V5 - Techniques in Formalin Irrigation for Treating Radiation-Associated Vascular Ectasias

Monday, May 12, 2025

10:45 AM – 10:50 AM PT

Location: Ballroom 6B, Upper Level

Video Abstract Presenter(s)

Kirbi Yelorda, MD

Fellow
Ichan School of Medicine at Mount Sinai
New York, NY, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Author(s)

EP

Elisa Paoluzzi Tomada, MD, MD

Resident Physician
Icahn School of Medicine at Mount Sinai Hospital
New York, New York, United States

Disclosure information not submitted.
Heather Carmichael, MD

Colorectal Surgery Fellow
Icahn School of Medicine at Mount Sinai
University of Colorado
New York, NY, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.
AB

Alexander Bulanov, DO

Assistant Professor of Surgery
Icahn School of Medicine at Mount Sinai
New York, New York, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

Senior Author(s)

SK

Sanghyun A. Kim, MD

Associate Professor of Surgery
Icahn School of Medicine at Mount Sinai
New York, New York, United States

Disclosure information not submitted.

Submitting Author(s)

Kirbi Yelorda, MD

Fellow
Ichan School of Medicine at Mount Sinai
New York, NY, United States

All of the relevant financial relationships listed below have been mitigated.
This individual has no financial relationships with ineligible companies.

All of the relevant financial relationships listed below have been mitigated.

Kirbi Yelorda, MD: This individual has no financial relationships with ineligible companies.

Heather Carmichael, MD: This individual has no financial relationships with ineligible companies.

Alexander Bulanov, DO: This individual has no financial relationships with ineligible companies.

Image or Table (Do Not add text here):

Purpose/Background: Purpose: Radiation-associated vascular ectasias (RAVE), previously referred to as radiation proctitis, are a recognized complication following pelvic radiotherapy, occurring in up to 5% of patients. These lesions lead to bleeding from vascular ectasias and ulcerations in the rectal mucosa. Among the various treatments, topical formalin has demonstrated a high success rate in controlling bleeding. This video demonstrates two formalin application techniques: topical formalin irrigation and direct application via cotton-tip application.

Methods/Interventions: Intervention: A 70-year-old male with a history of HIV and prostate cancer treated with radiotherapy in February 2021 presents with persistent rectal bleeding secondary to RAVE. Initial management with argon plasma coagulation and topical formalin yielded minimal improvement. He returned to the operating room for a second formalin irrigation procedure.
The procedure, performed under sedation with the patient in the lithotomy position, begins with a perianal block to aid in anal sphincter relaxation. After a digital rectal exam, rigid proctoscopy revealed circumferential mucosal friability and active bleeding. A clear-walled sigmoidoscope was used to monitor the irrigations. The first irrigation commenced 10 cm from the anal verge with 50 mL of 4% formalin insufflated into the rectum for five minutes. The effluent was then suctioned. The procedure was repeated at 7 cm and 5 cm from the anal verge. Finally, the rectum was irrigated with normal saline. By the end, the mucosa appeared pink with no further bleeding.
For the direct formalin application technique, a high-resolution anoscopy module with an integrated camera was employed. A formalin-soaked cotton-tip applicator was applied to bleeding areas of the rectal mucosa. The advantage of this method is the ability to use a higher concentration of formalin (up to 8%) due to its precise application.

Results/Outcomes: Result: The patient tolerated the procedure well, with no immediate complications.

Conclusion/Discussion:

Conclusion: Topical formalin application is a safe and effective treatment for RAVE. This video clearly illustrates the feasibility of both the formalin irrigation and direct application techniques.