The efficacy of selective arterial embolization in the management of colonic bleeding.

BACKGROUND: The aim of the present study was to determine the efficacy of mesenteric embolization in the management of acute haemorrhage from the colon. METHODS: A retrospective review was performed of a consecutive series of patients who underwent selective arterial embolization between 2002 and 2010 at two Australian institutions. An analysis was performed of each patient's present and past medical history, procedural details and subsequent post-procedural recovery. RESULTS: Seventy-one patients were reviewed in the study. Sixty-one patients (86 %) had immediate cessation of bleeding following embolization. In total, 20 % had some form of morbidity due to mesenteric embolization being performed, the three most common being worsening renal function, groin haematoma and contrast allergy (11, 9 and 7 %, respectively). Only one patient developed superficial bowel ischaemia. Overall, 11 patients (18 %) had recurrent bleeding. Of these patients, five had repeat embolization. Of the patients who underwent re-embolization, three stopped bleeding. Surgery was required in 5 patients 2 of whom died postoperatively of systemic complications. CONCLUSIONS: Colonic bleeding can be treated successfully in most patients by embolization, without causing ischaemia. Eighteen per cent of patients rebleed during the first hospital admission, and 20 % patients experienced a procedure-related complication. In those patients that proceed to surgery, the morbidity, mortality and length of hospital stay increase dramatically.

Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded?

BACKGROUND: It is routine practice to perform colonoscopy as a follow-up after an attack of diverticulitis, with the main aim to exclude any underlying malignancy. PURPOSE: This study aimed to determine whether colonoscopy is necessary and what additional information is gained from this procedure. DESIGN: This is a study of a retrospective cohort. SETTINGS AND PATIENTS: From January 2003 to June 2009, patients in whom left-sided diverticulitis was diagnosed on CT scan were matched with colonoscopy reports within 1 year from the date of CT by the use of radiology and endoscopy databases. Patients who had colonoscopy within 1 year before the CT scan were excluded. The Western Australian Cancer Registry was cross-referenced to identify patients who subsequently received diagnoses of cancers for whom colonoscopy reports were unavailable. MAIN OUTCOME MEASURES: The main outcome measures were the number of patients in whom colorectal cancers were diagnosed and other incidental findings, eg, polyps, colitis, and stricture. RESULTS: Left-sided diverticulitis was diagnosed in 1088 patients on CT scan, whereas follow-up colonoscopy reports were available for 319 patients. Eighty-two (26%) patients had incidental findings of polyps (9 polyps >1 cm), and 9 patients (2.8%) received diagnoses of colorectal cancers on colonoscopy. After cross-referencing with the cancer registry, the overall prevalence of colorectal cancer among the cohort within 1 year of CT scan was 2.1% (23 cases). The odds of a diagnosis of colorectal cancer were 6.7 times (95% CI 2.4-18.7) in patients with an abscess reported on CT, 4 times (95% CI 1.1-14.9) in patients with local perforation, and 18 times (95% CI 5.1-63.7) in patients with fistula compared with patients with uncomplicated diverticulitis. LIMITATIONS: This study was limited by the unavailability of data for private/interstate hospitals, and the relatively small number of cancer cases reduced the statistical power of the study. CONCLUSIONS: We recommend routine colonoscopy after an attack of presumed left-sided diverticulitis in patients who have not had recent colonic luminal evaluation. The rate of occult carcinoma is substantial in this patient population, in particular, when abscess, local perforation, and fistula are observed.

Sexual health in women following pelvic surgery for rectal cancer.

BACKGROUND: Sexual dysfunction is a recognized complication in men undergoing pelvic surgery for rectal cancer. There is, however, little information on the influence of such surgery on sexual health in women. The aim of this study was to evaluate sexual health in women undergoing pelvic surgery for rectal cancer. METHODS: The study group included women who underwent pelvic surgery for rectal cancer at the Colorectal Surgical Unit, Fremantle Hospital between 1996 and 2002. The patients were contacted by telephone and invited to complete an anonymized questionnaire on sexual health. A control group comprised women who had undergone surgery for colonic cancer during the same interval. RESULTS: Fifty women in the study group were contacted, of whom 22 completed questionnaires. Sixty-two women in the control group were contacted and 19 completed questionnaires. Women in the study group were significantly younger than those in the control group. Compared with those in the control group, women who had undergone pelvic surgery were significantly more likely to feel less attractive, feel that the vagina was either too short or less elastic during intercourse, experience superficial pain during intercourse, and complain of faecal soiling during intercourse. Women in the study group were concerned that these limitations would persist for the rest of their lives. There were no differences between the two groups in relationship to sexual arousal or libido. CONCLUSION: Pelvic surgery for rectal cancer has a significant influence on sexual health in women.

Transanal endoscopic microsurgery: a viable operative alternative in selected patients with rectal lesions.

BACKGROUND: Local excision of rectal lesions is being increasingly undertaken, especially in those unfit for major surgery. The traditional transanal approach is often cumbersome and limited to low and mid rectal lesions. Transanal endoscopic microsurgery (TEMS) is being used to excise both benign and malignant rectal lesions, including those in the upper rectum. METHODS: Prospective analysis of all patients undergoing a TEMS excision between January 1997 and December 2000 in a specialized colorectal unit. RESULTS: Forty patients underwent a TEMS resection, with a mean age of 72 years (SD, 10 years). The mean distance of the lesions from the anal verge was 9.8 cm (SD, 3.1 cm). In 24 patients, the lesion was located >or=10 cm from the anal verge, making them unsuitable for traditional transanal resection. The mean operative time was 91 minutes (SD, 34 minutes), and the mean postoperative stay was 3 days (SD, 1.5 days). No mortality was associated with the procedure, and there was minimal morbidity in 15%. There has been no recurrence in the 18 patients who had a malignant lesion excised. CONCLUSIONS: The TEMS operating system provides the surgeon with a suitable alternative for the resection of benign and malignant rectal neoplasms in selected patients. It has the advantage of providing visual clarity of the operative field, allowing more precise dissection and a minimally invasive approach to mid and upper rectal lesions. There has been no mortality and minimal morbidity. We advocate its inclusion as part of a colorectal surgeon's operative armamentarium for these selected cases.

The impact of new technology on surgery for colorectal cancer.

Advances in technology continue at a rapid pace and affect all aspects of life, including surgery. We have reviewed some of these advances and the impact they are having on the investigation and management of colorectal cancer. Modern endoscopes, with magnifying, variable stiffness and localisation capabilities are making the primary investigation of colonic cancer easier and more acceptable for patients. Imaging investigations looking at primary, metastatic and recurrent disease are shifting to digital data sets, which can be stored, reviewed remotely, potentially fused with other modalities and reconstructed as 3 dimensional (3D) images for the purposes of advanced diagnostic interpretation and computer assisted surgery. They include virtual colonoscopy, trans-rectal ultrasound, magnetic resonance imaging, positron emission tomography and radioimmunoscintigraphy. Once a colorectal carcinoma is diagnosed, the treatment options available are expanding. Colonic stents are being used to relieve large bowel obstruction, either as a palliative measure or to improve the patient's overall condition before definitive surgery. Transanal endoscopic microsurgery and minimally invasive techniques are being used with similar outcomes and a lower mortality, morbidity and hospital stay than open trans-abdominal surgery. Transanal endoscopic microsurgery allows precise excision of both benign and early malignant lesions in the mid and upper rectum. Survival of patients with inoperable hepatic metastases following radiofrequency ablation is encouraging. Robotics and telemedicine are taking surgery well into the 21(st) century. Artificial neural networks are being developed to enable us to predict the outcome for individual patients. New technology has a major impact on the way we practice surgery for colorectal cancer.