Argon plasma coagulation in the management of gastrointestinal hemorrhage
- Jonathan Cohen, MD
Jonathan Cohen, MD
- Clinical Professor of Medicine
- New York University School of Medicine
Argon plasma coagulation (APC) is a non-contact thermal method of hemostasis that has generated much attention and excitement in recent years. It was introduced as an alternative to contact thermal coagulation (heater probe and bipolar cautery) and to existing non-contact technologies (primarily laser). The theoretical advantages of APC include its ease of application, speedy treatment of multiple lesions in the case of angiodysplasias or wide areas (the base of resected polyps or tumor bleeding), safety due to reduced depth of penetration, and lower cost compared to laser.
This topic will review argon plasma coagulation, including how it is used and its efficacy. The general management of adult patients with upper and lower gastrointestinal bleeding, as well as a detailed discussion of angiodysplasia of the gastrointestinal tract are discussed elsewhere. (See "Approach to acute upper gastrointestinal bleeding in adults" and "Approach to acute lower gastrointestinal bleeding in adults" and "Angiodysplasia of the gastrointestinal tract".)
WHAT IS APC?
Contrary to a common misconception, argon plasma coagulation (APC) is not a laser. This technology uses argon gas to deliver plasma of evenly distributed thermal energy to a field of tissue adjacent to the probe. A high voltage spark is delivered at the tip of the probe that ionizes the argon gas as it is sprayed from the probe tip in the direction of the target tissue. Argon gas is non-flammable and inexpensive to refill. It is easily ionized by the 6000 volt peak energy delivered by the tungsten wire that terminates just proximal to the probe tip. This ionized gas or plasma then seeks a ground in the nearest tissue, delivering the thermal energy with a depth of penetration of roughly 2 to 3 mm. The plasma coagulates both linearly and tangentially. By delivering energy to all tissue near the probe tip, APC can be used to treat a lesion around a fold and not clearly in view or a lesion that cannot be positioned directly in front of the endoscope.
A similar technology has been used for many years by surgeons in the operating room, particularly during hepatic surgery, as a means of spray coagulation to control superficial, diffuse bleeding. In the early 1990s, special probes were developed by the ERBE Corp. to allow this technology to be applied to flexible endoscopy. The disposable probes are available with diameters of 1.5 mm, 2.3 mm (the most commonly used size), and 3.2 mm. The standard probes are 220 cm long (picture 1); 300 cm probes can be specially ordered for use during push enteroscopy.
In addition to the probe, the equipment consists of an electrosurgical generator that comes on a cart along with the argon plasma coagulator, a foot pedal, and two tanks of argon gas. Both the argon flow rate and the wattage delivered per pulse are easily adjusted by pressing buttons on the control panel. Newer models of this cart will include a water pump.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Grund KE, Storek D, Farin G. Endoscopic argon plasma coagulation (APC) first clinical experiences in flexible endoscopy. Endosc Surg Allied Technol 1994; 2:42.
- Wahab PJ, Mulder CJ, den Hartog G, Thies JE. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences. Endoscopy 1997; 29:176.
- Herrera S, Bordas JM, Llach J, et al. The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage. Gastrointest Endosc 2008; 68:440.
- Silva RA, Correia AJ, Dias LM, et al. Argon plasma coagulation therapy for hemorrhagic radiation proctosigmoiditis. Gastrointest Endosc 1999; 50:221.
- 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.
- Fantin AC, Binek J, Suter WR, Meyenberger C. Argon beam coagulation for treatment of symptomatic radiation-induced proctitis. Gastrointest Endosc 1999; 49:515.
- Fazel A, Presti ME, Saeed ZA. Utility of the argon plasma coagulator: A university hospital experience (abstract). Gastrointest Endosc 1999; 49:AB123.
- Vargo JJ. Clinical applications of the argon plasma coagulator. Gastrointest Endosc 2004; 59:81.
- Havanond C, Havanond P. Argon plasma coagulation therapy for acute non-variceal upper gastrointestinal bleeding. Cochrane Database Syst Rev 2005; :CD003791.
- Ginsberg GG, Barkun AN, Bosco JJ, et al. The argon plasma coagulator: February 2002. Gastrointest Endosc 2002; 55:807.
- Kwan V, Bourke MJ, Williams SJ, et al. Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up. Am J Gastroenterol 2006; 101:58.
- Shudo R, Yazaki Y, Sakurai S, et al. Diffuse antral vascular ectasia: EUS after argon plasma coagulation. Gastrointest Endosc 2001; 54:623.
- Rolachon A, Papillon E, Fournet J. [Is argon plasma coagulation an efficient treatment for digestive system vascular malformation and radiation proctitis?]. Gastroenterol Clin Biol 2000; 24:1205.
- Kitamura T, Tanabe S, Koizumi W, et al. Rendu-Osler-Weber disease successfully treated by argon plasma coagulation. Gastrointest Endosc 2001; 54:525.
- Probst A, Scheubel 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.
- Yusoff I, Brennan F, Ormonde D, Laurence B. Argon plasma coagulation for treatment of watermelon stomach. Endoscopy 2002; 34:407.
- Gostout CJ, Ahlquist DA, Radford CM, et al. Endoscopic laser therapy for watermelon stomach. Gastroenterology 1989; 96:1462.
- Gostout CJ, Viggiano TR, Ahlquist DA, et al. The clinical and endoscopic spectrum of the watermelon stomach. J Clin Gastroenterol 1992; 15:256.
- Petrini JL Jr, Johnston JH. Heat probe treatment for antral vascular ectasia. Gastrointest Endosc 1989; 35:324.
- Schmeck-Lindenau HJ, Kurtz W, Heine M. Inflammatory polyps: an unreported side effect of argon plasma coagulation. Endoscopy 1998; 30:S93.
- Tjandra JJ, Sengupta S. Argon plasma coagulation is an effective treatment for refractory hemorrhagic radiation proctitis. Dis Colon Rectum 2001; 44:1759.
- Taïeb S, Rolachon A, Cenni JC, et al. Effective use of argon plasma coagulation in the treatment of severe radiation proctitis. Dis Colon Rectum 2001; 44:1766.
- Swan MP, Moore GT, Sievert W, Devonshire DA. Efficacy and safety of single-session argon plasma coagulation in the management of chronic radiation proctitis. Gastrointest Endosc 2010; 72:150.
- Ravizza D, Fiori G, Trovato C, Crosta C. Frequency and outcomes of rectal ulcers during argon plasma coagulation for chronic radiation-induced proctopathy. Gastrointest Endosc 2003; 57:519.
- Ben Soussan E, Mathieu N, Roque I, Antonietti M. Bowel explosion with colonic perforation during argon plasma coagulation for hemorrhagic radiation-induced proctitis. Gastrointest Endosc 2003; 57:412.
- 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.
- 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.
- Heindorff H, Wøjdemann M, Bisgaard T, Svendsen LB. Endoscopic palliation of inoperable cancer of the oesophagus or cardia by argon electrocoagulation. Scand J Gastroenterol 1998; 33:21.
- Sessler MJ, Becker HD, Flesch I, Grund KE. Therapeutic effect of argon plasma coagulation on small malignant gastrointestinal tumors. J Cancer Res Clin Oncol 1995; 121:235.
- 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.
- Robertson GS, Thomas M, Jamieson J, et al. Palliation of oesophageal carcinoma using the argon beam coagulator. Br J Surg 1996; 83:1769.
- Kashin SV, Kuvaev R, Nadezhin AS, et al.. The new hybrid argon plasma coagulation (hybrid APC) for endoscopic ablation of Barrett's esohagus (BE): the results of the pilot trial. Gastrointest Endosc 2016; 83:AB495.
- Manner H, May A, Kouti I, et al. Efficacy and safety of Hybrid-APC for the ablation of Barrett's esophagus. Surg Endosc 2016; 30:1364.
- 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.
- Chau CH, Siu WT, Law BK, et al. Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcers. Gastrointest Endosc 2003; 57:455.
- Iacopini F, Petruzziello L, Marchese M, et al. Hemostasis of Dieulafoy's lesions by argon plasma coagulation (with video). Gastrointest Endosc 2007; 66:20.
- Conio M, Gostout CJ. Argon plasma coagulation (APC) in gastroenterology experimental and clinical experiences. Gastrointest Endosc 1998; 48:109.
- Tan AC, Schellekens PP, Wahab P, Mulder CJ. Pneumatosis intestinalis, retroperitonealis, and thoracalis after argon plasma coagulation. Endoscopy 1995; 27:698.
- Hoyer N, Thouet R, Zellweger U. Massive pneumoperitoneum after endoscopic argon plasma coagulation. Endoscopy 1998; 30:S44.
- WHAT IS APC?
- Watermelon stomach/GAVE syndrome
- Radiation telangiectasias
- Piecemeal polypectomy
- Tumor debulking and bleeding
- Endoscopic mucosal resection or ablation
- Ulcer hemostasis
- Esophageal varices
- Dieulafoy's lesions
- COMPARISONS BETWEEN TECHNIQUES
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS