The safety and efficacy of mesenteric embolization in the management of acute lower gastrointestinal hemorrhage

PURPOSE

Mesenteric embolization is an integral part in the management of acute lower gastrointestinal (GI) bleeding. The aim of this study was to highlight our experience after adopting mesenteric embolization in the management of acute lower GI hemorrhage.

METHODS

A retrospective review of all cases of mesenteric embolization for acute lower GI bleeding from October 2007 to August 2012 was performed.

RESULTS

Twenty-seven patients with a median age of 73 years (range, 31 to 86 years) formed the study group. More than half (n = 16, 59.3%) of the patients were on either antiplatelet and/or anticoagulant therapy. The underlying etiology included diverticular disease (n = 9), neoplasms (n = 5) and postprocedural complications (n = 6). The colon was the most common bleeding site and was seen in 21 patients (left, 10; right, 11). The median hemoglobin prior to the embolization was 8.6 g/dL (6.1 to 12.6 g/dL). A 100% technical success rate with immediate cessation of hemorrhage at the end of the session was achieved. There were three clinical failures (11.1%) in our series. Two patients re-bled, and both underwent a successful repeat embolization. The only patient who developed an infarcted bowel following embolization underwent an emergency operation and died one week later. There were no factors that predicted clinical failure.

CONCLUSION

Mesenteric embolization for acute lower GI bleeding can be safely performed and is associated with a high clinical success rate in most patients. A repeat embolization can be considered in selected cases, but postembolization ischemia is associated with bad outcomes.

How to decide on stent insertion or surgery in colorectal obstruction?

Colorectal cancer is one of the most common cancers in western society and malignant obstruction of the colon accounts for 8%-29% of all large bowel obstructions. Conventional treatment of these patients with malignant obstruction requiring urgent surgery is associated with a greater physiological insult on already nutritionally replete patients. Of late the utility of colonic stents has offered an option in the management of these patients in both the palliative and bridge to surgery setting. This has been the subject of many reviews which highlight its efficacy, particulary in reducing ostomy rates, allowing quicker return to oral diet, minimising extended post-operative recovery as well as some quality of life benefits. The uncertainity in managing patients with malignant colonic obstructions has lead to a more cautious use of stenting technology as community equipoise exists. Decision making analysis has demonstrated that surgeons' favored the use of stents in the palliative setting preferentially when compared to the curative setting where surgery was preferred. We aim to review the literature regarding the use of stent or surgery in colorectal obstruction, and then provide a discourse with regards to the approach in synthesising the data and applying it when deciding the appropriate application of stent or surgery in colorectal obstruction.

Colorectal surgeon consensus with diverticulitis clinical practice guidelines

AIM

To determine the application of clinical practice guidelines for the current management of diverticulitis and colorectal surgeon specialist consensus in Australia and New Zealand.

METHODS

A survey was distributed to 205 colorectal surgeons in Australia and New Zealand, using 22 hypothetical clinical scenarios.

RESULTS

The response rate was 102 (50%). For 19 guideline-based scenarios, only 11 (58%) reached consensus (defined as > 70% majority opinion) and agreed with guidelines; while 3 (16%) reached consensus and did not agree with guidelines. The remaining 5 (26%) scenarios showed community equipoise (defined as less than/equal to 70% majority opinion). These included diagnostic imaging where CT scan was contraindicated, management options in the failure of conservative therapy for complicated diverticulitis, surgical management of Hinchey grade 3, proximal extent of resection in sigmoid diverticulitis and use of oral mechanical bowel preparation and antibiotics for an elective colectomy. The consensus areas not agreeing with guidelines were management of simple diverticulitis, management following the failure of conservative therapy in uncomplicated diverticulitis and follow-up after an episode of complicated diverticulitis. Fifty-percent of rural/regional based surgeons would perform an urgent sigmoid colectomy in failed conservative therapy of diverticulitis compared to only 8% of surgeons city-based (Fisher's exact test P = 0.016). In right-sided complicated diverticulitis, a greater number of those in practice for more than ten years would perform an ileocecal resection and ileocolic anastomosis (79% vs 41%, P < 0.0001).

CONCLUSION

While there are areas of consensus in diverticulitis management, there are areas of community equipoise for future research, potentially in the form of RCTs.

Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR "Hemorrhoid"[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel "walk-in-walk-out" techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

Treatment of hemorrhoids: A survey of surgical practice in Australia and New Zealand

BACKGROUND

Hemorrhoidal disease is the most common anorectal disorder. Hemorrhoids can be classified as external or internal, according to their relation to the dentate line. External hemorrhoids originate below the dentate line and are managed conservatively unless the patient cannot keep the perianal region clean, or they cause significant discomfort. Internal hemorrhoids originate above the dentate line and can be managed according to the graded degree of prolapse, as described by Goligher. Generally, low-grade internal hemorrhoids are effectively treated conservatively, by non-operative measures, while high-grade internal hemorrhoids warrant procedural intervention.

AIM

To determine the application of clinical practice guidelines for the current management of hemorrhoids and colorectal surgeon consensus in Australia and New Zealand.

METHODS

An online survey was distributed to 206 colorectal surgeons in Australia and New Zealand using 17 guideline-based hypothetical clinical scenarios.

RESULTS

There were 82 respondents (40%) to 17 guideline-based scenarios. Nine (53%) reached consensus, of which only 1 (6%) disagreed with the guidelines. This was based on low quality evidence for the management of acutely thrombosed external hemorrhoids. There were 8 scenarios which showed community equipoise (47%) and they were equally divided for agreeing or disagreeing with the guidelines. These topics were based on low and moderate levels of evidence. They included the initial management of grade I internal hemorrhoids, grade III internal hemorrhoids when initial management had failed and the patient had recognised risks factors for septic complications; and finally, the decision-making when considering patient preferences, including a prompt return to work, or minimal post-operative pain.

CONCLUSION

Although there are areas of consensus in the management of hemorrhoids, there are many areas of community equipoise which would benefit from further research.

The Benefits of Colorectal Surgery Surveys in Australia and New Zealand

PURPOSE

Pertaining to the Colorectal Surgery Society of Australia and New Zealand (CSSANZ) Executive and Research Support Committee, this study aimed to assess the usefulness and outcomes of surveys sent out by the society to its members.

METHODS

From 2009 to 2017, CSSANZ members received 38 surveys, most of which were distributed from within the society, and a few of which originated from other affiliated groups. Surveys were categorised by type, topics, times required for completion, delivery method, response rates, and advancement to publication.

RESULTS

Of 38 surveys, 20 (53%) were published and 18 remain unpublished. Four surveys were distributed annually on average, with 2.2 published annually on average, with a mean impact factor of 2.41 ± 1.55. Mean time to publication was 31 ± 17 months. Surveys contributed to 13 publications (34%). The most common survey topics were rectal cancer decisionmaking, in 6 publications (16%), preoperative assessment of colorectal patients, in 5 publications (13%), and anal physiology: continence and defaecation, in 4 publications (11%). Publication of surveys was not related to the number of surveys distributed per year, the number of questions per survey, or the time required by respondents to complete the surveys.

CONCLUSION

Most of the CSSANZ-distributed surveys resulted in publications, and one third of the surveys contributed to higher degrees obtained by investigators. These surveys aid research into areas that are otherwise difficult to assess, often indicating areas for future research.