Adjunctive endoscopic clip marking enhances non-operative management of massive lower gastrointestinal bleeding.

BACKGROUNDS: Massive lower gastrointestinal bleeding (LGB) is common especially in elderly patients. Controversy in the approach to management stems from location of bleeding and morbidity of surgery. Colonic diverticula disease (CD) is the leading cause of painless haematochezia and haemodynamic instability. METHODS: The use of a novel technique of endoscopic pre-marking (EPM) with radiopaque metal clips to localize is described. EPM guided superselective active transarterial embolization (A-TAE) when active vascular blush was seen. When no active contrast extravasation was seen, EPM also guided prophylactic superselective transarterial embolization (P-TAE). RESULTS: From May 2004 to December 2021, there were 36 patients with massive LGB from diverticular disease encompassing 44 separate bleeding episodes. Spontaneous haemostasis was observed in 18.2% (8/44). The overall success rate in non-operative management was 83.3% (30/36) patients. Three patients proceeded for emergency surgery. Of the 36 patients, six patients had documented EPM followed by TAE due to recurrent bleed in the same episode. A-TAE was performed in two patients. P-TAE was performed in the four patients without active contrast extravasation. Initial haemostasis was successful in five out of six patients. One patient failed embolization and proceeded to emergency surgery. Three months later, one patient encountered late rebleeding and was scheduled for elective colectomy. None of the six developed intestinal infarction from embolization. The 30-day mortality was 0%. CONCLUSION: A consistent approach to LGB and defined protocol of endoscopic haemostasis, with routine EPM and embolization, has the potential to mitigate the morbidity and mortality in this group of vulnerable patients.

Image-guided radiofrequency ablation of liver malignancies: experience at Singapore General Hospital

<p><b>UNLABELLED</b>The aim of this paper was to study the efficacy, side effects and complications of radiofrequency (RF) ablation of primary and metastatic liver malignancies.</p><p><b>MATERIALS AND METHODS</b>We retrospectively reviewed 57 patients (39 men, 18 women; mean age, 63 years; age range, 44 to 83 years) who underwent RF ablation for liver malignancies from January 2002 to December 2004. A total of 87 tumours were ablated - 71 (81.6%) hepatocellular carcinomas and 16 (18.4%) metastases (from primaries in the colon, stomach and pancreas). RF ablation was performed either percutaneously (n = 71) under conscious sedation or intraoperatively (n = 16) under general anaesthesia. Follow-up ranged from 1 month to 41 months (mean, 15.2) and included computed tomography (CT) 1 day, 1 month and 3 months after ablation, and half-yearly thereafter. Patients were observed for local tumour progression and for the emergence of new tumours.</p><p><b>RESULTS</b>Four patients with a total of 5 tumours were lost to follow-up. Of the remaining 82 tumours treated, complete ablation was attained in 66 tumours after a single procedure, giving a primary effectiveness rate of 80.5%. Seven (8.5%) required 2 procedures to achieve complete ablation, giving a secondary effectiveness rate of 89% after 2 ablations. One tumour (1.2%) required 3 procedures to achieve complete ablation. One tumour required 4 procedures to date, with the latest follow-up CT still demonstrating incomplete ablation. Two tumours (2.4%) had an initial RF ablation and subsequent transarterial chemoembolisation (TACE). One tumour had an initial RF ablation followed by 32Phosphorus-biosilicon (BrachySil) injection, the latter as part of a Phase IIA trial. One tumour required 2 RF ablations and a subsequent TACE. Lastly, 3 tumours received initial RF ablation but subsequent local tumour progression was not treated as the patients were deemed unfit for repeat ablation. No procedure-related deaths or major complications were encountered. Minor complications were reported in 2 patients (3.8%) - subcapsular haematoma and thermal injury to the adjacent gastric antrum, both not necessitating surgical intervention.</p><p><b>CONCLUSIONS</b>RF ablation is an effective, safe and relatively simple procedure for the treatment of unresectable liver malignancies.</p>