Incidence of hemorrhage after colonoscopic polypectomy or biopsy is low, and in our series, hemorrhage resolved without the need for surgical intervention. Management includes initial stabilization followed by diagnostic evaluation. Technetium-tagged red blood cell nuclear scintigraphy identifies ongoing bleeding and identifies patients in whom additional invasive procedures (arteriography lower gastrointestinal tract endoscopy) are warranted.

Selected patients with colonoscopic perforation may be safely treated nonoperatively. Surgical treatment is reserved for patients with a large perforation or diffuse peritonitis.

Treatment of patients with malignant polyps must be individualized based on evolving criteria. Patients in whom polypectomy margins are inadequate should undergo colectomy. With appropriate selection criteria, patients selected for colectomy had a five-year survival rate similar to the rate of those treated by polypectomy alone.

One hundred seventy patients with gastrointestinal carcinoid tumors were treated at Ochsner Clinic from 1958 to 1990. Ninety-four rectal carcinoid tumors were diagnosed and treated during this time. Carcinoid tumors of the rectum represented the most frequent primary site (55 percent), followed by carcinoids of the ileum (12 percent), appendix (12 percent), colon (6 percent), stomach (6 percent), jejunum (2 percent), pancreas (2 percent), and other (5 percent). One-half of rectal carcinoids were discovered during anorectal examination of asymptomatic patients. The remainder were found primarily by examination of patients for symptoms of benign anorectal conditions. The diagnosis of rectal carcinoid was made at the time of initial examination in 61 patients. This allowed definitive treatment in a single session by local excision and fulguration in 48 patients. The remainder were treated by repeat biopsy and fulguration (25 patients) or by transanal excision (12 patients). Overall, 85 carcinoid tumors of the rectum measuring less than 2 cm were treated by local excision and fulguration or by transanal excision, with an average five-year follow-up. There were no local recurrences. Ten patients with metastasizing rectal carcinoids averaging 4 cm were treated. All were symptomatic at presentation and fared poorly despite radical surgery. Three were alive at three years but only one survived five years. At our institution, rectal carcinoids were the most frequently detected carcinoid tumor. Small carcinoids of the rectum were adequately treated by local excision and fulguration or by transanal excision, with no local recurrence. The true incidence of rectal carcinoids is detected only with careful and complete rectal examination of the asymptomatic screening population by experienced surgeons. With more widespread screening of the well population, rectal carcinoids may become recognized as the most frequent human carcinoid tumor.

A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 35 patients operated upon for anorectal fistulas. Twenty-nine had low intermuscular fistulas (multiple in seven), and six had high intermuscular (supralevator) fistulas. Fistulotomy alone was performed in 19 patients, and eight underwent partial fistulotomy and seton insertion. Five additional patients had proximal fecal diversion before fistulotomy. Three patients with severe colonic and anorectal disease underwent proctocolectomy as the initial procedure. Of the 32 patients who had fistulotomy performed, complete healing occurred in 30. Seven patients who healed required more than one operation for fistula. One patient was left with an asymptomatic fistula, and one required proctectomy for persistent symptomatic fistula and proctitis. Success of operation correlated with absence of rectal disease and quiescent disease elsewhere in the gastrointestinal tract. Aggressive medical treatment is required to control bowel disease preoperatively. In the majority of patients, subsequent surgery is justified and healing can be anticipated.