THE ROLE OF LASER IN GASTROENTEROLOGY

THE ROLE OF LASER IN GASTROENTEROLOGY

DEVELOPMENTS IN GASTROENTEROLOGY Volume 9 For a list of titles in this series see final page of the volume.

THE ROLE OF LASER IN GASTROENTEROLOGY Analysis of Eight years' experience by ELISABETH M. H. MATHUS-VLIEGEN Department of Hepato-Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands KLUWER ACADEMIC PUBLISHERS DORDRECHT / BOSTON / LONDON

Library of Congress Cataloging in Publication Data Mathus-Vliegen, Elisabeth M. H., 1949- The role of laser in gastroenterology: analysis of eight years experience I by Elisabeth M.H. Mathus-Vliegen. p. cm. -- (Developments in gastroenterology; 9) Includes bibliographical references. 1. Gastrointestinal system--surgery. 2. Lasers in surgery. I. Title. II. Series. [DNLM: 1. Gastrointestinal Diseases--radlotherapy. 2. Lasers -therapeutic use. Wl DE997VYB v. 9 I WI 100 M432rl RD540.M315 1990 617.4 3059--dc20 DNLM/DLC for Library of Congress 89-15627 ISBN-13: 978-94-010-7607-4 DOl: 10.1007/978-94-009-2454-3 e-isbn-13: 978-94-009-2454-3 Published by Kluwer Academic Publishers, P.O. Box 17, 3300 AA Dordrecht, The Netherlands. Kluwer Academic Publishers incorporates the publishing programmes of D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press. Sold and distributed in the U.S.A. and Canada by Kluwer Academic Publishers, 101 Philip Drive, Norwell, MA 02061, U.S.A. In all other countries, sold and distributed by Kluwer Academic Publishers Group, P.O. Box 322, 3300 AH Dordrecht, The Netherlands. printed on acid free paper All Rights Reserved 1989 by Kluwer Academic Publishers Softcover reprint of the hardcover 1 st edition 1989 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner.

Those diseases which medicines do not cure, the knife cures. Those which the knife cannot cure, cautery cures and those which cautery cannot cure are reckoned to be wholly incurable Hippocrates Aphorism 87

Foreword It is easy to make anecdotal claims for the efficacy of new forms of treatment based on the short term results in a small number of patients. Many authors have done this for endoscopic laser therapy in the gastrointestinal tract. It is very much more difficult to carry out a comprehensive assessment of the short and long term effects of new techniques and to compare these with the results of alternative treatments for the same diseases. This book, from one of the world's leading departments of gastroenterology, describes and analyses the largest series of patients yet reported from one centre treated endoscopically with the NdYAG laser for gastrointestinal disease. The follow up extends over 8 years and the results are impressive. Some of the early claims for laser therapy have been validated, others have not, but the real value of the book is that we now have a large amount of well organised data on which to judge the merits of laser therapy. Medical laser techniques are in their infancy and the potential for future development is enormous, but ideas on current applications have been consolidated and that is essential before the next concepts evolve. This book has taught us how to walk. The world is now ready to learn to run! S. G. Bown, Director National Medical Laser Centre London

Contents INTRODUCTION Introduction and purpose of the study 1 General aspects of laser 1.1. The properties of laser 1.1.1. Thermal action of laser 1.2. Types of laser 1.3. Clinical application of laser 1.3.1. Parameters of effective haemostasis 1.3.2. Endoscopic modalities and laser treatment for haemostasis 1.4. New developments in laser application 1.5. Conclusion 2 Application of laser energy in gastroenterology 2.1. Laser treatment in acute bleeding 2.2. Laser treatment of variceal bleeding 2.3. Laser treatment of non-variceal bleeding 2.3.1. Divergent selection criteria 2.3.2. Parameters for optimal haemostasis and optimal safety 2.4. Results of laser treatment 2.4.1. Haemostasis with the argon laser 2.4.2. Haemostasis with the Nd:YAG laser 2.4.3. Overall considerations 2.5. Comparison of laser with other endoscopic modalities in haemostasis 2.5.1. Experimental studies 2.5.2. Clinical studies 3 5 6 7 9 15 16 17 17 20 20 22 24 2.6. Conclusion and proposition for treatment of acute bleeding 25

3 Technical prerequisites, safety considerations and treatment settings in Amsterdam 3.1. Technical prerequisites 3.1.1. Laser equipment 3.1.2. Endoscopes 3.1.3. Auxilliary instruments 3.2. Safety considerations 27 27 29 3.3. Laser settings and treatment procedure 29 3.3.1. Mucosal vascular abnormalities as potentially bleeding lesions 3.3.2. Tumour treatment 3.4. Technical problems 32 3.5. Conclusion 33 PART I: HAEMOSTASIS 4 Mucosal vascular abnormalities as potentially bleeding lesions 37 in gastroenterology 4.1. Classification of vascular lesions 37 4.2. Mucosal vascular abnormalities 4.2.1. Pathology 4.2.2. Aetiology and pathogenesis 4.3. Angiodysplasia 4.3.1. Symptomatology and associated diseases 4.3.2. Diagnosis 4.4. Telangiectasia 38 40 43 4.5. Treatment of mucosal vascular abnormalities 44 4.5.1. Surgery 4.5.2. Endoscopic treatment 4.5.3. Treatment in the presence of associated valvular heart disease 5. Laser treatment of mucosal vascular abnormalities as potentially bleeding lesions 5.1. Design of the study 5.1.1. Patients and methods 5.1.2. Treatment and technique 5.1.3. Evaluation of the results 47 47

5.2. Results of the study: descriptive part 5.2.1. Demographic data 5.2.2. Diagnostic and investigational data 5.3. Results of the study: laser treatment 5.3.1. Angiodysplasia 5.3.2. Telangiectasia 5.3.3. Haemangioma 5.4. Results of the study: outcome without laser intervention 5.5. Discussion 5.6. Conclusion 49 54 65 66 68 PART II: TUMOUR ABLATION 6 Laser treatment of colorectal adenomas 71 6.1. Introduction 71 6.1.1. Adenomas of the colon 6.1.2. Familial polyposis coli 6.2. Prospective study of patients with colorectal adenomas and 75 rectal stump polyps between 1979 and 1987 6.2.1. Preliminary results (1979-1984) 6.2.2. Patients and methods (1979-1987) 6.3. Results 78 6.3.1. Group 1, 150 patients with colorectal adenoma 6.3.2. Group 2, 30 patients with familial polyposis coli 6.4. Follow-up observations 86 6.4.1. Effect of laser treatment after short and long exposure 6.4.2. Patients with malignant degeneration 6.5. Discussion 6.6. Conclusion 7. Palliation of gastro-oesophageal cancer 7.1. Introduction 7.2. Surgical treatment 7.2.1. Oesophageal cancer 7.2.2. Gastric cancer 89 91 93 93 93

7.3. Radiotherapy and chemotherapy 7.3.1. Oesophageal cancer 7.3.2. Gastric cancer 95 7.4. Endoscopic procedures 97 7.5. Conclusion 100 8 Laser photo ablation in the palliation of gastro-oesophageal cancer 101 8.1. Design oj the study 8.1.1. Patients and methods 8.1.2. Patient preparation and treatment 8.2. Evaluation oj the results 8.3. Results 8.3.1. Demographic data 8.3.2. Treatment data 8.3.3. Adverse effects of laser treatment 8.4. Discussion 8.5 Conclusion 9. Treatment modalities in colorectal cancer 9.1. Introduction 9.2. Operative treatment: general surgery 9.2.1. Elective surgery 9.2.2. Emergency surgery 9.2.3. Palliative surgery 101 102 104 114 119 120 120 121 9.3. Operative treatment: local surgery 125 9.4. Radiotherapy 128 9.5. Chemotherapy 129 9.6. Laser photocoagulation 129 10. Laser photocoagulation in the palliation of colorectal cancer 131 10.1. Design oj the study 10.1.1. Patients and methods 10.1.2. Patient preparation and treatment 131

10.2. Evaluation of results 10.3. Results 10.3.1. Demographic data 10.3.2. Treatment data 10.3.3. Adverse effects of laser treatment 10.4. Discussion 10.5. Conclusion 11. Laser photoablation of early gastrointestinal cancer 11.1. Introduction 11.2. Design of the study 11.3. Evaluation of the results 11.4. Results 11.4.1. Early gastric cancer 11.4.2. Early colonic cancer 11.5. Discussion 11.6. Conclusion 12. Laser photocoagulation in the small intestine 12.1. Design of the study 12.1.1. Patients, methods and technique 12.1.2. Evaluation of the results 12.2. Results 12.3. Discussion 132 133 148 151 152 152 153 153 154 158 159 160 160 161 166 APPENDIX Appendix I 169 Questionnaire on Nd:YAG laser treatment of mucosal vascular abnormalities Appendix II 172 Questionnaire on Nd:YAG laser treatment of gastro-oesophageal cancer Appendix III 175 Questionnaire on Nd:YAG laser treatment of colorectal cancer Appendix IV 178 Data of patients unfit for laser treatment of angiodysplasia

SUMMARY SAMENV ATTING REFERENCES 181 186 192