Hemostasis and Tumor Ablation

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Hemostasis and Tumor Ablation

• Learning objectives
• Discuss the general principles and the role of
  the GI nurse in thermal coagulation procedures
  and methods, including monopolar and bipolar
  electrosurgery, heater probes and laser
  photocoagulation.
• Discuss therapeutic treatments and endoscopic
  procedures used in the treatment of GI tumors.

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Hemostasis and Tumor Ablation

• Basic Principles
• First confirm the location of the hemorrhage
• Most common causes of bleeding in the GI tract
  are esophagitis, gastric, duodenal, and colonic
  ulcers erosive esophagitis, gastritis and
  duodenitis Mallory-Weiss tearsvarices tumors,
  arterio-venous malformation(AVMs) and colitis.
• At the time of diagnostic endoscopy, the Dr. and
  nurse should be prepared to teat the bleeding
  site with injection therapy, photocoagulation,
  electrosurgery with monopolar or bipolar
  accessories, and/or endoscopic clipping

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Hemostasis and Tumor Ablation

• Several factors affect the timing of the
  endoscopic examination
• Likelihood of finding the source of the bleeding
  is higher when the procedure is done within 24
  hrs of the bleed
• Ongoing upper gi bleed requires urgent endoscopy
  when the pt is stable.
• Active lower GI bleed, colonoscopy should not be
  performed until the colon has been cleaned out.

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Hemostasis and Tumor Ablation

• Causes of lower GI bleeding
• Rectal hemorrhoids
• Diverticulitis
• Polyps
• Cancer
• Arterio-venous malformations (AVMs)
• Colitis
• Colonic ischemia
• Post polypectomy bleeding

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• Causes of upper GI Bleeding
• bleeding cancers
• AVMs
• Polyps

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Hemostasis and Tumor Ablation

• Electrosurgery The terms electrocautery and
  electrosurgery are sometimes used
  interchangeably. Electrocautery refers to a
  direct a direct current where electrons flow in
  one direction and the current does not enter the
  pts body. In electrosurgery, an alternating
  current is used where the current enter the
  patients body and the patient is part jof the
  circuit.

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• The basic circuit used in gastroenterology is
  electricity that flows from the wall to the ESU
  through the active cord, via an accessory(snare),
  into the tissue, through the patient and back to
  ESU via a grounding pad.
• Electricity will always seek the path of least
  resistance.
• Joint prosthesis, pacmakers/defibrillators, and
  gastric stimulators, jewelry, and gurnery, can
  alter the pathway or change the flow of current.

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• The grounding pads that are being use today are
  single-patient use.
• The grounding pads should be placed smoothly on
  the skin surface and avoid tenting, gaps, or
  folds.
• Electrosurgery is contraindicated in patients
  with excessive bleeding,esoghageal varieces, or
  coagulopathy.
• Potential complications of electrosurgery include
  thermal injury, hemorrhage, perforation,
  transmural burns and explosion.

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Hemostasis and Tumor Ablation

• Monopolar electrocoagulation
• An electrocoagulation method in which the
  electrical current flows between a small, active
  electrode that is in contact with the target
  tissue and a larger grounding pad that is
  attached to the patients skin.
• Current leakage can be a problem
• Current may pass through the accessory, leak
  through the endoscope, and pass back to the
  endoscopist, causing burnt to the operator.

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• Current may pass through the accessory, leak
  through the scope, and pass to the patient at an
  internal point in which the pt is in contact with
  the scope, and then continue to the grounding
  pad. Presenting the potential for a burn at a
  scope-patient contact point.

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• Bipolar electrocoagulation
• An electrocoagulation method in which the
  electrical current flows between two small
  electrodes on the tip of the probe, both of which
  are in contact with the target tissue.

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• Heater Probes
• is very similar in application to the bipolar
  probe. It consists of a hollow aluminum cylinder
  with an inner heat coil and an outer coating of
  Teflon. The heater probe is applied directly to
  a vessel with firm pressure.

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• Laser Therapy
• Is a acronym for light amplification by
  stimulated emission of radiation.
• Only argon and neodymiumyttrium-aluminum-garnet
  (NdYAC) lasers have been widely used in
  endoscopy.
• Endoscopic laser therapy is contraindicated in
  uncooperative patients oro n patients with
  coagulopathy, extremely large vessels in the
  field, or inaccessible lesions.

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• Photocoagulation may cause a white, blanched
  appearance with edema. The coagulative effect
  of lasers allows them to be used to achieve
  hemostasis for acute GI bleeding and to treat
  GI lesions that are not actively bleeding.
• Photovaporization may cause a divot, charring of
  tissue, and smoke. The photovaporization effect
  of lasers allows them to destroy neoplastic
  tissue and to cut through normal tissue to
  achieve therapeutic goals.

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Hemostasis and Tumor Ablation

• Argon Plasma Coagulation (APC) was adapted from
  the surgical arena for use in GI in 1991.
• Electrical energy is delivered to the tissue by
  ionizing argon gas and creating a plasma. Plasma
  is a gas that has been partially or completely
  ionized, and is a collection of charged particles
  containing about equal numbers of positive ions
  and electrons.

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• The advantages of argon plasma coagulation
  compared to monopolar or bipolar electrosurgery
  are the ability to control the depth of burn, and
  that contact with the tissue is not essential.
• The advantages of argon plasma over the alser are
  the cost and portability.

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• Photodynamic Therapy
• Has been used effectively to treat superficial
  esophageal cancers, high-grade dysplasia,
  Barretts esophagus and superficial
  adenocarcinomas of the colon
• PDT drugs called photosensitizers are injected
  into the patients body, where they collect
  naturally in hyperprolific cells.

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• Brachytherapy
• Also known as sealed source radiotherpy or
  endocurietherapy, is a form of radiotherapy where
  a radioactive source id placed inside or next to
  the area requiring treatment.
• Endoscopic Mucosal resection
• Is a technique that has been developed to remove
  small nodules or flat lesions within the GI tract
  down to the submucosalayer.

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• Endoscopic Endoluminal Radiofrequency Ablation
• Is a procedure that involves using different
  straining techniques (methylene blue or lugols
  solution) and examining the esophagus for
  dysplasia

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• Infection Therapy
• therapy method involves the injection of a
  chemical agent through a needle injector into a
  around a bleeding site to stop bleeding through
  variceal thrombosis or local edema
• Variceal Sclerotherapy
• Involves the injection of a sclerosing agent in a
  blood vessel
• Transient side effects of injection sclerotherapy
  include mild to severe chest pain, dysphagia and
  fever.
• Complication of injection sclerotherapy include
  hemorrhage, aspiration, necrosis, mediastinitis,
  esophageal perforation, pleural effusion, sepsis
  orportal vein thrombosis.

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• Endoscopic variceal ligation(EVL)
• Dr Gregory V.Stiegmann-developed this method
• A technique that has also been used successfully
  for the eradication of rectal hemorrhoids.
• Disadvantages of this technique are poor
  visibility with profuse bleeding, reloading bands
  and overtube trauma.

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• Esophageal-Gastric Tamponade
• Tamponade involves the insertion of specialized
  tubes to provide pressure on bleeding areas of
  the esophagus or esophagogastric junction.
• Contraindicated for the patients with
  cardiopulmonary failure, recent surgical trauma
  to the esphagogastaic junction, or when variceal
  bleeding has stopped.

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• Sengstaken-Blakemore tube
• A three-lumen tube used for esophageal-gastric
  tamponade it has both gastric and esophageal
  balloons and a port for gastric aspiration.

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Linton Tube is a three-lumen tube that uses a
gastric balloon, but no esophageal balloon, and
provides ports for both esophageal and gastric
aspiration.
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• Minnesota Tube
• Is a rubber, radiopaque, 18 Fr, four lumen,
  double-balloon tube.
• The four lumens are used for gastric lavage and
  aspiration, esophageal aspiration, esophageal
  tamponade, and gastric tamponade.

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• Confocal Endoscopy
• Involves a combining a standard upper endoscope
  or colonscope with a confocal scanner.
• The scanner has the ability to deliver a laser
  light to the tissue and the confocal imaging is
  returned to a processor.
• Still new procedure, but will expand and enhance
  the practice in GI.