This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and Sutab. Hello, I'm Sumit Tiwani with Rockford Gastroenterology Associates, and this is the ASGE video tip on radiofrequency ablation for radiation proctopathy. I have no relevant disclosures. Radiation proctopathy is a risk of pelvic radiation used in the management of prostate and cervical cancers and can be an important cause of rectal bleeding and anemia. Additional symptoms may include tinesimus, urgency, pain, diarrhea, and incontinence. Endoscopically, radiation proctopathy appears as areas of friable neovascularization in the mucosa of the rectum, usually on the anterior surface, although a more diffuse distribution can also occur. Symptoms of radiation proctopathy most commonly involves endoscopic treatment using thermoablative techniques, the most widely used being argon plasma coagulation, or APC. Despite recurrent treatments, complete hemostasis is difficult to attain, and complications such as mucosal ulceration, stricture formation, perforation, and fistula formation may occur. Many patients remain dependent on oral iron replacement therapy and intermittent transfusions with poor quality of life due to ongoing bleeding. Radiofrequency ablation has emerged as an alternative technique for the management of radiation proctopathy. Initially used for the management of dysplastic barrens esophagus, the indications for RFA continue to evolve. In another video tip, we described the use of radiofrequency ablation for the management of gastric anterovascular atasia, or GAVE. In this video, we described the use of radiofrequency ablation for radiation proctopathy. Radiofrequency ablation uses an electrosurgical generator to deliver thermal energy to soft tissue in direct contact with the bipolar RFA electrode to achieve targeted tissue destruction by causing localized coagulation necrosis. Preset parameters of energy and power allow a consistent depth of ablation to be achieved. Several devices are available, including a self-adjusting balloon catheter to provide circumferential ablation within the esophagus, and various focal catheters that can be attached to the end of the endoscope for treatment of areas of non-circumferential disease. There is even an endoscopic catheter that can be inserted through the working channel of the endoscope. Before starting the procedure, ensure that the procedure is being performed for an appropriate indication. It is also important to consider contraindications, including the current or ongoing use of anticoagulation and antiplatelet therapy. In the case of radiation proctopathy, radiofrequency ablation can be applied to the area of involvement using any of the focal RFA catheters. These mount over the tip of the endoscope such that the electrode can be positioned in the 12 o'clock or 6 o'clock position. The through-the-scope endoscopic catheter can also be chosen. I select the catheter for use depending on the appearance and distribution of radiation proctopathy on the initial endoscopic evaluation. For larger areas of involvement, I may select a focal RFA catheter such as the 90 RFA focal catheter. And for focal treatment of small areas of residual disease after previous treatment, or treatment of areas close to the anal verge, I am more likely to select the endoscopic catheter. Once the focal RFA catheter is attached to the tip of the endoscope, the scope is advanced into the rectum and the target area for treatment is identified. The catheter is placed in direct contact against the target area. Two to four consecutive pulses of energy can be delivered to the same area before repositioning the electrode to a new area for treatment. Unlike the protocol for Barrett's esophagus that includes scraping of the coagulum off the mucosa between applications, in the case of radiation proctopathy, the rectal mucosal coagulum is not scraped between applications to reduce the risk of mucosal bleeding. In these pictures, you can see the application of radiofrequency ablation to radiation proctopathy, including one view in the retroflex view for treatment close to the anal verge. A significant benefit to the use of RFA is its ease of use, given its similar technical complexity to APC. It provides a controlled depth and area of treatment due to the nature of application for direct contact. RFA can itself also be used for the management of breakthrough bleeding that occurs during treatment. It is important to consider the potential risks and complications of the procedure, including but not limited to pain, bleeding, perforation, ulceration, stricture formation, and tenesmus. In this picture, you can see before and after diagrams after treatment of radiation proctopathy with radiofrequency ablation. In summary, radiation proctopathy is an important cause of rectal bleeding and anemia. Despite APC, many patients depend on oral iron replacement therapy and intermittent transfusions with poor quality of life related to ongoing rectal bleeding. RFA offers an alternative, safe, and effective option for treatment. Thank you.

radiofrequency ablation

radiation proctopathy

pelvic radiation

argon plasma coagulation

barrett esophagus