Colon explosion during argon plasma coagulation

REVIEW ARTICLE Colon explosion during argon plasma coagulation Hendrik Manner, MD, Nicola Plum, MD, Oliver Pech, MD, PhD, Christian Ell, MD, PhD, Markus D. Enderle, MD, PhD Wiesbaden, Tuebingen, Germany Since the development of flexible probes a decade ago, argon plasma coagulation (APC) has seen an expanding role in endoscopy.1-9 During APC procedures, various complications have been reported.1-9 Compared with the number of APC applications worldwide, the risk of colon explosion appears to be low.10 Nevertheless, even when APC procedures are performed in compliance with preventive measures, the risk of colon explosion cannot be excluded, and perforation11-15 and even death16 with use of thermal or any energy-based method may occur. This review is intended to give an overview of the occurrence of colon explosions and to report preventive measures. METHODS A MEDLINE (1954-present) computer search was performed to identify articles on APC and colon explosion. Key search words were argon plasma coagulation, explosion, colon, adenoma, polyp, radiation proctitis, gastrointestinal bleeding, tumor, and stenosis. The reference lists of potentially relevant articles were reviewed to identify studies that our search may have missed. PHYSICOCHEMICAL BACKGROUND The term ‘‘explosion’’ is defined by a sudden release of energy leading to a rapid increase of temperature and pressure. A sudden expansion of volume of preexisting gases is observed, caused by release of amounts of energy (eg, in a potentially explosive atmosphere). This sudden expansion of volume leads to a pressure wave. If a potentially explosive gas mixture, oxygen as a potentially combustive substance, and a sufficient combustion temperature (eg, created by a heat source such as APC, electrocautery, or laser) exist in one setting, an explosion may occur.17 The explosiveness of a gas mixture is characterized by the lower (LEL) and upper (UEL) explosion limits of the combustible compounds measured in volume percent (%).18 The explosion limit of a certain gas is the limiting concentration in air needed for the gas to explode. At concentrations below the lower limit, there is not enough combustive substance to continue an explosion. At concentrations above the upper limit, the combustive substance has displaced so much air that there is not enough oxygen to start a chemical reaction. Figure 1 shows the scheme of the explosion areas of the ternary systems methane/oxygen/inert gas and hydrogen/oxygen/inert gas, respectively. Hydrogen concentrations more than 4% and less than 75% are able to result in explosive gas mixtures, if the oxygen concentration is more than 4%. Also, the explosion area bordered by the red line is large. Thus, hydrogen should be of capital importance concerning colon explosion because there is a wide combination of gas concentrations possible leading to explosive gas mixture. The corresponding values for methane are 4.4% for the LEL and 16.3% for UEL. This mixture is able to explode if the oxygen concentration is above 10.7%. The explosion area is smaller compared with the explosion area of hydrogen. Therefore, the probability of an explosion caused by hydrogen is higher than for one caused by methane. The reaction enthalpy of the reaction of methane and oxygen is larger (DH Z -802 kJ/mol) compared with the reaction enthalpy of hydrogen and oxygen (DH Z -572.05 kJ/ mol).18 This means that a methane explosion results in a higher release of energy and may therefore cause even more damage compared with hydrogen. The potentially explosive gas mixture containing methane, hydrogen, and oxygen19 has been found to exist in relevant amounts only in the colon,20-22 and up to now only explosion of the colon has been reported during APC. Hydrogen and methane are produced in the colon lumen from fermentation of nonabsorbable (eg, lactulose, mannitol) or incompletely absorbed (lactose, fructose, sorbitol) carbohydrates by the colonic flora.19,23-25 In approximately half of the patients with an unprepared colon, potentially explosive concentrations of methane and especially of hydrogen have been observed.25,26 REPORTS ON COLON EXPLOSION DURING APC Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2008.02.035 www.giejournal.org Levy27 first reported colon explosion after ‘‘electrodesiccation’’ in 1954. During the last decade, several cases of Volume 67, No. 7 : 2008 GASTROINTESTINAL ENDOSCOPY 1123 Explosion during argon plasma coagulation Manner et al explosion event, no perforation was found, and no surgical intervention was required. Nürnberg et al11 reported the case of 69-year-old patient with colon explosion during APC treatment of angiodysplasias in the ascending colon. In contrast to the other reports on colon explosion during APC, the patient had been prepared with macrogol solution. The authors reported that a loud gas explosion was heard during the treatment of the first of the angiodysplasias. At laparotomy, 2 perforations of the ascending colon and the cecum were found, and a right-sided hemicolectomy was performed. The sites of perforation did not match the site of the treated angiodysplasia. The case of Nürnberg et al was the first case in literature of a colon perforation caused by a gas explosion during APC treatment in a patient prepared with macrogol solution.11 Figure 1. Graphic representation of the explosion areas of the ternary system consisting of a combustible gas (CH4, methane; H2, hydrogen), oxygen, and inert gas. LEL and UEL denote the lower and the upper explosion limits of the combustible gas measured in volume %. DISCUSSION colon explosion were reported during endoscopic APC treatment (Table 1). In these cases, APC was used in a variety of GI conditions including malignant stricture of the colon,28 radiation-induced proctitis,12 adenoma,14,15 and angiodysplasias.11 In the majority of cases (7 of 8 cases), enemas had been used for colon preparation, and no full bowel preparation had been carried out. In cases of explosion, perforation was found in 5 of the 8 cases, and all of these patients underwent surgery. No patient died after colon explosion induced by APC. Ben-Soussan et al12 treated 27 patients by APC for hemorrhagic radiation proctitis. Before the APC treatment, bowel preparation was performed by enema, polyethylene glycol, or sodium phosphate. During the treatment, 3 colon explosions occurred in 2 patients. The first patient had 2 colon explosions in successive sessions. The second patient had an explosion that led to immediate perforation that was distant from the coagulated areas. The patient required surgical treatment and made a complete recovery in 2 weeks. All 3 explosions occurred after enema preparation with persistent solid stool above the coagulated lesions. The incidence of bowel explosion was significantly higher after local preparation (3/19 sessions) compared with oral preparation (0/53 sessions).12 Zinsser et al28 reported a bowel explosion without perforation in a patient treated by APC for malignant colon stricture. Endoscopically, a stenotic circular growing adenocarcinoma of the rectosigmoid region had been found. Before the treatment, the remaining size of open lumen was reported to be 8 mm. During the fourth treatment session with APC, an explosion took place. The patient had been prepared with phosphosoda enemas. After the Various complications of APC have been reported during the treatment of colon lesions, especially of radiation proctitis.4 Here, the most common procedure-related symptom is anal or rectal pain, which is most likely to occur after treatment near the dentate line. Abdominal bloating and cramping and vagal symptoms related to colon distension have also been reported.4 A further but minor complication of APC is the so-called neuromuscular stimulation,29 which is a muscular contraction reflexively triggered by electrical stimulation of the nerves innervating the muscle. Colon explosion during APC treatment is a rare but dreaded event.10-13,15,28 It may lead to perforation and emergency surgery.11-15 On average, up to 1 case per year has been reported in literature during the last 10 years (Table 1). Because not all of the cases may have been reported, the true number of explosion events may be higher. The cases reported during the last decade show that insufficient bowel cleansing by using enemas might have been the predisposing factor for explosion. In the series of Ben-Soussan et al,12 the enemas used (monosodium phosphate and disodium phosphate) did not contain any fermentable agent likely to enhance gas production and facilitate the colon explosion, and the presence of stools above the lesions treated might have constituted the main risk for explosion. In a study of Monahan et al.,30 60 patients were prospectively evaluated to compare the presence of the combustible gases hydrogen and methane during colonoscopy and flexible sigmoidoscopy. Thirty patients underwent flexible sigmoidoscopy after phosphosoda enema preparation, and 30 patients underwent colonoscopy after a polyethylene glycol solution preparation. During colonoscopy, the concentrations of hydrogen and methane remained below combustible levels in all patients. Even segments of colon with significant fecal matter present did not have combustible levels of these 2 gases. However, 1124 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 7 : 2008 www.giejournal.org Manner et al Explosion during argon plasma coagulation TABLE 1. Overview of cases of APC-related colon explosion during the last decade Year Cases Authors Diagnosis 1999 1 Zinsser et al Malignant stricture of the rectosigmoid, with remaining size of lumen 8 mm before APC treatment Enemas Explosion without perforation 2003 1 Soussan et al Radiation-induced proctitis Enemas Perforation at rectosigmoid junction; surgery 2004 1 Pichon et al Adenoma of the sigmoid colon Enemas 3 sigmoid-perforating lesions; celioscopic suturing 2004 3 (in 2 patients) Ben-Soussan et al Radiation proctitis Enema 1 perforation; surgery 2007 1 Townshend et al Bleeding rectal adenoma Enema 2 perforations in the sigmoid colon; Hartmann’s procedure, parastomal hernia 2007 1 Nürnberg et al Angiodysplasia right colon Macrogol solution 2 perforations of the ascending colon and cecum; right-sided hemicolectomy at flexible sigmoidoscopy, combustible levels of hydrogen and methane were measured in 3 of 30 (10%) patients. Therefore, interventional endoscopy in the colon with thermal devices, such as APC or electrocautery, should not be performed after enema-only preparation but after full bowel preparation, even in case of only sigmoidoscopy, including the APC treatment of distally localized lesions (eg, in radiation proctitis). Nevertheless, in one of the cases of colonic explosion reported,11 a macrogol solution had been used for perorally administered full bowel cleansing. Therefore, even when meticulous bowel cleansing is performed, colon explosion cannot totally be avoided. In one of the cases reported, colon gas explosion occurred during APC treatment of a malignant stricture.28 The question arises as to whether mechanical dilation of the obstructed colon section before the APC procedure might have lowered the risk of explosion because an accumulation of explosive gases may have been present proximal to the stenosis. The cases reported during the last decade also show that in case of perforation the site of perforation does not necessarily match the site of APC treatment.11,12 In these cases, the damage to the colon may be explained by the fact that during an explosion, air moves along the path of least resistance and rupture may have occured where the pressure was highest.31 For a more detailed discussion of perforation caused by colon explosion, the Laplace law is a helpful basis: TZ P,r 2d The Laplace law describes the wall tension (T) against the pressure (P) inside a hollow organ (eg, the colon), www.giejournal.org Preparation Clinical complication the radius (r), and the wall thickness (d) of a hollow organ. Perforation may occur if the pressure is high enough or the radius is large enough or the wall thickness is small enough at the place where the explosion occurs. Although the focus of the current article is set on APCrelated colon explosion, such events cannot be considered as an APC-specific problem. Levy27 first reported colon explosion after ‘‘electrodesiccation’’ in the colon in 1954, and his report was followed by further articles on colon explosion observed during polypectomy.16,31,32 The question arises as to what kind of full bowel preparation should be used in patients undergoing interventional colonoscopy. Mannitol preparation was formerly considered as the reference agent for full bowel preparation. The patient reported by Bigard et al16 had been prepared by intestinal lavage of 5 L of isotonic mannitol solution the evening before a polypectomy procedure. After explosion and emergency surgery, the patient died. Fermentation of mannitol by Escherichia coli has been considered to be responsible for the production of potentially explosive gas mixtures after oral mannitol preparation.33,34 Because further reports on colon explosions after mannitol preparation have been published, new agents, such as polyethylene glycol electrolyte lavage solution and oral sodium phosphate solutions, are now chosen over mannitol preparation.16,17,22,25 It has been shown that these agents are able to decrease the concentrations of combustible gases in the colon.35-38 But mannitol does not appear to be the only sugar compound that may lead to raised combustible gas concentrations in the colon. A case of colon gas explosion was reported in a patient who underwent bowel preparation with a polyethylene glycol solution containing sorbitol.31 Studies have shown that the frequency of sorbitol malabsorption may be approximately 60% in healthy Volume 67, No. 7 : 2008 GASTROINTESTINAL ENDOSCOPY 1125 Explosion during argon plasma coagulation Manner et al TABLE 2. Preventive measures to avoid colon explosion during APC Recommended Avoid Degree of bowel preparation Full bowel preparation (perorally administered) before APC treatment, even in case of treatment of only distal parts of colon (postradiation colitis) Partial bowel preparation (eg, by means of enemas) Type of cleansing solution Polyethylene glycol (macrogol) or sodium phosphate solutions Cleaning solutions containing mannitol or other malabsorbed carbohydrates such as sorbitol Stenosis of the colon Mechanical dilation before APC treatment Direct application of APC (risk of accumulation of combustible gases proximal to the stenosis) subjects.22,39 A possible preventive measure against colon explosion might therefore consist of avoiding any bowel preparation regimens that contain sugar compounds.40 Our recommendations for the prevention of colon explosion during APC treatment in the colon are given in Table 2. Because intraluminal gas forms as a result of bacterial fermentation of nutrients by colonic bacteria,41,42 the administration of oral antibiotics before endoscopic procedures has been suggested. Nevertheless, there is no evidence to support the administration of antibiotics to decrease the risk of colon explosion, and this practice is neither accepted nor standard of care. The insufflation of inert gases such as carbon dioxide or argon gas43-46 during endoscopic procedures might reduce the risk of explosion because the presence of oxygen is a prerequisite for explosive gas mixtures. In pulmonology, the use of an argon plasma preflow system has been reported to prevent explosion by displacing oxygen by an inert gas.46 Nevertheless, no clear recommendation regarding the insufflation of inert gases before APC procedures can be made at the present. The question also arises whether small bowel explosion might occur during the treatment of colon angiodysplasias (eg, in the cecum). Because potentially explosive gas mixtures have been found to exist only in the colon, the risk of small bowel explosion may be very low, especially when a meticulous full bowel cleansing is carried out before the procedure. In conclusion, colon explosion is a rare complication of APC treatment in the colon. To reduce the risk of explosion, meticulous full bowel cleansing with a preparation without sugar compounds that may be malabsorbed should be carried out before any APC treatment. SUMMARY Even when APC and other high-energy driven procedures are performed in compliance with preventive measures, the risk of colon explosion cannot completely be avoided. To date, meticulous full bowel cleansing with preparation without sugar compounds that may be malabsorbed should be carried out before any APC treatment in the colon. 1126 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 7 : 2008 DISCLOSURE The following authors report that they have bo disclosures relevant to this publication: H. Manner, N. Plum, O. Pech, C. Ell. The following author reports an actual or potential conflict: M. D. Enderle is Medical Director of Erbe Elektromedizin, Tuebingen, Germany. Abbreviations: APC, argon plasma coagulation; LEL, lower explosion limits; UEL, upper explosion limits. REFERENCES 1. Vargo JJ. Clinical applications of the argon plasma coagulator. Gastrointest Endosc 2004;59:81-8. 2. Grund KD, Storek D, Farin G. Endoscopic argon plasma coagulation (APC): first clinical experiences in flexible endoscopy. Endosc Surg Allied Technol 1994;2:42-6. 3. Manner H, May A, Rabenstein T, et al. Prospective evaluation of a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy. Scand J Gastroenterol 2007;42:397-405. 4. Postgate A, Saunders B, Tjandra J, et al. Argon plasma coagulation in chronic radiation proctitis. Endoscopy 2007;39:361-5. 5. Manner H, May A, Miehlke S, et al. 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Ein neues Verfahren zur Reduktion der Brandgefahr bei Patienten mit respiratorischer Insuffizienz oder Atemwegs-Stent [German]. Pneumologie 2007;61:V335. Received December 12, 2007. Accepted February 15, 2008. Current affiliations: Department of Internal Medicine II (H.M., N.P., O.P., C.E.), HSK Wiesbaden, Wiesbaden, Erbe Elektromedizin GmbH (M.D.E.), Tuebingen, Germany. Reprint requests: Hendrik Manner, MD, Klinik Innere Medizin II, HSK Wiesbaden, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany. Volume 67, No. 7 : 2008 GASTROINTESTINAL ENDOSCOPY 1127