Reply to Rodrigues et al.

We sincerely thank Rodrigues et al. for their comments on our article regarding the long-lasting effect of argon plasma coagulation (APC) therapy in patients with chronic radiation proctitis [1]. Indeed, rectal bleeding due to radiation proctitis represents a challenging condition for physicians, as its management is still under consideration.

Our study showed that APC is highly effective in all patients with mild radiation proctitis and in the majority of those with severe disease [1]. During a mean follow-up of 17.9 months (range 6 – 33 months), 89.5 % of patients remained in clinical remission. Patients with mild proctitis required 1 – 2 sessions of APC, while patients with severe proctitis required a statistically significantly higher number of APC sessions (2.9 vs. 1.3; P < 0.05). Our findings are similar to those of Rodrigues et al. where overall, APC was successful in 28 / 30 patients (93.3 %) after a median of 2.5 sessions of APC (range 1 – 6). A higher number of sessions were required for patients with severe forms of proctitis. Both studies agree that APC is an effective treatment in patients with rectal bleeding with mild-to-moderate radiation proctitis. However, for ”difficult” patients the optimal management is still unknown. Rodrigues et al., in accordance with previous studies [2], suggest that multiple applications with the addition of sucralfate enemas could ameliorate symptoms in this patient group. Although this approach seems attractive and logical, there are currently no data for the optimal number of APC sessions for successful and safe coagulation. Even though APC has shown a safety profile with a low complication rate, repeat APC application on the same area of rectal mucosa could induce rectal strictures [3] [4].

Furthermore, our data showed that the recurrence rate was significantly higher in patients who used anticoagulant or aspirin medication (4 / 17 vs. 0 / 21; P = 0.02). A reason for the discrepancy with the findings of Rodrigues et al. could be the fact that 19 / 56 (34 %) of our patients were on anticoagulant or aspirin and 12 of them had a severe form of radiation proctitis. However, the number of our patients with recurrence of bleeding was small and the role of anticoagulant or aspirin as co-factors for rectal re-bleeding after APC treatment was not the primary point of our study. Therefore, the role of these agents should be clarified in further studies.

In conclusion, our study in accordance with the results of Rodrigues et al. supports the use of APC as an effective and long-lasting treatment in patients with radiation proctitis. In ”difficult” cases, multiple APC sessions are needed and the optimal treatment is under consideration.

Competing interests: None

References

• 1 Karamanolis G, Triantafyllou K, Tsiamoulos Z. et al . Argon plasma coagulation has a long-lasting therapeutic effect in patients with chronic radiation proctitis.  Endoscopy. 2009;  41 529-531
• 2 Ladas S D, Raptis S A. Sucralfate enemas in the treatment of chronic postradiation proctitis.  Am J Gastroenterol. 1989;  84 1587-1589
• 3 Tam W, Moore J, Schoeman M. Treatment of radiation proctitis with argon plasma coagulation.  Endoscopy. 2000;  32 667-672
• 4 Postgate A, Saunders B, Tjandra J, Vargo J. Argon plasma coagulation in chronic radiation proctitis.  Endoscopy. 2007;  39 361-365