thermal methods for therapy of nonvariceal...

FIFTH INTERNATIONAL COURSE ON THERAPEUTIC ENDOSCOPY

Thermal methods for therapy of nonvariceal bleeding

DAVID FLEISCI 11:Il, ML)

D FLEISCHER. Thermal methods for therapy of nonvariceal bleeding. Can J Gastroenteroll992;6(3):176-178. This presentation addresses the thermal methods for therapy of nonvariccal bleeJing. The following subtopics will be considered: overview of thermal options, combination therapy, data, technique, conclusions regarding peptic ulcer rherapy and unique situations.

Key Words: Endoscopic rhera/)Y, Gastrointestinal bleeding

Methodes therapeutiques thermiques utilisees clans les cas d'hemorragies non variqueuses

RESUME: Cc rcxte passc en revue les mcchodcs thcrapeutiqucs thermiqul.!s utilisces dans les cas d'hemorragies non variqueuses. Les themes suivan ts sont abordes: survol des options rhermiqucs, traitcmcnts d'association, donncco, techniques, conclusions relatives au tra irement de l'ulcere gastro-<luoclenal et cas paniculiers.

IN 19~9. T l IE NATIONAL INSTITUT ES

ofl-l ealih (NIH ) Conscnsu Confe rence on EnJo~copic Thernpy nf Peptic Ulcer Disea~c w ncluded that four cmlt,scopic therapies ofhlccding peptic ulcer should he considered: multipolar clcctrocoagularion (Ml'EC) , heater probe, Nd :YAG laser and injection 1hernpy ( I ). The ~!l'E<.' and heat prohc were rared most prcfe rahle because nf their safety, efficacy, low cost and portability. The Nd :YAG laser was deemed cffccti \'e hut less desirable hecausc it was les~ portable and more skill \\'a~ required to use it. Monopnlm electro-

cnagulat ion , electrohydrothermal therapy and microwave therapy are the thermal technologies which currently have little rnlc.

COMBINATION THERAPY Rutgcerts ct al (2) has studied and

popularized the method using com.bi nation t hcrapy fnr peptic ulcer bleeding. By injecting the bleeding site wiLh 1: 10,000 adrenaline prior to the instituti(ll1 of thermal therapy, Rurgeen s' group believes thar the efficacy of treatment can be increased. The logic is that rhe adrenaline will cau,c vasoC()n-

C eorgewwn Uni11t?rsi1 ;1 I !o.1/1iwl, \\'lashi11gw11, DC, USA Ccmespmul,mce and re prims: Dr Dm11d Fle,scltcr, Chief, Endoscopy, Professor of Medicine,

Ueorgewu,n Unwersity I /01/iiral, 3800 Reservoir Road N\,'(/ , \\'l1~1hingron, DC 20007. USA

scncnon which constricts the ,irtery, making it less <1 pt ro bleed, and fac il itates the heat sink effect (if there i, le,s moving blood flowing through the artery, less heat will he carried aw.iy, making the thermal treatment more effic ient). In <1ddi tion , the edema which is caused from the i niect1on ll'i 11 also cause some comprc,sion on the vc~sel making it less likely to bleed.

Some cxpcrimcnrnl work by Lam and colleagues (3 ) cvalu,11 cd mural weakness and tissue effccLs induced hy thermal and injection therapy in a porcine small bowel model. T hey wi~hcd LO determine what thermal and injection therapie , both alone and in cnmhination, arc due to wall ~trength to provide information ahout the risk of perforation when combined d,crapics arc employed. They J ctcrmincJ the mural weaknes~ was most marked Lwo Jays ;1ftcr thermal injury wall st rength returned to normal after four day~. Alcohol injection alone and alcohul followed by BlCAP or hc<1ter prnhc docs m1t

reduce wall strength. Adrenaline alone also doc~ not reduce wall ~trength , hut a'-lrcnalinc followed hy either BICAP or heater probe treatment dccrc,1~cs wa ll strength . In a clinical ~tudy by Rutgccrrs <1nd colleagues (2), adrenaline plus polidocc1110l was found w he more effective thc111 adrenaline plu~ Y AG laser therapy, wh ich is more effective than adrenaline alone for bleeding peptic ulcers.

176 C AN J GA:,;TRl)LNTEROL Vl)l 6 NO 3 M1\Y/] LJNL 1992

. COMPARATIVE DATA In an attempt en understand beut·r

which of the thermal methods b 111\lsl

desirable, it i., useful lo review several

studies uimparmg differem endoscl,p1c

therapies. In a multicenrre emlnscopic

trial, Jensen ct al ( 4, 5) fnund thm hoth

the Hit',\ r and heater prnht· wt• re supe

rior to no endoscopic thernpy for

pauenls with acuvcly hlced111g ulcer,

compared wnh nonhlecding ulcers with , i-.,ihlc vesseb. The RICAP and

heater pro he were s11rn lar when com

rared for numhcr of day:, in the inten,ive care unit, number of blllllll tranv

fusions, need fm ulcer surgery, ulcer

healing rates and lllllrtality during

hosp1tal 1:at ion.

Matthewson er al (6) compared the

Nd:Y A(, laser with heater pnihc for

control o( ,1ctively hlccd111g ulcers and

nonbleeding visihlc vessels. Then: was

nn srnllst1call), s1gn1fic,ml difference 111

morrnlny between the grnups, but rehlet·ding in laser-treated patients w,h

b,s than in the control gro11p and

heater probe-treated patients. The ,lllthnrs (6) found the YAG l.hcr supc

nm to the heater pmbe.

L111 t'l a l (7) randomi:ed 61 patients

with nonhlccding , 1sd1lc vessels lO

e ither hc:ncr prohe treatment or conservati l'e man,1gemen1 \\'ithout enJ11-

scopic therapy. There was no stalisu

cally significant difference bet ween the

two groups 111 rate of rchlccd111g; add1-

lionally, 1he ,issurancc nf ultimate

hernosw,b, number of bln1xl trans

fu~ions requirt•d, durnt 1011 of hnspnal

i:ation and e,·cntual mortality were

similar. H llWl'\'t'r, rht· need for emer

gency surgical intervention was less fre

quent in the heater prohc group.

Hui ,md co-workers (8) J1d a ran

domized comparative study llf lasL' r

phnwcoagulaunn, heater prohe and

bipo lnr e lcctrou>agulauon int reatme nt

nf actively hlccdmg ukcr:.. There was

no Clmtrol group 111 this :,tudy anJ the

authors found the three treatment

groups similar with regard l\l ratl' of reblccding, duration of hospital stay

anJ prnpnnion of emergcnq· surgery

required. They stated that they prl'·

fcr red the bipo lar e lec trocoagulation

and hemer prohe over the YA Ci laser

because the fmmer rwo me less cxpen-

sive (although the difference was nrn

significant) and rehleeding 111 the

hearer probe group was twice thm of the laser and clcunicoagubtion group.

Rutgccrr:, ct .ii (2) u1mpared the

Rll :AP and Y AG laser in patients wi th ,IL t 1vc h leeding ulcers ,md nlmhkeding

visible vessels, prclre,iung all lesiom

with I : l 0,000 ,1drenalinc. Hemosra~is

was similar in hoth groups and there

was no difference 111 mortality.

TECHNIQUE Treatment parameters: There has hecn

rene\,ed focus regardmg the amount of

power and pulse durarnlll for the d1f

krenr thermal devices. lnirial lv ~lPEl'

pnwer was in the range of 50 W with I to 2 s pube,,. Work by Jensen and Laine

( 3,4,9) suggests that the depth oft issue

effect (and poss1hly successful thernpy)

can be afteued hy power and pu be dura

t 11 ll1 settmgs. They recommend 2 5 W

and contact umcs of lO ro 14 s. With

thL· he,1ter probe. 30 J 1s ,1dvised and

um tact limes of 8 rn l Os required. The

d1..·p1 h of injury can be increased hy

keeping the prnhe proximate to the

treated area. With a Y A(J laser, the

standard seuing would ht· 70 to 80 Wfor

0. 3 to 0.5 s. T1:,sue effects will also vary wi th dist,1nce from I he laser fihrc tn

lls:,ue bct,iuse 1..·ncrgy density will vary

wnh distance (hecause the ht·nm is

di, ergent) 111 this mincontact med1lld.

If a spurrang ,lrlcry is treated wnh .i contact de,·ice (MPEC or heater pmbc ),

tht· device should he applied direcrly tn

the :,pun of blood for a direct ct1apli\'1..' effect. The Y AC laser\ beam i, aimed

al and around the spurt111g artery lo

creme some edema frllm the thermal

111 J llr)'.

Thcrt· is nll Lllnsensus on the he,t

methlld for Lreating ,1 v1~ihle vcs~el.

The m,lJ<lnty of experts hcl icl'e that

trl'ating ci rcumfcrenuall y around thl' ves:,,cl before lrl·aring tls centre adds a

safct y margm of mcreascd edema and

vaM>eonst riclillll of thl' bleeding vessel.

A minom y op mum bcl1c,·1..'s th,it direct

pressure to the vessel as eftcct ivl' and

minimizes injury tn surroundmg tissue.

If a clot 1s l'IKOuntcrcd, the N II I Con

sensus Conference 1-ecommemb that gentle washing be app lied and if the

cl11t docs l1l)l coml' off, trea1 rncnt is nnt

CAN J GA:;TRtllNTl:Rtll V11L 6 Ntl 3 M AY/JUN! 1992

Thermal therapy for bleeding

indicated. I ltiwever, 1( treatment is to

be carried out, there arc two apprllac h

es. Preinjecti11n aniund the c lnt with

adrenaline \\ ill cause vasllconsmclllln

oft he underlying vessel and the edema,

and bmh consLrict the vessel and limn

a 1m1und which will c,·1cl the c lot. Al

tern.1tively. a twll-channcl sCllpe cou ld

he used with a grasping forLcps placed

through lll1e of the l hanncls tn grah the

clot. If hlced ing ensue,, a thernpcunc

device pl,iced through the ,cumd

channel Cllu ld be poised for therapy.

CONCLUSIONS REGARDING PEPTIC ULCERS

~tl'EC, hearer prohc, and Y AC l,i-cr

therapy arc all effective ,ind sak for

treat ing hlecding peplll ulcers. ~ll'H'

and he,ner prohe appear to he

prekrnhle because c.ipt ivl' coagulmirn1

can he used, a \\'ash system as ava1l.1hle

and they arc portable. A spurtin1; anery

should be treated in all 111c1dcnces.

C11n,1dcrat 1011 fllr trl'ating ,1 v1s1hlc ,·c,

scl shou ld he given hccause the fre

quency of rd1lecd111g is ,1pproximately

5(1l\,. If a clot is enuiu111cred over an

ulcer and recent bleeding h,1s occurred,

o nl' may heg111 wnh gentle washmg. A

lk-cision as to whether an ancmpt

should be made ro pnw1dc further

endmcop1t treatnK·nt depends on the

din1ul ,cumg.

UNIQUE SITUATIONS A lthough thL· porrnbilary ot the

Ml'Ll · and heater probe make them

dcs1rahle for trcaung pepll1.. ulcers and

should be Cllnsidcred as the first line of

rhernrn l therapy, hccause the laser can he used 111 a noncontact fashion.

penetrate more deeply, treat a hruader

area ,111d more rapidly treat muluplc

lesions, there arc unique s1t uat1rn1s in

which laser therapy i:, preferable tn

MPH ,ind heater prnbc. These cond1-

tams include watermelon ,tomach,

multiple angmdy~plasia and radiauon

pnictiris. In add1rnin, hccause penL'lra

n on with the Y AC, laser 1~ decpn, ll is more cffcctl\'C than the cont ,1ct device~

for treatmg tumours lif the g,1-.,tn1111te~

tinal tract which hlced and for which endoscopic thernpy 1, deemed appro

priate.

177

FJ 11~( 111 H

REFERENCES l. Prnu:cdmg, of 1hc ( '.on,cn,w,

Cnnfercn(,' on Therap,'Ulll Endosu 1p\ .111J Blced111g Ulcers. G1stn>tnll'M End(hl l 99L\ l6(Suppl): l-64.

1 Ru1gccrts P. V.1111rappcn (.', Van 1 lnolgcm !', Cl ;ii. Nd: YAG la,cr wr,us J\.tl'E( · fur 1reatmeni of ,cn·rl·ly hlc,•d1ng ukcr, G:i-tro111rc,L End,,,l 1987: 3 3: l 99-202.

3. Lam T, Ncw,nmc J. R,iscn A. cl al. Mural weakness and ri"uc l'llcn, induccd hy thermal ,m,l 1nJec1 i,1n 1hcrnp1c, 111 ;i p11rc111e ,mall bow,·! 111111.lcl. Ci,1'lm111tc,l EnJ.,,,. (In pre,,)

4 Jcn,cn l)J\.l, I l1r.1b,11,1,h1 K, c l"l\r I lcm,>,1a,ts Rc,l·ard1 l,rnup. A ,1udy

178

,,f coagul,niun dcp1hs with Rlt 'A.I' and heater prohc w I mpn l\'C cndo.,cnp1c hcmo,t,ts1, of hlccJmg pcptK ulcers Ga,1n1int,•,r End1hl 1989; 35· l 8 l. (Ah,1)

5. Jensen DM, J\.lachK,td,1 C,A, Kovacs T<.. )Ci. ct al. l ~nmn>lled randomi:cd rn1dv of hearer pn1he ,111d Bil Al' for hl'll111't,1,1, of sl'\ ere ulcer hkcding. l ~.istrncnt ,·ml, 1gy 1988:94: A208. (Ah,t)

6. Mmtl1,•\\sOn K, Sw.1111 C, Bland M, Kirkham JS, R.m n S(,, NnrchfielJ TC. R,mJomi:cd c11mpans11n ,if Nd: Y AG laser, h,·,11 er pn,lw an,I no cnd(hC\lptc thcn1py f,1r hlccdmg pcplll ulcer,. Ga,tml'lltl'mlog, L 99t\98: 12 W-44.

7. Un MJ, Lee FY. K,mg WJ\.l, l'L .11 A cnntrolled study of l hcrnpt'Ulll endoscopy f( 1r pcpu, u k l'rs w11 h 1wn-blecd111g ,·i,1hk· ,·c"cl. G:mmmrcst Endosc 1990; 16:241 6

8. Hui WM. Ng N. Lok A, Lai C, Lan Y, Lam SV. A r.mdomi:e,I comparis1m of laser phntocoagulauon, heater pn,hl'. :111,I h1pnlar cnagulat ll>n 111 till' 1rc:1t 111L·nt of bleeding ulcer,. C,.,,m >tnll'st Endosc 1991:37:299-W4.

9. Lune L. Mult1polar i:le,1rnui.1gulattun 111 the rrearmcnt llf ,Ktt,·c upper ga,1rnin1c,1in:1I hcmm,,rhagl'· A pro~pccuve cllntrulbl trt:il. N Engl .I Med 1987:1 16:1611 7.

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