Acute diverticulitis with extraluminal air: is conservative treatment sufficient? A single-center retrospective study.

BACKGROUND: Acute diverticulitis with extraluminal air constitutes a heterogeneous condition whose management is controversial. The aims of this study are to report the failure rate of conservative treatment for diverticulitis with extraluminal air and to report risk factors of conservative treatment failure. METHODS: A retrospective study was performed from an institutional review board-approved database of patients admitted with acute diverticulitis with extraluminal air from 2015 to 2021 at a tertiary referral center. All patients managed for acute diverticulitis with covered perforation (without intraabdominal abscess) were included. The primary endpoint was failure of medical treatment, defined as a need for unplanned surgery or percutaneous drainage within 30 days after admission. RESULTS: Ninety-three patients (61% male, mean age 57 ± 17 years) were retrospectively included. Ten patients had failure of conservative treatment (11%). These patients were significantly older than 50 years (n = 9/10, 90% versus n = 47/83, 57%, p = 0.007), associated with cardiovascular disease (n = 6/10, 60% versus n = 10/83, 12%, p = 0.002), American Society of Anesthesiologists (ASA) score of 3-4 (n = 4/7, 57% versus 6/33, 18%, p = 0.05), under anticoagulant and antiplatelet (n = 6/10, 60% versus n = 11/83, 13%, p = 0.04) and steroid or immunosuppressive therapy (n = 3/10, 30% versus 5/83, 6%, p = 0.04), and with distant pneumoperitoneum location (n = 7/10, 70% versus n = 14/83, 17%, p = 0.001) compared with those with successful conservative treatment. On multivariate analysis, only distant pneumoperitoneum was an independent risk factor of failure (odds ratio (OR) 6.5, 95% confidence interval (CI) [2-21], p = 0.002). CONCLUSIONS: Conservative treatment with antibiotics for acute diverticulitis with extraluminal air is safe with a success rate of 89%. Patients with distant pneumoperitoneum should be carefully monitored.

Difficult diagnosis of right-sided colonic diverticulitis.

A giant colonic diverticulum is a rare entity, generally located into the sigmoid colon. We report the case of a giant colonic diverticulum in an young women which was intraoperatively diagnosed, during exploratory laparoscopy, in spite of normal colonoscopy.

Prostatic artery embolization using three-dimensional cone-beam computed tomography.

PURPOSE: The purpose of this study was to report the use of three-dimensional (3D) cone-beam computed tomography (CBCT) for prostatic artery embolization (PAE) in patients with benign prostatic hypertrophy (BPH). MATERIALS AND METHODS: Twenty-three consecutive men who underwent PAE using 3D CBCT from June 2016 to September 2018, were retrospectively included in this observational single-center study. There were 23 men with a mean age of 73±12 (SD) years (range: 52-94years) with moderate to severe lower urinary tract symptoms (mean international prostate symptom score, 21±5.7 [SD]; range: 9-30) due to BPH (mean prostate weight, 100g±63 [SD]; range: 30-250g). PAEs were analyzed with respect to procedure time, fluoroscopy time, technical success, complications and dosimetric indices. RESULTS: The mean catheterization time of the prostatic artery from the internal iliac artery was 17.3±12.5 (SD) min (range: 8-57min) on the right side and 23.6±14.9 (SD) min (range: 6-54min) on the left side. A technical success was achieved in 21 patients (21/23; 91%). PAE was bilateral in 14 patients (14/21; 66%) and unilateral in 7 patients (7/21; 33%). No occurrence of non-target embolization was reported. The mean dose area product was 146.7±47.9 (SD) Gy.cm2 (range: 54-254Gy.cm2) and mean cumulative air kerma was 771.4±333.3 (SD) mGy; range: 280-1560 mGy. The mean fluoroscopy time was 42.3±23.1 (SD) min (range: 19.4-118.2min). CONCLUSION: 3D CBCT is a useful tool to identify the prostatic arteries and facilitates catheterization of prostatic arteries with an acceptable level of radiation exposure.

Embolization of the superior rectal arteries for chronic bleeding due to haemorrhoidal disease.

AIM: The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior haemorrhoidal arteries) in patients ineligible for surgery. METHODS: Between January 2014 and April 2015, 30 consecutive patients (average age 58 years) suffering from disabling chronic bleeding due to haemorrhoidal disease and with a contraindication for surgery (n = 23) or with a failure of instrumental or surgical treatment (n = 7) underwent embolization. All cases were discussed at multidisciplinary meetings including a proctology specialist or a surgeon and an interventional radiologist. We performed super selective micro coil embolization (pushable 2-3 mm fibre coils) of the distal branches of the superior rectal arteries with a microcatheter, via a right femoral approach, under local anaesthesia. We assessed clinical outcome by evaluating bleeding and specific clinical scores relating to bleeding and changes in quality of life. RESULTS: Immediate technical success, with no complication, was achieved in 93% of cases. A mean of 3.1 arteries per patient was embolized, with a mean of 7.6 coils per patient. Median follow-up was 5 months. Clinical score improvement was observed in 72%, in 17 patients after a single embolization session, and in four additional patients after a second embolization session. No improvement in bleeding was observed in eight patients (28%). CONCLUSION: Distal coil embolization of the superior rectal arteries for disabling chronic bleeding due to haemorrhoidal disease is safe and effective in patients untreatable by surgery.

Transcatheter arterial embolization with ethylene vinyl alcohol copolymer (Onyx) for the treatment of hemorrhage due to uterine arteriovenous malformations.

PURPOSE: The purpose of this study was to evaluate the effectiveness of ethylene vinyl alcohol copolymer (Onyx) as a single embolic agent for percutaneous arterial treatment of hemorrhage due to uterine arteriovenous malformations (AVMs). MATERIALS AND METHODS: Twelve women (mean age, 33 years) with metrorrhagia due to uterine AVMs who were treated by percutaneous arterial embolization using Onyx as a single embolic agent were retrospectively included. The diagnosis of uterine AVM was suggested by pelvic ultrasound and/or magnetic resonance imaging findings and further confirmed by angiography. Clinical files and angiographic examinations were reviewed for angiographic findings, technical and clinical success, procedure complication and further pregnancies. Clinical success was defined by absence of metrorrhagia at 1 month following embolization. RESULTS: Sixteen arterial embolization procedures were performed. Angiographically, 6 women had high flow AVM and 6 had low flow AVM. The rate of technical and clinical success was 92% (11/12 patients). One woman with early repeat hemorrhage underwent two embolization procedures and further hysterectomy. No severe complications were observed after embolization. Three women (3/12; 25%) became pregnant following embolization including one full term pregnancy. CONCLUSION: In women with metrorrhagia due to AVM, arterial embolization with Onyx is effective and safe. Additional research is needed to confirm the possibility of future pregnancy after Onyx embolization.

Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 14 cases.

PURPOSE: The 'emborrhoid' technique consists of the embolization of the hemorrhoidal arteries. The endovascular arterial occlusion is performed using coils placed in the terminal branches of the superior rectal arteries. The emborrhoid technique has been modeled after elective transanal Doppler-guided hemorrhoidal artery ligation which has been shown to be effective in hemorrhoidal disease. We report the first 14 cases of our experience with emborrhoid technique. MATERIALS AND METHODS: Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique (3 women, 11 men). The stage of the hemorrhoidal disease was II (10 patients), III (3), and IV (1). This treatment was decided by a multidisciplinary team (proctologist, visceral surgeon, and radiologist). Seven patients underwent previous proctological surgery. Ten patients had coagulation disorders (anticoagulants or cirrhosis). Superior rectal arteries were embolized with pushable microcoils (0.018). RESULTS: Technical success of the embolization procedure was 100 %. Clinical success at 1 month was 72 % (10/14). Of the 4 patients who experienced rebleeding, two underwent additional embolization of the posterior rectal arteries with success. No pain or ischemic complications were observed in 13 patients. One patient experienced a temporary painful and edematous, perianal reaction. CONCLUSION: Our case studies suggest that coil embolization of the superior rectal arteries is technically feasible, safe and well tolerated. Additional studies are needed to evaluate the efficacy of this new 'emborrhoid' technique in the management of hemorrhoidal disease.