REBLEEDING AND OTHER OUTCOMES OF COLON SURGERY VS. TRANSCATHETER ARTERIAL EMBOLIZATION FOR DEFINITIVE DIVERTICULAR HEMORRHAGE
Thongsak Wongpongsalee*1,2,4, Usah Khrucharoen1,2,3, Dennis M. Jensen1,2,3, Mary Ellen Jensen1,2,3
1CURE - Digestive Diseases Research Center, Los Angeles, CA; 2David Geffen School of Medicine, University of California, Los Angeles, CA; 3West Los Angeles VA Medical Center, Los Angeles, CA; 4Siriraj Hospital, Mahidol University, Bangkok, Thailand
Background: Diverticular (TIC) hemorrhage is the most common cause of acute severe colonic bleeding in adults. The majority of patients with diverticular hemorrhage stop bleeding spontaneously. Urgent colonoscopy can play an important role in the diagnosis and treatment of acute diverticular hemorrhage. However, definitive treatment is required in those with severe or continued bleeding. In patients with multiple or unsuccessful colonoscopic treatments, interventional radiology with embolization or surgery may be required. To date, no studies have been reported comparing long-term outcomes of interventional angiography and surgical management in diverticular bleeding.
Aims: To compare the short and long-term outcomes of patients with definitive TIC hemorrhage treated with colon resection (CR) and transcatheter arterial embolization (TAE).
Methods: This is a retrospective study of prospectively collected data from two teaching hospitals from January 1993 to September 2019. A diagnosis of definitive TIC bleeding was made by urgent colonoscopy after purge (based on presence of stigmata of recent hemorrhage) and/or red blood cell scan or angiography (based on active arterial bleeding). Demographics and outcome data were compared using univariate analysis. Kaplan-Meier analysis was performed to estimate time-to-first rebleed.
Results: 30 patients were included, 15 cases with CR - 6 with right hemicolectomy, 4 subtotal colectomy, 2 segmental colectomy, 2 left hemicolectomy, and 1 total colectomy; and 15 cases with TAE. There were no significant differences in demographics between the two groups. Median (IQR) PRBCs transfused was 7 (2-8) vs. 5 (4-8) units, p=0.882. Median length of hospital stay in CR vs. TAE was 8 (5-14) vs. 9 (4-12) days, p=0.724. Median ICU stay was 4 (2-5) vs. 3 (1-6) days, p=0.676. Major postoperative complication rates were 6.7% vs. 13.3%, p=0.543 (1 anastomotic leakage in CR group; 1 colonic ischemia and 1 aspiration pneumonia in TAE group). The 30-day rebleeding rate was 0% vs. 13.4% (2/15), p=0.157. The 30-day readmission rate was similar for CR vs. TAE: 6.7% vs. 6.7%, p>0.99. Cumulative incidences of rebleeding for CR vs. TAE at 1, 2, 5, and 10 years were 0% vs. 26.7%; 6.7% vs. 40%; 6.7% vs. 46.7%; and 6.7% vs. 53.3%. For rebleeding and follow-up outcomes, see Table 1. By Kaplan-Meier analysis, the rebleeding rate was significantly higher in the TAE group (Figure 1). The all-cause mortality rate was 40% vs. 26.7%, p=0.439. No mortality was caused by diverticular bleeding. Median (IQR) follow-up time was 54 (26-95) vs. 38 (13-52) months, p=0.432.
Conclusions: 1. TAE resulted in a significantly higher rebleeding rate than surgery and increased every year. 2. All-cause mortality was high but none was caused by diverticular hemorrhage.
Table 1. Rebleeding and other outcomes of diverticular bleed compared for surgery (CR) and Transcatheter Arterial Embolization (TAE)
Figure 1. Kaplan-Meier analysis estimates of recurrent diverticular (TIC) bleed after CR and TAE showed that the rebleeding rate of was significantly higher in the TAE group (Log rank test, p=0.006).
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