Reply to H. J. N. Andreyev

We thank Dr. Andreyev for his interest in our technical review but would strongly disagree with the nihilistic tone of some of his comments regarding argon plasma coagulation (APC). Patients with bleeding from radiation proctitis may have a greatly reduced quality of life and to offer nothing except short-term drug therapy is, in our opinion, inappropriately defeatist. We share Dr. Andreyev’s frustration with the lack of carefully conducted randomized studies in this area and this was why our article was an expert opinion of APC technique rather than a comprehensive review of the management of radiation proctitis.

We agree that APC (like any therapy) has the potential to be harmful particularly when applied by the inexperienced endoscopist. However in expert hands it is an exquisitely precise technology [1] [2]. Telangiectasia can be targeted and destroyed without causing deep thermal injury or trauma to adjacent tissue, thus avoiding large areas of deep ulceration, the expert often electing to apply further caution by performing ablation over several sessions [3]. In this respect, APC is an inherently more controlled therapy than any topical drug treatment.

We agree with the general statement ”physician, first do no harm“, but no treatment is without some risk, and symptomatic patients (fully informed) should not be denied the option of a treatment which can be highly effective, just because definitive studies showing benefit have not been performed.

References

• 1 Zincola R, Rutter M, Falasco G. et al . Haemorrhagic radiation proctitis: endoscopic severity may be useful to guide therapy.  Int J Colorect Dis. 2003;  18 439-444
• 2 Tjandra J, Sengupta S. Argon plasma coagulation is effective in the treatment of refractory radiation proctitis.  Dis Colon Rectum. 2001;  44 1759-1765
• 3 Norton I, Wang L, Levine S. et al . In vivo characterization of colonic thermal injury caused by argon plasma coagulation.  Gastrointest Endosc. 2002;  55 631-636