Possibilities and Immediate Results of Endoscopic Argon Plasma Coagulation in the Treatment of Patients with Acute Gastrointestinal and Esophageal Bleeding of Various Etiology

The research is dedicated to evaluating the effectiveness of argon plasma coagulation (APC) in the treatment of patients with acute gastrointestinal and esophageal bleeding of various etiologies. The relevance of the work is due to the high mortality rate in acute gastrointestinal bleeding, which persists despite advances in surgery, anesthesiology, and clinical endoscopy. The study developed and tested an algorithm for the application of APC as a standalone monomethod for emergency and preventive anti-rebleeding endoscopic hemostasis in cases of ongoing and established bleeding of non-variceal etiology. The scientific novelty lies in the first-time evaluation of the effectiveness of priority application of argon plasma coagulation and the development of the corresponding methodology. The practical significance of the work is manifested in the possibility of improving immediate treatment outcomes, shortening the average hospital stay, and achieving substantial savings in material costs.

Relevance of the Topic. The problem of treating acute bleeding from the gastrointestinal tract is currently one of the most important issues in urgent surgery (Savelyev V.S., 2003). At the same time, 80–90% of gastrointestinal bleeding consists of bleeding from the upper gastrointestinal tract (Insakov I.N., 1996; Sotnikov V.N., Dubinskaya T.K., 2000; Shapkin Yu.G., 2000). Since the early 1990s and to the present day, there has been an increase in the absolute and relative number of patients with gastrointestinal bleeding of ulcerous etiology, which has led to an increase in overall and postoperative mortality (Borisov A.E. et al., 1997, 2002; Pantsyrev Yu.M., 2003) among patients in this group. Despite significant advances in surgery, anesthesiology-resuscitation, and clinical endoscopy, mortality in acute gastrointestinal bleeding remains high and shows no tendency to decrease (Kondratenko P.G., 1990; Aisakhanov S.K., 1994; Verbitsky V.G., Bagnenko S.F., 2004). According to data from a number of authors, its level currently amounts to 5–10%, and in the case of recurrence increases to 30–40% (Petrov V.P., Eryukhin I.A., 1987; Bratus V.D., 1991; Timen L.Ya. et al., 2001; Pantsyrev Yu.M. et al., 2003; Chernehovskaya N.E., 2004; Petrov S.V. et al., 2005; Gostishchev V.K., Evseev M.A., 2005).

One of the causes of high mortality is the absence of an effective standardized approach to patient treatment. A surgeon in this situation is forced to find a compromise between conservative treatment, which provides no guarantees, and always risky, traumatic surgical intervention (Chikala E.T., 1992; Chernov V.N., 1999). That is why timely and accurate diagnosis of gastrointestinal bleeding is a crucial moment determining not only the treatment tactic but also the outcomes of treatment.

With the introduction of endoscopic investigations into clinical practice, it became possible not only to effectively identify the source of bleeding but also to actively impact it.

Over the last 35 years, methods of endoscopic cessation of acute esophageal and gastroduodenal bleeding have gained wide prevalence in clinical practice. The very idea of stopping bleeding endoscopically without laparotomy and then, with adequate conservative therapy, overcoming the disease has long attracted the attention of abdominal surgeons, endoscopists, and gastroenterologists (Pantsyrev Yu.M. et al., 2003; Kurygin A.A., 2004; Gostishchev V.K., Evseev M.A., 2005).

Modern endoscopy possesses a wide range of methods of endoscopic hemostasis (EH), differing in their physical nature, effectiveness, accessibility, safety, and cost (Baranchuk V.N., 1992; Balalykin A.S. et al., 2000; Sotnikov V.N. et al., 2000; Kuzmin-Krutetsky M.I. et al., 2001; Kороткевич A.G., 2004; Savelyev V.S., 2003; Kurygin A.A., 2004; Demling L., 1973; Voiosu R., Sugawa C., 1989; Kimura K. et al., 1991; Goh P., Tekant Y., 1993; Kohler B., 1997; Freeman M.L., 1997; Amaro R. et al., 1998; Chong Y.Y., 1998).

As Butorin N.N., Tsukanov V.V. (2005) believe, these methods make it possible to achieve not only temporary but also definitive local hemostasis, as well as to conduct measures preventing the resumption of bleeding, which makes it possible to avoid emergency surgery or, if necessary, perform open surgery under more favorable conditions.

Depending on the source of bleeding, its intensity, the equipment of the endoscopic suite, and the experience of the endoscopist, one or another method of local hemostasis is selected (Voytashhevskaya N.V., Fedorov A.G., 2005). However, the most widespread methods of endoscopic hemostasis — application and injection, for example, are largely ineffective both in stopping high-intensity bleeding and in preventing recurrence (Pantsyrev Yu.M., Gallinger Yu.I., 1984; Korobchenko A.A., 1995; Petrov Yu.I. et al., 2005).

High-technology methods — clipping and ligation — are sufficiently expensive, labor-intensive, and require a high level of endoscopist qualification, and therefore have not gained wide prevalence and are used only in a number of clinics (Timen L.Ya. et al., 2001; Pantsyrev Yu.M., Fedorov E.D., 2001; Kuzmin-Krutetsky M.I. et al., 2001; Kороткевич A.G., 2004; Rollhauser S., Fleischer D.E., 2000). Combined methods share the same disadvantages (Kuzmin-Krutetsky M.I., Chaichenko F.S., 2000; Ohta S. et al., 1996). Therefore, despite the presence in the arsenal of numerous types and methods of hemostasis, the results of treatment today are far from desirable. All this served as the reason for the search for a new method of endoscopic hemostasis meeting a number of requirements — clinically effective, simple to apply, accessible in acquisition, inexpensive, and reliable in operation, and not requiring the use of additional endoscopic techniques. In our view, all these requirements are met by the method of endoscopic APC.

The goal of the study is to improve the immediate results of treatment of patients with acute esophageal and gastrointestinal bleeding by applying argon plasma coagulation as an independent monomethod of endoscopic hemostasis.

To achieve the stated goal, it is necessary to solve the following tasks:

1. To evaluate the effectiveness of the method of endoscopic argon plasma coagulation for achieving primary hemostasis in acute gastroduodenal and esophageal bleeding.

2. To determine the influence of the method of endoscopic argon plasma coagulation on the frequency of recurrent bleeding, to compare the effectiveness of APC in recurrent bleeding with the injection technique of endoscopic hemostasis.

3. To establish the possibility of endoscopic argon plasma coagulation as a monomethod in terms of achieving definitive hemostasis.

4. To analyze the clinical effectiveness of the method of endoscopic argon plasma coagulation.

5. To determine the economic effectiveness of its application.

Scientific Novelty. For the first time, the effectiveness of the priority application of the method of endoscopic argon plasma coagulation in the treatment of acute gastrointestinal and esophageal bleeding has been evaluated. A new contribution is the development of an algorithm and methodology for the application of argon plasma coagulation as an independent monomethod of emergency and preventive anti-rebleeding endoscopic hemostasis in cases of ongoing (including high-intensity) and established esophageal and gastrointestinal bleeding of varying intensity from sources of different etiology.

Practical and Theoretical Significance. The application of argon plasma coagulation made it possible to improve the immediate results of treatment of patients with acute esophageal and gastroduodenal bleeding of various etiologies, excluding variceal. Endoscopic APC makes it possible to effectively perform primary emergency hemostasis and preventive anti-rebleeding hemostasis within a single method.

The method provides the possibility of completely refusing surgical intervention in the overwhelming majority of cases, which is especially important for patients in the high surgical risk group (with severe comorbid pathology, elderly patients). In the remaining cases, patients can be operated under more favorable conditions — after temporary cessation of bleeding, correction of anemia, and preoperative preparation.

With the use of the APC method, the average hospital stay of patients is shortened, and substantial savings in material costs are achieved.

Validation of the Results of the Dissertation Research. The results of the dissertation research were reported and discussed at a conference during the work of the interregional exhibition "Medicine and Health Protection 2003, 2004" (Tyumen, 2003, 2004) (diploma for the introduction of new technologies into surgical practice); at the regional conference "High Technologies in Medicine" (Tyumen, 2004) (noted by the Department of Health of the Tyumen Region); at a meeting of the Tyumen Regional Surgical Society (Tyumen, 2005); at the I and II Scientific-Practical Conferences "Clinical Observations of Interns, Residents, and Postgraduates" (Tyumen, 2004, 2005); at the 9th Moscow International Congress of Endoscopic Surgery (Moscow, 2005) (RNKH RAMN); at a scientific-practical conference dedicated to the 10th anniversary of ZAO MSCH "NEFTYANIK" (Tyumen, 2005); and at the 7th Slaviano-Baltic Gastroenterological Forum (St. Petersburg, 2005). Seventeen printed works have been published on the research topic.

Basic Propositions of the Dissertation to be Defended.

1. The method of endoscopic argon plasma coagulation is a highly effective method of hemostasis in acute gastroduodenal and esophageal bleeding of non-variceal etiology.

2. The application of the method of endoscopic argon plasma coagulation makes it possible to improve the immediate results of treatment of patients with acute gastroduodenal and esophageal bleeding of non-variceal etiology and to reduce material costs.