Effective treatment of chronic radiation proctitis using radiofrequency ablation

Abstract

Endoscopic argon plasma coagulation and bipolar electrocautery are currently preferred treatments for chronic radiation proctitis, but ulcerations and strictures frequently occur. Radiofrequency ablation (RFA) has been successful for mucosal ablation in the esophagus. Here we report the efficacy of RFA with the BarRx Halo(90) system in three patients with bleeding from chronic radiation proctitis. In all cases, the procedure was well tolerated and hemostasis was achieved after 1 or 2 RFA sessions. Re-epithelialization of squamous mucosa was observed over areas of prior hemorrhage. No stricturing or ulceration was seen on follow-up up to 19 months after RFA treatment. Real-time endoscopic optical coherence tomography (EOCT) visualized epithelialization and subsurface tissue microvasculature pre- and post-treatment, demonstrating its potential for follow-up assessment of endoscopic therapies.

Figure 1.

Endoscopic and EOCT images acquired for Case 1 pre-RFA treatment and 2 and 12 months post-RFA treatment. Ectatic vessels (V) due to radiation proctitis and ulcerations (U) due to APC 3 days earlier were observed under (a) endoscopic and (b) EOCT imaging prior to RFA treatment. The slowly oozing ulcerations were revealed after the overlying blood and clots were gently flushed away. Two months after the initial RFA treatment, (c) endoscopic NBI and (d) EOCT demonstrated squamous epithelialization over the treated area (right of the dashed line), while columnar epithelium was observed over the untreated area (left of the dashed line) with EOCT. At 14 months post-RFA treatment, (e) endoscopic and (f) EOCT imaging shows excellent re-epithelialization over the treated area.

Figure 2.

Endoscopic and EOCT images acquired for Case 2 at pre- and 8 months post-RFA treatment. Ectatic vessels (V) were observed under (a) endoscopic examination and (b) EOCT prior to the RFA treatment. Eight months post-RFA treatment, squamous epithelialization over the RFA-treated area was observed with (c) endoscopic and (d) EOCT imaging. The dentate line is estimated to have extended ∼2cm from the anal verge.

Figure 3.

Endoscopic and EOCT images acquired for Case 3at pre- and 6 months post-RFA treatment. Ectatic vessels (V) were observed under (a) endoscopic examination and (b) EOCT prior to the RFA treatment. Six months post-RFA treatment, ectatic vessels were observed under (c) endoscopic examination and (d) EOCT over a small area orad to the treatment site, while most of the treated rectum was well epithelialized.