Surgical aspects of radiation injury to the intestine

Effectiveness of a Clinical Pathway for Inpatients Undergoing Ileal/Ileocecal Resection for Chronic Radiation Enteritis with Intestinal Obstruction

Surgery is associated with elevated morbidity and mortality in chronic radiation enteritis (CRE). The objective of this study was to evaluate the effect of a fast-track clinical pathway (CP) on postoperative outcomes in patients undergoing ileal/ileocecal resection for CRE with intestinal obstruction. There were 85 patients with CRE (January 2011 to March 2013) with intestinal obstruction admitted to our department for ileal/ileocecal resection. The patients were divided into a prepathway group and a pathway group. The clinical outcomes were then assessed and compared. The postoperative lengths of hospital stay were 8.52 days for the pathway group and 11.32 days for the prepathway group ( P = 0.02). The pathway group had a lower stoma rate (21.6 vs 56%, P = 0.033) and fewer postoperative moderate to severe complications (8.1 vs 25%, P = 0.043) compared with the prepathway group. Implementation of the CP may reduce stoma rate, postoperative moderate to severe complications, and postoperative length of hospital stay for patients undergoing ileal/ileocecal resection for the treatment of CRE with intestinal obstruction.

Radiation colitis and proctitis

Radiation therapy is commonly utilized as a major component in the treatment of pelvic malignancy. Unfortunately, secondary toxicity to the lower gastrointestinal tract can occur. This most commonly affects the rectum, although injuries to the colon and small intestine are not uncommon. The presentation can be acute or chronic, and different mechanisms are responsible for each. Symptomatology is quite variable but can result in significant compromise for the patient. Numerous preventive and treatment strategies have been applied to this disease process. This article presents a summary of the current knowledge regarding radiation injury to the lower gastrointestinal tract with special emphasis on treatment options for radiation proctitis.

Role of home parenteral nutrition in chronic radiation enteritis

OBJECTIVES

The management of chronic radiation enteritis (CRE) is difficult and often controversial. The aim of the study was to compare long-term outcome of patients with radiation-induced intestinal obstruction treated either surgically or with intestinal rest and home parenteral nutrition (HPN).

METHODS

Thirty patients, with mechanical bowel obstruction due to CRE, were retrospectively included in the study and divided in two groups according to the first treatment approach. Seventeen patients underwent surgery (S group) and 13 patients were supported with HPN (HPN group). Survival, nutrition autonomy, number of surgeries, related complications and persistence of symptoms were evaluated in the two groups. Associations between factors and treatment group were assessed by means of the Wilcoxon rank sum test for continuous variables and the Fisher exact test for categorical variables. Overall survival was calculated using the Kaplan-Meier method.

RESULTS

The two groups were similar in terms of age, dose of radiation therapy, time of occurrence and degree of signs and symptoms. 7/13 patients in the HPN group resolved the obstruction without surgery. 10/17 patients of the S group developed intestinal failure which required HPN. Nutrition autonomy was achieved in 100% and 58.8% of HPN and S group respectively (p = 0.01). The overall five-year survival was 90.0% and 68.4% respectively in the HPN and S group (p = 0.0231).

CONCLUSIONS

Both HPN and surgery are often necessary in patients with chronic radiation-induced intestinal obstruction. However, the long term nutrition autonomy and survival seem to be better in patients initially treated with intestinal rest and HPN.

Characterization of altered absorptive and secretory functions in the rat colon after abdominal irradiation: comparison with the effects of total-body irradiation

The aim of this work was to determine the alterations in the absorptive and secretory functions of the rat colon after abdominal irradiation and to compare the effects of abdominal and whole-body irradiation. Rats received an abdominal irradiation with 8 to 12 Gy and were studied at 1, 4 and 7 days after exposure. Water and electrolyte absorption was measured in vivo by insertion of an agarose cylinder into the colons of anesthetized rats. In vitro measurements of potential difference, short-circuit current and tissue conductance were performed in Ussing chambers under basal and agonist-stimulated conditions. Most of the changes appeared at 4 days after abdominal irradiation. At this time, a decrease in water and electrolyte absorption in the colon was observed for radiation doses > or = 9 Gy. The response to secretagogues (VIP, 5-HT and forskolin) was attenuated after 10 and 12 Gy. Epithelial integrity, estimated by potential difference and tissue conductance, was altered from 1 to 7 days after 12 Gy abdominal irradiation. These results show that the function of the colon was affected by abdominal irradiation. Comparison with earlier results for total-body irradiation demonstrated a difference of 2 Gy in the radiation dose needed to induce changes in the function of the colon.

Argon plasma coagulation is an effective treatment for refractory hemorrhagic radiation proctitis

INTRODUCTION

Chronic radiation proctitis complicating pelvic radiotherapy can be debilitating. It commonly presents with rectal bleeding, which can be difficult to control. Medical management of hemorrhagic radiation proctitis is not very successful, although surgery carries high risks. Thus, endoscopic treatments are preferred. The aim of this study is to assess the efficacy of argon plasma coagulation applied endoscopically to treat hemorrhagic radiation proctitis that has been refractory to topical formalin therapy.

METHODS

Twelve patients who had ongoing bleeding from radiation proctitis, after previously failed formalin therapy, underwent endoscopic treatment using argon plasma coagulation. The efficacy of treatment was assessed by grading the frequency and severity of bleeding (0-4, 0 being no bleeding), hemoglobin level, and transfusion requirements.

RESULTS

At a median follow-up of 11 months, ten patients (83 percent) had a significant reduction in the severity and frequency of bleeding, with complete cessation in six (50 percent). The presence of coexistent radiation-induced sigmoiditis in two patients was associated with reduced but persistent bleeding, because of difficulty in targeting the bleeding sites in the sigmoid colon. The median number of treatment sessions per patient was two (range, 1-3), with the number of sessions correlated with the extent of the proctitis. All patients had an improvement in their hemoglobin level, with the mean increasing from 11.2 to 12.3 g/dl. In the six months before starting therapy, all patients had been taking iron supplements, and four had required blood transfusions (median 3 units, range, 2-6). Iron supplements were ceased four weeks after the completion of therapy in all cases, and no further transfusions were required during the study period. None of the patients experienced any significant side effects or complications.

CONCLUSIONS

Argon plasma coagulation is an effective and safe treatment for hemorrhagic radiation proctitis that has been refractory to topical formalin therapy.

Strictureplasty for obstructing small-bowel lesions in diffuse radiation enteritis--successful outcome in five patients

INTRODUCTION

Complications from chronic radiation enteritis can lead to resection or bypass of large segments of intestine, placing the patient at risk for short-bowel syndrome. We have operated on five patients with complications of chronic radiation enteritis in the setting of limited intestinal reserve. In each case, strictureplasty was used as an adjunct to resection or bypass to treat short, relatively isolated radiation strictures with the goal of preserving intestinal length and avoiding dependence on parenteral nutrition.

METHODS

There were four females and 1 male, mean age 57 (range, 45-71) years. Complications developed from 1 to 30 years after radiation therapy and all patients had undergone at least one prior laparotomy for complications of radiation enteritis. Four patients had resultant short bowel syndrome and were dependent on parenteral nutrition preoperatively. Indications for the present operations were chronic small-bowel obstruction (3 patients), enterocutaneous fistula and bowel obstruction (1 patient), and chronic small-bowel obstruction along with a rectovaginal fistula (1 patient). Details of the operative procedure, postoperative complications, and eventual weaning from parenteral nutrition were determined by review of the medical records.

RESULTS

Strictureplasty was performed either alone (1 patient) or was accompanied by resection or bypass (4 patients). Postoperative complications developed in 3 patients and were comprised of pancreatitis (1), acute renal failure (1), and wound infection (1). There were no anastomotic leaks, reoperations, or deaths. All four patients on preoperative parenteral nutrition were successfully weaned postoperatively and were maintained on enteral nutrition at last follow-up (mean 42, range, 18-120 months). One patient developed recurrent small-bowel obstruction requiring reoperation ten years after the strictureplasty surgery.

CONCLUSIONS

Strictureplasty may be an effective and safe tool to conserve intestinal length in certain highly selected patients with chronic radiation enteritis and small-bowel strictures, namely those with limited intestinal reserve where strictures are located within long segments of diseased bowel which, if resected or bypassed, would have significant nutritional or metabolic consequences. Strictureplasty is not indicated for the treatment of perforation, hemorrhage, fistula, or short segments of disease in patients with adequate intestinal reserve.

Review article: current therapeutic options for radiation proctopathy

Radiation proctopathy is a common unfortunate complication following radiation therapy of pelvic malignancies. Symptoms of chronic radiation proctopathy include haematochezia, urgency, constipation, tenesmus, diarrhoea and rectal pain. Currently, a wide variety of pharmacological options, endoscopic cautery techniques and surgical procedures have been proposed for the treatment of chronic radiation proctopathy. Although these have been proposed primarily as treatment for rectal bleeding, the control of other symptoms has been noted with some of these agents. Pharmacological options include 5-aminosalicylic acid preparations, coticosteroid enemas, sucralfate (oral, enemas), formalin, short chain fatty acid enemas, oestrogen/progesterone, hyperbaric oxygen, antioxidants, sodium pentosan polysulphate and misoprostol rectal suppositories. Of these, sucralfate and formalin therapy appear to be effective for bleeding control. Misoprostol rectal suppositories and oral sucralfate may be useful in the prevention of acute and chronic symptoms of radiation proctopathy. Endoscopic cautery techniques have included the use of Nd:YAG laser and argon laser for coagulation of bleeding neovascular telangiectasias. Argon plasma coagulation offers a safe non-contact method of delivering haemostasis which has proven to be particularly useful in targeting difficult to reach lesions tangentially. Surgery is generally reserved for severe refractory cases involving ongoing haemorrhage, obstruction, stricture formation, fistulas and perforation. Given that formal randomized placebo-controlled studies are lacking for most treatments, the management of these patients is often challenging and unclear. Hence, there is a need for more research and education on radiation proctopathy.

Intestinal permeability in humans is increased after radiation therapy

PURPOSE

Irradiation inflicts acute injuries to the intestinal mucosa with rapid apoptosis induction and subsequent reduction in epithelial surface area. It may therefore be assumed that the intestinal barrier function is affected. The aim of this study was to compare the mucosal permeability in irradiated rectum and nonirradiated sigmoid colon from patients subjected to radiation therapy before surgical treatment for rectal cancer.

METHODS

Segments from sigmoid colon and rectum obtained from irradiated and nonirradiated patients were stripped from the serosa-muscle layer and mounted in Ussing diffusion chambers. The mucosa-to-serosa passage of the marker molecules 14C-mannitol, fluorescein isothiocyanate-dextran 4,400, and ovalbumin was followed for 120 minutes.

RESULTS

The permeability to the markers was size-dependent and increased linearly across time in all specimens. The passage of all markers was increased in irradiated rectum compared with nonirradiated sigmoid colon, whereas in specimens from nonirradiated patients there were no differences between rectum and sigmoid colon. Histologic signs of crypt and mucosal atrophy were found in the irradiated rectal specimens.

CONCLUSIONS

Early gastrointestinal complications after radiation therapy may be the result of mucosal atrophy in addition to mucosal damage, with a loss of barrier integrity.

Argon beam coagulation for treatment of symptomatic radiation-induced proctitis

BACKGROUND

Radiation proctitis is a complication of radiotherapy for malignant pelvic disease. Argon beam coagulation is a new and rapidly evolving technology that permits a "no-touch" electrocoagulation of diseased tissue.

METHODS

We analyzed retrospectively the records of 7 patients with prostatic and endometrial cancers treated with irrradiation (median radiation dose was 6840 cGy, range 2400 to 7200 cGy). The median time to onset of symptoms after the conclusion of radiotherapy was 20 months (range 16 to 48 months); symptoms consisted of rectal bleeding and tenesmus in all patients. The patients underwent argon beam coagulation after colonoscopic evaluation. The usual treatment interval was 3 weeks (range 1 to 3 weeks).

RESULTS

A median of 2 treatment sessions (range 2 to 4) was necessary for complete symptom relief. All interventions were well tolerated without complications. During follow-up (median 24 months, range 18 to 24 months), there was no recurrence of symptoms (bleeding, tenesmus).

CONCLUSIONS

Argon beam coagulation is a safe, well tolerated, and effective treatment option in symptomatic radiation proctitis.

Efficacy of radioprotective agents in preventing small and large bowel radiation injury

PURPOSE

A variety of adjuvant treatments and cytoprotective agents have been proposed to lessen the toxicity of radiation therapy. The following study was designed to evaluate the benefit of six agents or combinations using anastomotic bursting strength as a measure of transmural radiation injury.

METHODS

The 40-Gy study consisted of the following. Seventy-two male Sprague-Dawley rats were divided into eight equal groups: nonradiated control, radiated untreated control, and six radiated treated groups. The radioprotective treatments included ribose-cysteine (Rib-Cys), WR-2721, glutamine, vitamin E, MgCl2/adenosine triphosphate, and RibCys/glutamine in combination. Radiated animals received 40 Gy to the abdomen. Two weeks after radiation, all animals underwent small bowel and colonic resection with primary anastomosis. Animals were sacrificed one week postoperatively, at which time anastomoses were evaluated and bursting strengths determined. The 70-Gy study consisted of the following. The same protocol was repeated for five groups of nine rats divided into nonradiated, radiated untreated, and three radiated treated groups receiving RibCys (8 mmol/kg), RibCys (20 mmol/kg), and WR-2721. All radiated animals received 70-Gy doses.

RESULTS

In the 40-Gy group, there were 10 radiation-related deaths and 6 anastomotic leaks among 70 rats studied. None of the differences between groups were significant. Nonradiated control group small bowel and large bowel anastomotic bursting pressures were significantly elevated compared with all radiated groups. Compared with radiated controls, there were significant improvements in small bowel bursting strength in the RibCys, WR-2721, RibCys-glutamine, and vitamin E groups and significant improvement in colonic bursting strength in MgCl2/adenosine triphosphate, WR-2721, and RibCys groups. In the 70-Gy group, all nine nonradiated control rats survived. All eight untreated radiated control rats died, four of eight WR-2721 animals died (P = 0.03), all RibCys (8 mmol/kg) animals died (P = 0.03), and three of nine treated with RibCys (20 mmol/kg) survived (P = 0.08).

CONCLUSIONS

WR-2721 and RibCys gave consistent protection against large and small bowel radiation injury. The lower incidence of treatment-related toxicity and potentially equal or greater radioprotective effects may make RibCys more clinically useful than WR-2721.

Argon laser therapy for hemorrhagic radiation proctitis: long-term results

In chronic radiation proctitis bleeding occurs from mucosal friability and neovascular telangiectasias. Fourteen patients with bleeding from chronic radiation proctitis underwent endoscopic argon laser therapy at 4 to 8 W. The goal of treatment was obliteration of all telangiectasias. The average follow-up was 35 months. Of the 51 procedures, 48 (94%) were performed on outpatients with enema preparation and little or no sedation. A median of three procedures was performed per patient, with two sessions required for initial control of bleeding. Ten patients (71%) required maintenance therapy for recurrent bleeding from telangiectasias that developed after initial therapy. The mean interval between maintenance sessions was 7 months. No immediate or late complications occurred.

Protective effect of RibCys following high-dose irradiation of the rectosigmoid

Ribose-cysteine (RibCys) is a prodrug of L-cysteine that stimulates glutathione biosynthesis. Increased glutathione levels have been shown to have a protective effect against radiation-induced injury and oxidative stress. Surface oximetry has previously been used successfully to predict anastomotic leakage.

PURPOSE

The following study was done to evaluate the protective effect of RibCys and the predictive value of PtO2 determinations in a swine model.

METHODS

Domestic swine were divided into three groups: Group A served as a nonradiated control; Group B received 6,000 to 6,500 rad to the rectosigmoid; and Group C received RibCys (1 g/kg) prior to receiving 6,000 to 6,500 rad. Radiated animals and controls underwent rectosigmoid resection after a three-week rest period. Intraoperative anastomotic PtO2 was checked with a modified Clark electrode. Anastomoses were evaluated radiographically at three and seven days; animals were sacrificed, and bursting strength was recorded at 10 days.

RESULTS

Mean bursting pressures were 243.8 +/- 59.4, 199.5 +/- 37.8, and 209.5 +/- 54.9 mmHg (NS) for Groups A, B, and C, respectively. Anastomotic PtO2 ranged from 19 to 98 mmHg and could not be correlated with anastomotic leaks or bursting pressure. There were 11/15 radiation-related deaths and leaks (eight deaths and three leaks) in the radiated group and 4/12 radiation-related deaths and leaks (three deaths and one leak) in the group receiving radiation and RibCys (P < 0.04).

CONCLUSIONS

1) RibCys protected animals against radiation-related deaths and anastomotic leaks following high doses of pelvic irradiation; 2) anastomotic PtO2 levels did not correlate with anastomotic healing in this model.

A simple and effective treatment for hemorrhagic radiation proctitis using formalin

Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In the more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Eight patients (seven females and one male) with hemorrhagic radiation proctitis were treated over a six-month period with endoluminal formalin. The technique used ensured minimal contact with formalin. The median age of the patients was 68 years (range, 42-73 years). Seven patients had had cancer of the uterine cervix, and one patient had had cancer of the prostate treated with radiotherapy at a median time of 30 months (range, 9-46 months) previously. The median duration of time of symptomatic rectal hemorrhage before formalin therapy was eight months (range, 1-12 months). The median number of units of blood transfused previously per patient was four (range, 2-32). The time taken for formalin therapy was 20 minutes (range, 10-70 minutes). One patient required repeat formalin application at two weeks. Bleeding ceased immediately in seven patients after formalin treatment. No further bleeding was noted, nor was any blood transfusion needed, at follow-up at four months (range, 1-6 months). Formalin therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis.

Surgical management of intestinal radiation injury

The management of 14 cases of radiation injury to the intestinal tract over a 4-year period is evaluated. The longest latent interval between radiation treatment and symptoms was 30 years. Eight patients were treated surgically; six were treated conservatively by laser therapy or application of formalin to the affected mucosa. The indications for surgery were rectovaginal fistula (four), rectal stricture (one), radiation proctitis (eight), and small bowel obstruction (one). Seven patients underwent large bowel resection. These consisted of four anastomoses with coloanal J-reservoirs, two low anterior resections, and one coloanal anastomosis without reservoir. There was no perioperative mortality. Morbidity occurred in one of the eight surgical cases. Radical resection of the radiation-damaged rectum has been shown to be a safe and reliable treatment for rectovaginal fistulas, rectal strictures, and proctitis unresponsive to medical measures. Coloanal J-reservoir is the procedure of choice to avoid urgency and frequency symptoms associated with coloanal sleeve anastomosis. Laser therapy for hemorrhagic proctitis can achieve an important place in the management of this problem without recourse to surgery.

Severe hemorrhagic radiation proctitis advancing to gradual cessation with hyperbaric oxygen

We report a case of a male patient suffering from a severe hemorrhagic radiation proctitis which gradually ceased with hyperbaric oxygen. We discuss the mechanisms of chronic radiation injury and the effect of the hyperbaric oxygen. This therapy is proposed as an alternative to surgical intervention for this abnormality.

Radiation-induced proctosigmoiditis. Prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate

In a prospective study, 37 consecutive patients with radiation-induced proctosigmoiditis were randomized to receive a four-week course of either 3.0 g oral sulfasalazine plus 20 mg twice daily rectal prednisolone enemas (group I, N = 18) or 2.0 g twice daily rectal sucralfate enemas plus oral placebo (group II, N = 19). The two groups were comparable with respect to demographic features, duration of symptoms, and clinical and endoscopic staging of the disease. Fifteen patients in group I and 17 in group II completed the trial. At four weeks, both groups showed significant clinical improvement (P less than 0.01 for group I and P less than 0.001 for group II) and endoscopic healing (P less than 0.01 for group I and P less than 0.001 for group II). When the two groups were compared, sucralfate enemas showed a significantly better response as assessed clinically (P less than 0.05), although endoscopically the response was not statistically different (P greater than 0.05). We conclude that both treatment regimens are effective in the management of radiation proctitis. Sucralfate enemas give a better clinical response, are tolerated better, and because of the lower cost should be the preferred mode of short-term treatment.

Late radiation injury of the colon and rectum. Surgical management and outcome

After a median latency of 2 years, the initial late colorectal radiation injuries in 182 patients were: stricture (37 percent), minor lesions (36 percent), rectovaginal fistula (22 percent), and gangrene or other fistulas (5 percent). Due to progression, new colorectal injuries, primarily stricture (55 percent) and fistula (42 percent), occurred in 68 patients (37 percent). Resection provided the best results. However, the resectability rate was low (46 percent) and resection was primarily performed in patients with a circumscript well-defined stricture of the proximal rectum or sigmoid colon with an anastomotic leakage rate of 5 percent. The prevailing management of 78 patients with fistula or stricture with synchronous fistula was defunctioning colostomy, primarily end-sigmoidostomy, providing fair results in half of the patients. Stomal complications occurred in 15 percent. The radiation-induced colorectal mortality was 8 percent. Colorectal fistula and associated radiation injuries of the urinary tract, and especially of the small bowel, were the major determinants of fatal outcome, yielding an overall radiation-induced mortality of 25 percent. After a median observation time of 13 years, half of the patients were alive at follow-up; 56 percent of these had a fair outcome whereas the remaining patients continued to have mild symptoms responding to conservative measures (34 percent) or disabling symptoms (10 percent).

Failure of 5-aminosalicylic acid enemas to improve chronic radiation proctitis

Radiation proctitis is a well-known complication of abdominal and pelvic radiation. Conventional medical and surgical treatment often is disappointing. 5-Aminosalicylic acid (5-ASA) is the active component in sulfasalazine and is effective in the treatment of distal ulcerative colitis. Four patients with radiation proctitis were treated with 4 g 5-ASA by enema nightly for two to six months. Patients were seen monthly, interviewed, and a sigmoidoscopic exam performed. No change was seen in the degree of mucosal inflammation on follow-up sigmoidoscopic exams. Three patients noted no change in their symptoms of bleeding, pain, or tenesmus. One patient noted initial improvement, but this was not sustained. 5-ASA enemas do not appear to be effective in the treatment of radiation proctitis.

Surgical treatment of intestinal radiation injury

A review of 43 consecutive patients requiring operation for serious intestinal radiation injury was undertaken to elucidate the efficacy of surgical treatment. The most common site of radiation injury was the rectum (19 cases), followed by the small bowel (13 cases), the colon (7 cases), and the combination of these (4 cases). The overall operative mortality was 14%; morbidity, 47%; and the postoperative symptom-free period, 18 +/- 30 months. Colostomy (N = 20) carried the lowest risk of mortality, 0%, as compared with resection (N = 17) and bypass procedure (N = 6), which were accompanied by the mortalities of 24% and 33%, respectively. During the follow-up (3-13 years) 12 patients (28%) died of recurrent cancer and 9 patients (21%) of persistent radiation injury, which yielded an overall mortality of 65% after resection and 50% and 65% after bypass and colostomy procedures, respectively. Continuing radiation damage led to 15 late reoperations. Ten of these were performed after colostomy, four after resection, and one after bypass. We conclude that colostomy cannot be regarded as a preferred operative method, because it does not prevent the progression of radiation injury and because it is, for this reason, associated with a higher late-complication rate. A more radical surgery is recommended but with the limitation that the operative method must be adapted to the operative finding.

Natural history and surgical management of radiation enteritis

Radiation enteritis is an increasing problem. The effect of ionizing radiation is due to a direct effect on proliferating cells and due to a progressive obliterative vasculitis. Predisposing factors include the dose of radiation, combination with chemotherapy, previous operations and vascular disease. Management is related to the stage of disease at presentation, and tailored to the clinical problem. Surgical management must take into account the poor healing associated with irradiated intestine.

Medical management of radiation enteritis--an algorithmic guide

An algorithmic guide to the differential diagnosis and management of late radiation enteritis is proposed. The proposition is based on physiological principles and clinical experience rather than on published reports. Too few patients with late radiation enteritis are seen in most oncology centres for a large prospective trial of the algorithm to be set up, but we hope it will stimulate further investigation.

Radical surgical approach to radiation injury of the small bowel

During a period of 12 years, 52 patients without tumor recurrence were treated for chronic radiation injury to the small bowel. Eighteen patients also had concomitant large bowel injuries. Forty-seven patients were treated surgically, 42 of whom presented with obstruction, necrosis, or perforation of the bowel and had emergency operations. Thirty-eight patients underwent wide resection of the injured bowel, and six had bypass procedures. Anastomotic leakage occurred in 6 percent of the patients. The operative morbidity rate was 34 percent, and the mortality rate, 9 percent. Based on this experience, when surgery for small intestinal radiation injury is mandatory, the procedure should be a generous small bowel resection whenever possible, and probably should be performed only by experienced surgeons.

[Unwanted sequelae of irradiation in the intestinal tract--pathogenesis, diagnosis, therapy]

The therapy of irradiation sequelae in the intestinal tract is still problematic. Within the period from 1967-1984 285 patients have been treated for late radiation injuries of the intestine. Our experiences are demonstrated and discussed with reference to the literature. Specific topics are: pathogenesis, clinical problems and aspects of conservative and operative treatment.

Safety of low anterior resection in the presence of chronic radiation changes in dogs

Thirty mongrel dogs underwent 4000- or 5000-rad single treatment orthovoltage irradiation to the pelvis according to the nominal standard dose equation. Following a resting period of six months, 21 dogs were randomized to low anterior resection with either stapled or handsewn anastomoses. Anastomotic leaks were evaluated on clinical and radiographic grounds. The radiographic leak rate was 81 percent for sutured and 0 percent for stapled anastomoses. The clinical leak rate was 18 percent for sutured and 0 percent for stapled anastomoses. The difference between the 4000- and 5000-rad groups was not significant. The data suggest that late effects of irradiation do not preclude the safe construction of low anterior anastomoses, and that the circular stapling device is superior to hand-sewn techniques.

The natural history of clinically established radiation enteritis

70 patients presenting to a surgical unit with radiation enteritis were followed up. 11 of the 61 who underwent operations died of operation-related causes. The 51 patients who survived for more than 3 months were followed up for up to 12 years (median 12 months). 24 had no further symptoms related to their radiation enteritis. The other 27 patients had persistence of symptoms, post-operative complications, new radiation-related problems, or a combination of these. The twenty new radiation-related problems were stricture (8 patients), malabsorption (5), fistula (1), and miscellaneous (6). These developed in 12 of 36 patients presenting initially with stricture, compared with 8 of 9 patients presenting with a perforation or fistula (p = 0.007 Fisher's exact test) and none whose first symptom was bleeding (p = 0.001 vs perforation and fistula combined). 10 of the 27 patients with further problems required operations and 5 of them died. Radiation enteritis is thus a progressive disease, with further complications becoming apparent in about half of those surviving the initial lesion. Perforation or fistula formation indicates a poorer prognosis than does stricture or haemorrhage.

Surgical aspects of radiation enteritis of the small bowel

Injury to the small bowel is one of the tragic complications of radiotherapy. We performed a retrospective analysis of patients operated upon for stenosis, perforation, fistulization, and chronic blood loss of the small bowel after radiotherapy for multiple malignant diseases. In the period 1970 to 1982 in the Department of General Surgery of the St. Radboud University Hospital, Nijmegen, and the Department of Surgical Oncology of the State University, Groningen, 27 patients were treated surgically. Twenty patients presented with obstruction. In 17 patients a side-to-side ileotransversostomy was performed; in three the injured bowel was resected. Of the five patients with fistulization, three underwent a bypass procedure; in two cases the affected bowel was resected. In one patient with perforation, a resection was performed, as in a patient with chronic blood loss. Two of the 20 patients (10 per cent) in whom the diseased bowel was bypassed died postoperatively. Of the seven patients whose affected bowel was resected four (57 per cent) died of intra-abdominal sepsis. Management of the patient with chronic radiation enteritis is discussed. We conclude, on the basis of our experience, that in patients with obstruction and fistulization, a bypass procedure of the affected bowel is a safe method of treatment. In case of resection, the anastomosis should be performed during a second operation.

The avoidance of small intestine injury in gynecologic cancer

The evolution of systematized operative staging and radical surgical procedures in the management of gynecologic cancer has increased the complexities of integrating radiation therapy. High dose irradiation to large treatment volumes has been associated with an increased incidence of small intestine injury. This complication is morbid and often fatal. Although predisposing factors have been extensively studied, there has been a paucity of reports evaluating preventative measures. Between 1975 and 1980, 140 patients with gynecologic cancer were treated at the Valley Presbyterian Hospital in the Division of Radiation Therapy. Twenty-six patients with cervix cancer received definitive irradiation and seven received adjunct irradiation. Seventy-two with corpus cancer received adjunct irradiation, seven received definitive irradiation and three palliative irradiation. Eleven patients with ovarian cancer received adjunct irradiation and 15 palliative irradiation. Eight-five patients were at potential risk for small intestine injury and had treatment planning small intestine X rays. Fixation was observed in 7/39 (18%) without prior pelvic surgery and 30/46 (65%) with prior pelvic surgery. Information from the small intestine X rays were used in 41 patients to make 60 treatment modifications. Twenty-five of 140 (17%) had a reduction of total dose, 26/140 (18%) had exclusion of the small intestine by shrinking fields, or patient positioning and 13/140 (9%) had displacement of the small intestine by distention of the bladder. No patient developed small intestine injury. The disease free survival for cervix cancer was 27/33 (82%), corpus cancer 68/79 (86%) and ovarian cancer 5/11 (45%). Pelvic failure was observed in 19/123 patients who received definitive or adjunct irradiation. One patient with corpus cancer and three patients with ovarian cancer might have benefited from the use of a larger treatment volume or a higher total dose.

The surgical management of the radiation-injured intestine

The grim prognosis for patients with severe radiation injury of the intestine need not be considered unalterable. Aggressive, wide-resectional techniques, new nutritional methods, and earlier diagnosis should provide significantly improved results. Reshaping of traditional conservative attitudes, which have been associated with mortality ranging from 20 to 50 per cent, is strongly encouraged. A selectively bolder approach to the intestine injured by radiation is endorsed as a means of reducing the mortality and morbidity and of providing a greater opportunity for preserving or reconstituting acceptable gastrointestinal function.

Chronic radiation injury to the intestine: a clinico-pathological study

This paper draws attention to the continuing problem of chronic radiation injury to bowel. Fifty-seven symptomatic patients with this disorder were studied, 31 with predominantly small bowel injury and 26 with colonic disease. The mean latent interval following irradiation was 4.7 years. Small bowel disease presented initially as intestinal obstruction (19 cases) or malabsorption (11 cases) and the radiation related mortality in small bowel disease was 32%, while that for colonic disease was 4%. There was a high incidence of prior pelvic surgery and of adjunctive chemotherapy in patients developing small bowel disease. Analysis of the radiotherapy techniques used highlighted that an unsatisfactory distribution of radiation dosage occurred when parallel opposed fields were used particularly where one field only was treated daily. Difficulty in matching external beams with intracavity sources may also have contributed to radiation injury.

[The abdominoendorectal resection with peranal anastomosis in the treatment of radiation injuries of the rectum (author's transl)]

During the period 1974-1980 39 patients underwent operations at the Prosper Hospital in Recklinghausen for radiation injuries to the rectum or rectosigmoid. They comprised 22 patients with rectovaginal fistulas, 6 with ulcers, 3 suffering from severe hemorrhagic proctitis, 5 with rectal strictures, 1 with necrosis, and 2 with radiation ulcers and carcinoma. A sphincter-saving operative method of treating postirradiation damage of the rectum is presented. The technique involves the peranal anastomosis of healthy colon to the midanal canal using a sleeve anastomosis. Technical and functional results of resectional surgery for the rectal complications of radiation therapy are reported. Subjectively, total continence was present in 78%, only 1 patient was incontinent because of flatus and watery stools.

Radiation injury of the rectum: evaluation of surgical treatment

One hundred four patients, 80 women and 24 men, with radiation injury of the rectum following treatment for gynecologic and urologic malignancy were studied. In 50 patients, the rectal injury was treated surgically; 54 patients were treated conservatively. The age and sex distributions were the same in each group. In 63 patients, symptoms developed one month to one year after radiotherapy. The longest latent interval was 17 years. Of the 50 surgical patients, 23 had associated small bowel injury. The indications for surgery for the rectal injury were 1) proctitis unresponsive to conservative measures in 14 patients, 2) rectal stricture or fistula or both in 32, and 3) rectosigmoid perforation in four. Forty-one patients had external diversions. Eleven had intestinal continuity restored; six of the 11 had required the stoma for proctitis unresponsive to medical measures. Nineteen patients did not undergo colostomy closure, although symptoms wer greatly improved. Diversion alone was insufficient treatment in the remaining 11 patients. Twenty-six patients died. The 12 deaths in the surgical group comprised four due to residual malignancy, four from postoperative complications, and four from unrelated causes. Of the 14 deaths in the nonsurgical group, 11 died of the primary malignancy and three of unrelated causes. Diversion is considered the safest form of treatment for rectovaginal fistulae, rectal strictures, and proctitis unresponsive to medical measures. Intestinal resection resulted in sharp rise in the morbidity and mortality rates.

The surgical treatment of radiation injuries after radiotherapy for uterine carcinoma

The outcome of serious radiation injuries to the pelvic viscera in 400 patients treated by radiotherapy for carcinoma of the uterus between January 1974 and December 1978 has been reviewed. Twenty-eight instances of serious radiation damage have been found, 13 of predominantly small bowel damage, 11 of predominantly large bowel damage and 4 of bladder damage. Many patients had involvement at multiple sites. Fourteen patients have died, and 9 survivors have artificial abdominal stomas. Leaking anastomoses and progressive sepsis were major problems in the postoperative period and could be related either to inadequate resection of irradiated bowel or to damage to other organs at operation. The possibilities of earlier diagnosis and better surgical procedures are discussed.