Surgical aspects of radiation enteritis of the small bowel

Surgical complications of oncological treatments: A narrative review

Gastrointestinal complications are common in patients undergoing various forms of cancer treatments, including chemotherapy, radiation therapy, and molecular-targeted therapies. Surgical complications of oncologic therapies can occur in the upper gastrointestinal tract, small bowel, colon, and rectum. The mechanisms of action of these therapies are different. Chemotherapy includes cytotoxic drugs, which block the activity of cancer cells by targeting intracellular DNA, RNA, or proteins. Gastrointestinal symptoms are very common during chemotherapy, due to a direct effect on the intestinal mucosa resulting in edema, inflammation, ulceration, and stricture. Serious adverse events have been described as complications of molecular targeted therapies, including bowel perforation, bleeding, and pneumatosis intestinalis, which may require surgical evaluation. Radiotherapy is a local anti-cancer therapy, which uses ionizing radiation to cause inhibition of cell division and ultimately lead to cell death. Complications related to radiotherapy can be both acute and chronic. Ablative therapies, including radiofrequency, laser, microwave, cryoablation, and chemical ablation with acetic acid or ethanol, can cause thermal or chemical injuries to the nearby structures. Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication. Furthermore, it is important to know the stage and prognosis of the disease, and a multidisciplinary approach is necessary to personalize the surgical treatment. The purpose of this narrative review is to describe complications related to different oncologic therapies that may require surgical interventions.

Radiation-Induced Problems in Colorectal Surgery

Radiotherapy not only plays a pivotal role in the cancer care pathways of many patients with pelvic malignancies, but can also lead to significant injury of normal tissue in the radiation field (pelvic radiation disease) that is sometimes as challenging to treat as the neoplasms themselves. Acute symptoms are usually self-limited and respond to medical therapy. Chronic symptoms often require operative intervention that is made hazardous by hostile surgical planes and unforgiving tissues. Management of these challenging patients is best guided by the utmost caution and humility.

Complications of oncologic therapy in the abdomen and pelvis: a review

Cancer therapy has significantly improved in the past few decades with development of various newer classes of cytotoxic chemotherapy as well as novel, molecularly targeted chemotherapy. Similar to chemotherapy, radiotherapy is another important therapeutic option used in the curative and palliative management of various abdominal malignancies. However, both these treatments affect the tumor as well as the normal tissues, leading to significant toxicity. These side effects range from mild to life threatening, and may involve multiple organs. Imaging plays an important role in the early identification of such complications, which may allow more effective patient management. The aim of this article is to discuss and illustrate the wide spectrum of chemotherapy and radiotherapy induced complications in the abdomen and pelvis.

Practical approaches to effective management of intestinal radiation injury: Benefit of resectional surgery

AIM: To study the outcome of patients undergoing surgical resection of the bowel for sustained radiation-induced damage intractable to conservative management.

METHODS: During a 7-year period we operated on 17 cases (5 male, 12 female) admitted to our surgical department with intestinal radiation injury (IRI). They were originally treated for a pelvic malignancy by surgical resection followed by postoperative radiotherapy. During follow-up, they developed radiation enteritis requiring surgical treatment due to failure of conservative management.

RESULTS: IRI was located in the terminal ileum in 12 patients, in the rectum in 2 patients, in the descending colon in 2 patients, and in the cecum in one patient. All patients had resection of the affected region(s). There were no postoperative deaths, while 3 cases presented with postoperative complications (17.7%). All patients remained free of symptoms without evidence of recurrence of IRI for a median follow-up period of 42 mo (range, 6-96 mo).

CONCLUSION: We report a favorable outcome without IRI recurrence of 17 patients treated by resection of the diseased bowel segment.

Risk of recurrence after surgery for chronic radiation enteritis

Background

Approximately one-third of patients with chronic radiation enteritis (CRE) require surgery, which is associated with a high morbidity rate and a high risk of reoperation. The aim of this study was to report outcome after surgery for CRE.

Methods

Patients with CRE who underwent operation with extensive small bowel resection between 1980 and 2009 were included in the study. Postoperative morbidity and mortality, reoperation for recurrent enteritis and risk factors for reoperation were analysed.

Results

Of 107 patients (94 women; 87·8 per cent) with CRE included in the study, the main indication for surgery was symptomatic stricture (82 patients; 76·6 per cent). Forty-nine ileocaecal resections (45·8 per cent) were performed. Overall and surgical morbidity rates were 74·8 per cent (80 patients) and 28·0 per cent (30) respectively. Fourteen patients (13·1 per cent) underwent reoperation for complications. Reoperation rates for CRE at 1 and 3 years of follow-up were 37 and 54 per cent respectively. Risk factors for reoperation for recurrent enteritis were: emergency surgery (odds ratio (OR) 2·72, 95 per cent confidence interval 1·57 to 4·86), anastomotic leakage (OR 2·53, 1·54 to 4·42) and male sex (OR 3·57, 1·82 to 7·29). The only protective factor for reoperation was ileocaecal resection during the first surgical procedure (OR 4·48, 2·52 to 8·31).

Conclusion

Ileocaecal resection was the only factor that protected against reoperation for recurrent CRE, demonstrating the importance of resecting all damaged tissue in these patients. These results suggest that there is little place for intestinal bypass surgery or adhesiolysis.

[Therapy of radiation enteritis--current challenges]

Radiation enteritis is one of the most feared complications after abdominal and pelvic radiation therapy. The incidence varies from 0.5 to 5%. It is not rare that the slowly progressing condition will be fatal. During a period of 13 years 24 patients were operated due to the complication of radiation enteritis. Despite different types of surgery repeated operation was required in 25% of cases and finally 4 patients died. Analyzing these cases predisposing factors and different therapeutic options of this condition are discussed. Treatment options of radiation induced enteritis are limited; however, targeted therapy significantly improves the outcome. Cooperation between oncologist, gastroenterologist and surgeon is required to establish adequate therapeutic plan.

[Surgical prevention of radiation enteritis: case report and review of literature]

Due to high morbidity and mortality rates, radiation enteritis is one of the most feared complications of abdominal and pelvic radiation therapy. Advances in radiation technology and radiation planning contributed to recent significant achievements. Surgical prevention provides further opportunities in decreasing the risk of radiation enteritis. A 75 year old male underwent transurethral resection for urothelial carcinoma of the bladder. Prior to initiation of radiation therapy, we performed Shouldice repair for bilateral inguinal hernias to prevent radiation injury to the fixed small intestines. Later our patient received 55 Gy of radiation therapy and two series of Carboplatin chemotherapy. Following radio-chemotherapy our patient did not developed radiation enteritis. In our report we discuss hernioplasty as an important method for prevention of radiation enteritis. We also review other options of surgical prevention.

Surgical Complications of Childhood Tumors

Most childhood tumors will first present to a physician; some tumors will present in an atypical manner and may mimic a surgical condition. The diagnosis may be missed if the surgeon is not aware of the possibility of cancer. A very great number of rare presentations of childhood cancer have been described in the literature. It is important that the surgeon who is not experienced in the management of childhood cancer is aware that an apparently benign condition could be a manifestation of an underlying malignancy [71, 83] (Table 22.1).

Radiation Enterocolitis Requiring Surgery in Patients With Gynecological Malignancies

PURPOSE

To identify the characteristics, risk factors, and clinical outcomes of radiation enterocolitis requiring surgery in patients with gynecologic malignancies.

METHODS AND MATERIALS

The records of 1,349 patients treated with pelvic radiotherapy were retrospectively reviewed. The majority of the patients (88%) were treated with 50 Gy or 50.4 Gy pelvic irradiation in conventional fractionations with anteroposterior fields.

RESULTS

Forty-eight patients (3.6%) developed radiation enterocolitis requiring surgery. Terminal ileum was the most frequent site (50%) and most of the lesions had stenosis or perforation. On univariate analysis, previous abdominopelvic surgery, diabetes mellitus (DM), smoking and primary site had an impact on the complications, and on multivariate analysis, abdominopelvic surgery, DM, and smoking were independent predictors of the complications requiring surgery. After the surgical intervention, the frequency of Grade 2 or more bleeding was significantly lower in patients treated with intestinal resection in addition to decompression than those treated with intestinal decompression alone.

CONCLUSIONS

Severe radiation enterocolitis requiring surgery usually occurred at the terminal ileum and was strongly correlated with previous abdominopelvic surgery, DM, and smoking. Concerning the management, liberal resection of the affected bowel appears to be the preferable therapy.

Late small bowel toxicity after adjuvant treatment for rectal cancer

BACKGROUND

For locally advanced rectal cancer surgery as sole treatment results in poor local control and survival. After adjuvant radiotherapy for locally advanced rectal cancer, small bowel toxicity has been the most frequent and serious side effect. The gain in survival and local control was accompanied by severe late chronic toxicity reducing the benefit of adjuvant treatment.

REVIEW

Clinical factors, pathology and treatment of late small bowel toxicity after adjuvant radiotherapy for locally advanced rectal cancer will be discussed. This review will focus on different surgical and radiotherapeutic means reducing the risk of late small bowel damage.

Phase II study of vitamin E and pentoxifylline in patients with late side effects of pelvic radiotherapy

BACKGROUND AND PURPOSE

Radiation-induced tissue fibrosis is a common adverse effect of curative treatment for pelvic cancer. Pilot studies testing alpha-tocopherol and pentoxifylline provide evidence of clinical regression of superficial radiation fibrosis after radiotherapy.

PATIENTS AND METHODS

Twenty-seven eligible research volunteers with a minimum of one grade 3 or 4 disability (LENT SOMA) due to previous radiotherapy were entered into the study. Volunteers were given dl-alpha tocopheryl acetate 500 mg twice a day orally plus pentoxifylline 400mg twice a day orally over a period of 6 months. Clinical assessment of late side effects recorded using LENT SOMA scales was selected as the primary endpoint, taken at baseline and at 6 and 12 months post-registration. Patient self-assessment of function and quality of life was assessed as a secondary endpoint using the EORTC QLQ-C30 core questionnaire and the EORTC QLQ-CR38 pelvic module. Magnetic resonance imaging was undertaken in 13/23 evaluable volunteers before and after 6 months of therapy.

RESULTS

At 12 months post-registration there were 4 out of 23 responders. At 6 months post-registration there was a statistically significant improvement (i.e. reduction) in the median of the LENT SOMA summed scores in all areas assessed apart from 'male sexual dysfunction', 'vulva' and 'vagina' which were unchanged at 6 months. The median total LENT SOMA score at baseline and 6 months was 49 and 34, respectively, with a median change in total LENT SOMA score between baseline and 6 months of 9 (IQR 7-18) (P<0.001). The maximum LENT SOMA scores improved over the study period, with a total number of 82 maximum grade 3 or 4 normal tissue scores at baseline (median of four complications per person) reduced to a total number of 67 maximum grade 3 or 4 scores at 6 months post-registration (median of 3 complications per person), i.e. a median reduction in severe complications of one per person. LENT SOMA scores at 12 months were similar to those observed at 6 month suggesting no further improvement nor deterioration in late side effects. These findings were, however, not reflected in the patient self-assessment of function and quality of life, raising question about the possibility of observer bias in recording LENT SOMA scores. No significant changes were reported on magnetic resonance images at 6 months from baseline.

CONCLUSIONS

Despite only seeing four a priori defined responders in this pilot study testing dl-alpha tocopheryl acetate plus pentoxifylline in patients suffering complications of pelvic radiotherapy, changes in LENT SOMA scores suggest beneficial effects. However, we are not convinced that these effects are real, since no significant changes in symptoms and functional status were recorded by detailed prospective patient self-assessments.

Reappraisal of Surgical Treatment for Radiation Enteritis

Although radiation enteritis is a well-recognized sequel of therapeutic irradiation, the standard surgical method is not universally agreed upon. Not only the short-term effect but also the long-term effect after a surgical intervention has been fairly well reported. To reassess the surgical therapy for radiation enteritis, we retrospectively analyzed 48 patients (5 males and 43 females, mean age 58.6 years) who had been operated on in our department. These patients were divided into two types according to the time of surgery or the clinical manifestation, and operative methods were analyzed. Patient's status such as bowel movement, body weight, and serum albumin value after surgery were analyzed, together with the patients survival. Our surgical methods were small intestinal resection for the intestinal obstruction, and pull-through reconstruction for proctitis. Two patients died of multiple organ failure caused by perforated peritonitis irrespective of emergent operation. Although the overall morbidity was 21.7%, there was no leakage when bowels were anastomosed. Overall survival after radiation-related complication in patients without previous neoplastic disease recurrence was 89%, 79%, and 69%, at 1, 3, and 5 years after surgery, respectively. Bowel motility, serum albumin level, and body weight recovered gradually soon after the operation and reached satisfactory levels within 6 months. Our analysis showed that small bowel injury should be treated by generous resection of the affected bowel followed by careful anastomosis of the disease-free ends, while rectal resection is best dealt with by restorative proctectomy. This may provide a good quality of life and minimize major postoperative complications such as leakage.

Duodenocaval Fistula: A Late Complication of Retroperitoneal Irradiation and Vena Cava Replacement

Duodenocaval fistula (DCF), an unusual pathology, is associated with a 40% mortality rate in the 36 patients previously reported. Although migrating or ingested foreign bodies, trauma, and peptic ulcer disease are often described etiologies, 11 patients have been described who developed DCF after resection of retroperitoneal tumors, 9 of whom also had postoperative radiotherapy. We report two patients who developed DCF after resection of retroperitoneal tumors followed by radiation therapy. The first patient, a 56-year-old female, presented with upper gastrointestinal hemorrhage requiring transfusion caused by a duodenoprosthetic caval fistula 7 years after successful resection of a retroperitoneal leiomyosarcoma and replacement of the inferior vena cava followed by radiation and chemotherapy. The second patient, a 37-year-old male who had previously undergone resection of a retroperitoneal sarcoma followed by external radiotherapy, developed massive upper and lower gastrointestinal bleeding secondary to a duodenocaval fistula. The etiology, diagnosis, and treatment of DCF are analyzed with an emphasis on DCF following resection and irradiation of retroperitoneal tumors. In most patients, "spontaneous" DCF have occurred as a late complication of high-dose radiation for carcinoma of the right kidney or retroperitoneal structures.

Operative and long term results after surgery for chronic radiation enteritis

BACKGROUND

About one third of patients with chronic radiation enteritis will need to be operated on during follow-up. Morbidity and life expectancy after resection and conservative surgical management for chronic radiation enteritis have not been well documented.

METHODS

From 1984 to 1994, 109 patients were operated on with a mean follow-up of 40 months (range 1 to 293). Postoperative mortality, early and late morbidity, long-term survival were studied in patients after resection (n = 65) and after conservative surgical management (n = 42), and in patients after planned or emergency procedure. Existence of possible risk factors for reoperation after a first surgical procedure was analyzed.

RESULTS

Five (5%) patients died in the postoperative course. Operative mortality was significantly higher when the procedure was performed as an emergency (P <0.05). Although not statistically significant, mortality was higher in the resection group (5% versus 0%). Thirty-three (30%) patients experienced postoperative complications including anastomotic leak in 11. Morbidity was not statistically related to the nature of the treatment (ie, conservative versus resection) or to the indication (emergency versus elective). During follow-up, reoperation was required in 40% of the patients, because of recurrence of digestive symptoms suggestive of chronic radiation enteritis; the reoperation rate was higher in the patients of the conservative group (50% versus 34%). Overall survival, after a mean follow-up of 40 months in patients without cancer recurrence was 85% at 1 year and 69% at 5 years after surgery, respectively. Overall survival was influenced by the nature of the treatment with 51% and 71% 5-year survival after conservative and resection treatment, respectively.

CONCLUSIONS

Despite high initial mortality and morbidity rates, life expectancy in patients with chronic radiation enteritis without recurrence of their previous neoplastic disease was good. Resection seems to provide a smaller reoperation rate and a better 5-year survival, but a higher postoperative mortality.

Aggressive initial surgery for chronic radiation enteritis: long-term results of resection vs non-resection in 44 consecutive cases

OBJECTIVE

One third of patients with chronic radiation enteritis will require surgery. There is, however, no consensus on the best surgical strategy. The long-term results of intestinal resection vs a `conservative' procedure, including stoma, bypass, and/or adhesiolysis, were reviewed with special reference to reoperation rates and the ultimate need for long-term parenteral nutrition.

PATIENTS AND METHODS

Forty-four patients operated for chronic radiation enteritis were divided into two groups: Group I resection (n = 21) and Group II conservative (n = 23). Twenty patients had received preoperative total parenteral nutrition, 16 (76%) in the resection group vs four (17%) in the conservative group (P < 0.001). In the resection group, intestinal resection was combined with a stoma in six patients. In the conservative group, 10 patients underwent adhesiolysis, five a bypass procedure, and eight diverting stoma.

RESULTS

Post-operative mortality was similar in both groups (9.5% vs 8.5%). Mean follow up was 53 and 55 months for Group I and Group II, respectively. The reoperation rate was significantly lower in Group I: 9 (47%) vs 19 (86%), P < 0.01. Although not significant, the ultimate need for long-term parenteral nutrition rate was lower in Group I than in Group II: 6 (32%) vs 10 (48%).

CONCLUSION

Resection resulted in better treatment outcomes than `conservative' surgery for chronic radiation enteritis.

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.

Treatment of severe actinic rectitis

BACKGROUND

The authors report the treatment of three female patients with severe actinic rectitis, with stenosis or perforation, submitted to anterior proctosigmoidectomy and transanal coloanal anastomosis.

METHODS

In all cases surgery consisted of total proctosigmoidectomy, mucosectomy of the anal canal, lowering of the left colon through the pelvis and transanal anastomosis performed manually at the level of the pectineal line using separate absorbable sutures. A protective intestinal shunt was performed in all cases.

RESULTS

The three patients did not present transoperative or immediate postoperative complications, but the first patient developed deep venous thrombosis of the leg that was submitted to successful clinical treatment. The intestinal shunts were later closed in all three cases. Sphicter function was considered very good in the first case and regular in the remaining two.

CONCLUSION

The surgical technique utilized was considered to be adequate for the cases reported and is the first option for the maintenance of transit in patients with severe actinic rectitis since the anastomosis is performed using non-irradiated colon with the pectineal line, practically outside the pelvis.

Effect of irradiation on healing of newly made colonic anastomoses in the rat

PURPOSE

Short-term effects of radiotherapy on the healing process of newly made colonic anastomoses are investigated by measuring the anastomotic strength in a rat model.

METHODS AND MATERIALS

Four groups of Wistar rats were used. In all groups, rats underwent a 1 cm sigmoid resection with end-to-end anastomosis. Group I served as a control group. In group II the anastomosis was irradiated after closure of the abdominal wall with a single dose of 20 Gy of 250 kV x rays. Group III was irradiated with a single dose of 20 Gy while the abdominal wall was not closed, and the surrounding tissues were carefully covered by a lead plate, simulating intra-operative radiotherapy. Group IV was treated as group III, but a larger dose of 25 Gy was applied. Animals were sacrificed 3 or 7 days after the operation. General condition of the rats was determined by observation, weight loss, serum protein and albumin at sacrifice. Anastomotic healing was evaluated by inspection, bursting pressure, hydroxyproline and protein contents of the anastomotic segment.

RESULTS

Direct postoperative externally irradiated rats (group II) showed a marked weight loss, hypoproteinaemia and hypo-albuminaemia because of involvement of small bowel in the irradiated volume. With respect to anastomotic healing there were no significant differences between control and irradiated groups.

CONCLUSION

These data suggest that the application of a single dose of irradiation (20 and 25 Gy) on colonic anastomoses given in a direct postoperative or intraoperative model has no measurable side effect on the early healing of newly made colonic anastomoses. Direct postoperative external irradiation results in unwanted side effects in the adjacent bowel.

Surgical management of radiation enteropathy

Acute radiation enteropathy is usually self-limited and rarely requires surgical intervention. Chronic radiation enteropathy may occur months, years, or decades after treatment. Patients may present with crampy abdominal pain, diarrhea, or cachexia or may present acutely with bowel obstruction or fistula. The bowel and its mesentery are shortened, and mucosal ulceration and submucosal fibrosis are present. The vasculature of the bowel is markedly compromised by progressive endarteritis. Ideally, nutritional support should be given and surgery performed electively. Regardless of presentation, both large and small bowel must be evaluated for concurrent problems. At surgery, resection and restoration of continuity of the gastrointestinal tract is optimal management. Recurrent obstruction and fistulae are real risks, and optimal management is resection of bowel damaged by radiation and anastomosis using bowel spared from irradiation. However, if the patient is unstable or necessary dissection and mobilization of the bowel judged too morbid, bypass of the affected loop is acceptable. Occasionally, only diversion of the bowel by enterostomy is possible.

Chronic radiation enteritis: a community hospital experience

A retrospective study was undertaken to evaluate the operative management of patients with chronic radiation enteropathy. Thirty-eight affected patients from 1974 to 1986 were reviewed. Patients with recurrent cancer responsible for symptoms were excluded. Seventy-one percent of patients presented with bowel obstruction. Twenty-one patients were treated with bowel resection, while 17 were treated with a bypass procedure or diverting ostomy alone. Overall morbidity was 45%, and postoperative mortality was 16%. Patients in the bypass group were significantly older than those in the resection group (70.3 vs. 55.5 years, P = .024), suggesting that age may have been a determinant of the procedure performed. In our study there was no difference in outcome based on preexisting vascular disease, tumor site, type of procedure performed, or radiation dose. We conclude that resection is the procedure of choice in cases of chronic radiation enteritis requiring surgery except in cases with dense adhesions when enteroenterostomal bypass is a viable alternative.

Fractionated low doses of abdominal irradiation alters jejunal uptake of nutrients

Abdominal radiation is associated with changes in intestinal uptake of nutrients that begins within three days and persist for over 33 weeks. Clinically, fractionated doses of radiation (FDR) are used in an attempt to minimize the complications of this therapy, but the effects of fractionated doses of radiation on intestinal transport have not been defined. Accordingly, an in vitro technique was used to assess the jejunal and ileal uptake of varying concentrations of glucose and leucine, as well as the uptake of single concentrations of fatty acids and decanol in rats exposed 3, 7, and 14 days previously to a course of 200 cGy given on each of five consecutive days. FDR was associated with an increase in the uptake of decanol, and therefore a decrease in the effective resistance of the unstirred water layer. FDR had a variable effect on the uptake of glucose and leucine, with a decline in the value of the Michaelis constant (Km) and the passive permeability coefficient for glucose (Pd), whereas the Km for leucine was unchanged and the Pd for leucine was variably affected by FDR. The maximal transport rate (Jdm) for leucine progressively rose following FDR, whereas the Jdm for glucose initially rose, then fell. The uptake of galactose and medium chain-length fatty acids was unchanged by FDR, whereas the jejunal uptake of myristic acid rose, and the uptake of cholic acid declined, then returned to normal. FDR was associated with greater body weight gain and jejunal and ileal weight, but these changes did not adequately explain the variable alterations in the kinetics of uptake. The changes in nutrient uptake following FDR differed from the absorption changes occurring after a single dose of radiation. Thus, fractionated doses of abdominal radiation produce complex changes in the intestinal uptake of actively and passively transported nutrients, and these variable changes are influenced by the time following radiation exposure and by the solute studied.

Radical surgical approach to radiation injury of the small bowel

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