1
|
Yan Naing CL, Gittens J, Fok M, Fowler H, Vimalachandran D, Clifford RE. Does endoscopic management have a role in chronic radiation proctopathy: A systematic review. Colorectal Dis 2025; 27:e70086. [PMID: 40200602 DOI: 10.1111/codi.70086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Revised: 01/28/2025] [Accepted: 03/05/2025] [Indexed: 04/10/2025]
Abstract
AIM Chronic radiation proctopathy (CRP) is a significant side-effect of radiotherapy, and poses a challenge in clinical management, necessitating effective and standardized therapeutic approaches. The aim of this review is to investigate the role of endoscopic interventions for CRP, focusing on argon plasma coagulation (APC) and formalin application. METHOD A literature search was undertaken for studies that investigated the clinical responses to endoscopic management in patients with CRP. A systematic review was performed in accordance with PRISMA guidelines, and a meta-analysis of proportions was conducted with a random-effects model. ROBINS-I and the Cochrane Collaboration's tool were used to assess risk of bias in cohort studies and randomized control trials, respectively. RESULTS A total of 82 studies met the inclusion criteria, including 11 randomized control trials, 20 systematic reviews, one cohort study and 50 case series. A robust 89% (95% CI 84%-92%, p < 0.01 and 95% CI 84%-93%, p = 0.03) pooled response rate was demonstrated for both APC and formalin therapies, respectively. Adverse effects were generally minimal. CONCLUSION Endoscopic therapies, particularly APC and formalin, exhibit commendable clinical response rates in the management of CRP. However, the lack of standardized treatment protocols highlights the need for larger prospective studies. Clear guidelines, informed by defined outcomes and quality-of-life assessments, are imperative for enhancing patient outcomes and minimizing the morbidity associated with CRP.
Collapse
Affiliation(s)
- Chyu Lai Yan Naing
- Aintree University Hospital, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Jayden Gittens
- Institute of Systems, Integrative and Molecular Biology, The University of Liverpool, Liverpool, UK
| | - Matthew Fok
- Royal Liverpool University Hospital, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Hayley Fowler
- Institute of Systems, Integrative and Molecular Biology, The University of Liverpool, Liverpool, UK
| | - Dale Vimalachandran
- Institute of Systems, Integrative and Molecular Biology, The University of Liverpool, Liverpool, UK
- The Countess of Chester Hospital, Chester, UK
| | | |
Collapse
|
2
|
De Sena G, Mongardini FM, Porpora D, Mauro M, Bentivoglio D, Centore D, Brusciano L, Gambardella C, Lauro A, Docimo L, Napolitano V. DDS-SIRC Cooperative Conferences Feel the Burn: RFA for Chronic Radiation Proctitis. Dig Dis Sci 2024; 69:3147-3155. [PMID: 39009917 DOI: 10.1007/s10620-024-08553-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/25/2024] [Indexed: 07/17/2024]
Abstract
Chronic radiation proctitis, although relatively rare, can be the source of severe comorbidity in patients who had undergone prior radiotherapy for pelvic malignancy. Although current treatments for radiation proctitis include argon plasma coagulation, heater probe, bipolar neodymium/yttrium aluminum garnet (Nd: YAG) lasers, these interventions are often burdened by the frequent occurrence of rectal ulcerations and stenosis. Since radiofrequency ablation (RFA) is frequently used to ablate esophageal malignancy and pre-malignancy, we report the efficacy of RFA using through the scope system in two patients with rectal bleeding due to radiation proctitis. In both cases, the procedure was well-tolerated with hemostasis achieved after 1 or 2 sessions of RFA. Mucosal re-epithelialization was observed in areas of previous bleeding with no stenosis or ulceration observed at follow-up.
Collapse
Affiliation(s)
- Gabriele De Sena
- Department of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Ostrava Syllabova 19, Ostrava Vitkovice, 70030, Czech Republic
- Unit of Endoscopic Surgery, Department of Surgery, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Federico Maria Mongardini
- Division of General, Oncological, Mini‑Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", 80131, Naples, Italy.
| | - Danilo Porpora
- Unit of Endoscopic Surgery, Department of Surgery, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Maria Mauro
- Unit of Endoscopic Surgery, Department of Surgery, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Davide Bentivoglio
- Division of General, Oncological, Mini‑Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Davide Centore
- Division of General, Oncological, Mini‑Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Luigi Brusciano
- Division of General, Oncological, Mini‑Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Claudio Gambardella
- Division of General, Oncological, Mini‑Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Augusto Lauro
- Department of Surgery, Sapienza University, 00185, Rome, Italy
| | - Ludovico Docimo
- Division of General, Oncological, Mini‑Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Vincenzo Napolitano
- Unit of Endoscopic Surgery, Department of Surgery, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| |
Collapse
|
3
|
Bhatia M, Suliman H, Ahmed R, Kostadinov D, Singhal T. Radiation Proctitis: A Review of Pathophysiology and Treatment Strategies. Cureus 2024; 16:e70581. [PMID: 39483948 PMCID: PMC11525059 DOI: 10.7759/cureus.70581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2024] [Indexed: 11/03/2024] Open
Abstract
Radiotherapy (RT) has become an integral part of cancer treatment worldwide; it aims to arrest the uncontrolled growth of tumor cells by using high-energy rays. Radiation proctitis is a known clinical manifestation after the RT regime for pelvic malignancies. Radiation proctitis can have a variable presentation, and there are a lot of patient-related factors that can affect the eventual outcome. In most instances, it is self-limiting; however, it can become chronic in some cases and can affect the quality of life. Many treatment options are recommended, but there has been no consensus on the treatment protocols for managing this known clinical condition. We have tried to briefly describe its pathogenesis, important factors affecting the outcome, and available treatment strategies.
Collapse
Affiliation(s)
- Mohit Bhatia
- Colorectal and General Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Hadeel Suliman
- Colorectal and General Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Rizwan Ahmed
- General Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Danko Kostadinov
- Colorectal and General Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Tarun Singhal
- Colorectal and General Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| |
Collapse
|
4
|
Omer NNCDS, Araujo IDD, Cruz GMGD, Rodrigues FG. Therapeutics in Radiation-induced Proctopathy: A Systematic Review. JOURNAL OF COLOPROCTOLOGY 2022. [DOI: 10.1055/s-0041-1742258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractMalignant neoplasms are increasingly prevalent in the daily clinical practice. Up to 61% of patients with pelvic malignancies undergo pelvic radiotherapy in different doses, which may cause intestinal damage, and the rectum is the segment most frequently affected due to its fixed position in the pelvis. Currently, there are several strategies to minimize the effects of radiation on the tissues surrounding the neoplastic site; despite those strategies, radiotherapy can still result in serious damage to organs and structures, and these injuries accompany patients throughout their lives. One of the most common damages resulting from pelvic radiotherapy is acute proctitis.The diagnosis is confirmed by visualizing the rectal mucosa through rigid or flexible rectosigmoidoscopy and colonoscopy. The objective of the present study was to review the forms of radiation-induced proctopathytherapy, and to evaluate the results of each method to propose a standardization for the treatment of this pathology. Despite the prevalence of radiation-induced proctopathy, there is no definitive standardized treatment strategy so far. The first approach can be tried with local agents, such as mesalazine and formalin. For refractory cases, control can usually be achieved with argon plasma coagulation, hyperbaric oxygen, and radiofrequency ablation therapies. Regarding the study of radiation-induced proctopathy, there is a lack of robust studies with large samples and standardized therapies to be compared. There is a lack of double-blinded, randomized controlled studies to determine a definitive standard treatment algorithm.
Collapse
Affiliation(s)
| | - Ivana Duval de Araujo
- Doctor and Associate Professor IV, Department of Surgery, Universidade Federal de Minas Gerais, Brazil
| | | | | |
Collapse
|
5
|
O'Reilly M, Mellotte G, Ryan B, O'Connor A. Gastrointestinal side effects of cancer treatments. Ther Adv Chronic Dis 2020; 11:2040622320970354. [PMID: 33294145 PMCID: PMC7705778 DOI: 10.1177/2040622320970354] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/12/2020] [Indexed: 12/13/2022] Open
Abstract
Cancer survival rates have significantly improved over the last number of
years due to advancements in cancer therapies. Unfortunately this has
come at a cost. Therapeutic side effects are feared complications of
therapy that may result in decreased quality of life and early
cessation of the therapy, which can have knock-on effects on outcomes.
This article outlines the main gastrointestinal side effects seen with
radiation therapy, chemotherapy and immunotherapy, and discusses
appropriate investigation and management.
Collapse
Affiliation(s)
- Mary O'Reilly
- Department of Gastroenterology, Tallaght University Hospital/Trinity College Dublin, Ireland
| | - Gregory Mellotte
- Department of Gastroenterology, Tallaght University Hospital/Trinity College Dublin, Ireland
| | - Barbara Ryan
- Department of Gastroenterology, Tallaght University Hospital/Trinity College Dublin, Ireland
| | - Anthony O'Connor
- Department of Gastroenterology, Tallaght University Hospital/Trinity College Dublin, Belgard Road, Tallaght, Dublin, D24NR0A, Ireland
| |
Collapse
|
6
|
Savoie MB, Laffan A, Brickman C, Daniels B, Levin A, Rowen T, Smith J, Van Blarigan EL, Hope TA, Berry-Lawhorn JM, Anwar M, Van Loon K. A multi-disciplinary model of survivorship care following definitive chemoradiation for anal cancer. BMC Cancer 2019; 19:906. [PMID: 31510960 PMCID: PMC6737598 DOI: 10.1186/s12885-019-6053-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022] Open
Abstract
Following definitive chemoradiation for anal squamous cell carcinoma (ASCC), patients face a variety of chronic issues including: bowel dysfunction, accelerated bone loss, sexual dysfunction, and psychosocial distress. The increasing incidence of this disease, high cure rates, and significant long-term sequelae warrant increased focus on optimal survivorship care following definitive chemoradiation. In order to establish our survivorship care model for ASCC patients, a multi-disciplinary team of experts performed a comprehensive literature review and summarized best practices for the multi-disciplinary management of this unique patient population. We reviewed principle domains of our survivorship approach: (1) management of chronic toxicities; (2) sexual health; (3) HIV management in affected patients; (4) psychosocial wellbeing; and (5) surveillance for disease recurrence and survivorship care delivery. We provide recommendations for the optimization of survivorship care for ASCC patients can through a multi-disciplinary approach that supports physical and psychological wellness.
Collapse
Affiliation(s)
- Marissa B Savoie
- School of Medicine, University of California, San Francisco, USA
| | - Angela Laffan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
| | - Cristina Brickman
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, USA
| | - Bevin Daniels
- Department of Physical Therapy, University of California, San Francisco, USA
| | - Anna Levin
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Psycho-Oncology, University of California, San Francisco, USA
| | - Tami Rowen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
| | - James Smith
- Department of Urology, University of California, San Francisco, USA
| | - Erin L Van Blarigan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Urology, University of California, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Thomas A Hope
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA
| | - J Michael Berry-Lawhorn
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA
| | - Mekhail Anwar
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiation Oncology, University of California, San Francisco, USA
| | - Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA.
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA.
| |
Collapse
|
7
|
Lee JK, Agrawal D, Thosani N, Al-Haddad M, Buxbaum JL, Calderwood AH, Fishman DS, Fujii-Lau LL, Jamil LH, Jue TL, Khashab MA, Law JK, Naveed M, Qumseya BJ, Sawhney MS, Storm AC, Yang J, Wani SB. ASGE guideline on the role of endoscopy for bleeding from chronic radiation proctopathy. Gastrointest Endosc 2019; 90:171-182.e1. [PMID: 31235260 DOI: 10.1016/j.gie.2019.04.234] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/22/2019] [Indexed: 12/11/2022]
Abstract
Chronic radiation proctopathy is a common sequela of radiation therapy for malignancies in the pelvic region. A variety of medical and endoscopic therapies have been used for the management of bleeding from chronic radiation proctopathy. In this guideline, we reviewed the results of a systematic search of the literature from 1946 to 2017 to formulate clinical questions and recommendations on the role of endoscopy for bleeding from chronic radiation proctopathy. The following endoscopic modalities are discussed in our document: argon plasma coagulation, bipolar electrocoagulation, heater probe, radiofrequency ablation, and cryoablation. Most studies were small observational studies, and the evidence for effectiveness of endoscopic therapy for chronic radiation proctopathy was limited because of a lack of controlled trials and comparative studies. Despite this limitation, our systematic review found that argon plasma coagulation, bipolar electrocoagulation, heater probe, and radiofrequency ablation were effective in the treatment of rectal bleeding from chronic radiation proctopathy.
Collapse
Affiliation(s)
- Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Audrey H Calderwood
- Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Douglas S Fishman
- Department of Gastroenterology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | | | - Laith H Jamil
- Pancreatic and Biliary Diseases Program, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| |
Collapse
|
8
|
Sultania S, Sarkar R, Das K, Dhali GK. Argon plasma coagulation is an effective treatment for chronic radiation proctitis in gynaecological malignancy: an observational study. Colorectal Dis 2019; 21:465-471. [PMID: 30585689 DOI: 10.1111/codi.14541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 11/12/2018] [Indexed: 12/31/2022]
Abstract
AIM Chronic radiation proctitis (CRP) develops in 5-15% of patients after pelvic radiation therapy, with rectal bleeding being the main symptom. Reports suggest that argon plasma coagulation (APC) can be an effective therapy for CRP following radiotherapy for prostate cancer, but there is less information about how useful it is after radiotherapy for gynaecological malignancy. The aim of this work therefore was to study the efficacy of APC for CRP after radiotherapy for gynaecological malignancy. METHOD This was a prospective study of consecutive patients with CRP following radiotherapy for gynaecological malignancy at IPGME&R, SDLD, Kolkata, India; symptoms included rectal bleeding grade (RBG) ≥ 2. APC was performed at monthly intervals to a maximum of four treatment sessions. Severity of disease at baseline was graded (endoscopically) by the total colonoscopic severity score (TCSS) and treatment response was assessed by reduction in RBG from ≥ 2 to ≤ 1 measured at > 6 months after cessation of APC. RESULTS Seventy patients [90% with cervical cancer, 10% with endometrial cancer; mean age 51.93 ± 9.15 years; median RBG 3 (range 2-4)] received APC. Seven patients died due to underlying malignancy and seven patients were lost to follow-up. Fifty-six (85.7%) patients responded to therapy after a median of 2 (range 1-4) treatment sessions. Multivariate analysis demonstrated that a lower haemoglobin at the start of treatment predicted failure of therapy (P < 0.05). CONCLUSION APC is an effective management option for CRP in female patients with gynaecological malignancy. However, the more anaemic the patient the less likely it is to be successful.
Collapse
Affiliation(s)
- S Sultania
- Department of Gastroenterology, CKS Hospitals, Jaipur, Rajasthan, India
| | - R Sarkar
- Department of Gastroenterology, School of Digestive and Liver disease, Kolkata, West Bengal, India
| | - K Das
- Department of Gastroenterology, School of Digestive and Liver disease, Kolkata, West Bengal, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver disease, Kolkata, West Bengal, India
| |
Collapse
|
9
|
Ang ZH, Buxey K, Muhlmann M. Novel use of argon plasma coagulation (APC) in the treatment of high output small bowel mucous fistula. Tech Coloproctol 2018; 22:805-807. [PMID: 30465104 DOI: 10.1007/s10151-018-1877-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/08/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Z H Ang
- Department of Colorectal Surgery, Prince of Wales Hospital, Sydney, Australia.
- Prince of Wales Clinical School, The University of New South Wales, Kensington, Australia.
- Department of General Surgery, Prince of Wales Hospital, Barker Street, Randwick, NSW, 2032, Australia.
| | - K Buxey
- Department of Colorectal Surgery, Prince of Wales Hospital, Sydney, Australia
- Prince of Wales Clinical School, The University of New South Wales, Kensington, Australia
| | - M Muhlmann
- Department of Colorectal Surgery, Prince of Wales Hospital, Sydney, Australia
- Prince of Wales Clinical School, The University of New South Wales, Kensington, Australia
| |
Collapse
|
10
|
Gupta S, Greenwald DA. Prevention of Recurrent Lower Gastrointestinal Hemorrhage. Gastrointest Endosc Clin N Am 2018; 28:409-424. [PMID: 29933784 DOI: 10.1016/j.giec.2018.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This article summarizes current knowledge regarding the incidence of and risk factors associated with recurrent lower gastrointestinal hemorrhage. The literature regarding medical, endoscopic, and surgical methods to prevent rebleeding from diverticulosis, angioectasia, and chronic hemorrhagic radiation proctopathy is reviewed. In addition, the evidence for endoscopic clipping as primary prophylaxis against postpolypectomy bleeding is explored.
Collapse
Affiliation(s)
- Shivani Gupta
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1069, New York, NY 10029-6574, USA.
| | - David A Greenwald
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1069, New York, NY 10029-6574, USA
| |
Collapse
|
11
|
Davidson BA, Moss HA, Arquiette J, Kamal AH. Top Ten Tips Palliative Care Clinicians Should Know When Caring for Patients with Endometrial Cancer. J Palliat Med 2018; 21:857-861. [PMID: 29649395 DOI: 10.1089/jpm.2018.0053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Endometrial cancer incidence has been increasing over the last two decades, likely due to the obesity epidemic. The majority of these cancers are confined to the uterus at diagnosis and can be cured with surgery. Overall, five-year disease-specific survival is about 80%, but some patients have locally advanced or metastatic disease that is not amenable to control with radiation and/or chemotherapy. Disease-related symptoms are most common in this subset of patients with endometrial cancer, although women with early-stage disease may also experience side effects related to surgical menopause or adjuvant treatment. In recent years, professional societies have been increasingly vocal about the importance of incorporating palliative care early in a patient's disease course. As these calls increase, palliative care clinicians will likely increasingly comanage patients with advanced or recurrent endometrial cancer. We brought together a team of gynecologic oncology and palliative care experts to assemble practical tips for the care of women with endometrial cancer. In this article, we use a "Top 10" format to highlight issues that may help palliative care physicians understand a patient's prognosis, address common misconceptions about endometrial cancer, and improve the quality of shared decision making and goals of care discussions.
Collapse
Affiliation(s)
- Brittany A Davidson
- 1 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University , Durham, North Carolina
| | - Haley A Moss
- 1 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University , Durham, North Carolina
| | - Jaclyn Arquiette
- 2 Department of Obstetrics and Gynecology, Duke University , Durham, North Carolina
| | - Arif H Kamal
- 3 Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke Fuqua School of Business, Duke University , Durham, North Carolina
| |
Collapse
|
12
|
Efficacy and Safety of Argon Plasma Coagulation for Hemorrhagic Chronic Radiation Proctopathy: A Systematic Review. Gastroenterol Res Pract 2018; 2018:3087603. [PMID: 29681929 PMCID: PMC5845516 DOI: 10.1155/2018/3087603] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/13/2017] [Accepted: 01/08/2018] [Indexed: 12/15/2022] Open
Abstract
Hemorrhagic chronic radiation proctopathy (CRP) is a common complication after pelvic radiotherapy in patients with prostate or gynecological cancers. This systematic review was conducted to evaluate the efficacy and safety of argon plasma coagulation (APC) in treating hemorrhagic CRP. The databases of PubMed, Embase, and Cochrane Library were searched for related studies from inception to July 2017. Finally, 33 studies were identified with a total of 821 hemorrhagic CRP patients. After APC treatment, hemoglobin levels increased from 7.7–13.4 g/L to 11–14 g/L (including 15 studies). All (n = 33) studies reported an effective rate in rectal bleeding, among which five studies had a rate of 100%. Short-term complications were reported in 31 studies, while long-term complications in 33 studies and no complication in 11 studies. As for the severe complications, perforation was reported by 2 out of 33 studies, and the incidences were 3.3% (1/30) and 3.7% (1/27), respectively. As for APC setting, argon gas flow rate (median 1.5 L/min) and electric power (median 50 W) had no significant influence on complications and hemostasis. In conclusion, current literature indicated that APC therapy was an effective and safe strategy for hemorrhagic CRP, and large-scale prospective studies are needed to warrant our study.
Collapse
|
13
|
Weiner J, Schwartz D, Martinez M, Safdieh J, Aytaman A, Schreiber D. Long-term results on the efficacy of argon plasma coagulation for patients with chronic radiation proctitis after conventionally fractionated, dose-escalated radiation therapy for prostate cancer. Pract Radiat Oncol 2016; 7:e35-e42. [PMID: 27663931 DOI: 10.1016/j.prro.2016.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/23/2016] [Accepted: 07/27/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE This study was designed to assess the efficacy and outcomes of argon plasma coagulation (APC) in the management of chronic radiation proctitis after conventionally fractionated, dose-escalated radiation therapy (≥7560 cGy). METHODS AND MATERIALS We retrospectively reviewed the charts on all patients treated with external beam radiation therapy (minimum dose, 7560 cGy) for histologically confirmed prostate cancer at our institution from 2003 to 2011. Five hundred patients met these criteria; of these, 35 patients (7.0%) developed radiation proctitis necessitating intervention with APC. Indications for APC treatment were either the need for blood transfusions resulting from proctitis-related anemia or refractory bleeding despite medical management. RESULTS The median follow-up from the completion of radiation treatment was 78 months (range, 19-129) and the median follow up from the most recent APC treatment was 56 months (range, 3-112). Fifteen men (42.9%) needed blood transfusions because of proctitis-related anemia. For 19 patients (54.3%), bleeding was controlled after 1 or 2 treatments. Eventual bleeding control was obtained in 30 patients (85.7%). The median number of sessions per patient was 2 (range, 1-13). Post-APC ulceration was noted in 8 cases (22.9%). Two patients (5.7%) developed colovesicular fistulas, with 1 patient dying from this complication. A short interval between treatments (≤35 days) was associated with an increased risk of ulcer or fistula formation. CONCLUSIONS APC is an effective treatment for patients with medically refractive radiation proctitis after dose-escalated radiation therapy, frequently controlling bleeding after only one or two sessions. However, rectal ulceration is a common complication, along with a small risk of life-threatening toxicity.
Collapse
Affiliation(s)
- Joseph Weiner
- Department of Radiation Oncology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York.
| | - David Schwartz
- Department of Radiation Oncology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Manuel Martinez
- Department of Gastroenterology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Gastroenterology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Joseph Safdieh
- Department of Radiation Oncology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Ayse Aytaman
- Department of Gastroenterology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York
| | - David Schreiber
- Department of Radiation Oncology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York
| |
Collapse
|
14
|
Nelamangala Ramakrishnaiah VP, Krishnamachari S. Chronic haemorrhagic radiation proctitis: A review. World J Gastrointest Surg 2016; 8:483-491. [PMID: 27462390 PMCID: PMC4942748 DOI: 10.4240/wjgs.v8.i7.483] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 01/06/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023] Open
Abstract
Chronic haemorrhagic radiation proctitis (CHRP) is a difficult problem faced by the patients following radiation for pelvic malignancy. There is no standard treatment for this condition, but many methods of treatment are available. The aim of this study was to review the literature to see whether there is an improvement in the available evidence in comparison with previously published systematic reviews in treating patients with CHRP. The PubMed/Medline database and Google Scholar search was selectively searched. Studies, which treated patients with rectal bleeding due to chronic radiation proctitis or CHRP, were included. Seventy studies were finally selected out of which 14 were randomized controlled clinical trials. Though these studies could not be compared, it could be seen that there was an improvement in the methodology of the studies. There was an objective assessment of symptoms, signs and an objective assessment of outcomes. But, still, there were only a few studies that looked into the quality of life following treatment of CHRP. To increase recruitment to trials, a national registry of cases with established late radiation toxicity would facilitate the further improvement of such studies. Some of the conclusions that could be reached based on the available evidence are 4% formalin should be the first line treatment for patients with CHRP. Formalin and argon plasma coagulation (APC) are equally effective, but formalin is better for severe disease. Refractory patients, not responding to formalin or APC, need to be referred for hyperbaric oxygen therapy or surgery. Radio-frequency ablation is a promising modality that needs to be studied further in randomized trials.
Collapse
|
15
|
Long-Term Endoscopic Follow-Up of Patients with Chronic Radiation Proctopathy after Brachytherapy for Prostate Cancer. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2016; 2016:1414090. [PMID: 27378828 PMCID: PMC4917689 DOI: 10.1155/2016/1414090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/16/2016] [Indexed: 02/07/2023]
Abstract
Background. Chronic radiation proctopathy (CRP) is late toxicity and associated with morbidity. Aim. To investigate the predictors of prognosis in patients with CRP after brachytherapy (BT). Methods. One hundred four patients with prostate cancer were treated with BT or BT followed by external-beam radiotherapy (BT + EBRT). We retrospectively investigated the 5-year incidence of rectal bleeding and endoscopic findings of CRP using the Vienna Rectoscopy Score (VRS). Twenty patients with VRS ≥ 1 were divided into the improved VRS group without treatment, unchanged VRS group, and treated group. The parameters associated with alteration of VRS were analyzed. Results. The incidence of rectal bleeding was 24%. The risk of rectal bleeding was higher in patients treated with BT + EBRT compared to those treated with BT (p < 0.0001). The incidence of superficial microulceration was higher in the improved VRS group than in the unchanged VRS group (p < 0.05). The incidence of multiple confluent telangiectasia or superficial ulcers > 1 cm2 was higher in the treated group than in both the improved and unchanged VRS groups (p < 0.05). Conclusions. Patients treated with BT + EBRT have a high risk of CRP. Endoscopic findings were useful for prognostic prediction of CRP.
Collapse
|
16
|
Lenz L, Rohr R, Nakao F, Libera E, Ferrari A. Chronic radiation proctopathy: A practical review of endoscopic treatment. World J Gastrointest Surg 2016; 8:151-60. [PMID: 26981189 PMCID: PMC4770169 DOI: 10.4240/wjgs.v8.i2.151] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 11/20/2015] [Accepted: 12/13/2015] [Indexed: 02/06/2023] Open
Abstract
Chronic radiation proctopathy (CRP) is a troublesome complication of pelvic radiotherapy. The most common presentation is rectal bleeding. CRP symptoms interfere with daily activities and decrease quality of life. Rectal bleeding management in patients with CRP represents a conundrum for practitioners. Medical therapy is ineffective in general and surgical approach has a high morbid-mortality. Endoscopy has a role in the diagnosis, staging and treatment of this disease. Currently available endoscopic modalities are formalin, potassium titanyl phosphate laser, neodymium:yttrium-aluminum-garnet laser, argon laser, bipolar electrocoagulation (BiCAP), heater probe, band ligation, cryotherapy, radiofrequency ablation and argon plasma coagulation (APC). Among these options, APC is the most promising.
Collapse
|
17
|
Vanneste BGL, Van De Voorde L, de Ridder RJ, Van Limbergen EJ, Lambin P, van Lin EN. Chronic radiation proctitis: tricks to prevent and treat. Int J Colorectal Dis 2015; 30:1293-303. [PMID: 26198994 PMCID: PMC4575375 DOI: 10.1007/s00384-015-2289-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to give an overview of the measures used to prevent chronic radiation proctitis (CRP) and to provide an algorithm for the treatment of CRP. METHODS Medical literature databases including PubMed and Medline were screened and critically analyzed for relevance in the scope of our purpose. RESULTS CRP is a relatively frequent late side effect (5-20%) and mainly dependent on the dose and volume of irradiated rectum. Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. Also, newer techniques like protons and new devices such as rectum spacers and balloons have been developed to spare rectal structures. Biopsies do not contribute to diagnosing CRP and should be avoided because of the risk of severe rectal wall damage, such as necrosis and fistulas. There is no consensus on the optimal treatment of CRP. A variety of possibilities is available and includes topical and oral agents, hyperbaric oxygen therapy, and endoscopic interventions. CONCLUSIONS CRP has a natural history of improving over time, even without treatment. This is important to take into account when considering these treatments: first be conservative (topical and oral agents) and be aware that invasive treatments can be very toxic.
Collapse
Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands.
| | - Lien Van De Voorde
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Emile N van Lin
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| |
Collapse
|
18
|
Abstract
Radiation therapy is a widely utilized treatment modality for pelvic malignancies, including prostate cancer, rectal cancer, and cervical cancer. Given its fixed position in the pelvis, the rectum is at a high risk for injury secondary to ionizing radiation. Despite advances made in radiation science, up to 75% of the patients will suffer from acute radiation proctitis and up to 20% may experience chronic symptoms. Symptoms can be variable and include diarrhea, bleeding, incontinence, and fistulization. A multitude of treatment options exist. This article summarizes the latest knowledge relating to radiation proctopathy focusing on the vast array of treatment options.
Collapse
Affiliation(s)
- Marc B. Grodsky
- Section of Colon and Rectal Surgery, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Shafik M. Sidani
- Department of Colorectal Surgery, Virginia Hospital Center Physician Group, Arlington, Virginia
| |
Collapse
|
19
|
Patel A, Pathak R, Deshpande V, Patel SH, Wickremesinghe PC, Vadada D. Radiofrequency ablation using BarRx for the endoscopic treatment of radiation proctopathy: a series of three cases. Clin Exp Gastroenterol 2014; 7:453-60. [PMID: 25525377 PMCID: PMC4266256 DOI: 10.2147/ceg.s66534] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Radiation proctopathy is a complication of pelvic radiotherapy, which occurs in patients treated for carcinoma of the prostate, rectum, urinary bladder, cervix, uterus, and testes. If it presents within 6 weeks to 9 months after therapy, it is called acute radiation proctitis/proctopathy (ARP), and if it occurs 9 months to a year after treatment, it is classified as chronic radiation proctitis/proctopathy (CRP). CRP occurs in 5%–20% of patients receiving pelvic radiation, depending on the radiation dose and the presence or absence of chemotherapy. In many cases, CRP resolves spontaneously, but in some, it can lead to persistent rectal bleeding. Other symptoms of CRP include diarrhea, mucoid discharge, urgency, tenesmus, rectal pain, and fecal incontinence. Despite the availability of several therapies, many patients fail to respond, and continue to suffer in their quality of life. Radiofrequency ablation (RFA) is a newer endoscopic technique that uses radiofrequency energy to ablate tissue. This is an emerging way to treat radiation proctopathy and other mucosal telangiectasia. We present three cases of radiation proctopathy treated with RFA at our institute and review the literature on treatment modalities for CRP. We were also able to find 16 other cases of CRP that used RFA, and review their literature as well as literature on other treatment modalities.
Collapse
Affiliation(s)
- Anish Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Rahul Pathak
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Vrushak Deshpande
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Sunil H Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | | | - Deepak Vadada
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| |
Collapse
|
20
|
Severe gastrointestinal complications in the era of image-guided high-dose-rate intracavitary brachytherapy for cervical cancer. Clin Ther 2014; 37:49-60. [PMID: 25444669 DOI: 10.1016/j.clinthera.2014.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/06/2014] [Accepted: 11/06/2014] [Indexed: 11/23/2022]
Abstract
PURPOSE The purposes of this analysis are to report a modern series of severe gastrointestinal toxic effects after definitive chemoradiotherapy in the treatment of locally advanced cervical cancer at our institution and to review the existing literature on factors that contribute to toxic effects and preventive strategies and management. METHODS Our institution's cervical cancer cohort was evaluated for patients with late grade 3 to 4 gastrointestinal toxic effects who were retrospectively reviewed for clinical or dosimetric parameters that could have contributed to late toxic effects. A review of the published literature was performed to identify factors associated with late toxic effects, prophylactic agents, and corrective therapy. FINDINGS Five of 85 patients were identified as having late grade 3 to 4 gastrointestinal toxic effects with a median follow-up of 13.3 months. Two of 5 patients developed late grade 3 toxic effects, and 3 of 5 developed late grade 4 toxic effects. Three of the 5 patients reviewed ultimately required permanent colostomies. Cumulative median dose (in equivalent dose in 2-Gy fractions) of clinical target volume to the hottest 90% was 107.2 Gy, rectal dose to the hottest 2 cc (D2cc) was 81.7 Gy, sigmoid D2cc was 61.7 Gy, and bladder D2cc was 79.5 Gy. No patient had evidence of disease recurrence in the pelvis. One patient developed oligometastatic disease in the suprarenal gland and was successfully salvaged with adrenalectomy. IMPLICATIONS Despite its risk of toxic effects, intracavitary brachytherapy remains a critical component of the treatment of locally advanced cervical cancer. Even with modern radiotherapy planning and delivery techniques, extra attention is warranted to continue to strive for optimal outcomes.
Collapse
|
21
|
Jung HJ, Ryu SH, Park KS, Yoon WJ, Kim JN, Kim YS, Moon JS. A case of spontaneous bacterial peritonitis following argon plasma coagulation for angiodysplasias in the colon. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 64:115-8. [PMID: 25168055 DOI: 10.4166/kjg.2014.64.2.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Spontaneous bacterial peritonitis (SBP) is the most common infection in liver cirrhosis patients, and is not a result of surgery or intra abdominal infection. Argon plasma coagulation (APC) is an endoscopic procedure used with a high-frequency electrical current for control of bleeding from gastrointestinal vascular ectasias including angiodysplasia and gastric antral vascular ectasia. This procedure is known to be safe because it uses a noncontact method. Therefore, tissue injury is minimal and up to two to three millimeters. However, we experienced a case of SBP occurring immediately after performance of APC for control of severe bleeding from angiodysplasia in the colon in a patient with liver cirrhosis and hepatocellular carcinoma.
Collapse
Affiliation(s)
- Hye Jin Jung
- Department of Internal Medicine, Inje University Seoul Paik Hospital, 9 Mareunnae-ro, Jung-gu, Seoul 100-032, Korea
| | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Radiation damage to the rectum following radiotherapy for pelvic malignancies can range from acute dose-limiting side effects to major morbidity affecting health-related quality of life. No standard guidelines exist for diagnosis and management of radiation proctitis. This article reviews the definitions, staging, and clinical features of radiation proctitis, and summarizes the modalities available for the treatment of acute and chronic radiation proctitis. Because of the paucity of well-controlled, blinded, randomized studies, it is not possible to fully assess the comparative efficacy of the different approaches to management. However, the evidence and rationale for use of the different strategies are presented.
Collapse
Affiliation(s)
- Ankit Sarin
- Division of Colon and Rectal Surgery, University of California-San Francisco, San Francisco, CA, USA
| | | |
Collapse
|
23
|
Karamanolis G, Psatha P, Triantafyllou K. Endoscopic treatments for chronic radiation proctitis. World J Gastrointest Endosc 2013; 5:308-312. [PMID: 23858374 PMCID: PMC3711061 DOI: 10.4253/wjge.v5.i7.308] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 05/29/2013] [Accepted: 06/18/2013] [Indexed: 02/05/2023] Open
Abstract
Chronic radiation proctitis is a complication that occurs in patients who receive radiation therapy for pelvic malignancies. The common presentation is with rectal bleeding, but also rectal pain, diarrhea, tenesmus and even passage of mucus can occur. The optimal treatment of bleeding due to radiation proctitis remains unclear. Among various therapeutic options, medical management is generally ineffective and surgical intervention has a high incidence of morbidity. Promising advances have been made in endoscopic therapy, including argon plasma coagulation (APC), formalin application as well as new techniques such as radiofrequency ablation and cryoablation. APC is a safe, highly effective and long-lasting therapy in patients with rectal bleeding associated with radiation proctitis. It has been shown that several sessions of APC reduce the rate of bleeding and therefore the blood transfusion requirements. Moreover, the effect of treatment is long lasting. However, best results are achieved in patients with mild to moderate radiation proctitis, leaving space for alternative treatments for patients with more severe disease. In patients with severe or refractory radiation proctitis intra rectal formalin application is an appropriate treatment option. Radiofrequency ablation and cryoablation have shown efficacy as alternative methods in a limited number of patients with refractory chronic radiation proctitis.
Collapse
|
24
|
Moawad FJ, Maydonovitch CL, Horwhat JD. Efficacy of cryospray ablation for the treatment of chronic radiation proctitis in a pilot study. Dig Endosc 2013; 25:174-9. [PMID: 23362977 DOI: 10.1111/j.1443-1661.2012.01355.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 06/06/2012] [Indexed: 12/13/2022]
Abstract
AIM Radiation proctitis, a common condition associated with radiotherapy for the treatment of pelvic cancers, is characterized by difficult to manage rectal pain and bleeding. Cryotherapy is a novel technique, previously used in the treatment of vascular ectasias in the upper gastrointestinal tract. The aim of the present study was to determine the efficacy of cryospray application in the treatment of radiation proctitis. METHODS This is a prospective case-series pilot study. Ten patients with symptomatic chronic radiation proctitis were consecutively enrolled over a 2-year period. Baseline clinical data were collected and an endoscopic score was calculated based on the density of ectasias and circumferential involvement. Subjects underwent up to four cryospray ablation treatment sessions at approximately 4-week intervals or until resolution of the proctitis. The endpoints of the study were endoscopic and clinical improvement in radiation proctitis. RESULTS Ten patients (nine males and one female) with a mean age of 74 ± 7 years underwent cryospray treatment; sessions ranged from one to four (six patients had one session, three patients had two sessions, and one patient underwent four sessions). Endoscopic score significantly decreased from a mean of 10.2 ± 3.0 to 4.0 ± 2.8 (P = 0.016). Rectal pain significantly decreased from a mean of 3.1 ± 3.0 to 1.2 ± 1.7 (P = 0.042) and rectal bleeding improved in 86% (six out of seven) of patients. Nine patients reported improvement in overall well-being. No major complications were encountered. CONCLUSIONS Cryotherapy is an effective method in the management of chronic radiation proctitis with minimal complications.
Collapse
Affiliation(s)
- Fouad J Moawad
- Gastroenterology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
| | | | | |
Collapse
|
25
|
Zhang L, Xie XY, Wang Y, Wang YH, Chen Y, Ren ZG. Treatment of radiation-induced hemorrhagic gastritis with prednisolone: A case report. World J Gastroenterol 2012; 18:7402-7404. [PMID: 23326152 PMCID: PMC3544049 DOI: 10.3748/wjg.v18.i48.7402] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 09/28/2012] [Indexed: 02/06/2023] Open
Abstract
Radiation-induced gastritis is an infrequent cause of gastrointestinal bleeding. It is a serious complication arising from radiation therapy, and the standard treatment method has not been established. The initial injury is characteristically acute inflammation of gastric mucosa. We presented a 46-year-old male patient with hemorrhagic gastritis induced by external radiotherapy for metastatic retroperitoneal lymph node of hepatocellular carcinoma. The endoscopic examination showed diffuse edematous hyperemicmucosa with telangiectasias in the whole muscosa of the stomach and duodenal bulb. Multiple hemorrhagic patches with active oozing were found over the antrum. Anti-secretary therapy was initiated for hemostasis, but melena still occurred off and on. Finally, he was successfully treated by prednisolone therapy. We therefore strongly argue in favor of perdnisolone therapy to effectively treat patients with radiation-induced hemorrhagic gastritis.
Collapse
|
26
|
Fuccio L, Guido A, Andreyev HJN. Management of intestinal complications in patients with pelvic radiation disease. Clin Gastroenterol Hepatol 2012; 10:1326-1334.e4. [PMID: 22858731 DOI: 10.1016/j.cgh.2012.07.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/22/2012] [Accepted: 07/20/2012] [Indexed: 02/07/2023]
Abstract
Gastrointestinal toxicity after radiotherapy for pelvic cancer is a major complication-the most commonly reported symptoms include rectal bleeding, diarrhea, and fecal incontinence, which substantially impair patients' quality of life. Management of these symptoms can be a challenge, although available treatment strategies generally are ignored or underused. Radiation-induced symptoms have multiple mechanisms of pathogenesis; the first step for the correct management is to identify the mechanism that is causing the symptoms. Optimal management requires close liaisons among physicians, gastroenterologists with specialist interests, radiotherapists, oncologists, dieticians, nurses, and surgeons. Patients should be reassured that treatment options (medical, endoscopic, and surgical) exist and are in most cases successful if patients are referred to experts in pelvic radiation disease. However, although new therapeutic approaches are not yet always supported by high-quality trials, research projects are underway to improve management of patients. Clinicians should focus on using proven treatments correctly and avoiding misuse.
Collapse
Affiliation(s)
- Lorenzo Fuccio
- Department of Clinical Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy.
| | | | | |
Collapse
|
27
|
Abstract
BACKGROUND Chronic radiation proctopathy is associated with significant morbidity. The effectiveness of endoscopic and medical therapies has not been evaluated. OBJECTIVES The aim of this study was to conduct a systematic review of the effectiveness of endoscopic and comparative medical therapies for chronic radiation proctopathy. DATA SOURCES A comprehensive search Medline and PubMed was performed. STUDY SELECTION A comprehensive literature search was performed for studies of endoscopic and medical therapy for clinical and endoscopic improvement in chronic radiation proctopathy from January 1990 until December 2010. The quality of the overall evidence was rated according to the Grading of Recommendations, Assessment, Development, and Evaluation Working Group. SETTING Patients in both inpatient and outpatient settings were assessed. PATIENTS Patients experiencing chronic radiation proctopathy were included. INTERVENTIONS Patients had undergone medical or endoscopic treatments for chronic radiation proctopathy. MAIN OUTCOME MEASUREMENTS The primary outcomes measured were the resolution or improvement in symptoms. RESULTS A total of 39 studies were found, of which 27 evaluated endoscopic therapy and 12 evaluated medical therapy chronic radiation proctopathy. Overall, there is low-level evidence for the effectiveness of endoscopic therapy with argon plasma coagulation in reducing short-term (≤6 weeks) symptoms of chronic radiation proctopathy and insufficient evidence for long-term improvement. There is moderate-level evidence for the use of sucralfate enemas and low-level evidence for use of short-chain fatty acid enemas and hyperbaric oxygen. There is insufficient evidence for other agents: topical formalin, 5-aminosalicylic acid compounds, sulfasalazine, vitamin A, and pentoxifylline. LIMITATIONS Individual authors were not contacted, and the search was limited to English language journals only. CONCLUSION Endoscopic treatment with argon plasma coagulation appears effective in the short-term outcome of chronic radiation proctopathy. There is a moderate level of evidence for the use of sucralfate enemas. Large, randomized, placebo-controlled studies evaluating endoscopic and medical therapies for chronic radiation proctopathy are needed.
Collapse
|
28
|
Kintzinger C, Demoor-Goldschmidt C, Abderrahmani R, Paris F, Supiot S. Toxicité rectale de la radiothérapie : signes cliniques, physiopathologie et prise en charge. Cancer Radiother 2012; 16:372-6. [DOI: 10.1016/j.canrad.2012.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 05/28/2012] [Indexed: 12/29/2022]
|
29
|
Lam MCW, Parliament M, Wong CKW. Argon plasma coagulation for the treatment of hemorrhagic radiation colitis. Case Rep Gastroenterol 2012; 6:446-51. [PMID: 22933988 PMCID: PMC3398092 DOI: 10.1159/000339462] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Radiation colitis is a common consequence of pelvic radiation. Its complications may include anemia due to chronic bleeding requiring transfusions. Many of these patients are managed with rectal medications which are often inadequate for control. Argon plasma coagulation (APC) has been well described for its efficacy in treating radiation proctitis. Here we present two cases in whom APC therapy was used to treat severe radiation colitis. We reviewed two cases originally seen at the regional cancer center (Cross Cancer Institute) in Edmonton, Alberta, Canada. Both patients received pelvic radiation for recurrent endometrial cancers and were referred for active bleeding secondary to radiation colitis that had required numerous transfusions. Radiation-induced telangiectasias were found from 10–50 cm in the sigmoid colon. Both patients had significant improvement of symptoms after one session of APC treatment set at 40–60 W and gas flow of 2.0 l/min. There were no complications from the procedures. Neither patient required blood transfusions after the treatment with improvement in their hemoglobin levels and were doing well at 3- and 6-month follow-up. APC can be used effectively to provide immediate and sustained resolution of symptoms in patients with radiation colitis.
Collapse
Affiliation(s)
- Mindy C W Lam
- Cross Cancer Institute and Royal Alexandra Hospital, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alta., Canada
| | | | | |
Collapse
|
30
|
Rustagi T, Mashimo H. Endoscopic management of chronic radiation proctitis. World J Gastroenterol 2011; 17:4554-62. [PMID: 22147960 PMCID: PMC3225092 DOI: 10.3748/wjg.v17.i41.4554] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 05/14/2011] [Accepted: 05/21/2011] [Indexed: 02/06/2023] Open
Abstract
Chronic radiation proctopathy occurs in 5%-20% of patients following pelvic radiotherapy. Although many cases resolve spontaneously, some lead to chronic symptoms including diarrhea, tenesmus, urgency and persistent rectal bleeding with iron deficiency anemia requiring blood transfusions. Treatments for chronic radiation proctitis remain unsatisfactory and the basis of evidence for various therapies is generally insufficient. There are very few controlled or prospective trials, and comparisons between therapies are limited because of different evaluation methods. Medical treatments, including formalin, topical sucralfate, 5-amino salicylic acid enemas, and short chain fatty acids have been used with limited success. Surgical management is associated with high morbidity and mortality. Endoscopic therapy using modalities such as the heater probe, neodymium:yttrium-aluminium-garnet laser, potassium titanyl phosphate laser and bipolar electrocoagulation has been reported to be of some benefit, but with frequent complications. Argon plasma coagulation is touted to be the preferred endoscopic therapy due to its efficacy and safety profile. Newer methods of endoscopic ablation such as radiofrequency ablation and cryotherapy have been recently described which may afford broader areas of treatment per application, with lower rate of complications. This review will focus on endoscopic ablation therapies, including such newer modalities, for chronic radiation proctitis.
Collapse
|
31
|
Sato Y, Takayama T, Sagawa T, Hirakawa M, Ohnuma H, Miyanishi K, Sato T, Takimoto R, Kobune M, Okamoto K, Takeuchi H, Kato J. Argon plasma coagulation treatment of hemorrhagic radiation proctopathy: the optimal settings for application and long-term outcome. Gastrointest Endosc 2011; 73:543-9. [PMID: 21257166 DOI: 10.1016/j.gie.2010.11.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 11/08/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND No standard treatment exists for hemorrhagic radiation proctopathy (HRP). Recently it was reported that argon plasma coagulation (APC) is effective for HRP. However, previous studies documented complications such as ulcers, strictures, and perforations in as many as 20% of APC-treated patients. OBJECTIVE The aim of this study was to determine the optimal parameters for APC by using swine rectum and to assess the safety and effectiveness of APC in HRP patients. DESIGN Prospective case series. SETTING University teaching hospital. PATIENTS Sixty-five patients with HRP were prospectively enrolled between 2000 and 2010. INTERVENTIONS APC for HRP. MAIN OUTCOME MEASUREMENTS Optimal APC parameters, number of treatments, success rate, complications, clinical remissions. RESULTS APC in swine rectal wall ex vivo was optimal with a 40-W current, 1.2-L/min gas flow rate, and 2-second application, which was sufficient to treat the submucosal telangiectasia but did not adversely affect the muscle layer. Sixty-five patients (46 men, 19 women; median age 72 years) with HRP occurring at a mean of 20 months after radiotherapy were studied. Proctopathy was classified as grade A (mild) in 7 patients (10.8%), grade B (moderate) in 41 (63.1%), and grade C (severe) in 17 (26.2%). The treatment success rate was 98.5% after a median of 2 (range 1-5) APC sessions. The median clinical score for rectal bleeding was significantly decreased after APC (P < .0001), and the hemoglobin level was significantly increased (P < .0001). APC was well tolerated, and no significant side effects or complications occurred. During a mean follow-up of 34.6 months (range 3.6 -121.1 months), 4 patients (6.3%) had minor recurrent rectal bleeding and 60 (93.8%) remained in remission. LIMITATIONS Nonrandomized study. CONCLUSIONS HRP treatment with optimal APC settings yields a high success rate and long-lasting clinical remission with no significant complications.
Collapse
Affiliation(s)
- Yasushi Sato
- Fourth Department of Internal Medicine, Sapporo Medical University, School of Medicine, South 1 West 16, Chuo-ku, 060-8543 Sapporo, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Nikfarjam M, Faulx A, Laughinghouse M, Marks JM. Feasibility of radiofrequency ablation for the treatment of chronic radiation proctitis. Surg Innov 2010; 17:92-4. [PMID: 20504783 DOI: 10.1177/1553350610365701] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic radiation proctitis can be difficult to manage. Radiofrequency ablation has recently been shown to be effective in the management of gastric antral vascular ectasia and Barrett's esophagus, but its utility in the treatment of chronic radiation proctitis is undetermined. METHOD A 77-year-old man with extensive chronic radiation proctitis had continued bleeding despite argon plasma coagulation. The HALO(90) radiofrequency system (BARRX Medical, Sunnyvale, CA) was used for treatment regions of proctitis at an energy density of 12 J/cm(2). RESULTS At monthly intervals, over 3 months, radiofrequency ablation was performed with a mean of 7 regions ablated at a time. The mean treatment time was 29 minutes. There was no significant bleeding after the first treatment session. The patient was symptom free at 6 months follow-up with minimal evidence of residual mucosal abnormalities. CONCLUSIONS Radiofrequency ablation appears feasible for treatment of refractory chronic radiation proctitis, with further studies required.
Collapse
|
33
|
Abstract
A spectrum of oncologic treatments including chemotherapy, radiotherapy, and molecular targeted therapies is available to combat cancer. These treatments are associated with adverse effects in several organ systems including the gastrointestinal (GI) tract. The immunocompromised state induced by oncologic therapy is also an important contributing factor underlying GI complications. This review discusses common GI complications that can result from cancer therapy. The pathologic mechanisms underlying each complication and the pharmacology of the agents used to treat these complications are discussed.
Collapse
|
34
|
Staiano T, Grassia R, Iiritano E, Bianchi G, Dizioli P, Buffoli F. Treatment of radiation-induced hemorrhagic gastritis with endoscopic band ligation. Gastrointest Endosc 2010; 72:452-3. [PMID: 20226458 DOI: 10.1016/j.gie.2009.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 11/12/2009] [Indexed: 12/10/2022]
Affiliation(s)
- Teresa Staiano
- Digestive Endoscopy and Gastroenterology Unit, A.O. Istituti Ospitalieri di Cremona, Cremona, Italy
| | | | | | | | | | | |
Collapse
|
35
|
Abstract
Platelet transfusion therapy is the standard of care for thrombocytopenic patients with hemato-oncological disorders and bone marrow failure states due to intensive chemoradiotherapy. Guidelines to lower triggers for prophylactic and therapeutic transfusions are being developed based on better levels of evidence. The optimum transfusion dose, the choice of platelet concentrate and transfusion interval pose a challenge to balance scientific advances with cost-effective strategies. Platelet refractoriness requires "matched" platelets and is a difficult to treat phenomenon. Pathogen inactivation is a crucial issue in view of susceptibility of platelet concentrates to bacterial contamination. This article reviews the current developments and challenges in optimizing platelet transfusion therapy.
Collapse
Affiliation(s)
- Neelam Marwaha
- Department of Transfusion Medicine, PGIMER, Chandigarh, India.
| | | |
Collapse
|
36
|
Zhou C, Adler DC, Becker L, Chen Y, Tsai TH, Figueiredo M, Schmitt JM, Fujimoto JG, Mashimo H. Effective treatment of chronic radiation proctitis using radiofrequency ablation. Therap Adv Gastroenterol 2009; 2:149-156. [PMID: 20593010 DOI: 10.1177/1756283x08103341] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Endoscopic argon plasma coagulation and bipolar electrocautery are currently preferred treatments for chronic radiation proctitis, but ulcerations and strictures frequently occur. Radiofrequency ablation (RFA) has been successful for mucosal ablation in the esophagus. Here we report the efficacy of RFA with the BarRx Halo(90) system in three patients with bleeding from chronic radiation proctitis. In all cases, the procedure was well tolerated and hemostasis was achieved after 1 or 2 RFA sessions. Re-epithelialization of squamous mucosa was observed over areas of prior hemorrhage. No stricturing or ulceration was seen on follow-up up to 19 months after RFA treatment. Real-time endoscopic optical coherence tomography (EOCT) visualized epithelialization and subsurface tissue microvasculature pre- and post-treatment, demonstrating its potential for follow-up assessment of endoscopic therapies.
Collapse
Affiliation(s)
- Chao Zhou
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
Radiation colitis refers to the characteristic changes in the mucosa of the colon and rectum secondary to pelvic radiation. Based on the interval from radiation to mucosal changes or symptoms, there are two well-defined forms of radiation colitis: acute, manifested by mucosal sloughing causing diarrhea, mucus discharge, and tenesmus; and chronic, characterized by obstructed defecation or ischemia of the mucosa due to obliterative endarteritis and resulting in mucosal telangiectasias, mucosal pallor, and friability causing rectal bleeding. Up to 25% of all patients receiving pelvic radiation develop mild symptoms, and 2% to 3% develop moderate to severe symptoms. Radiation colitis can be difficult to treat in some patients. There are several options for treating its symptoms. Argon plasma coagulation is the most common method of treating telangiectasias. Topical formaldehyde has also been used for distal telangiectasias. Obstructed defecation caused by radiation strictures (which are very fibrotic) usually can be treated successfully with stool softeners, colonic dilation, or steroid injection. Surgery should be avoided if possible because of its technical difficulty and the high incidence of postoperative complications such as anastomotic leak and fistula formation. New advances in radiation delivery techniques (eg, intensity-modulated radiation therapy) using specialized computer algorithms and medications such as amifostine may decrease the incidence of radiation colitis.
Collapse
|
38
|
Adler DG, Chand B, Conway JD, Diehl DL, Kantsevoy SV, Kwon RS, Mamula P, Shah RJ, Wong Kee Song LM, Tierney WM. Mucosal ablation devices. Gastrointest Endosc 2008; 68:1031-42. [PMID: 19028211 DOI: 10.1016/j.gie.2008.06.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 06/17/2008] [Indexed: 02/08/2023]
|
39
|
Gastrointestinal complications of oncologic therapy. ACTA ACUST UNITED AC 2008; 5:682-96. [PMID: 18941434 DOI: 10.1038/ncpgasthep1277] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 09/11/2008] [Indexed: 12/19/2022]
Abstract
Gastrointestinal complications are common in patients undergoing various forms of cancer treatment, including chemotherapy, radiation therapy, and molecular-targeted therapies. Many of these complications are life-threatening and require prompt diagnosis and treatment. Complications of oncologic therapy can occur in the esophagus (esophagitis, strictures, bacterial, viral and fungal infections), upper gastrointestinal tract (mucositis, bleeding, nausea and vomiting), colon (diarrhea, graft-versus-host disease, colitis and constipation), liver (drug hepatotoxicity and graft-versus-host disease), and pancreas (pancreatitis). Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication.
Collapse
|
40
|
[Nonsurgical treatment of chronic radiation-induced hemorrhagic proctitis]. Presse Med 2008; 37:1113-20. [PMID: 18077130 DOI: 10.1016/j.lpm.2007.07.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Revised: 07/22/2007] [Accepted: 07/27/2007] [Indexed: 12/25/2022] Open
Abstract
The incidence of radiation-induced chronic hemorrhagic proctitis is less than 10 to 20%. The onset of this proctitis is delayed relative to the radiation therapy and generally develops from 6 to 24 months later. There are numerous predisposing factors, the most important of which is the radiation therapy dose: risk increases exponentially above 40-45 Gy. Its pathophysiology involves progressive obliterating endarteritis and transmural interstitial fibrosis, which induce chronic ischemia that is irreversible and progressive during the years after radiation therapy. Its diagnosis depends most often on the combination of clinical history and typical endoscopic appearance (congestive mucosa and/or telangiectases). Topical administrative of sucralfate or corticosteroids as well as argon plasma coagulation, with formalin treatment if necessary, provides relief for most patients.
Collapse
|
41
|
Eickhoff A, Hartmann D, Eickhoff JC, Riemann JF, Enderle MD. Pain sensation and neuromuscular stimulation during argon plasma coagulation in gastrointestinal endoscopy. Surg Endosc 2007; 22:1701-7. [PMID: 18071803 DOI: 10.1007/s00464-007-9700-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 09/20/2007] [Accepted: 10/16/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Argon plasma coagulation (APC) is a thermal coagulation technique that uses ionized argon for contact-free transmission of high-frequency electrical current to tissue. Prospective data on complications with the new APC-2 (VIO) system are lacking. METHODS A prospective trial was conducted with 152 patients treated for various gastrointestinal diseases using three modes of the APC-2. The study aimed to assess complications, focusing on the pain and neuromuscular stimulation (NMS) experienced during and after treatment. Patients reported pain and NMS using a scale ranging from 0 to 10 and were interviewed for symptoms such as tingling, paresthesia, muscle pain, and cramping or twitching. The endoscopists also graded NMS using a separate questionnaire. RESULTS A total of 85 males and 67 females (median age, 66 years) were enrolled in the study. All APC therapies were completed successfully. Two peri-interventional perforations were recorded. Of the 152 patients, 26 (17%) reported pain sensation during or after APC. The median pain sensation reported by the patients on the standardized scale was 3.7. The findings showed NMS in 14 (9.2%) of the 152 patients. Significantly more NMS events were seen with pulsed APC than with forced or precise APC. Additional risk factors for NMS were gender (female) and type of sedation (combination midazolam and pethidine). No complications were noted among patients with intracardiac defibrillators or cardiac pacemakers. CONCLUSIONS According to the findings, APC may be associated with minor complications such as pain sensation and NMS. These complications were rarely seen, but occurred more often with pulsed APC than with forced or precise APC. Physicians should be aware of these complications.
Collapse
Affiliation(s)
- A Eickhoff
- Medical Department C, Klinikum Ludwigshafen gGmbH, Bremserstrasse 79, D-67063, Ludwigshafen, Germany.
| | | | | | | | | |
Collapse
|
42
|
de Parades V, Bauer P, Marteau P, Chauveinc L, Bouillet T, Atienza P. Traitement non chirurgical des rectites radiques chroniques hémorragiques. ACTA ACUST UNITED AC 2007; 31:919-28. [PMID: 18166879 DOI: 10.1016/s0399-8320(07)78299-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
43
|
Leiper K, Morris AI. Treatment of radiation proctitis. Clin Oncol (R Coll Radiol) 2007; 19:724-9. [PMID: 17728120 DOI: 10.1016/j.clon.2007.07.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Accepted: 07/20/2007] [Indexed: 12/11/2022]
Abstract
Late complications of pelvic radiotherapy occur in 5-20% of patients, particularly chronic radiation proctitis (CRP). Rectal bleeding is the most common symptom. Other symptoms include difficulty in defaecation or tenesmus because of loss of distensibility of the rectum or rectal structuring. Treatment options of CRP include oral therapy (5-aminosalicylates, metronidazole), rectal instillation therapy (hydrocortisone, sucralfate, 5-aminosalicylates, formalin), thermal therapy (argon plasma coagulation, heater probe or laser) and hyperbaric oxygen. It is difficult to recommend evidence-based therapy. There are no adequately powered studies of the treatment of CRP and most data are uncontrolled, non-blinded observation studies from single sites. There are no standard evaluation tools (including endoscopic grading, symptom scores and quality-of-life scores), adequate description of preceding radiotherapy dose or adequate follow-up in most studies. Many studies have poor documentation of complications and few are carried out prospectively. A pragmatic approach is to use sucralfate enemas and oral metronidazole. Thermal methods seem to be effective and safe. Simple heater probe treatment or argon plasma coagulation are the preferred methods due to their better safety profile. Intra-rectal formalin seems to be effective, but possibly has a higher rate of complications. For resistant disease, hyperbaric oxygen may be an option.
Collapse
Affiliation(s)
- K Leiper
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK.
| | | |
Collapse
|
44
|
Abstract
Lower gastrointestinal (GI) hemorrhage is a significant cause of morbidity and mortality, particularly in elderly patients. Lower endoscopic evaluation is established as the diagnostic procedure of choice in the setting of acute lower GI hemorrhage.
Collapse
Affiliation(s)
- Brenna Casey Bounds
- Harvard Medical School, Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Blake 453D, Boston, MA 02114, USA.
| | | |
Collapse
|
45
|
AGRAWAL PP, BANSAL N, BAHADUR AK, SINGH K, RATHI AK. Management of chronic hemorrhagic radiation proctitis. Asia Pac J Clin Oncol 2007. [DOI: 10.1111/j.1743-7563.2006.00084.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
46
|
Haas EM, Bailey HR, Faragher I. Application of 10 percent formalin for the treatment of radiation-induced hemorrhagic proctitis. Dis Colon Rectum 2007; 50:213-7. [PMID: 17080283 DOI: 10.1007/s10350-006-0707-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Rectal instillation of 4 percent formalin solution has been described as a successful treatment for hemorrhagic radiation proctitis recalcitrant to medical treatment. We present our experience with a new method of treatment involving the topical application of 10 percent buffered formalin, which is well tolerated and suitable for office use. METHODS Patients with marked or refractory rectal bleeding and clinical features consistent with radiation proctitis were reviewed. Treatment involved direct application of a 10 percent buffered formalin solution to the affected mucosa using a 16-inch cotton tip applicator applied through a proctoscope in the office setting. RESULTS A total of 100 patients with a mean age of 75 (range, 49-91) years were followed for 18 (range, 1-79) months. The interval from radiation exposure to formalin treatment was 21 months. Overall, 93 percent of patients had cessation of bleeding after an average of 3.5 formalin applications at two-week to four-week intervals. Patients with severe (Grade 3) proctitis and those taking aspirin required an average of 1.5 additional treatments. A total of eight patients rebled at a mean of 24 months from treatment; however, all responded to further applications of formalin. Three patients complained of anal pain and one experienced dizziness postprocedure for a complication rate of 1.1 percent. CONCLUSIONS We present a simple, cost-effective, and well-tolerated method of controlling hemorrhagic radiation proctitis. It is performed by using materials readily available in the office of a colon and rectal surgeon, eliminating the need for bowel preparation, anesthesia, or a surgical suite.
Collapse
Affiliation(s)
- Eric M Haas
- Department of Surgery, The Methodist Hospital, Houston, TX, USA.
| | | | | |
Collapse
|
47
|
Shukuwa K, Kume K, Yamasaki M, Yoshikawa I, Otsuki M. Argon plasma coagulation therapy for a hemorrhagic radiation-induced gastritis in patient with pancreatic cancer. Intern Med 2007; 46:975-7. [PMID: 17603236 DOI: 10.2169/internalmedicine.46.0076] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Radiation-induced gastritis is a serious complication of radiation therapy for pancreatic cancer which is difficult to manage. A 79-year-old man had been diagnosed as having inoperable pancreatic cancer (stage IVa). We encountered this patient with hemorrhagic gastritis induced by external radiotherapy for pancreatic cancer that was well-treated using argon plasma coagulation (APC). After endoscopic treatment using APC, anemia associated with hemorrhagic radiation gastritis improved and required no further blood transfusion.
Collapse
Affiliation(s)
- Kazutaka Shukuwa
- Department of Gastroenterology and Metabolism, University of Occupational and Environmental Health, Japan, Shool of Medicine, Kitakyushu
| | | | | | | | | |
Collapse
|
48
|
Abstract
PURPOSE OF REVIEW Chronic radiation proctopathy is a complication of pelvic radiation therapy. The acute phase of radiation injury to the rectum occurs during or up to 3 months following radiation. Acute radiation injury can continue into a chronic phase or chronic radiation proctopathy may develop after a latent period of several months or years. Symptoms associated with the condition include diarrhea, rectal pain, bleeding, tenesmus, and stricture formation. Of the various symptoms, only bleeding from radiation-induced telangiectasias is amenable to endoscopic therapy. This paper summarizes the findings of experts in the field on endoscopic treatment of bleeding from chronic radiation proctopathy. RECENT FINDINGS Medical management is generally ineffective in controlling bleeding from chronic radiation proctopathy. Surgical intervention has a high incidence of morbidity. Promising advances have been made in endoscopic therapy, including formalin, neodymium/yttrium aluminum garnet, argon and potassium titanyl phosphate laser treatments, as well as argon plasma coagulation. Argon plasma coagulation presents an effective, efficient, inexpensive and reasonably safe noncontact method for destruction of radiation telangiectasias. SUMMARY Based on currently available data and trends, argon plasma coagulation is the favored treatment for bleeding from chronic radiation proctopathy.
Collapse
Affiliation(s)
- Sydney A Wilson
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | |
Collapse
|
49
|
Abstract
Although acute LGIB is only about one fifth as common and is usually less hemodynamically significant than upper gastrointestinal bleeding, it presents numerous unique clinical challenges. The best diagnostic approach for patients with active bleeding is unknown, but urgent prepared colonoscopy is safe and likely to be beneficial (Fig. 3, Table 2). In patients who have aggressive bleeding or recurrent bleeding, it is critical for the practitioner to judge when angiography and surgery are necessary.
Collapse
Affiliation(s)
- Bryan T Green
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
| | | |
Collapse
|
50
|
Abstract
Several recent advances have been made in the evaluation and management of acute lower gastrointestinal bleeding. This review focuses on the management of lower gastrointestinal bleeding, especially acute severe bleeding. The aim of the study was to critically review the published literature on important management issues in lower gastrointestinal bleeding, including haemodynamic resuscitation, diagnostic evaluation, and endoscopic, radiologic, and surgical therapy, and to develop an algorithm for the management of lower gastrointestinal bleeding, based on this literature review. Publications pertaining to lower gastrointestinal bleeding were identified by searches of the MEDLINE database for the years 1966 to December 2004. Clinical trials and review articles were specifically identified, and their reference citation lists were searched for additional publications not identified in the database searches. Clinical trials and current clinical recommendations were assessed by using commonly applied criteria. Specific recommendations are made based on the evidence reviewed. Approximately, 200 original and review articles were reviewed and graded. There is a paucity of high-quality evidence to guide the management of lower gastrointestinal bleeding, and current endoscopic, radiologic, and surgical practices appear to reflect local expertise and availability of services. Endoscopic literature supports the role of urgent colonoscopy and therapy where possible. Radiology literature supports the role of angiography, especially after a positive bleeding scan has been obtained. Limited surgical data support the role of segmental resection in the management of persistent lower gastrointestinal bleeding after localization by either colonoscopy or angiography. There is limited high-quality research in the area of lower gastrointestinal bleeding. Recent advances have improved the endoscopic, radiologic and surgical management of this problem. However, treatment decisions are still often based on local expertise and preference. With increased access to urgent therapeutic endoscopy for the management of acute upper gastrointestinal bleeding, diagnostic and therapeutic colonoscopy can be expected to play an increasing role in the management of acute lower gastrointestinal bleeding.
Collapse
Affiliation(s)
- J J Farrell
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA 90095, USA.
| | | |
Collapse
|