Long-term outcome of severe radiation enteritis treated by total parenteral nutrition

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Radiation enteritis: Diagnostic and therapeutic issues

Abdominal pelvic radiation therapy can induce acute or chronic lesions in the small bowel wall, called radiation enteritis. Treatment of acute radiation enteritis is essentially symptomatic; symptoms regress when radiation is discontinued. Conversely, late toxicity can occur up to 30 years after discontinuation of radiation therapy, posing diagnostic problems. Approximately one out of five patients treated by radiation therapy will present clinical signs of radiation enteritis, including obstruction, malabsorption, malnutrition and/or other complications. Management should be multidisciplinary, centered mainly on correction of malnutrition. Surgery is indicated in case of complications (i.e., abscess, perforation, fistula) and/or resistance to medical treatment; intestinal resection should be preferred over internal bypass. The main risk in case of iterative resections is the short bowel syndrome and the need for definitive nutritional assistance.

Reducing radiation-induced gastrointestinal toxicity - the role of the PHD/HIF axis

Radiotherapy is an effective treatment strategy for cancer, but a significant proportion of patients experience radiation-induced toxicity due to damage to normal tissue in the irradiation field. The use of chemical or biological approaches aimed at reducing or preventing normal tissue toxicity induced by radiotherapy is a long-held goal. Hypoxia-inducible factors (HIFs) regulate the production of factors that may protect several cellular compartments affected by radiation-induced toxicity. Pharmacological inhibitors of prolyl hydroxylase domain-containing enzymes (PHDs), which result in stabilization of HIFs, have recently been proposed as a new class of radioprotectors. In this review, radiation-induced toxicity in the gastrointestinal (GI) tract and the main cellular compartments studied in this context will be discussed. The effects of PHD inhibition on GI radioprotection will be described in detail.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

Radiation-induced small bowel disease: latest developments and clinical guidance

Ionizing radiation is commonly used to treat a number of malignancies. Although highly effective and now more targeted, many patients suffer side effects. The number of cancer survivors has increased and so there are more patients presenting with symptoms that have arisen as a result of radiotherapy. Radiation damage to small bowel tissue can cause acute or chronic radiation enteritis producing symptoms such as pain, bloating, nausea, faecal urgency, diarrhoea and rectal bleeding which can have a significant impact on patient's quality of life. This review outlines the pathogenesis of radiation injury to the small bowel along with the prevention of radiation damage via radiotherapy techniques plus medications such as angiotensin-converting enzyme inhibitors, statins and probiotics. It also covers the treatment of both acute and chronic radiation enteritis via a variety of medical (including hyperbaric oxygen), dietetic, endoscopic and surgical therapies.

Long-term outcome after extensive intestinal resection for chronic radiation enteritis

INTRODUCTION

Management of chronic radiation enteritis is often controversial, particularly due to the risk of short bowel syndrome.

METHODS

One hundred and seven chronic radiation enteritis patients with short bowel syndrome were studied retrospectively between 1980 and 2009. Survival and home parenteral nutrition dependence rates were evaluated with univariate and multivariate analysis.

RESULTS

The survival probabilities were 93%, 67% and 44.5% at 1, 5 and 10 years, respectively. On multivariate analysis, survival was significantly decreased with residual neoplastic disease (HR=0.21 [0.11-0.38], p<0.001), an American Society of Anesthesiologists score >3 (HR=0.38 [0.20-0.73], p=0.004) and an age of chronic radiation enteritis diagnosis >60 years (HR=0.45 [0.22-0.89], p=0.02). The actuarial home parenteral nutrition dependence probabilities were 66%, 55% and 43% at 1, 2 and 3 years, respectively. On multivariate analysis, this dependence was significantly decreased when there was a residual small bowel length >100 cm (HR=0.35 [0.18-0.68], p=0.002), adaptive hyperphagia (HR=0.39 [0.17-0.87], p=0.02) and the absence of a definitive stoma (HR=0.48 [0.27-0.84], p=0.01).

CONCLUSION

The survival of patients with diffuse chronic radiation enteritis after extensive intestinal resection was good and was mainly influenced by underlying comorbidities. Almost two-thirds of patients were able to be weaned off home parenteral nutrition.

Outcome on home parenteral nutrition for benign intestinal failure: a review of the literature and benchmarking with the European prospective survey of ESPEN

BACKGROUND & AIMS

Indications and timing for referral for intestinal transplantation (ITx) were investigated through a review of the literature on home parenteral nutrition (HPN) for benign intestinal failure and a benchmarking to the results of a prospective European survey which evaluated the appropriateness of the current indications for ITx.

METHODS

Manuscripts reporting outcomes of adults and children on HPN were retrieved through a PubMed search. Data from the European survey were compared with those on HPN reported in the literature, and with those on ITx reported by the USA registry and by the Pittsburgh center.

RESULTS

HPN is a safe treatment with a high probability of survival. The risk of death during HPN is increased by the absence of a specialist team, and appears greater during the early period of treatment. Survival probability is decreased in patients with: age >40 or <2 years, very short bowel remnant, presence of a stoma, chronic intestinal pseudo-obstruction of myopathic origin, systemic sclerosis, radiation enteritis, intra-abdominal desmoids, necrotizing enterocolitis, congenital mucosal diseases. Liver failure is the HPN-related complication with the greatest risk of death. Death related to venous catheter complications is rare. The benchmarking supported the results of the European survey.

ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context

This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.

Non-surgical oncology - Guidelines on Parenteral Nutrition, Chapter 19

Reduced nutritional state is associated with unfavourable outcomes and a lower quality of life in patients with malignancies. Patients with active tumour disease frequently have insufficient food intake. The resting energy expenditure in cancer patients can be increased, decreased, or remain unchanged compared to predicted values. Tumours may result in varying degrees of systemic pro-inflammatory processes with secondary effects on all significant metabolic pathways. Therapeutic objectives are to stabilise nutritional state with oral/enteral nutrition and parenteral nutrition (PN) and thus to prevent or reduce progressive weight loss. The maintenance or improvement of quality of life, and the increase in the effectiveness and a reduction in the side-effects of antitumor therapy are further objectives. Indications for PN in tumour patients are essentially identical to those in patients with benign illnesses, with preference given to oral or enteral nutrition when feasible. A combined nutritional concept is preferred if oral or enteral nutrition are possible but not sufficient. There are generally no accepted standards for ideal energy and nutrient intakes in oncological patients, particularly when exclusive artificial nutrition is administered. The use of PN as a general accompaniment to radiotherapy or chemotherapy is not indicated, but PN is indicated in chronic severe radiogenic enteritis or after allogenic transplantation with pronounced mucositis or GvH-related gastrointestinal damage for prolonged periods, with particular attention to increased risk of bleeding and infection. No PN is necessary in the terminal phase.

Recent advances in the management of radiation colitis

Radiation colitis, an insidious, progressive disease of increasing frequency, develops 6 mo to 5 years after regional radiotherapy for malignancy, owing to the deleterious effects of the latter on the colon and the small intestine. When dealing with radiation colitis and its complications, the most conservative modality should be employed because the areas of intestinal injury do not tend to heal. Acute radiation colitis is mostly self-limited, and usually, only supportive management is required. Chronic radiation colitis, a poorly predictable progressive disease, is considered as a precancerous lesion; radiation-associated malignancy has a tendency to be diagnosed at an advanced stage and to bear a dismal prognosis. Therefore, management of chronic radiation colitis remains a major challenge owing to the progressive evolution of the disease, including development of fibrosis, endarteritis, edema, fragility, perforation, partial obstruction, and cancer. Patients are commonly managed conservatively. Surgical intervention is difficult to perform because of the extension of fibrosis and alterations in the gut and mesentery, and should be reserved for intestinal obstruction, perforation, fistulas, and severe bleeding. Owing to the difficulty in managing the complications of acute and chronic radiation colitis, particular attention should be focused onto the prevention strategies. Uncovering the fibrosis mechanisms and the molecular events underlying radiation bowel disease could lead to the introduction of new therapeutic and/or preventive approaches. A variety of novel, mostly experimental, agents have been used mainly as a prophylaxis, and improvements have been made in radiotherapy delivery, including techniques to reduce the amount of exposed intestine in the radiation field, as a critical strategy for prevention.

Radiation damage to the gastrointestinal tract: mechanisms, diagnosis, and management

PURPOSE OF REVIEW

To summarize current knowledge about gastrointestinal radiation toxicity, with emphasis on mechanisms and clinical diagnosis and management.

RECENT FINDINGS

While there has been only modest change in cancer incidence and cancer mortality rates during the past 30 years, the number of cancer survivors has more than doubled. Moreover, the recognition of uncomplicated cancer cure as the ultimate goal in oncology has intensified efforts to prevent, diagnose, and manage side effects of radiation therapy. These efforts have been facilitated by recent insight into the underlying pathophysiology.

SUMMARY

The risk of injury to the intestine is dose limiting during abdominal and pelvic radiation therapy. Delayed bowel toxicity is difficult to manage and adversely impacts the quality of life of cancer survivors. More than 200,000 patients per year receive abdominal or pelvic radiation therapy, and the estimated number of cancer survivors with postradiation intestinal dysfunction is 1.5-2 million. Worthwhile progress towards reducing toxicity of radiation therapy has been made by dose-sculpting treatment techniques. Approaches derived from an improved understanding of the pathophysiology of bowel injury, however, will result in further advances. This article discusses the mechanisms of radiation-induced bowel toxicity and reviews current principles in diagnosis and management.

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.

Role of nutritional intervention in patients treated with radiotherapy for pelvic malignancy

Up to 12000 patients with gynaecological, urological and rectal cancer undergo radical pelvic radiotherapy annually in the UK. More than 70% develop acute inflammatory changes causing gastrointestinal symptoms during treatment because healthy bowel tissue is encompassed in the radiation field. In total, 50% go on to develop chronic bowel symptoms, which affect quality of life due to permanent changes in the small and large intestine. Nutritional intervention may influence acute and chronic bowel symptoms but the validity of the advice given to patients is not clear. To assess the incidence and significance of malnutrition and to examine the efficacy of therapeutic nutritional interventions used to manage gastrointestinal side effects in patients undergoing pelvic radiotherapy and those with chronic bowel side effects after treatment, a critical review of relevant original studies on human subjects was carried out using a specific set of mesh terms in MEDLINE and EMBASE databases and the Cochrane Library in September 2003. Full texts of all relevant articles were collected and reference lists were checked. Sources of grey literature including conference abstracts and web-based information were also reviewed. A total of 36 papers published in peer-reviewed journals between 1966 and 2003 were identified. In all, 14 randomised controlled trials, 12 prospective cohorts, four retrospective, two qualitative, one validation, one pilot study and two case reports were obtained. These included 2646 patients. Eight articles including three conference abstracts and web-based information were found. None of the studies was definitive because of weakness in methodology. No studies could be combined because the interventions and the end points were different. There is no evidence base for the use of nutritional interventions to prevent or manage bowel symptoms attributable to radiotherapy. Low-fat diets, probiotic supplementation and elemental diet merit further investigation.

Outcome of patients with radiation enteritis treated with home parenteral nutrition

OBJECTIVES

Intestinal failure requiring either surgery or home parenteral nutrition (HPN) develops in approximately 5% of patients treated with radiation. The aim of the study was to determine survival, duration of HPN, and complications associated with HPN in patients with intestinal failure after radiation therapy.

METHODS

Fifty-four patients with radiation enteritis who received HPN were studied (39 women and 15 men with a mean age of 57.9 yr). Retrospective data were collected from the patients' medical records dated between 1975 and 1999. The probability of survival was calculated by the Kaplan-Meier method.

RESULTS

HPN was initiated a median of 20 months (range = 2-432) from the start of radiation therapy. The mean number of intestinal operations for radiation-related complications was 2.2/patient (range = 0-6). The causes of intestinal failure resulting from radiation therapy were intestinal obstruction (27 patients), short bowel (17), malabsorption (five), fistula (three), and dysmotility (two). The mean duration of HPN was 20.4 months (range = 2-108). At last follow-up, 37 patients (68%) were dead, most as a result of recurrent cancer. One patient died of catheter sepsis, and no other deaths were directly related to HPN. The overall estimated 5-yr probability of survival on HPN calculated by Kaplan-Meier analysis was 64%.

CONCLUSIONS

HPN is a reasonable treatment option in patients with intestinal failure as a result of radiation enteritis. Survival and complications associated with HPN in patients with radiation enteritis seem to be similar to those in other HPN-treated groups.

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.

The incidence and clinical consequences of treatment-related bowel injury

OBJECTIVE

To assess the frequency and clinical features of treatment-induced bowel injury in rectal carcinoma patients receiving perioperative external beam radiotherapy (EBRT). The frequency of and factors associated with treatment-induced intestinal injury have previously not been well quantified for rectal cancer patients. Postoperative adjuvant chemoirradiation is recommended for Stage II and III rectal cancers, making such data of significant interest.

METHODS AND MATERIALS

The records of 386 consecutive patients undergoing radiotherapy with or without chemotherapy (CT) for rectal carcinoma between 1981-90 were reviewed. Eight-two patients were excluded for receiving nontherapeutic EBRT or modalities other than EBRT.

RESULTS

Symptomatic acute treatment-related enteritis (within 30 days of EBRT +/- CT) was diagnosed in 13 patients, 3 of whom developed chronic bowel injury. Chronic treatment-related enteritis was identified in 18 patients and reoperation was required in 17 (5% of the 304 patients with complete follow-up). Chronic proctitis was documented in 38 patients, including 3 patients with small bowel injury. The probability of developing treatment-induced bowel injury at 5 years following treatment was 19%. Variables associated with an increased risk of bowel injury using multivariate analysis were transanal excision (p = 0.002), escalating radiation dose (p = 0.005), and increasing age (p = 0.01). Twenty of the affected patients required operative treatment, and 2 deaths resulted from treatment-induced enteritis.

CONCLUSION

Patients with rectal carcinoma treated with EBRT +/- CT have the risk of developing treatment-induced bowel injury. The pelvic radiation dose should be limited to < or = 5040 cGy unless small bowel can be displaced. Reperitonealization of the pelvis, or other surgical methods of excluding the small intestine should be used whenever possible.