The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding.

PURPOSE: This study was designed to identify the short-term safety and efficacy of super-selective embolization for lower gastrointestinal bleeding and to examine the long-term durability. METHODS: Outcomes of patients who underwent super-selective embolization for lower gastrointestinal bleeding from January 1999 to September 2005 were identified retrospectively at a single institution. RESULTS: Seventy-five hospitalizations (71 patients) were identified. Mean age was 73 years. Short-term outcomes: this technique was successful in achieving immediate hemostasis in 73 of 75 cases identified (97 percent). Twelve patients (16 percent) rebled, eight required surgery, and four were successfully reembolized. Five patients (7 percent) developed postembolization ischemia: four required operations, and one was followed clinically. Long-term outcomes: 52 patients were followed for a mean of 32 months. Eight patients were readmitted for recurrent bleeding: four required surgeries, one was successfully reembolized, and the remaining three patients were followed clinically. CONCLUSIONS: This large series reaffirms the high success rate (97 percent) and relatively low acute ischemia risk (7 percent) of super-selective embolization for lower gastrointestinal bleeding. Furthermore, only 15 percent of patients ultimately required readmission for recurrent bleeding. It is our recommendation that super-selective embolization be used as the primary therapeutic modality in the treatment of angiogram positive lower gastrointestinal bleeding.

Multimedia article. Success of episioproctotomy for cloaca and rectovaginal fistula.

PURPOSE: Surgical repair of rectovaginal fistula with an advancement flap has had suboptimal results. The existing literature documenting episioproctotomy as a surgical option in females with rectovaginal fistula or cloaca is limited. This study was designed to examine our experience with episioproctotomy in this group. Additionally we were interested in risk factors, which might predict failure. METHODS: All females who had repair of a rectovaginal fistula or cloaca with episioproctotomy from 1998 to 2004 were studied. Data were collected from chart review and telephone contact. This included demographics, body mass index, tobacco use, Crohn's disease, previous surgery, and diverting stoma. RESULTS: Data were obtained from 42 females (mean age, 39.2 (range, 25-70) years). The mean follow-up was 37 (range, 2-84) months. Nine females had a cloaca and the rest had a rectovaginal fistula with an anterior sphincter defect. Eleven (all with anterior tissue) had recurrence of fistula. None with cloaca had recurrence. Eight of 11 recurrences occurred in females who had failed at least one previous repair. No variables that were studied significantly affected recurrence. Median (25th, 75th percentiles) postoperative Wexner incontinence scores for those with and without recurrence were 8 (7, 12) and 5 (2, 6) respectively. CONCLUSIONS: Episioproctotomy is a successful technique for repair of rectovaginal fistula and cloaca. Incontinence score postoperatively were acceptable. It should be considered a first line of surgical treatment in those with a fistula that includes compromise of the anterior sphincter complex.

Preoperative colonoscopy decreases the need for laparoscopic management of colonic polyps.

PURPOSE: Patients are commonly referred to surgeons for surgical resection of polyps that cannot be excised colonoscopically. Repeating the colonoscopy may be met with resistance by both the patient and the referring endoscopist. However, there are two distinct benefits. First, if the lesion was not marked, tattooing facilitates laparoscopic resection. Second, and more importantly, many of these polyps can be removed endoscopically by an experienced colorectal surgeon, avoiding unnecessary colon resection. Over a period of five years, we have reviewed preoperative colonoscopy in patients who were referred for surgical treatment of benign polyps. METHODS: From January 1999 through September 2003 all patients referred for surgical resection of a benign polyp were consecutively entered into a database by a single group of colorectal surgeons. All patients underwent preoperative colonoscopy on the day before the planned colon resection. Patient charts were reviewed, and demographics were recorded. The referral and preoperative colonoscopy reports and all pathology results were reviewed to record the polyp size, location, histology, and subsequent treatment. RESULTS: Altogether, 71 patients were included in this study. The average size of the polyps was 24 mm (range, 10-60 mm). The location of the polyp as determined by preoperative colonoscopy differed from the location noted on referral colonoscopy in nine patients (13 percent). Surgery was canceled in 23 patients (32 percent), primarily because of complete polypectomy at preoperative colonoscopy. Of the 48 who underwent surgery, 23 (47 percent) had a colonic tattoo placed, at the discretion of the surgeon. Lesions clearly located in the cecum were not tattooed routinely. Of the 48 patients who underwent surgery, 45 (94 percent) underwent laparoscopic colon resection. CONCLUSIONS: We concluded that patients referred for surgical resection of a polyp should undergo repeat colonoscopy preoperatively, given that in our study one-third of patients were spared unnecessary colectomy. In addition, repeat endoscopy by the operating surgeon offers an opportunity to confirm the location of the lesion and place a colonic tattoo to facilitate laparoscopic resection.