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.

Anastomotic leaks: what is the best diagnostic imaging study?

PURPOSE: Postoperative anastomotic leaks are one of the most devastating consequences of colorectal surgery. Diagnostic imaging for upper gastrointestinal anastomotic leaks has been evaluated and reported on extensively. No study has compared the utility and effectiveness of CT scans and water-soluble enemas for the identification of postoperative lower gastrointestinal anastomotic leaks. The present study was designed to evaluate and compare these two common radiographic imaging modalities in detecting lower gastrointestinal anastomotic leaks. METHODS: A retrospective chart review was performed that identified 36 patients during a seven-year period who underwent reoperative surgery for a lower gastrointestinal anastomotic leak. Patient's imaging studies were classified as positive if extravasation of contrast material was demonstrated. When negative, a study was retrospectively reviewed in an attempt to identify findings suggestive of an anastomotic leak. RESULTS: There were 36 patients identified with a postoperative lower gastrointestinal leak requiring surgical intervention. There were 28 of 36 patients (78 percent) re-explored on the basis of a radiologic study demonstrating an anastomotic leak. A total of 27 CT scans were performed, of which 4 (14.8 percent) were considered positive for an anastomotic leak. On review of the remaining negative CT scans, nine (33.3 percent) were considered descriptive positive with a large amount of fluid or air in the peritoneal cavity but without obvious extravasation of contrast. Eighteen patients were evaluated with a water-soluble enema and 15 (83.3 percent) demonstrated extravasation of contrast material. In the 26 patients with a distal anastomotic leak, 17 water-soluble enemas were performed, with 15 (88 percent) demonstrating a leak. In contrast, only 2 of 17 (12 percent) CT scans were positive in this group of patients (P < 0.001). There were ten patients who initially had a CT scan followed by a water-soluble enema. Of these patients, eight of nine (88 percent) initially had a negative CT scan but were considered to be clinically suspicious of having an anastomotic leak and subsequently had a leak demonstrated on a water-soluble enema. CONCLUSIONS: Early intervention in patients who develop an anastomotic leak can be shown to improve the ultimate outcome, especially with respect to mortality. It is usually necessary to obtain objective tests of anastomotic integrity because of the nonspecificity of clinical signs. Our study supported the superiority of water-soluble enema to CT imaging in patients in whom both modalities were used. This difference was most pronounced for distal anastomotic leaks, whereas no radiologic imaging study proved effective in evaluating proximal anastomoses.

Pain control following elective gastrointestinal surgery: is epidural anesthesia warranted?

Fifty-nine patients undergoing elective major gastrointestinal surgery were entered into a prospective, randomized trial between January 1993 and July 1994 comparing the effectiveness, side effects, and hospital costs of postoperative epidural anesthesia (Group 1, n = 29) and intramuscular narcotic injections (Group 2, n = 30). Epidural catheters were inserted by a team that supervised catheter care and infusion rates in the postoperative period. The nonepidural group received intramuscular injections on a regular basis. Patients filled out visual analog scales to measure levels of pain ( 1 = minimal, 10 = maximal) every eight hours. Patient activity, bowel, and urinary function were recorded by the nursing staff. Control of pain (as measured by the daily average visual analog score) was more effective in Group 1 (P < .001) on postoperative days 1-3 (1.3 vs 3.6 on day 1, 0.7 vs 2.6 on day 2, 0.9 vs 3 on day 3). There was no significant difference in mean values between groups 1 and 2 with respect to first ambulation on the hospital ward, onset of liquid diet, intake of solid food, first spontaneous voiding, first bowel movement, length of hospitalization, or charge of hospitalization ($13,439 +/- 7,452 vs $11,821 +/- 6,630). We conclude that epidural anesthesia significantly lessens incisional pain following major elective lower gastrointestinal surgery when compared to analgesic injections alone. However, while not statistically significant, the overall charge was increased by 14% in the epidural group. This finding should be examined in light of the relatively low pain level in patients receiving narcotic injections alone.

Mesenteric angiography for lower gastrointestinal hemorrhage: are there predictors for a positive study?

PURPOSE: Selective mesenteric angiography is an expensive, invasive, diagnostic, and therapeutic tool for lower gastrointestinal hemorrhage. Some institutions have required a positive nuclear medicine bleeding scan before angiography. We have attempted to determine if this is a valid screening test for mesenteric angiography. Are there any other factors to predict which patients are actively bleeding and who will benefit from angiography? METHODS: All cases of mesenteric angiography for hemorrhage performed during a 12-year period were reviewed. RESULTS: A total of 131 angiograms were performed during a 12-year period with 45 patients demonstrating active bleeding; 54 patients had a bleeding scan before angiography. A positive bleeding scan did not increase the percentage of positive angiograms. A history of prior gastrointestinal bleeding, transfusions, orthostatic hypotension, or tachycardia were not predictors for a positive angiogram. DISCUSSION: This study could not identify any single useful predictor that will increase the likelihood of obtaining a positive angiogram. Nuclear medicine scans should not be used routinely as a screening test for angiography.

Management of angiogram positive lower gastrointestinal hemorrhage: long term follow-up of non-operative treatments.

After positive mesenteric angiography for massive lower gastrointestinal hemorrhage, one is faced with a localized bleeding site and the therapeutic options of embolization, vasopressin infusion, observation, or operation. This review was designed to determine long term outcomes of angiographically controlled bleeding. All cases of mesenteric angiography for hemorrhage performed over a twelve year period were reviewed, with focus on those treated non-operatively. A total of 37 patients had angiographically localized bleeding distal to the ligament of Treitz. Twenty-one patients were controlled with vasopressin, embolization, or spontaneous cessation. Only three patients had recurrent bleeding, at one month, one year, and eight years. No patients died from recurrent bleeding. Five patients died without any further bleeding; mean time to death was 2 years. Twelve patients had no further bleeding at a mean follow-up of 2.6 years. Bleeding controlled by any angiographic measure, was followed by recurrent bleeding in 14% without the need for operative intervention.

Long-term management of diverticulitis in young patients.

PURPOSE: This study was designed to determine the natural history of documented diverticulitis that resolves after treatment with intravenous antibiotics and bowel rest in patients under the age of 50. METHODS: Records of 40 patients aged 50 or under who were hospitalized with the diagnosis of acute diverticulitis between 1980 and 1984 were reviewed to obtain data regarding how the diagnosis was made. Patients successfully treated with antibiotics were contacted five to nine years after their attack and surveyed via telephone questionnaire about symptoms, recurrent attacks, and surgical interventions. RESULTS: A total of 40 patients were included in the study. Ten patients (25 percent) required surgery during initial admission, and 30 patients were discharged with resolution of their symptoms after treatment with intravenous antibiotics and bowel rest. A five-year to nine-year follow-up was obtained on patients treated medically, one-third of whom underwent operation for diverticulitis during this period, and two-thirds of whom did not require surgery during the follow-up period. All operations were elective with single-stage resections. CONCLUSION: Based on our data, we do not recommend surgery in this population after a single episode of diverticulitis that resolves after treatment with antibiotics.

Large bowel obstruction caused by incarcerated inguinal hernia: report of three cases.

We report two patients with left colonic obstruction and one patient with cecal obstruction caused by incarceration in inguinal hernias. None of the patients had colonic malignancies within the hernial sacs. Reduction of the hernias was followed by resolution of the bowel obstruction and successful hernial repair in all patients.

Preoperative evaluation and postoperative surveillance for patients with colorectal carcinoma.

As the understanding of the biology of carcinoma of the colon and rectum increases and the effectiveness of adjuvant therapy for patients with such carcinoma improves, preoperative staging of disease has assumed an increasingly important role. The rationale and specifics of preoperative evaluation and the role, rationale, and controversies regarding postoperative surveillance after curative resection of colorectal carcinoma are discussed.

Acute mesenteric ischemia caused by isolated superior mesenteric artery dissection.

Isolated dissection of a peripheral artery is a rare event. Only 11 reports exist in the literature of dissection of the superior mesenteric artery, most of which have been fatal. This is the first documented case of the successful treatment of an acute ischemic event caused by a superior mesenteric artery dissection. In addition, the new technique of right gastroepiploic artery-to-superior mesenteric artery bypass is introduced as a satisfactory method of revascularization.