJA. On 1-year follow-up, patient weight loss was 14 lb. and 8.58 %TBWL. The follow-up endoscopy showed a 12 mm diameter GJA., Conclusion: Endoluminal therapies are safe, reproducible, and effective in the treatment of weight regain and should be utilized as a first-line approach to manage this condition. This novel-combined approach is feasible and may be more effective in the treatment of weight regain.

Introduction: The objective of this study was to understand how J-Plasma® (Bovie Medical Corporation, Clearwater, Florida) surgical energy compares to monopolar, argon beam, and CO2 laser devices in terms of depth of penetration and lateral thermal spread in a porcine tissue model., Materials and Methods: Using a porcine animal model, we applied the thermal energy of the J-Plasma® laser, Bovie Monopolar Pencil™ (Bovie Medical Corporation, Clearwater, Florida), argon beam coagulator, and CO2 laser to porcine small bowel, bladder, and peritoneal tissues at equivalent settings. Tissue was excised and sent to pathology for histologic evaluation. Primary outcome was depth of penetration and lateral thermal spread., Results: When applied to peritoneum tissue, CO2 laser had the greatest lateral thermal spread at 2.99mm, while the argon beam had the lowest at just under 1.5mm. With regard to depth of penetration, the monopolar pencil had the highest while J-Plasma® had the lowest. When applied to bladder tissue, the argon beam was associated with the greatest lateral thermal spread (3.1mm) as compared to the other three devices (all less than 1mm). In terms of depth of penetration of bladder tissue, J-Plasma® again had the lowest value, while the monopolar pencil had the highest. When applied to small intestine tissue, the argon beam had the greatest lateral spread (3.51mm), while J-Plasma® had the lowest (less than 1mm). Regarding depth of penetration of small intestine tissue, argon beam had the highest value at 1.8mm compared to the other three devices (all below 0.6mm)., Conclusion: Consistent with our previous study, J-Plasma® had minimal lateral and depth spread when applied to various tissue types. J-Plasma® performed better or similar when compared to monopolar, argon beam, and laser electrosurgical devices. Further studies in-vivo are needed to evaluate safety and surgical application of the J-Plasma® device.

Competing Interests: None

Background and Aims: Excision of all visible neoplastic tissue is the goal of EMR of colorectal laterally spreading tumors. Flat and fibrotic tissue can resist snaring. Ablation of visible polyps is associated with high recurrence rates. Avulsion is a technique to continue resection when snaring fails., Methods: We retrospectively analyzed colonic EMRs of 564 consecutive referred polyps between 2015 and 2017. Hot avulsion was used when snaring was unsuccessful. Polyps treated with and without avulsion were compared., Results: Hot avulsion was used in 20.9% (n = 112) of all resected lesions. The recurrence rates on follow-up colonoscopy were 17.52% in the avulsion group versus 16.02% in the non-avulsion group (P = .76). Hot avulsion was associated with a trend toward higher rates of delayed hemorrhage (5.35% vs 2.58%; P = .15) and post-coagulation syndrome (1.8% vs 0.47%; P = .15), but polyps treated with any avulsion were larger than those in which no avulsion was used (P < .001). There were an insufficient number of adverse events to perform a multivariable analysis to test the effects of avulsion, size, and location on the risk of overall adverse events., Conclusions: Unlike previous reports of using argon plasma coagulation to treat visible polyps during EMR, hot avulsion of visible/fibrotic neoplasia was associated with similar EMR efficacy compared with cases that did not require hot avulsion. The safety profile of hot avulsion appears acceptable., (Copyright © 2019. Published by Elsevier Inc.)

Aim: Chronic radiation proctitis (CRP) develops in 5-15% of patients after pelvic radiation therapy, with rectal bleeding being the main symptom. Reports suggest that argon plasma coagulation (APC) can be an effective therapy for CRP following radiotherapy for prostate cancer, but there is less information about how useful it is after radiotherapy for gynaecological malignancy. The aim of this work therefore was to study the efficacy of APC for CRP after radiotherapy for gynaecological malignancy., Method: This was a prospective study of consecutive patients with CRP following radiotherapy for gynaecological malignancy at IPGME&R, SDLD, Kolkata, India; symptoms included rectal bleeding grade (RBG) ≥ 2. APC was performed at monthly intervals to a maximum of four treatment sessions. Severity of disease at baseline was graded (endoscopically) by the total colonoscopic severity score (TCSS) and treatment response was assessed by reduction in RBG from ≥ 2 to ≤ 1 measured at > 6 months after cessation of APC., Results: Seventy patients [90% with cervical cancer, 10% with endometrial cancer; mean age 51.93 ± 9.15 years; median RBG 3 (range 2-4)] received APC. Seven patients died due to underlying malignancy and seven patients were lost to follow-up. Fifty-six (85.7%) patients responded to therapy after a median of 2 (range 1-4) treatment sessions. Multivariate analysis demonstrated that a lower haemoglobin at the start of treatment predicted failure of therapy (P < 0.05)., Conclusion: APC is an effective management option for CRP in female patients with gynaecological malignancy. However, the more anaemic the patient the less likely it is to be successful., (Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.)

Introduction: The term angiodysplasia (AD) refers to acquired malformation of the blood vessels (communications between veins and capillaries), frequently found within the gastrointestinal mucosa and submucosa. AD of stomach and duodenum are cause of upper gastrointestinal bleeding in 4%-7% of patients. The means of treatment are usually endoscopic, including argon plasma coagulation (APC), electrocoagulation, mechanical hemostasis by clippsing, laser photo-coagulation and injection therapy., Aim: To compare the success rate, and adverse events (ulcer lesions, perforations) of APC and injection therapy in the treatment of bleeding angiodysplasia in the upper gastrointestinal tract (GIT)., Material and Methods: In a prospective study including 50 patients with bleeding angiodysplasia of the upper GIT, 35 patients were treated with APC, and remaining 15 with injection therapy using adrenaline and 1.5% solution of polidocanol. Follow-up period was 6 months., Results: A total of 50 patients aged 18 to 64 years, 64% male and 36% female, have been treated during 2 years period. The rate of recurrent bleeding and side effects was significantly higher in the adrenaline group (p <0.01). Blood transfusion was required in 68% during the first hospital admission. Angiodysplasia of the stomach was present in 66%, versus 34% in duodenum., Conclusion: Endoscopy is "gold standard" for diagnosis and treatment of AD in the gastrointestinal tract. The study unveiled APC as more effective treatment option with lower degree of complications and adverse events in comparison to injection therapy in patients with bleeding AD.

We investigated the effects of tonsillectomy by low-temperature plasma on the growth development and psychological behavior in children with obstructive sleep apnea hypopnea syndrome (OSAHS).This study included 72 moderate and severe OSAHS children with tonsils or adenoids hypertrophy, which were randomly assigned into either the study group (n = 36) or the control group (n = 36). Patients in study group underwent tonsillectomy by low-temperature plasma, while in the control group underwent tonsil-pecking, then the efficacy were compared.The time of surgery, VAS scores on postoperative day 1, 3, and 7 were significantly lower in the study group than in the control group, and the efficiency was significantly higher in the study group than the control group (P = .018). In the study group, the BMI was lower, the score of C-WISC (VIQ, PIQ, and FIQ) was higher, the score of CBCL social competence was higher and the score of behavioral questions was lower than that in the control group; differences were statistically significant (P = .022). The serum levels of IgA, IgG, and IgM, as well as the percentage of T lymphocytes, between the study group and the control group were not significantly different (P = .132).Tonsillectomy by low-temperature plasma was effective on the treatment of children with severe OSAHS, and could improve growth development and psychological behavior.

A 63-year-old man presented with intermittent, progressively worsening dyspnoea associated with cough and blood-tinged sputum. Initial work-up showed left axis deviation on ECG, chest X-ray with an elevated left hemidiaphragm and a non-contrast CT chest that showed a multilobulated mass in the proximal trachea. Bronchoscopy showed a whitish-appearing lesion, which was then sampled and partially resected with pathology showing a schwannoma with no malignant cells. He felt partial relief post procedure; however, he presented a month later with similar symptoms of dyspnoea and a repeat CT scan showed enlargement of the mass in the same location. The patient underwent another flexible bronchoscopy and resection with argon plasma coagulation (APC)/electrocautery snare. APC/electrocautery is an effective interventional bronchoscopy technique that can be used to resect endoluminal lesions or extraluminal lesions that have infiltrated into the airway using flexible/rigid bronchoscopy. It is more cost-effective, safe, works well with vascular lesions and achieves excellent haemostasis as compared with Nd:YAG lasers., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: The early improvement in metabolic profile after sleeve gastrectomy (SG) indicates that the significant benefits of metabolic surgery are gastric in origin. We have previously demonstrated that devitalization of the gastric mucosa (without a reduction in gastric volume) in metabolically disturbed obese rats results in an improvement of obesity and its associated comorbidities. The aims of this study were to assess the technical feasibility, efficacy, and safety of gastric mucosal devitalization (GMD) in a large animal (porcine) model., Methods: A 3-arm (GMD versus SG versus sham [SH]) prospective randomized controlled trial with an 8-week follow-up period was performed. The primary endpoint was relative weight loss. Secondary endpoints were absolute body weight, abdominal visceral adiposity, abdominal subcutaneous adiposity, organ lipid content, and serum ghrelin level., Results: GMD resulted in a significant relative weight loss of 36% over SH at 8 weeks (P < .05). There was no significant difference in relative weight loss between GMD and SG at 4 weeks; however, SG resulted in a 29% superior relative weight loss at 8 weeks (P < .05). With regard to visceral adiposity, there was a significant benefit of GMD over SH at 8 weeks. Despite differences in relative weight loss, there was no significant difference in visceral adiposity between SG and GMD at 8 weeks. Significant improvements in GMD over SH were noted with regard to skeletal and heart muscle lipid content. GMD pigs at 8 weeks demonstrated regeneration of the gastric mucosa without ulceration or significant scarring. Despite mucosal regeneration, the abundance of serum ghrelin was significantly lower in the GMD cohort compared with the SG and SH cohorts., Conclusions: GMD was technically feasible and resulted in relative weight loss and an improvement in visceral adiposity. The benefits noted were out of proportion to what would be expected with weight loss alone., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Endoscopic snare papillectomy (ESP) is an effective treatment for ampullary adenoma. Argon plasma coagulation (APC) is widely used as an additional method to control bleeding or ablate the residual tumor. However, the efficacy of this procedure has not yet been fully evaluated. This study aimed to evaluate the usefulness of APC as an additional method to ESP., Methods: Patients who underwent ESP for ampullary adenoma between September 2005 and September 2015 were retrospectively reviewed. Using propensity score matching, we compared short- and long-term outcomes between the ESP-with-additional-APC group (ESP + APC group) and the ESP-only group. Primary outcome was early post-ESP adverse events (AE), and secondary outcomes were late AE and recurrence., Results: Among 109 patients, additional APC was carried out in 59 (54.1%) patients. After matching, 41 patients were included in both groups, respectively. Bleeding rate was significantly lower in the ESP + APC group than in the ESP-only group (7.3% vs 31.7%, odds ratio = 0.180, P < 0.01). However, there were no significant differences in other procedure-related early AE such as pancreatitis (12.2% vs 19.5%, P = 0.365), cholangitis (2.4% vs 9.8%, P = 0.198), and perforation (2.4% vs 2.4%, P = 1.000) between the ESP + APC group and the ESP-only group. During the follow-up period (mean 904 ± 868 days), papillary stricture (9.8% vs 4.9%, P = 0.405) and recurrence rates (24.4% vs 24.4%, P = 0.797) were not significantly different between the ESP + APC group and the ESP-only group., Conclusion: Additional APC during ESP may have a beneficial effect by decreasing bleeding rate without harmful effects., (© 2017 Japan Gastroenterological Endoscopy Society.)

Zenker's diverticulum (ZD), or pharyngeal pouch, is an anatomical defect characterized by herniation of the posterior pharyngeal wall through Killian's dehiscence, and may result in dysphagia and regurgitation. Multiple therapeutic modalities including surgery, rigid and flexible endoscopy have been developed to manage ZD. Although surgical management with open and endoscopically assisted techniques have historically been the mainstay of ZD treatment, minimally invasive flexible endoscopic techniques, carried out under conscious sedation, are increasingly favored. Over the last two decades, the advent of new accessories and techniques have changed the landscape of endotherapy for ZD, with the current armamentarium including, but not limited to, endoscopic stapling, CO 2 laser, argon plasma coagulation, needle knife, bipolar forceps, hook knife, clutch cutter, stag beetle knife, and submucosal tunneling endoscopic septum division. We hereby review the latest evidence to support the endoscopic management of ZD., (© 2018 Japan Gastroenterological Endoscopy Society.)

Background: The development of central airway obstruction during malignant diseases is an important cause of morbidity and mortality. Endobronchial therapies can decrease the patient's symptoms and improve quality of life. Here, we compare airway recanalization methods: argon plasma coagulation with mechanical tumor resection (APC + MTR) and cryorecanalization (CR efficiency, complications, restenosis rate, and time to restenosis) in patients with malignant exophytic endobronchial airway obstruction., Methods: A total of 89 patients were included who were admitted to our hospital between 2005 and 2012. The data were analyzed retrospectively. Initially, a CR procedure was performed in 52 patients using rigid bronchoscopy under general anesthesia; the APC + MTR procedure was performed in 37 patients with malignant airway obstruction., Results: The airway patency rate with APC + MTR was 97.3% (n = 36) and CR was 80.8% (n = 42). The APC + MTR procedure was more effective than CR for recanalization of malignant endobronchial exophytic airway obstruction. Additionally, the achievement rate of airway patency with APC + MTR was significantly higher in tumors with distal bronchial involvement. There was no statistically significant difference between groups in terms of complications, restenosis rate, and time to restenosis., Conclusions: The APC + MTR procedure is preferred over CR to introduce and maintain airway patency in patients with malignancy-related endobronchial exophytic airway obstruction.

A 65-year-old man presented with obstructive pneumonia due to squamous cell carcinoma of the lung, which invaded the right main bronchus. Argon plasma coagulation was performed, which reduced his symptoms. Right pneumonectomy was performed after preoperative chemotherapy; the pathological diagnosis was T3N1M0 Stage IIIA. Fifteen months after surgery, he presented with bloody sputum. Bronchoscopy showed multiple endotracheal tumors, and a pathological examination revealed squamous cell carcinoma; the same histology as the primary lung cancer. We hypothesized that direct implantation during bronchoscopic therapy or hematogenous or lymphatic spread might have led to metastasis. A careful follow-up is required after bronchoscopic therapy.

Argon plasma coagulation (APC) is an electrosurgical technique which can be used to ablate skin lesions with limited invasion depth into dermal tissue. Hence, APC might be well suited for the removal of epithelial tumours. However, there are no data on the effects of APC on human skin tissue. Thus, the aim of this study was to determine the extent of epidermal and dermal damage after APC of human skin. We performed APC ex-vivo on 91 freshly resected human skin samples, which were obtained after reconstructive surgical closures in actinically damaged areas. Tissue effects were evaluated histologically and compared across different power settings. Using 15, 30, and 45 W, median (interquartile range; IQR) coagulation depths were 110.0 µm (91.7-130.0), 113.3 µm (85.8-135.0), and 130.0 µm (100.0-153.3.0), respectively. Median (IQR) thickness of necrosis zone was 30.0 µm (23.3-40.0) at 15 W, 26.7 µm (20.0-41.6) at 30 W, and 43.3 µm (30.8-57.5) at 45 W. The Kruskal-Wallis test showed significant differences between 15 and 30 W versus 45 W for coagulation depth (P = 0.0414), necrosis zone (P = 0.0017), and necrosis according to overlaying epidermal thickness (P = 0.0467). In summary, APC is a simple and controllable electrosurgical technique to remove epidermal tissue with limited penetration to the dermis. Thus, APC is particularly suited for the ablation of epithelial skin lesions and, therefore, may serve as possible treatment approach for intraepithelial neoplasms such as actinic keratosis.

Competing Interests: None

Competing Interests: Andrea Anderloni is a consultant for Boston Scientific.