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 23 October 2017

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Bernard Maroy Electrocoagulation for bleeding sigmoid carcinoma in a patient with severe heart failure and anticoagulation
Bernard Maroy, 17 October 2008
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A 74-year old man bled severely from a small sigmoid cancer. He suffered from severe heart failure necessitating anti vitamin-K treatment and precluding any kind of surgery.

Electrocoagulation with flexible device stopped bleeding immediately after the first session. Scar was barely visible 1 year later. Finally, the patient died after 2 years without any clinical recurrence.

Electrocoagulation remains a good tool at rectal level, but also, owing to the flexible device, among peritonized parts of the digestive tract. It is important to perform without any deep sedation to keep pain as an alarm.

Introduction

Complications of colonic carcinoma in inoperable patients pose difficult problems. Obstruction is treated by stenting [1] and bleeding can improve with radiotherapy [2], however, the latter is possible only on fixed parts of the colon.

Electrocoagulation has long been used for the treatment of small carcinoma, as well as for palliation [3-5], however, it has been almost forgotten [6, 7]. It is dangerous when used on peritonized parts of the digestive tract.

I describe here the successful treatment of a bleeding sigmoid carcinoma by electrocoagulation.

Case report

A 74-year-old male patient was referred for important anal bleeding since 1 month prior. He was suffering of severe congestive heart failure despite maximum medical treatment and was taking acenocoumarol for anticoagulation.

Colonoscopy was performed without sedation under oxygenotherapy. It attributed bleeding to a sigmoid 16 to 19 cm, 1/4 circumferential, well-differentiated carcinoma, 3 cm large, mostly fungating, without any important ulceration (Fig 1). Work-up failed to disclose any distant location. Abdominal ultrasonography failed to show any involvement of muscularis propria.

Figure 1 Hemorrhagic cancer before coagulation.

Cardiologists and anesthesiologists stated that surgical intervention was absolutely impossible and that anticoagulation could not be stopped.

Dialogue with oncologists ruled out radiotherapy owing to the mobility of the sigmoid loop and chemotherapy owing to heart failure.

So, I used electrocoagulation according to a previously described method [8], with a tungsten ball screwed on an isolated wire before introducing the scope. It permits to adapt electrocoagulation principles to flexible endoscopy. The main problem was to stop bleeding and, if possible, to destroy the tumor, without taking any risk of complication.

Coagulation was performed with low intensity, according to Albert Poirier's principles [3], starting 2 cm apart from the tumor, from distal to proximal end, to obtain a progressive whitening without any pain. As a matter of fact, pain during coagulation means heating of peritoneum, and, therefore a risk of immediate or delayed perforation. This is a further reason to perform electrocoagulation on peritonized locations without any deep sedation.

Bleeding stopped immediately and failed to recur.

Control colonoscopy, 2 weeks later, showed a clean, white ulceration. Further light coagulation was performed on the borders and on ulceration itself.

Later follow-up failed to disclose any recurrence. Scar was barely visible 1 year later (Fig 2), attesting that coagulation spared muscularis propria. Biopsies remained negative. Finally, the patient died of terminal cardiac failure 2 years after coagulation, without any bleeding.

Figure 2 The scar is barely visible one year later.

Discussion

In an inoperable patient, electrocoagulation stopped threatening bleeding and more over, cured the lesion for at least 1 year.

Treatment of rectal cancer by electrocoagulation is well known since the works of Poirier [3] and Madden [5]. It is very efficient for palliative purposes [9] and allows long term cure of selected patients: well differenciated cancer, mostly fungating, measuring 3 cm in diameter or less [3-5].

It is important to destroy the whole cancer during the first session, whenever possible. A close follow-up is, of course, necessary. This method has the drawback of impeding microscopic assessment of extension and it is the reason why it has been supplanted by others, like transanal surgery, endoscopic mucosectomy and argon laser beam [10]. The 2 former were not possible among a cancerous, colonic lesion. The latter is more costly and necessitate specific devices. Moreover, its superficial action, although safer, precludes any hope of curative treatment and would necessitate multiple sessions to control durably bleeding.

Conclusion

Prudent electrocoagulation, using a flexible device, should be kept in mind in case of bleeding colonic carcinoma among inoperable patients.

This article was first published on GastroHep.com on 17 October 2008.

Contact

Bernard Maroy MD
GastroLunesse
24 rue Chabernaud
F16340 L’Isle d’Espagnac
France
Tel: +(33) 545940094
Fax: +(33) 545942500
Email: bmaroy@yahoo.fr
Website: http://bmaroy.free.fr

References

  1. Bittinger M, Messmann H. Self-expanding metal stents as nonsurgical palliative therapy for malignant colonic obstruction: time to change the standard of care? Gastrointest Endosc 2007; 66: 928-30.

  2. Rao AR, Kagan AR, Chan PY, et al. Effectiveness of local radiotherapy in colorectal carcinoma. Cancer 1978; 42: 1082-6.

  3. Poirier A, Poirier B. Electrocoagulation du cancer du rectum. Gaz Med Fr 1955; 62: 1525-8.

  4. Salvati EP, Rubin RJ. Electrocoagulation as primary therapy for rectal carcinoma. Dis Colon Rectum 1982; 25: 215-8.

  5. Madden JL, Kandalaft SI. Electrocoagulation as a primary curative method in the treatment of carcinoma of the rectum. Surg Gynecol Obstet 1983; 157: 164-79.

  6. Moore HG, Guillem JG. Local therapy for rectal cancer. Surg Clin North Am 2002; 82: 967-81.

  7. Tepetes K. Electrocoagulation: an alternative treatment for rectal cancer. Tech Coloproctol 2004; 8 Suppl 1: s76-8.

  8. Maroy B, Lebailly J. Endoscopic electrocoagulation of the digestive tract using a large diameter ball screwed on the flexible device before insertion of the scope. Endoscopy 2000; S71

  9. Maroy B, Moullot P. Electrocoagulation palliative d’un cancer sténosant du colon sigmoïde. Gastroenterol Clin Biol 1989; 13: 225.

  10. Johanns W, Luis W, Janssen J, et al. Argon plasma coagulation (APC) in gastroenterology: experimental and clinical experiences. Eur J Gastroenterol Hepatol 1997; 9: 581-7.

 
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