Sclerotherapy of rectal hemangiomas in a child with Klippel-Trenaunay-Weber syndrome

Gastrointestinal involvement in Klippel-Trénaunay syndrome: pathophysiology, evaluation, and management

Klippel-Trénaunay syndrome is typically a complex combined capillary-lymphatic-venous malformation in lower limb. Gastrointestinal involvement is not infrequent in Klippel-Trénaunay syndrome. Rectal bleeding is the most common complication. In recent years, this condition has been increasingly reported. However, most authors simply described extreme manifestations or various combinations of clinical observations. The underlying pathophysiology of gastrointestinal involvement in Klippel-Trénaunay syndrome has been underrecognized. Pathophysiologically, some seemingly adequate managements are pitfalls in treatment. Anorectosigmoid vascular malformations in KTS have distinct and more complicated pathophysiologies than anorectal vascular malformation. Once understanding the pathophysiology, some patients can be successfully managed with a staged plan in our practice. Therefore, recognizing the pathophysiologies of gastrointestinal involvement is needed to evaluate, prevent pitfalls, and determine adequate managements for practitioners. Because of the complexity and rarity of this condition, prospective controlled study or a large cohort of patients is impossible. Based on literature review and our practice, we discuss pathophysiologies, evaluation, pitfalls, and treatment strategies for gastrointestinal involvement in Klippel-Trénaunay syndrome.

Laparoscopic total mesorectal excision for rectal venous malformation: A case report with a brief literature review

Rectal vascular malformation is a rare disease on which few reports have been published. Here, we report the case of a 38-year-old woman who presented with severe weakness, dyspnea, and recurrent episodes of rectal bleeding. Her colonoscopy showed an extensive pigmented lesion in the lower rectum. CT angiography showed diffuse circumferential wall thickening of the rectum, perirectal fat stranding, tiny round foci of calcification, and no arterial feeders. Multiphasic MRI confirmed the diagnosis. The patient underwent a total mesorectal excision with hand-sewn coloanal anastomosis. The venous malformation was confined to the mesorectal tissue. The avascular plane between the ectodermal and mesodermal tissue was well maintained. Blood loss was 200 mL. The patient has had no recurrence of disease in the 18 months since surgery. Although total mesorectal excision is described for rectal cancer, it may be indicated for benign disease like rectal vascular malformation to achieve complete removal of the disease and to minimize intraoperative blood loss.

Conservative management of diffuse cavernous haemangioma of the sigmoid and rectum

Diffuse cavernous haemangioma is a rare disease of the rectum. It usually presents with a history of rectal bleeding in children and young adults. When conservative methods fail to control bleeding, traditionally resection is recommended. A 50-year-old man presented with per rectal bleeding and was diagnosed with diffuse cavernous haemangioma of the sigmoid and rectum extending up to 40 cm in the left colon through endoscopy, magnetic resonance imaging and computed tomography. The diagnosis was confirmed by biopsy. This patient was successful managed conservatively with tranexamic acid as needed, avoiding the need for resection.

Rectal Venous Malformation Treated by Superior Rectal Artery Embolization

A 25-year-old female was referred to the Interventional Radiology Department for investigation and treatment of a rectal venous malformation (RVM) causing large recurrent episodes of rectal bleeding and chronic anaemia. Magnetic resonance imaging (MRI) demonstrated a large venous malformation affecting the rectum, lower pelvis and left thigh. After three failed attempts at injection foam sclerotherapy using fluoroscopic colonoscopy, a multidisciplinary team proposed an embolization procedure of the arterial inflow to the venous malformation. Following discussion with the patient, embolization of the superior rectal arteries was undertaken with immediate on-table fluoroscopic improvement in the RVM. Post-treatment, a significant reduction in bleeding, was reported by day 10 with subsequent return to activities of daily living and full employment. Follow-up MRI at 1 year demonstrated significant reduction in bowel-wall thickening.

Nd:YAG laser therapy for rectal and vaginal venous malformations

BACKGROUND

Limited therapeutic options exist for rectal and vaginal venous malformations (VM). We describe our center's experience using Nd:YAG laser for targeted ablation of abnormal veins to treat mucosally involved pelvic VM.

METHODS

Records of patients undergoing non-contact Nd:YAG laser therapy of pelvic VM at a tertiary children's hospital were reviewed. Symptoms, operative findings and details, complications, and outcomes were evaluated.

RESULTS

Nine patients (age 0-24) underwent Nd:YAG laser therapy of rectal and/or vaginal VM. Rectal bleeding was present in all patients and vaginal bleeding in all females (n = 5). 5/7 patients had extensive pelvic involvement on MRI. Typical settings were 30 (rectum) and 20-25 W (vagina), with 0.5-1.0 s pulse duration. Patients underwent the same-day discharge. Treatment intervals ranged from 14 to 180 (average = 56) weeks, with 6.1-year mean follow-up. Five patients experienced symptom relief with a single treatment. Serial treatments managed recurrent bleeding successfully in all patients, with complete resolution of vaginal lesions in 40% of cases. No complications occurred.

CONCLUSIONS

Nd:YAG laser treatment of rectal and vaginal VM results in substantial improvement and symptom control, with low complication risk. Given the high morbidity of surgical resection, Nd:YAG laser treatment of pelvic VM should be considered as first line therapy.

Ethanol sclerotherapy of rectal venous abnormalities in Klippel-Trenaunay syndrome

Klippel–Trenaunay syndrome (KTS) is a rare congenital disorder characterized by the triad of capillary malformations, atypical venous malformations and varicosities and bony and/or soft tissue hypertrophy. We present the case of an 18-year-old man with KTS affected by haematochezia secondary to rectal venous malformations that was managed with endoscopic sclerotherapy. In this case, we compared the use of ethanol to phenol as a sclerosant.

Rectal bleeding, deep venous thrombosis, and coagulopathy in a patient with Klippel-Trénaunay syndrome

Klippel-Trénaunay syndrome (KTS) is a rare noninheritable congenital disorder comprising vascular malformations that predispose patients to a paradoxical condition where bleeding occurs in a hypercoagulable state. A 16-year-old boy with a complicated lifetime course of KTS presented with massive rectal bleeding. He underwent a partial colectomy, endorectal resection, and splenectomy. Postoperatively, he developed a saddle pulmonary embolus, ultimately requiring placement of an inferior vena cava filter. He eventually did well and has since had his diverting ostomy reversed and resumed his usual activities. This report validates the use of endorectal resection for venous malformation of the rectum in patients with KTS and highlights the difficult balance of controlling bleeding by correction of a consumptive coagulopathy and the increased risk of thromboembolic complications.