Endoscopiclaser treatment vascular anomalies upper ... · Vascular anomalies of the upper and lower gastro-intestinal tract can cause acute and chronic blood loss and although relatively

Gut, 1985, 26, 1338-1348

Endoscopic laser treatment of vascular anomalies of theupper gastrointestinal tractS G BOWN, C P SWAIN, D W STOREY, C COLLINS, K MATTHEWSON,P R SALMON, AND C G CLARK

From the Departments of Gastroenterology, Surgery and Pathology, University College Hospital, London

SUMMARY Vascular anomalies of the gastrointestinal tract are an important source of both acuteand chronic blood loss. They present difficult management problems as they are often multiple,involving more than one part of the gastrointestinal tract, and may give rise to bleeds ofincreasing frequency and severity over a period of many years. We present the results ofendoscopic argon and Nd YAG laser treatment of 18 patients with documented recurrent, severehaemorrhage from vascular lesions of the upper gastrointestinal tract with follow up of up to fiveyears. Four patients with hereditary haemorrhagic telangiectasia, five with single angiodysplasiasand three with multiple angiodysplasias have had their transfusion requirements reduced tominimal levels after one or more courses of laser treatment. Two of these have required no bloodfor over two years despite previous total requirements of 52 and 129 units of blood. Four patientswere submitted to surgery (two in whom the laser failed to control haemorrhage and two who didnot have immediate access to laser therapy at the time of severe bleed). Two of these, however,bled again soon afterwards. Two patients are still undergoing courses of laser therapy althoughhave already shown reductions in transfusion requirements. Both lasers were effective. The NdYAG laser appears to produce better long term results as its greater penetration makes it possibleto ablate the main areas of vascular ectasia in the submucosa, although it does have a slightlyhigher risk of causing haemorrhage in the first few days after treatment.

Vascular anomalies of the upper and lower gastro-intestinal tract can cause acute and chronic bloodloss and although relatively rare, are being recog-nised with increasing frequency both at endoscopyand angiography. They may be responsible for up to3% of upper gastrointestinal bleeds' and as many as35% of severe acute lower gastrointestinal bleeds.2A range of non-neoplastic vascular anomalies occurin the gastrointestinal tract. The most specificlesions are those of hereditary haemorrhagic telan-giectasia or Osler-Weber-Rendu Syndrome. About13% of patients with haemorrhagic telangiectasiahave significant gastrointestinal haemorrhage.3Single or multiple lesions without the associatedfeatures of haemorrhagic telangiectasia are morelikely to be degenerative in nature and are referredto in this report as angiodysplasias.4 These havebeen associated with valvular heart disease (particu-Address for correspondence: Dr S G Bown, Department of Surgery, School ofMedicine, University College London, The Rayne Institute, University Street,London WC1E 6JJ.

Received for publication 31 January 1985

larly aortic stenosis), chronic haemodialysis, con-nective tissue disease and previous radiotherapy andtheir incidence increases with advancing age.5 6Those in the caecum have been thought to beproduced by chronic, intermittent low-grade ob-struction of submucosal veins.4

In both haemorrhagic telangiectasia andangiodysplasia, the essential features are fragileleashes of thin walled blood vessels in the submu-cosa which may break through the mucosa (perhapsby minor local trauma or increased venous pressure)and cause significant blood loss into the lumen of thegut.4 7 8The treatment modalities that have been tried

include surgery,39 oestrogen therapyl1 and variousendoscopic techniques. The endoscopic methods oftreatment that have been reported to be of valueinclude diathermy,5 11 sclerotherapy12 andlasers.1-16 Few reports, however, have discussedthe precise aims of endoscopic therapy or docu-mented the details of blood loss before and aftertreatment in individual patients.

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Endoscopic laser treatment of vascular anomalies of the upper gastrointestinal tract

In this report, we analyse 18 cases referred forlaser treatment for whom we have precise details ofrecurrent haemorrhage of varying severity prior toreferral and follow up for periods up to five years.

Methods

PATIENTSAll patients were referred to University CollegeHospital for laser treatment with a firm or pro-visional diagnosis of haemorrhage from vascularlesions of the upper gastrointestinal tract. Thediagnosis was confirmed at endoscopy carried outunder sedation with diazepam and performed withcare to minimise local trauma from the instrument(particularly from suction artefacts). Gastric secre-tions and any old or fresh blood were cleared fromsuspicious areas by gentle washing. A positivediagnosis was based on the identification of one ormore bright red lesions on the mucosa (occasionallyassociated with small areas of superficial ulcera-tion). These were raised (umbilicated), flat ordepressed, but all lesions in any one patient weresimilar. Lesions seen to bleed spontaneously orwhich oozed on gentle washing or on treatment werethought most likely to be sites of significant bloodloss. They varied in size from 1 cm diameter to lessthan 1 mm across, the latter only being distinguishedfrom innocent red spots by the observation ofbleeding. All but one had sharply defined marginsand most were roughly oval in shape. (It should benoted that occasional large raised vascular lesionscan be cavernous and deep and are not suitable forlaser therapy). Patients with typical mucocutaneouslesions and a positive family history were consideredas haemorrhagic telangiectasia (although one pa-tient (case 7) without a family history was includedas she had typical mucocutaneous lesions andmultiple arteriovenous malformations, particularlyin the liver and pancreas).3 Patients without thesefeatures were considered as angiodysplasias. Allwere given blood transfusions and iron supplementsas required to maintain an adequate haemoglobin.

Initially, in 1979, only an argon ion laser wasavailable (Model 770, Spectra Physics Ltd, StAlbans). This was used at a power of 5-6 w withpulses of 1-3 seconds duration to ablate the mucosallesion as seen endoscopically - that is, to blanch ordestroy the red areas of vascular ectasia. Thisusually created a shallow ulcer and care was taken tolimit the total energy deposited on any one spot tobelow 50 J (the safe limit established in animalexperiments to avoid perforation).17 Some oozingwas usually seen during treatment but this alwaysceased spontaneously. After laser treatment, fulldoses of cimetidine or ranitidine were prescribed for

one month to hasten healing of the iatrogenic ulcers.In 1981, a Nd YAG laser became available

(Fiberlase 100, Barr & Stroud Ltd, Glasgow) andsince this time, all endoscopic treatment for thiskind of lesion has been carried out with thisinstrument. As with the argon laser, the total energyon any one spot in one treatment session was limitedto the safe limit established in animal experiments(600 J for this laser)18 using shots of 60-70 w for 0 5seconds. The immediate visual effect was, however,often different as the first change was blanching, tobe followed a few days later by superficial ulcerationrather than the immediate loss of superficial cellsoften seen with the argon laser. Both lasers causedsuperficial charring if fired at fresh blood. With bothlasers, if the safe limit of energy dissipation wasreached on any lesion without adequate visualeffect, treatment on that spot was stopped, to becontinued after a time interval of at least two weekswhen the treated area would have had sufficientopportunity to heal to make further treatment safe.In all cases of haemorrhagic telangiectasia, therewere too many lesions to treat in one session, butendoscopy could be repeated every few days, asdifferent lesions were treated on each occasion. Allpatients had repeated endoscopies until it wasjudged that the vascular anomalies as visualisedendoscopically had been ablated. If blood loss couldnot be adequately controlled endoscopically,surgery was carried out to resect the area containingthe most significant lesions. Long term follow upwas carried out at the referring hospitals and thepatient seen again by us if further bleeding occurred.Blood transfusion requirements were documentedas precisely as possible from the first evidence ofgastrointestinal blood loss to the present time.

Results

Eighteen patients have been treated, eight withhereditary haemorrhagic telangiectasia and 10 withangiodysplasia (single and multiple lesions). All hadrequired blood transfusion for acute blood lossbefore referral and eight had developed majorproblems in cross matching in view of the largenumbers of transfusions they had received. Five hadrequired previous surgical intervention for gas-trointestinal blood loss. Two had segmental jejunalresections, one had a vagotomy and pyloroplastyand one a hemicolectomy. The fifth had a partialgastrectomy, a hemicolectomy and a segmentaljejunal resection. Of all these seven procedures,only one of the jejunal resections and the partialgastrectomy had any definite benefit on reducing theblood loss. One patient had had previous successfulembolisation of an arteriovenous malformation of

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Bown, Swain, Storey, Collins, Matthewson, Salmon, and Clark

the pancreas. Five patients also had lesions of themitral or aortic valves and one was on chronichaemodialysis.

Details of the patients are shown in Table 1 andthe results of treatment in Tables 2 and 3. Thepattern of blood loss in the two groups was different.The patients with haemorrhagic telangiectasia hadlonger histories of blood loss with less severe acuteepisodes, although all had increasing loss in theperiod leading up to their referral. To provide a

comparison between patients in this group, thepretreatment requirements in Table 2 are given as

the average monthly requirements for the threemonth periods up to and including initial or subse-quent courses of treatment. Most of the patientswith angiodysplasia had shorter histories (less than a

year) of recurrent episodes of bleeding leading totheir referral to us. The duration of this periodvaried from one to 24 months and the pretreatmenttransfusion column in Table 3 shows the averagemonthly requirements during this period. In cases inwhich major haemorrhage recurred, the periodleading up to the second referral is shown as a

second line in the pretreatment column. Figure 1shows the pattern of blood loss in relation to thetherapeutic manoeuvres applied for three illustra-tive cases. The number of laser endoscopies re-

quired to complete courses of therapy is shown inTable 4. The large number of sessions required tocomplete the initial course of treatment for patients1 and 2 (11 and nine endoscopies respectively)reflects both our caution with a new technique andthe large number of lesions present in each of theseladies. The multiple sessions required to treat singlelarge angiodysplasias reflect the need to limit theenergy dissipated on one spot at one time. Theresults for each course of therapy are shown in Table5 and the current situation for each patient in Table6.There were no perforations. The only compli-

cation that might be attributable to the lasertreatment was exacerbation of the bleeding. Fourcases of haemorrhagic telangiectasia (numbers 1, 2,

7, and 8) required transfusion during their initialcourse of treatment. For three (cases 1, 2, and 8) thequantity of blood needed diminished as the numberof lesions treated increased, suggesting a steadyresponse to therapy. Haemorrhage was only con-trolled for two months in case 1 and when itrecurred, could not be adequately controlled by fourfurther laser endoscopies, necessitating a partialgastrectomy. Case 7 required 12 units of blood in theweek before referral. The bleeding came predomi-nantly from a single lesion (only 1-2 mm indiameter) in the body of the stomach. This was

stopped temporarily on six separate occasions over a

period of two months (twice, arterial haemorrhagewas arrested with the laser), but haemostasis never

lasted more than a few days and eventually sheunderwent a sleeve resection of the main lesion,since when she has been well. Although the laserfailed to control her blood loss, it probably did notexacerbate it, as the rate of transfusion required washighest in the week before her referral.Three angiodysplasia cases bled during the course

of treatment. Case 17 had three major bleeds ofcomparable severity (8-10 units of blood trans-fused), the first before referral, the second four daysafter his first treatment (both of which settled onconservative therapy) and the third, 13 days after histhird treatment, at which time he was submitted tolaparotomy, as no experienced laser endoscopistwas available. Several lesions had received no lasertreatment at the time of laparotomy and it was notpossible to establish whether he had bled fromtreated or untreated lesions. In the other two (cases14 and 18), haemorrhage seemed more likely to bedirectly related to therapy. These bleeds occurred a

few hours and seven days after treatment, butsettled spontaneously, only requiring 4 and 2 unitsof blood respectively. The most serious complica-tion occurred in case 6 who bled three days after NdYAG laser treatment of residual telangiectasia inthe stomach at a routine follow up endoscopy. Hewas admitted from home to the referring hospital,where he required a laparotomy to oversew a

Table 1 Details ofpatients in study

Angiodysplasia

HHT Single Multiple Diffuse

Patients (no) 8 5 4 1Sex 5F3M 3F2M 3F1M 1FAge 62 (42-74) 66 (47-88) 76 (72-81) 62Period of GI bleeding 13 yrs (2-32 yrs) 7 m (3-16 m) 9 m (1-24 m) 17 mTotal blood transfused (units of 540 ml) 130 (19-300) 45 (16-107) 57 (4-177) 87

HHT=haemorrhagic telangiectasia.

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Table 2 Results for patients with hereditary haemorrhagic telangiectasia (HHT). Blood transfusion requirements are givenin units of540 ml

Average blood Average bloodrequirements Laser or other treatment requirementsbefore treatment after treatment

Case no (units per month) Initial Subsequent (units per month) Duration of remission

1 8 Argon 1 2 m11 Surgery 1-7 16 m7 Surgery 0-5 Well at 40 m

2 8 Argon 1 12 m3-7 Argon 0-8 12 m3 Nd YAG 0-2 Well at 18 m

3 2-7 Nd YAG Nil Well at 35 m4 1-3 Nd YAG Nil 9 m

1.3 Nd YAG Nil Well at 6 m5 2-7 Nd YAG Nil 4 m

2-7 Nd YAG Nil Well at 10 m6 6-7 Nd YAG 0-2 12 m

Surgery* Nil Well at 1 m7 16 Nd YAG Nil. Laser failure

Surgery Nil Well at 4 m8 6 Nd YAG 2-7 Still under treatment

* Rebled three days after Nd YAG laser treatment of residual lesions at routine follow up endoscopy and submitted to surgery at referringhospital.

Table 3 Results forpatients with angiodysplasia. Blood transfusion requirements are given in units of540 ml

Average blood Average bloodrequirements Laser or other treatment requirementsbefore treatment after treatment

Case No Lesion (units per month) Initial Subsequent (units per month) Duration of remission

9 Single, 5-3 Argon Nil Well at 48 mgastric

10 Single, 16 Nd YAG 0-3 8mduodenum 7 Nd YAG 0-3 Died of septicaemia at

9m11 Single, 8-7 Nd YAG Nil Well at 27 m

gastric12 Single, 2-7 Nd YAG Nil Well at 8 m

gastric13 Single, 1-8 Nd YAG Nil Well at 6 m

gastric14 Multiple, 10.3 Argon Nil 14 m

Roux loop 5-2 Nd YAG 0-3 Well at 20 m15 Multiple, 1-5 Argon Nil 8 m

gastric 4 Nd YAG Nil Died of myocardialinfarction at 3 m

16 Multiple, 4 Argon Nil Died of peritonitis atgastric 18 m

17 Multiple, 8-7 Nd YAG - Rebled during course ofgastric therapy when no laser

operator available.Surgery Rebled within a month

3 Nd YAG Nil Well at 10m18 Diffuse, crosses 4-2 Nd YAG 2-7 Still under treatment

pylorus

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Argonlaser

20

10.

.1II11111II . I I

Argonlaser

Nd YAGlaser

I I I II

Nd YAG40 laser

Case 10

30 Vagotomy andpyloroplasty

Nd YAG20 s laser

Diedt of10. septicaemia

O I..iiii LX ,11..I.401

30'

Fig. 1 Transfusionrequirements and therapeuticprocedures for 3 illustrativecases. Case 2 (HHT), case 10(single angiodysplasia) andcase 14 (multipleangiodysplasia). Each verticalline represents the units ofblood transfused in one month.

20

10'

Partialgastrecomy

Nd YAGlaser

'I

Jejunal Rightresection hemicolectomy

'IArgonI laser '1.

1 II -I 11--I~~~~I.11..11 1 . I

1978 1979

Table 4 Number of laser endoscopies required to completeeach course of treatment (this table does not include thethree courses of treatment thatfailed to controlhaemorrhage)

Initial Course Subsequent Coursemean (range) mean (range)

HHT 5(2-11) 2(1-2)Single 3 (1-4) 2 (1 case only)angiodysplasiaMultiple 2 (1-4) 2 (2-3)

Two cases still under treatment:Case 8- six endoscopies so far. Multiple large lesions in stomach

still to treat.Case 18 - ten endoscopies so far. Doubt if full extent of lesion has

been identified or treated.

Case 14

1980 1981 1982 1983 1984

bleeding point in one of the treated lesions.Detailed studies were possible on two of the three

specimens available following resection of gastriclesions previously treated endoscopically. Figure 2shows an angiogram of the resected stomach in case

1, which reveals discrete areas of vascular ectasia.Only the argon laser was used in this case. A sectionthrough a treated lesion is shown in Fig. 3. Figure 4illustrates a section taken adjacent to a treatedtelangiectasia. Only a small sleeve resection was

made in case 7 and we were unable to identify theprecise bleeding point in the specimen. Figure 5,however, shows a section through the treated area

(only the Nd YAG laser was used in this case).Quantitative measurements showed the zone of

Case 2

I

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Table 5 Outcome ofeach course of laser therapy (1-3 courses per patient)

Definite Probable Courses Patientsbenefit benefit Failure (total no) (no)

HHT 6 5* 3t 14 8Single angiodysplasia 6 - 6 5Multiple angiodysplasia 3 3 it 7 4

* One course of treatment not yet complete. t Includes one patient who rebled at referring hospital four days after laser treatment. : Laseroperator unavailable at time of bleed.Definite benefit: reduction in average monthly transfusion requirements for six months after treatment to less than 10% of those in threemonths before treatment and at least eight units total transfusion requirement before treatment.Probable benefit: (a) reduction in average monthly transfusion requirements for three months after treatment to less than 50% of those inthree months before treatment, or (b) no transfusions after treatment, but less than eight units required before treatment.Failure: laser unable to control blood loss, urgent surgery required.

coagulative necrosis to extend 0 5 mm below thesurface of the resected stomach after argon lasertreatment and 2-1 mm after the Nd YAG. The zone

of inflammation and fibrosis extended 1-0 mm belowthe surface for the Argon laser and 3-4 mm for theNd YAG.

Discussion

The primary defect in these vascular lesions isunknown, but is probably one of connective tissue insmall veins. Both haemorrhagic telangiectasia andangiodysplasias consist of collections of delicatevessels lined by a single layer of endothelial cells andsupported by a fine layer of connective tissue withno elastic lamina. Tortuosity of the vessels withineach lesion is common. In the gastrointestinal tractthey occur predominantly in the submucosa, thoughmay involve the mucosa or the external musclelayer.4 7 8 The natural history of haemorrhage fromlesions such as these is poorly documented. Manyare entirely asymptomatic. Boley showed submucos-al lesions of varying severity in otherwise normalregions of colons resected for carcinoma and sug-gested that these might evolve into typical angio-dysplasias that could bleed.4 Theodore identified 40patients with angiodysplasias (proven on biopsy) inthe stomach or duodenum in 3300 upper GIendoscopies, but only five bled.19

The factors precipitating episodes of haemorrhageare often unknown. Local trauma from food passingmay play a part, although increased pressure in thepathological vessels is probably more important.The association between haemorrhage fromangiodysplasia and valvular heart disease may bedue to increased venous pressure. One of our

patients (case 17) was noted to be in mild congestivecardiac failure the day before an episode of bleedingstarted and there has been an anecdotal report ofbleeds from an angiodysplasia of the caecum ceasingafter surgery for aortic stenosis (personal communi-cation). In general, most reports suggest that once

bleeding does occur, it becomes more frequent andmore severe with advancing age3 5 but the intermit-tent occurrence of bleeding episodes makes itdifficult to assess the effect of therapeutic man-

oeuvres unless a long period of follow up is possible.Spontaneous cessation of haemorrhage for severalyears may occur. Case 3 in this report first requiredtransfusion in 1950, averaged 4 units per year until1960, but then needed none for five years. Afterthat, she again averaged 4 units per year until theaccelerated blood loss developed which led to herreferral to University College Hospital.Treatment of the underlying condition has proved

difficult. No satisfactory pharmacological agent hasbeen identified to reduce GI blood loss (althoughoestrogens do reduce loss from epistaxis in patients

Table 6 Current situation of treated patients

No major blood loss after lasertreatment alone (died since laser Well after surgery for Still undertherapy of unrelated causes) haemorrhage treatment Total

HHT 4(0) 3(1*) 1 8Single angiodysplasia 5 (1) _ 5Multiple angiodysplasia 3 (2) 1* - 4Diffuse angiodysplasia - -1 1

* These two patients were only submitted to surgery as laser treatment was not available at the time of a severe bleed.

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Fig. 2 Angiogram of resected stomach in case 1. Arrowsindicate the main areas of vascular ectasia, each fed byseveral small arterioles. (x 15).

with haemorrhagic telangiectasia).10 Singleangiodysplasias can be treated successfully bysurgery if their location can be identified preciselyby angiography or endoscopy.9 20 Likewise, the fivecases with single upper gastrointestinal tract lesionsthat we have treated endoscopically have done well,only one requiring a second course of treatment,which was successful. The distribution of multiplelesions often makes complete resection impossible,particularly as new lesions tend to form later inother areas.3 Two of our four cases that came tosurgery bled again later. Case 1 required a revisiongastrectomy 16 months after the first operation.Case 17 bled again from the gastric remnant within amonth of his subtotal gastrectomy, but was thensuccessfully treated with the Nd YAG laser. Inretrospect, both these patients might not haverebled if their initial operation had been a totalgastrectomy, but even now, both are potentially atrisk from haemorrhage from other parts of the GItract. In many cases, the physician is also faced withthe difficult task of deciding whether a particularlesion is a significant source of blood loss. In four ofour patients (cases 7, 11, 14, and 18) lesions werepositively identified by angiography or endoscopy in

Fig. 3 Section oftelangiectasia in case 1, previously treated with the Argon laser. Closed arrow: approximate limit ofzoneofcoagulative necrosis. Open arrow: approximate limit ofzone ofinflammation and fibrosis (H & E x35 originalmagnification).

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Fig. 4 Section adjacent to a treated telangiectasia (case 1).Normal mucosa overlies the extensive vascular ectasia in thesubmucosa (H & E x350 original magnification).

the small or large bowel, but resection of theaffected areas failed to stop the bleeding. Haemor-rhage from single lesions is virtually unknown inhaemorrhagic telangiectasia (although case 7 bledpredominantly from one site) and about half ofpatients with angiodysplasia have multiple lesions.'Thus, an endoscopic technique must be the mostpromising approach, particularly as the vast major-ity of lesions which bleed are located within reach ofthe gastroduodenoscope or colonoscope.The first and most extensively used technique has

been diathermy. Rogers reported control ofhaemorrhage in five cases of caecal 'haemangiomas'without complicaiton" but a more detailed analysisby Weaver5 reveals several problems. After treat-ment designed to ablate the vascular lesions, deepulcerations developed in most areas of coagulationand in several instances, there was delayed bleedingfrom these iatrogenic ulcers. In those cases, it was

difficult to decide whether the patient was bleedingfrom the iatrogenic ulcer or from the originalvascular malformation. No perforations occurred,however, and three out of four patients benefited(one requiring multiple coagulations). Jensen hashad encouraging results with the heater probe andbicap probe in 26 patients. 13 Another technique thathas been reported recently is endoscopic sclerother-apy.12 One half to 1 millilitre of sodium morrhuatewas injected submucosally, and this stopped allbleeding from three patients with haemorrhagictelangiectasia (follow up six to 12 months). Thisapproach is simple and inexpensive, but needs fullerassessment.Problems of electrode tissue adherence and diffi-

culty predicting the extent of tissue damage pro-duced by diathermy led to a search for alternativeno-touch techniques. The argon and Nd YAG lasersseemed the most promising of these. The laserenergy is delivered via a flexible fibre passedthrough the biopsy channel of the endoscope andheld above the target area without touching it.Experimental studies show that the extent of dam-age is more predictable than with diathermy anddepends on the energy dissipated.'7 21 22 Encourag-ing results with the argon laser have been reported.Waitman et al had complete cessation of bleeding in66% of 50 patients with six months to four yearsfollow up.'1In 30 patients, Jensen et al showed asignificant reduction in emergency admissions forhaemorrhage, total transfusions and surgery.'3 Ourown early results with this laser were promising.When our first case required an emergency gastrec-tomy and we had the opportunity to study the effectsof our treatment on the resected specimen, how-ever, it became apparent that the argon laser wasonly treating the tip of the iceberg. Even though asmall ulcer had been deliberately created at endo-scopy, the extensive submucosal vascular malforma-tion had hardly been touched, either immediatelybelow the treated area or more laterally undernormal mucosa (Figs 3 and 4). This would make itmore likely that the bleeding could recur later iffurther vascular ectasias formed in the mucosawhich could link the persisting submucosal vascularlake with the lumen of the intestine. It was for thisreason that we changed to the Nd YAG laser whichcan coagulate through a greater depth of tissue.Case 7 gave us an opportunity to study the effectsafter treatment with the Nd YAG laser (Fig. 5) andfrom the measurements on these sections (givenabove) it is apparent that the zone of inflammationand fibrosis is three to four times thicker than withthe argon laser. This zone represents the regionwhere one can hope to ablate the vascular ectasiaand replace it with fibrosis and as its thickness is

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*f yr. ' W X _ .. D

Fig. 5 Section oftelangiectasia in case 7previously treated with the Nd YAG laser. Closed arrow: approximate limit ofzone ofcoagulative necrosis. Open arrow: approximate limit ofzone ofinflammation andfibrosis (haemotoxylin andtartrazine x23 original magnification).

only adequate to cover the full thickness of thesubmucosa following Nd YAG laser treatment, thislaser would seem the more suitable for treatingthese lesions.

Fortunately, the lesions of both haemorrhagictelangiectasia (as in Fig. 2) and angiodysplasias9 areusually well localised, so Nd YAG laser treatmentshould be able to ablate them without loss of largeareas of functioning gastric mucosa and submucosa.Endoscopically, it is impossible to know the preciseextent of submucosal spread beyond the visiblemucosal lesion. High quality microangiography mayhelp to delineate the extent of single large lesions,but it is difficult to correlate with endoscopicfindings in the presence of multiple lesions. Ourcurrent practice is to treat the area of the mucosallesion and a band around its edge knowing that theNd YAG laser light is scattered up to 5 mm in alldirections within the tissue and hope that this issufficient to destroy the most important areas ofsubmucosal ectasia. Johnson achieved reduction orcomplete cessation of bleeding in 19 of 22 patientswith the Nd YAG laser, although reported delayedmassive haemorrhage seven to 16 days after treat-ment in three.14 Examination of his surgical speci-

mens revealed haemorrhage from induced ulcera-tion at the treatment site comparable to Weaver'sresults after diathermy.5 This ulceration was morethan one might wish, but the energy used was notstated, and may have been particularly high in thesecases. We also had three cases in which delayedhaemorrhage may have been related to Nd YAGlaser treatment one of which was severe enough towarrant surgery. Experimental studies show that thetissue damage in gastric mucosa after single shotsfrom a Nd YAG laser is maximum seven days aftertreatment23 (in contrast with the argon laser wherethe maximum effect is apparent at once).'7 Aroundeach treated spot there is a range of effects, asshown in Fig. 5, the extent of each depending on thepower and exposure time used. At the centre,necrosed tissue sloughs. Adjacent areas mount aninflammatory response which leads to fibrosis andbeyond this only oedema is seen. Thus, if the edgeof the zone of necrosis occurs within the area ofvascular ectasia, this might lead to delayed hae-morrhage. Ideal laser treatment parameters wouldmaximise fibrosis and minimise necrosis associatedwith sloughing. No data are available to determinethese optimum values, but it is likely that lower

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Endoscopic laser treatment of vascular anomalies of the upper gastrointestinal tract 1347

powers with longer exposure times are most approp-riate (in contrast with the high power, short ex-posure times found to be most effective in treatinghaemorrhage from peptic ulcers).22 We limited thetotal energy on any one area to minimise the risk ofperforation, but it is difficult to relate the energydissipated to the risk of delayed haemorrhage -there was no correlation in this series. The risk ofdelayed haemorrhage may be reduced by startingtreatment at the edge of the lesion rather than thecentre, so the feeding vessels at the sides areoccluded first, and this is our current practice.The large variations in transfusion requirements

between patients, and the small total numbers in thisseries, make it difficult to compare the clinicalresults with the two lasers. Two patients hadtreatment from both. Case 14 had comparableresults with each, Case 2 has had a considerablybetter and longer remission after the Nd YAG laserthan after either of her argon courses. Cases 3 and11 had particularly good results after Nd YAGtherapy. Neither has required transfusion for overtwo years, after previous total transfusions of 129and 52 units respectively. On histological grounds,the Nd YAG should be superior as it can ablate thesubmucosal lesions without risk of perforation and itis our clinical impression that this is the case. Thereis a small risk, however, that this laser can causedelayed haemorrhage which was not seen with theargon laser. This may be avoidable by usingalternative laser settings.On current evidence, carefully controlled endo-

scopic thermal ablation of these lesions seems themost appropriate approach to the long termmanagement of these patients and the Nd YAGlaser appears superior to diathermy and the argonlaser. Further long term studies are needed, how-ever, to compare laser therapy with the variousalternative techniques available.

We should like to thank the following for referringthese cases from all parts of England and Wales andfor help in documenting precise transfusion require-ments and for permission to report these results: DrsC H Burns Cox, J R Dowdle, I Gilbert, P LGolding, N F Jones, E C B Keat, R Lendrum, J NMickerson, A Pearson, N Peters, D Rampton, Mr JSpencer, Drs R Taylor, D S Tunstall-Pedoe, M JWilliams and A J Wing. We should also like tothank Miss S Williams, Mr D Ellis and Mr P Lutherfor preparing the illustrations, Miss J Forster fortyping the manuscript and Sister Ramu and the staffof the Endoscopy Unit for their continual help andsupport. This work was carried out with the supportof a grant from the DHSS.

References

1 Clawse RE, Costigan DJ, Mills BA, Zuckerman GR.Angiodysplasia of the stomach and duodenum: areview of 30 cases. Gastrointest Endosc 1982; 28: 129.

2 Jensen DM, Machicado GA, Tapia JI et al. Argon laserphotocoagulation of bleeding colonic lesions. Proceed-ings of Laser Tokyo '81: 1981; 20-4.

3 Smith CR, Bartholomew LG, Cain JC. Hereditaryhaemorrhagic telangiectasia and gastrointestinalhaemorrhage. Gastroenterology 1963; 44: 1-6.

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Endoscopiclaser treatment vascular anomalies upper ... · Vascular anomalies of the upper and lower gastro-intestinal tract can cause acute and chronic blood loss and although relatively