1
|
Kohoutova D, Wilson A, Gee C, Elhusseiny R, Wanders L, Cunningham D. Intrarectal formalin treatment for haemorrhagic radiation-induced proctopathy: efficacy and safety. Colorectal Dis 2024; 26:932-939. [PMID: 38519847 DOI: 10.1111/codi.16956] [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: 12/13/2022] [Revised: 01/15/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024]
Abstract
AIM Pelvic radiotherapy is limited by dose-dependent toxicity to surrounding organs. The aim of this prospective study was to evaluate the efficacy and safety of intrarectal formalin treatment for radiotherapy-induced haemorrhagic proctopathy (RHP) at the Royal Marsden Hospital. METHOD Adult patients were enrolled. Haemoglobin was evaluated before and after formalin treatment. Antiplatelet and/or anticoagulation treatment and administration of transfusion were recorded. The interval between completion of radiotherapy and the first intrarectal 5% formalin treatment was assessed and the dose of radiotherapy was evaluated. Clinical assessment of the frequency and amount of rectal bleeding (rectal bleeding score 1-6) and endoscopic appearance (grade 0-3) were classified. Complications were recorded. RESULTS Nineteen patients were enrolled, comprising 13 men (68%) and 6 women. The mean age was 75 ± 9 years. The median time between completion of radiotherapy and the first treatment was 20 months [interquartile range (IQR) 15 months] and the median dose of radiotherapy was 68 Gy (IQR 14 Gy). Thirty-two procedures were performed (average 1.7 per patient). In total, 9/19 (47%) patients were receiving anticoagulation and/or antiplatelet medication and 5/19 (26%) received transfusion prior to treatment. The mean value of serum haemoglobin before the first treatment was 110 ± 18 g/L and afterwards it was 123 ± 16 g/L (p = 0.022). The median rectal bleeding score before the first treatment was 6 (IQR 0) and afterwards 2 (IQR 1-4; p < 0.001), while the median endoscopy score on the day of first treatment was 3 (IQR 0) compared with 1 (IQR 1-2) on the day of the last treatment 1 (p < 0.001). One female patient with a persistent rectal ulcer that eventually healed (18 months of healing) subsequently developed rectovaginal fistula (complication rate 1/19, 5%). CONCLUSIONS Treatment with intrarectal formalin in RHP is effective and safe.
Collapse
Affiliation(s)
| | - Ana Wilson
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
- St Mark's Hospital, London, UK
| | - Caroline Gee
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | - Linda Wanders
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
- Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | | |
Collapse
|
2
|
Polese L, Giugliano E, Cadrobbi R, Boemo DG. Diode Laser Therapy for Radiation-Induced Vascular Ectasia: Long-Term Results and Cost Analysis. Life (Basel) 2023; 13:life13041025. [PMID: 37109554 PMCID: PMC10144337 DOI: 10.3390/life13041025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Collateral damage to surrounding healthy tissues has been reported in patients who undergo radiation therapy for pelvic malignancies. This study aimed to evaluate the safety, efficacy and cost efficiency of endoscopic diode laser therapy in patients diagnosed with chronic radiation proctitis (CRP). METHODS The data of 24 patients (median age 78, range 67-90 years) who presented rectal bleeding and were diagnosed with CRP after undergoing high-dose radiotherapy for prostatic cancer and underwent diode laser therapy were evaluated retrospectively. Non-contact fibers were used in the patients who underwent the procedure without sedation in an outpatient setting. RESULTS The patients underwent a median of two sessions; overall, a mean of 1591 J of laser energy per session was used. No complications were noted during or after the procedures. Bleeding was completely resolved in 21/24 (88%) patients, and two patients showed improvement (96%). It was not necessary to suspend antiplatelet (six patients) or anticoagulant (four patients) therapy during the treatment course. The mean cost per session was EUR 473.4. CONCLUSIONS The study findings demonstrated that endoscopic non-contact diode laser treatment in CRP patients is safe, effective and cost efficient. For this procedure, antiplatelet and anticoagulant therapy suspension, intraprocedural sedation and hospital admission are not required.
Collapse
Affiliation(s)
- Lino Polese
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Emilia Giugliano
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Roberto Cadrobbi
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | | |
Collapse
|
3
|
Firmino F, Villela-Castro DL, Santos JD, Conceição de Gouveia Santos VL. Topical Management of Bleeding From Malignant Wounds Caused by Breast Cancer: A Systematic Review. J Pain Symptom Manage 2021; 61:1278-1286. [PMID: 33096218 DOI: 10.1016/j.jpainsymman.2020.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/06/2020] [Accepted: 10/11/2020] [Indexed: 01/10/2023]
Abstract
CONTEXT Topical management is the main form of control of signs and symptoms regarding malignant wounds (MWs) arising from tumor progression on the skin. Nevertheless, few studies have explored this theme and evidence on the effectiveness of the methods used to control bleeding is unknown, leading to a lack of consensus to support clinical practice. OBJECTIVES Identify and evaluate current evidence on topical MW hemostasis from breast cancer and suggest new topics for future research. METHODS This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes. Seven indexed databases were consulted using the terms: "breast neoplasms"; "breast cancer"; "malignant fungating wounds"; "malignant wounds"; "bleeding." RESULTS From the 112 articles identified in total, six were included in this review: a descriptive cohort study (n = 32), two case series (n = 21) and three case reports (n = 3). Fifty-six patients were exposed to 11 types of topical treatments using calcium alginate, surgical hemostats, adrenaline, nonadherent dressings, silver nitrate, modified Mohs Paste, and 10% formalin. There were no reports of significant adverse effects. CONCLUSION Although studies have promoted positive results of topical hemostasis, scientific evidence is still weak and arises from studies with poor methodological quality. Randomized controlled trials were not identified. The results highlight the crucial need for pilot studies to evaluate effect size, study procedures, and measurable results.
Collapse
Affiliation(s)
- Flavia Firmino
- Palliative Care Service, National Cancer Institute, School of Nursing, University of São Paulo, Brazil.
| | | | - Juliano Dos Santos
- National Cancer Institute, Breast Cancer Service, Rio de Janeiro, Brazil
| | | |
Collapse
|
4
|
Glaser SM, Mohindra P, Mahantshetty U, Beriwal S. Complications of intracavitary brachytherapy for gynecologic cancers and their management: A comprehensive review. Brachytherapy 2021; 20:984-994. [PMID: 33478905 DOI: 10.1016/j.brachy.2020.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
Intracavitary gynecologic brachytherapy in the form of tandem-based brachytherapy and vaginal cylinder-based brachytherapy represents a fundamental component of the treatment of women with cervical or uterine cancer due to the ability to deliver a therapeutic dose of radiation with sharp dose falloff. This results in highly effective treatment in terms of oncologic outcomes with an overall favorable toxicity profile. Still, complications and side effects of brachytherapy do exist. While advances in brachytherapy techniques have led to a significant decrease in the rates of toxicity, a thorough understanding of the potential complications is crucial to ensuring optimal outcomes for women with gynecologic cancer undergoing brachytherapy. Use of equivalent dose at 2 Gy per fraction (EQD2) models has allowed incorporation of external beam radiotherapy dose to the brachytherapy dose leading to development of consolidated dose constraints for organs-at-risk in the modern era. This manuscript offers a comprehensive review of potential complications associated with intracavitary brachytherapy for gynecologic cancer including predictive factors, mitigation tactics, and management strategies.
Collapse
Affiliation(s)
- Scott M Glaser
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA.
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| |
Collapse
|
5
|
|
6
|
Yuan ZX, Qin QY, Zhu MM, Zhong QH, Fichera A, Wang H, Wang HM, Huang XY, Cao WT, Zhao YB, Wang L, Ma TH. Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy. World J Gastroenterol 2020; 26:850-864. [PMID: 32148382 PMCID: PMC7052535 DOI: 10.3748/wjg.v26.i8.850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/04/2019] [Accepted: 02/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe chronic radiation proctopathy (CRP) is difficult to treat.
AIM To evaluate the efficacy of colostomy and stoma reversal for CRP.
METHODS To assess the efficacy of colostomy in CRP, patients with severe hemorrhagic CRP who underwent colostomy or conservative treatment were enrolled. Patients with tumor recurrence, rectal-vaginal fistula or other types of rectal fistulas, or who were lost to follow-up were excluded. Rectal bleeding, hemoglobin (Hb), endoscopic features, endo-ultrasound, rectal manometry, and magnetic resonance imaging findings were recorded. Quality of life before stoma and after closure reversal was scored with questionnaires. Anorectal functions were assessed using the CRP symptom scale, which contains the following items: Watery stool, urgency, perianal pain, tenesmus, rectal bleeding, and fecal/gas incontinence.
RESULTS A total of 738 continual CRP patients were screened. After exclusion, 14 patients in the colostomy group and 25 in the conservative group were included in the final analysis. Preoperative Hb was only 63 g/L ± 17.8 g/L in the colostomy group compared to 88.2 g/L ± 19.3 g/L (P < 0.001) in the conservative group. All 14 patients in the former group achieved complete remission of bleeding, and the colostomy was successfully reversed in 13 of 14 (93%), excepting one very old patient. The median duration of stoma was 16 (range: 9-53) mo. The Hb level increased gradually from 75 g/L at 3 mo, 99 g/L at 6 mo, and 107 g/L at 9 mo to 111 g/L at 1 year and 117 g/L at 2 years after the stoma, but no bleeding cessation or significant increase in Hb levels was observed in the conservative group. Endoscopic telangiectasia and bleeding were greatly improved. Endo-ultrasound showed decreased vascularity, and magnetic resonance imaging revealed an increasing presarcal space and thickened rectal wall. Anorectal functions and quality of life were significantly improved after stoma reversal, when compared to those before stoma creation.
CONCLUSION Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP. Stoma can be reversed, and anorectal functions can be recovered after reversal.
Collapse
Affiliation(s)
- Zi-Xu Yuan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Qi-Yuan Qin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Miao-Miao Zhu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Qing-Hua Zhong
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Alessandro Fichera
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, United States
| | - Hui Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Huai-Ming Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Xiao-Yan Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Wu-Teng Cao
- Department of Radiology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Ye-Biao Zhao
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Lei Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| | - Teng-Hui Ma
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
| |
Collapse
|
7
|
Zhong QH, Liu ZZ, Yuan ZX, Ma TH, Huang XY, Wang HM, Chen DC, Wang JP, Wang L. Efficacy and complications of argon plasma coagulation for hemorrhagic chronic radiation proctitis. World J Gastroenterol 2019; 25:1618-1627. [PMID: 30983821 PMCID: PMC6452229 DOI: 10.3748/wjg.v25.i13.1618] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 02/20/2019] [Accepted: 02/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic radiation proctitis (CRP) is a complication which occurs in 1%-5% of patients who undergo radiotherapy for pelvic malignancies. Although a wide range of therapeutic modalities are available, there is no literature to date showing any particularly appropriate therapeutic modality for each disease stage. Argon plasma coagulation (APC) is currently recommended as the first-choice treatment for hemorrhagic CRP, however, its indication based on long-term follow-up is still unclear. On the hypothesis that the long-term efficacy and safety of APC are not fully understood, we reviewed APC treatment for patients with hemorrhagic CRP from a single center.
AIM To assess the long-term efficacy and safety of APC for hemorrhagic CRP.
METHODS This is a retrospective study of consecutive patients treated with APC for hemorrhagic CRP from January 2013 to October 2017. Demographics, clinical variables, and typical endoscopic features were recorded independently. Success was defined as either cessation of bleeding or only occasional traces of bloody stools with no further treatments for at least 12 mo after the last APC treatment. We performed univariate and multivariate analyses to identify factors associated with success and risk factors for fistulas.
RESULTS Forty-five patients with a median follow-up period of 24 mo (range: 12-67 mo) were enrolled. Fifteen (33.3%) patients required blood transfusion before APC. Successful treatment with APC was achieved in 31 (68.9%) patients. The mean number of APC sessions was 1.3 (1-3). Multivariate analysis showed that APC failure was independently associated with telangiectasias present on more than 50% of the surface area [odds ratio (OR) = 6.53, 95% confidence interval (CI): 1.09-39.19, P = 0.04] and ulcerated area greater than 1 cm2 (OR = 8.15, 95%CI: 1.63-40.88, P = 0.01). Six (13.3%) patients had severe complications involving rectal fistulation. The only factor significantly associated with severe complications was ulcerated area greater than 1 cm2 (P = 0.035).
CONCLUSION The long-term efficacy of APC for hemorrhagic CRP is uncertain in patients with telangiectasias present on > 50% of the surface area and ulceration > 1 cm2.
Collapse
Affiliation(s)
- Qing-Hua Zhong
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Zhan-Zhen Liu
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Zi-Xu Yuan
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Teng-Hui Ma
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Xiao-Yan Huang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, Guangzhou 510655, Guangdong Province, China
| | - Huai-Ming Wang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Dai-Ci Chen
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, Guangzhou 510655, Guangdong Province, China
| | - Jian-Ping Wang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, Guangzhou 510655, Guangdong Province, China
| | - Lei Wang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Institute of Gastroenterology, Guangzhou 510655, Guangdong Province, China
| |
Collapse
|
8
|
Li YD, Xu JH, Lin JJ, Zhu WF. Application of 4% formaldehyde under electronic colonoscope as a minimally invasive treatment of chronic hemorrhagic radiation proctitis. World J Emerg Med 2019; 10:228-231. [PMID: 31534597 DOI: 10.5847/wjem.j.1920-8642.2019.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To investigate the effectiveness of topical application of 4% formaldehyde as a minimally invasive treatment of rectal bleeding due to chronic radiation proctitis (CRP) under direct vision of electronic colonoscope. METHODS The clinical data of 13 CRP patients complicated with ≥ grade II bleeding admitted to our hospital between January 2003 and December 2018 were retrospectively analyzed. Under the guidance of electronic colonoscope, 4% formaldehyde combined with 5-aminosalicylic acid (5-ASA) suppositories was topically applied. Patients were followed up for two months after treatment, and the therapeutic effectiveness was observed and analyzed. RESULTS The rectal bleeding due to CRP was markedly reduced after topical application of 4% formaldehyde under colonoscope in all 13 patients. The bleeding stopped after one treatment session in 11 patients and after the second session in 2 patients. 5-ASA was also applied along with the use of 4% formaldehyde. The therapeutic effectiveness was satisfactory during the 1- and 2-month follow-up period. CONCLUSION Topical application of 4% formaldehyde under the direct vision of colonoscope as a minimally invasive treatment for CRB-induced bleeding is a simple, effective, affordable, and repeatable technique without obvious complications, which deserves further exploration and promotion.
Collapse
Affiliation(s)
- Yan-Dong Li
- Division of Colon& Rectal Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jia-He Xu
- Division of Colon& Rectal Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jian-Jiang Lin
- Division of Colon& Rectal Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Wei-Fang Zhu
- Division of Dermatology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| |
Collapse
|
9
|
The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Chronic Radiation Proctitis. Dis Colon Rectum 2018; 61:1135-1140. [PMID: 30192320 DOI: 10.1097/dcr.0000000000001209] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
10
|
Abstract
Radiation proctitis is radiation-induced rectal mucositis, occurring as a result of radiation therapy for various pelvic malignancies. The management of radiation proctitis is challenging as guidelines are not currently available, and studies of the various treatment modalities are limited. There are various medical, endoscopic, and surgical measures for treating chronic radiation proctitis. Medical options such as anti-inflammatory agents, antioxidants, formalin application, and hyperbaric oxygen may improve bleeding related to chronic radiation proctitis. Endoscopic measures such as argon plasma coagulation are effective and safe. Surgery is considered for refractory or severe cases. A review and discussion of the different treatment modalities is presented.
Collapse
Affiliation(s)
- Lameese Tabaja
- Department of Colon and Rectal Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. .,Lerner School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| | - Shafik M Sidani
- Department of Colon and Rectal Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Lerner School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
11
|
Polese L, Marini L, Rizzato R, Picardi E, Merigliano S. Endoscopic diode laser therapy for chronic radiation proctitis. Lasers Med Sci 2017; 33:35-39. [DOI: 10.1007/s10103-017-2323-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/05/2017] [Indexed: 12/20/2022]
|
12
|
Viani GA, Sakamoto A. Outpatient application of formalin for chronic rectal bleeding after prostate irradiation: a quasi-experimental study. Int J Colorectal Dis 2017; 32:1037-1040. [PMID: 28108788 DOI: 10.1007/s00384-017-2759-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this quasi-experimental study is to evaluate a novel technique for an outpatient application of formalin for chronic rectal bleeding after prostate irradiation. METHODS This is a quasi- experimental clinical trial developed between January 2010 and July 2015, including 35 patients with chronic radiation rectitis (CRP) due to a previous prostate radiation course. The study's eligibility was (1) completed external beam radiation therapy for prostate carcinoma >6 months previously, (2) rectal bleeding, defined as a frequency of >1× per week and/or needing of blood transfusions, and (3) diagnosis of chronic proctitis at colonoscopy. The 5% formalin application was performed by a custom applicator, which requires neither anesthesia nor sigmoidoscopy. The endpoint of the study was bleeding cessation and hemoglobin level. RESULTS The onset of bleeding due to chronic rectitis was 12 months (6-36). During a median follow-up of 24 months, the rate of overall efficacy was 94%. The sustained complete response in 1 and 2 years was 80% and 73%, respectively. The Hb mean pre- and post-treatment differed significantly (12.2 vs 14.4, p = 0.0001). The rates of blood transfusion differed significantly, pre- and post-treatment (17% vs 5.7%, p = 0.031). CONCLUSION The technique is very effective and safe, resulting to a significant improvement of hemoglobin levels and quality of life scores. Further studies are warranted to compare this technique with other treatment options for chronic radiation-induced rectal bleeding.
Collapse
Affiliation(s)
- Gustavo Arruda Viani
- Oncoclinicas institute, São Paulo, Brazil.
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.
- Faculdade de Medicina de Marília (FAMEMA), Marília, SP, Brazil.
| | - Aline Sakamoto
- Faculdade de Medicina de Marília (FAMEMA), Marília, SP, Brazil
| |
Collapse
|
13
|
Yuan ZX, Ma TH, Zhong QH, Wang HM, Yu XH, Qin QY, Chu LL, Wang L, Wang JP. Novel and Effective Almagate Enema for Hemorrhagic Chronic Radiation Proctitis and Risk Factors for Fistula Development. Asian Pac J Cancer Prev 2017; 17:631-8. [PMID: 26925655 DOI: 10.7314/apjcp.2016.17.2.631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Radiation proctitis is a common complication after radiotherapy for pelvic malignant tumors. This study was conducted to assess the efficacy of novel almagate enemas in hemorrhagic chronic radiation proctitis (CRP) and evaluate risk factors related to rectal deep ulcer or fistula secondary to CRP. All patients underwent a colonoscopy to confirm the diagnosis of CRP and symptoms were graded. Typical endoscopic and pathological images, risk factors, and quality of life were also recorded. A total of 59 patients were enrolled. Gynecological cancers composed 93.1% of the primary malignancies. Complete or obvious reduction of bleeding was observed in 90% (53/59) patients after almagate enema. The mean score of bleeding improved from 2.17 to 0.83 (P<0.001) after the enemas. The mean response time was 12 days. No adverse effects were found. Moreover, long-term successful rate in controlling bleeding was 69% and the quality of life was dramatically improved (P=0.001). The efficacy was equivalent to rectal sucralfate, but the almagate with its antacid properties acted more rapidly than sucralfate. Furthermore, we firstly found that moderate to severe anemia was the risk factor of CRP patients who developed rectal deep ulcer or fistulas (P= 0.015). We also found abnormal hyaline-like thick wall vessels, which revealed endarteritis obliterans and the fibrosis underlying this disease. These findings indicate that almagate enema is a novel effective, rapid and well-tolerated method for hemorrhagic CRP. Moderate to severe anemia is a risk factor for deep ulceration or fistula.
Collapse
Affiliation(s)
- Zi-Xu Yuan
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China E-mail : , wangl9@mail. sysu.edu.cn,
| | | | | | | | | | | | | | | | | |
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: 20] [Impact Index Per Article: 2.5] [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
|
Yuan ZX, Ma TH, Wang HM, Zhong QH, Yu XH, Qin QY, Wang JP, Wang L. Colostomy is a simple and effective procedure for severe chronic radiation proctitis. World J Gastroenterol 2016; 22:5598-5608. [PMID: 27350738 PMCID: PMC4917620 DOI: 10.3748/wjg.v22.i24.5598] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 04/05/2016] [Accepted: 05/04/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the efficacy and safety of diverting colostomy in treating severe hemorrhagic chronic radiation proctitis (CRP).
METHODS: Patients with severe hemorrhagic CRP who were admitted from 2008 to 2014 were enrolled into this study. All CRP patients were diagnosed by a combination of pelvic radiation history, clinical rectal bleeding, and endoscopic findings. Inclusion criteria were CRP patients with refractory bleeding with moderate to severe anemia with a hemoglobin level < 90 g/L. The study group included patients who were treated by diverting colostomy, while the control group included patients who received conservative treatment. The remission of bleeding was defined as complete cessation or only occasional bleeding that needed no further treatment. The primary outcome was bleeding remission at 6 mo after treatment. Quality of life before treatment and at follow-up was evaluated according to EORTC QLQ C30. Severe CRP complications were recorded during follow-up.
RESULTS: Forty-seven consecutive patients were enrolled, including 22 in the colostomy group and 27 in the conservative treatment group. When compared to conservative treatment, colostomy obtained a higher rate of bleeding remission (94% vs 12%), especially in control of transfusion-dependent bleeding (100% vs 0%), and offered a better control of refractory perianal pain (100% vs 0%), and a lower score of bleeding (P < 0.001) at 6 mo after treatment. At 1 year after treatment, colostomy achieved better remission of both moderate bleeding (100% vs 21.5%, P = 0.002) and severe bleeding (100% vs 0%, P < 0.001), obtained a lower score of bleeding (0.8 vs 2.0, P < 0.001), and achieved obvious elevated hemoglobin levels (P = 0.003), when compared to the conservative treatment group. The quality of life dramatically improved after colostomy, which included global health, function, and symptoms, but it was not improved in the control group. Pathological evaluation after colostomy found diffused chronic inflammation cells, and massive fibrosis collagen depositions under the rectal wall, which revealed potential fibrosis formation.
CONCLUSION: Diverting colostomy is a simple, effective and safe procedure for severe hemorrhagic CRP. Colostomy can improve quality of life and reduce serious complications secondary to radiotherapy.
Collapse
|
16
|
van de Wetering FT, Verleye L, Andreyev HJN, Maher J, Vlayen J, Pieters BR, van Tienhoven G, Scholten RJPM. Non-surgical interventions for late rectal problems (proctopathy) of radiotherapy in people who have received radiotherapy to the pelvis. Cochrane Database Syst Rev 2016; 4:CD003455. [PMID: 27111831 PMCID: PMC7173735 DOI: 10.1002/14651858.cd003455.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND This is an update of a Cochrane review first published in 2002, and previously updated in 2007. Late radiation rectal problems (proctopathy) include bleeding, pain, faecal urgency, and incontinence and may develop after pelvic radiotherapy treatment for cancer. OBJECTIVES To assess the effectiveness and safety of non-surgical interventions for managing late radiation proctopathy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 11, 2015); MEDLINE (Ovid); EMBASE (Ovid); CANCERCD; Science Citation Index; and CINAHL from inception to November 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing non-surgical interventions for the management of late radiation proctopathy in people with cancer who have undergone pelvic radiotherapy for cancer. Primary outcomes considered were: episodes of bowel activity, bleeding, pain, tenesmus, urgency, and sphincter dysfunction. DATA COLLECTION AND ANALYSIS Study selection, 'Risk of bias' assessment, and data extraction were performed in duplicate, and any disagreements were resolved by involving a third review author. MAIN RESULTS We identified 1221 unique references and 16 studies including 993 participants that met our inclusion criteria. One study found through the last update was moved to the 'Studies awaiting classification' section. We did not pool outcomes for a meta-analysis due to variation in study characteristics and endpoints across included studies.Since radiation proctopathy is a condition with various symptoms or combinations of symptoms, the studies were heterogeneous in their intended effect. Some studies investigated treatments targeted at bleeding only (group 1), some investigated treatments targeted at a combination of anorectal symptoms, but not a single treatment (group 2). The third group focused on the treatment of the collection of symptoms referred to as pelvic radiation disease. In order to enable some comparison of this heterogeneous collection of studies, we describe the effects in these three groups separately.Nine studies assessed treatments for rectal bleeding and were unclear or at high risk of bias. The only treatments that made a significant difference on primary outcomes were argon plasma coagulation (APC) followed by oral sucralfate versus APC with placebo (endoscopic score 6 to 9 in favour of APC with placebo, risk ratio (RR) 2.26, 95% confidence interval (CI) 1.12 to 4.55; 1 study, 122 participants, low- to moderate-quality evidence); formalin dab treatment (4%) versus sucralfate steroid retention enema (symptom score after treatment graded by the Radiation Proctopathy System Assessments Scale (RPSAS) and sigmoidoscopic score in favour of formalin (P = 0.001, effect not quantified, 1 study, 102 participants, very low- to low-quality evidence), and colonic irrigation plus ciprofloxacin and metronidazole versus formalin application (4%) (bleeding (P = 0.007, effect not quantified), urgency (P = 0.0004, effect not quantified), and diarrhoea (P = 0.007, effect not quantified) in favour of colonic irrigation (1 study, 50 participants, low-quality evidence).Three studies, of unclear and high risk of bias, assessed treatments targeted at something very localised but not a single pathology. We identified no significant differences on our primary outcomes. We graded all studies as very low-quality evidence due to unclear risk of bias and very serious imprecision.Four studies, of unclear and high risk of bias, assessed treatments targeted at more than one symptom yet confined to the anorectal region. Studies that demonstrated an effect on symptoms included: gastroenterologist-led algorithm-based treatment versus usual care (detailed self help booklet) (significant difference in favour of gastroenterologist-led algorithm-based treatment on change in Inflammatory Bowel Disease Questionnaire-Bowel (IBDQ-B) score at six months, mean difference (MD) 5.47, 95% CI 1.14 to 9.81) and nurse-led algorithm-based treatment versus usual care (significant difference in favour of the nurse-led algorithm-based treatment on change in IBDQ-B score at six months, MD 4.12, 95% CI 0.04 to 8.19) (1 study, 218 participants, low-quality evidence); hyperbaric oxygen therapy (at 2.0 atmospheres absolute) versus placebo (improvement of Subjective, Objective, Management, Analytic - Late Effects of Normal Tissue (SOMA-LENT) score in favour of hyperbaric oxygen therapy (HBOT), P = 0.0019) (1 study, 150 participants, moderate-quality evidence, retinol palmitate versus placebo (improvement in RPSAS in favour of retinol palmitate, P = 0.01) (1 study, 19 participants, low-quality evidence) and integrated Chinese traditional plus Western medicine versus Western medicine (grade 0 to 1 radio-proctopathy after treatment in favour of integrated Chinese traditional medicine, RR 2.55, 95% CI 1.30 to 5.02) (1 study, 58 participants, low-quality evidence).The level of evidence for the majority of outcomes was downgraded using GRADE to low or very low, mainly due to imprecision and study limitations. AUTHORS' CONCLUSIONS Although some interventions for late radiation proctopathy look promising (including rectal sucralfate, metronidazole added to an anti-inflammatory regimen, and hyperbaric oxygen therapy), single small studies provide limited evidence. Furthermore, outcomes important to people with cancer, including quality of life (QoL) and long-term effects, were not well recorded. The episodic and variable nature of late radiation proctopathy requires large multi-centre placebo-controlled trials (RCTs) to establish whether treatments are effective. Future studies should address the possibility of associated injury to other gastro-intestinal, urinary, or sexual organs, known as pelvic radiation disease. The interventions, as well as the outcome parameters, should be broader and include those important to people with cancer, such as QoL evaluations.
Collapse
Affiliation(s)
- Fleur T van de Wetering
- Julius Center for Health Sciences and Primary Care / University Medical Center UtrechtDutch Cochrane CentrePO Box 85500UtrechtNetherlands3508 GA
| | - Leen Verleye
- Belgian Health Care Knowledge CentreKruidtuinlaan 55BrusselsBelgium1000
| | | | - Jane Maher
- Mount Vernon HospitalDepartment of Radiotherapy and OncologyRickmansworth RoadNorthwoodMiddlesexUKHA6 2RN
| | - Joan Vlayen
- Belgian Health Care Knowledge CentreKruidtuinlaan 55BrusselsBelgium1000
| | - Bradley R Pieters
- Academic Medical Center / University of AmsterdamDepartment of Radiation OncologyMeibergdreef 9AmsterdamNetherlands1105
| | - Geertjan van Tienhoven
- Academic Medical CenterRadiation Oncology and HyperthermiaP.O. Box 22700Meibergdreef 9AmsterdamNetherlands1100 DE
| | - Rob JPM Scholten
- Julius Center for Health Sciences and Primary Care / University Medical Center UtrechtDutch Cochrane CentrePO Box 85500UtrechtNetherlands3508 GA
| | | |
Collapse
|
17
|
Nash GF. Minimally invasive treatment of radiation proctitis and piles - a video vignette. Colorectal Dis 2015; 17:1122-4. [PMID: 26382829 DOI: 10.1111/codi.13122] [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: 03/10/2015] [Accepted: 05/26/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Guy F Nash
- Department of Surgery, Poole Hospital, Poole, BH15 2JB, UK.
| |
Collapse
|
18
|
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: 65] [Impact Index Per Article: 7.2] [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
|
19
|
Mallick S, Madan R, Julka PK, Rath GK. Radiation Induced Cystitis and Proctitis - Prediction, Assessment and Management. Asian Pac J Cancer Prev 2015; 16:5589-94. [DOI: 10.7314/apjcp.2015.16.14.5589] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
20
|
Ozone Therapy in the Management of Persistent Radiation-Induced Rectal Bleeding in Prostate Cancer Patients. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:480369. [PMID: 26357522 PMCID: PMC4556325 DOI: 10.1155/2015/480369] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 06/24/2015] [Accepted: 06/30/2015] [Indexed: 12/19/2022]
Abstract
Introduction. Persistent radiation-induced proctitis and rectal bleeding are debilitating complications with limited therapeutic options. We present our experience with ozone therapy in the management of such refractory rectal bleeding. Methods. Patients (n = 12) previously irradiated for prostate cancer with persistent or severe rectal bleeding without response to conventional treatment were enrolled to receive ozone therapy via rectal insufflations and/or topical application of ozonized-oil. Ten (83%) patients had Grade 3 or Grade 4 toxicity. Median follow-up after ozone therapy was 104 months (range: 52-119). Results. Following ozone therapy, the median grade of toxicity improved from 3 to 1 (p < 0.001) and the number of endoscopy treatments from 37 to 4 (p = 0.032). Hemoglobin levels changed from 11.1 (7-14) g/dL to 13 (10-15) g/dL, before and after ozone therapy, respectively (p = 0.008). Ozone therapy was well tolerated and no adverse effects were noted, except soft and temporary flatulence for some hours after each session. Conclusions. Ozone therapy was effective in radiation-induced rectal bleeding in prostate cancer patients without serious adverse events. It proved useful in the management of rectal bleeding and merits further evaluation.
Collapse
|
21
|
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
|
22
|
Ma TH, Yuan ZX, Zhong QH, Wang HM, Qin QY, Chen XX, Wang JP, Wang L. Formalin irrigation for hemorrhagic chronic radiation proctitis. World J Gastroenterol 2015; 21:3593-3598. [PMID: 25834325 PMCID: PMC4375582 DOI: 10.3748/wjg.v21.i12.3593] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/19/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the efficacy and safety of a modified topical formalin irrigation method in refractory hemorrhagic chronic radiation proctitis (CRP).
METHODS: Patients with CRP who did not respond to previous medical treatments and presented with grade II-III rectal bleeding according to the Common Terminology Criteria for Adverse Events were enrolled. Patients with anorectal strictures, deep ulcerations, and fistulas were excluded. All patients underwent flexible endoscopic evaluation before treatment. Patient demographics and clinical data, including primary tumor, radiotherapy and previous treatment options, were collected. Patients received topical 4% formalin irrigation in a clasp-knife position under spinal epidural anesthesia in the operating room. Remission of rectal bleeding and related complications were recorded. Defecation, remission of bleeding, and other symptoms were investigated at follow-up. Endoscopic findings in patients with rectovaginal fistulas were analyzed.
RESULTS: Twenty-four patients (19 female, 5 male) with a mean age of 61.5 ± 9.5 years were enrolled. The mean time from the end of radiotherapy to the onset of bleeding was 11.1 ± 9.0 mo (range: 2-24 mo). Six patients (25.0%) were blood transfusion dependent. The median preoperative Vienna Rectoscopy Score (VRS) was 3 points. Nineteen patients (79.2%) received only one course of topical formalin irrigation, and five (20.8%) required a second course. No side effects were observed. One month after treatment, bleeding cessation was complete in five patients and obvious in 14; the effectiveness rate was 79.1% (19/24). For long-term efficacy, 5/16, 1/9 and 0/6 patients complained of persistent bleeding at 1, 2 and 5 years after treatment, respectively. Three rectovaginal fistulas were found at 1 mo, 3 mo and 2 years after treatment. Univariate analysis showed associations of higher endoscopic VRS and ulceration score with risk of developing rectovaginal fistula.
CONCLUSION: Modified formalin irrigation is an effective and safe method for hemorrhagic CRP, but should be performed cautiously in patients with a high endoscopic VRS.
Collapse
|
23
|
Dziki Ł, Kujawski R, Mik M, Berut M, Dziki A, Trzciński R. Formalin therapy for hemorrhagic radiation proctitis. Pharmacol Rep 2015; 67:896-900. [PMID: 26398382 DOI: 10.1016/j.pharep.2015.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 02/02/2015] [Accepted: 03/11/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Radiotherapy within pelvis is a vital component of curative therapy for urological, gynecological and rectal malignances. Rectum is especially vulnerable to secondary radiation injury resulting in proctitis. The most common and life-threatening symptom is rectal hemorrhage. Formalin application into the rectum causes local cauterization of telangiectatic mucosal vessels. The aim of our study was to assess the efficacy of local formalin application in patients with hemorrhagic radiation proctitis. METHODS A solution of 4.0% formalin was used in the treatment of 20 patients with clinical and proctoscopic evidence of radiadion proctitis. Treatment involved direct application of 4.0% formalin into the rectum. All patients were followed-up in terms of complete resolution of symptoms or recurrences of bleeding. RESULTS A total of 20 patients with a mean age of 69.7 (range, 57-80) years were followed for 51.2 (range, 1-93) months. The mean duration of symptoms was 4.5 (range, 1-10) months and the interval between the end of radiotherapy and symptoms was mostly between 5 and 30 months. Patients required an average of 2 (range, 1-5) formalin treatments. Of the 20 patients, 10 had complete resolution of their symptoms after their first treatment. In 10 patients bleeding recurred and they were offered another formalin instillation and/or 5-ASA suppositories and argon therapy. Complete resolution of symptoms was achieved in all patients. CONCLUSIONS Topical formalin instillation is effective, safe, and well-tolerated method for the patients with radiation proctopathy. This therapy may be repeated in case of recurrent bleeding and combined with other methods of treatment.
Collapse
Affiliation(s)
- Łukasz Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Ryszard Kujawski
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Michał Mik
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Maciej Berut
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Adam Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Radzisław Trzciński
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland.
| |
Collapse
|
24
|
Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis. Inflamm Bowel Dis 2015; 21:703-15. [PMID: 25687266 DOI: 10.1097/mib.0000000000000227] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic proctitis refers to persistent or relapsing inflammation of the rectum, which results from a wide range of etiologies with various pathogenic mechanisms. The patients may share similar clinical presentations. Ulcerative proctitis, chronic radiation proctitis or proctopathy, and diversion proctitis are the 3 most common forms of chronic proctitis. Although the diagnosis of these disease entities may be straightforward in the most instances based on the clinical history, endoscopic, and histologic features, differential diagnosis may sometimes become problematic, especially when their etiologies and the disease processes overlap. The treatment for the 3 forms of chronic proctitis is different, which may shed some lights on their pathogenetic pathway. This article provides an overview of the latest data on the clinical features, etiologies, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.
Collapse
|
25
|
Late rectal toxicity after low-dose-rate brachytherapy: incidence, predictors, and management of side effects. Brachytherapy 2014; 14:148-59. [PMID: 25516492 DOI: 10.1016/j.brachy.2014.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 12/20/2022]
Abstract
As clinical outcomes for patients with clinically localized prostate cancer continue to improve, patients and physicians are increasing making treatment decisions based on concerns regarding long-term morbidity. A primary concern is late radiation proctitis, a clinical entity embodied by various signs and symptoms, ranging from diarrhea to rectal fistulas. Here, we present a comprehensive literature review examining the clinical manifestations and pathophysiology of late radiation proctitis after low-dose-rate brachytherapy (BT), as well as its incidence and predictors. The long-term risks of rectal bleeding after BT are on the order of 5-7%, whereas the risks of severe ulceration or fistula are on the order of 0.6%. The most robust predictor appears to be the volume of rectum receiving the prescription dose. In certain situations (e.g., salvage setting, for patients with increased radiosensitivity, and following aggressive biopsy after BT), the risk of these severe toxicities may be increased by up to 10-fold. A variety of excellent management options exist for rectal bleeding, with endoscopic methods being the most commonly used.
Collapse
|
26
|
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: 0.9] [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
|
27
|
Abstract
The optimal management of radiation proctitis is ill defined. A variety of alternatives are available and include topical agents (ie, sucralfate enemas, formalin), oral agents (ie, pentoxyfylline, vitamin A), hyperbaric oxygen, and endoscopic interventions (ie, argon plasma coagulation). It is prudent to manage patients conservatively and to intervene only when necessary with the option least likely to exacerbate the proctitis. Rectal biopsies should be avoided as they may precipitate a complication. More aggressive measures, such as argon laser coagulation, should be employed only when more conservative approaches fail.
Collapse
|
28
|
Guo GH, Yu FY, Wang XJ, Lu F. A randomized controlled clinical trial of formalin for treatment of chronic hemorrhagic radiation proctopathy in cervical carcinoma patients. Support Care Cancer 2014; 23:441-6. [PMID: 25128068 DOI: 10.1007/s00520-014-2401-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/11/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE Chronic hemorrhagic radiation proctopathy is not uncommon after radiotherapy for cervical carcinoma. The outcomes of several treatments have been variable. Many studies demonstrate that topical treatment with 4 % formalin is effective and safe. However, a nonrandomized control study showed a high response rate and good tolerance in chronic radiation proctopathy patients treated with 10 % formalin. The optimal concentration of formalin therefore remains unclear. METHODS To compare the effectiveness and safety of 4 and 10 % formalin for the treatment of chronic hemorrhagic radiation proctopathy, a prospective trial was conducted at the Department of Gynecology of the Affiliated Hospital of Binzhou Medical College from January 2009 to December 2012. One hundred and twenty patients with chronic hemorrhagic radiation proctopathy following radiotherapy for cervical carcinoma were recruited and randomized to receive 4 or 10 % formalin. A standard protocol was followed for formalin application. Symptom and rectoscopy scores were evaluated before and at 12 weeks after treatment. RESULTS In the 4 % formalin group, 49 (86.0 %) and 53 (91.4 %) patients showed an improvement in symptom score and rectoscopy score, respectively (P = 0.36). Symptom and rectoscopy scores decreased significantly after treatment in both the 4 % formalin group and the 10 % formalin group (P < 0.001). Symptom score was correlated with rectoscopy score (P < 0.001). More patients in the 10 % group suffered treatment-related complications than did those in the 4 % group (P = 0.03). CONCLUSIONS For the treatment of chronic hemorrhagic radiation proctopathy, 4 % should be the preferred formalin concentration.
Collapse
Affiliation(s)
- Guang-Hong Guo
- Department of Gynecology, Affiliated Hospital of Binzhou Medical College, No. 661, Yellow-River Second Street, Binzhou, 256600, China,
| | | | | | | |
Collapse
|
29
|
Argon plasma coagulation therapy versus topical formalin for intractable rectal bleeding and anorectal dysfunction after radiation therapy for prostate carcinoma. Int J Radiat Oncol Biol Phys 2013; 87:954-9. [PMID: 24113059 DOI: 10.1016/j.ijrobp.2013.08.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 08/23/2013] [Accepted: 08/25/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate and compare the effect of argon plasma coagulation (APC) and topical formalin for intractable rectal bleeding and anorectal dysfunction associated with chronic radiation proctitis. METHODS AND MATERIALS Thirty men (median age, 72 years; range, 49-87 years) with intractable rectal bleeding (defined as ≥1× per week and/or requiring blood transfusions) after radiation therapy for prostate carcinoma were randomized to treatment with APC (n=17) or topical formalin (n=13). Each patient underwent evaluations of (1) anorectal symptoms (validated questionnaires, including modified Late Effects in Normal Tissues-Subjective, Objective, Management, and Analytic and visual analogue scales for rectal bleeding); (2) anorectal motor and sensory function (manometry and graded rectal balloon distension); and (3) anal sphincteric morphology (endoanal ultrasound) before and after the treatment endpoint (defined as reduction in rectal bleeding to 1× per month or better, reduction in visual analogue scales to ≤25 mm, and no longer needing blood transfusions). RESULTS The treatment endpoint was achieved in 94% of the APC group and 100% of the topical formalin group after a median (range) of 2 (1-5) sessions of either treatment. After a follow-up duration of 111 (29-170) months, only 1 patient in each group needed further treatment. Reductions in rectal compliance and volumes of sensory perception occurred after APC, but no effect on anorectal symptoms other than rectal bleeding was observed. There were no differences between APC and topical formalin for anorectal symptoms and function, nor for anal sphincteric morphology. CONCLUSIONS Argon plasma coagulation and topical formalin had comparable efficacy in the durable control of rectal bleeding associated with chronic radiation proctitis but had no beneficial effect on anorectal dysfunction.
Collapse
|
30
|
Samalavicius NE, Dulskas A, Kilius A, Petrulis K, Norkus D, Burneckis A, Valuckas KP. Treatment of hemorrhagic radiation-induced proctopathy with a 4% formalin application under perianal anesthetic infiltration. World J Gastroenterol 2013; 19:4944-4949. [PMID: 23946599 PMCID: PMC3740424 DOI: 10.3748/wjg.v19.i30.4944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 04/05/2013] [Accepted: 05/08/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the results of hemorrhagic radiation proctopathy treatment with a 4% formalin application.
METHODS: A prospective study was performed. Over a three-year period, 38 patients underwent 4% formalin application under perianal anesthetic infiltration for hemorrhagic radiation proctopathy. All patients included in the study were irradiated for prostate cancer. The patients ranged in age from 56-77 years (average 70 ± 5 years). All of the patients were referred for formalin therapy after noninvasive management had failed. Twenty-four (63.2%) patients underwent a single application, 10 (26.3%) patients underwent 2 applications, and 4 (10.5%) patients underwent 3 applications.
RESULTS: Two to 36 mo (average 12 ± 3 mo) following treatment, 34 patients were interviewed (four were lost to follow-up). Twenty (58.8%) subjects reported complete cure, 8 (23.5%) subjects reported significant improvement, and 6 (17.7%) subjects reported no change. One patient (who underwent a colostomy at a regional hospital with no specialized services available for previous bleeding episodes from radiation proctopathy) was cured, and the colostomy was closed. One patient (2.6%) developed rectal mucosal damage after the second application.
CONCLUSION: A 4-min application of 4% formalin for hemorrhagic radiation-induced proctopathy under perianal anesthetic infiltration in patients who have received external radial radiation therapy for prostate cancer is simple, reasonably safe, inexpensive, generally well tolerated, and effective.
Collapse
|
31
|
Eriksen PL, Tougaard RS, Tøttrup A. Clinical and proctoscopic evaluation of topical formalin application in the treatment of chronic radiation proctitis. Scand J Surg 2013; 102:96-100. [PMID: 23820684 DOI: 10.1177/1457496913482240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Chronic radiation proctitis is a disease associated with radiotherapy of cancer in the pelvic region. The main symptom is rectal bleeding. Several treatment modalities have been attempted, but few have demonstrated satisfactory effects. We present our experience with formalin applied locally to the rectal mucosa in the treatment of chronic radiation proctitis. Furthermore, we assess possible complications, the gravest suggested being cancer. Previous studies on the subject have reported good results, but often with a somewhat vaguely defined follow-up. Our evaluation of the treatment was based on both subjective symptoms and proctoscopic findings. MATERIAL AND METHODS A small study (N = 11) was conducted retrospectively. All patients treated for chronic radiation proctitis with formalin in our clinic were identified, and data concerning effect and complications were collected by studying the patients' records, with a questionnaire and a follow-up interview and proctoscopy. RESULTS The study showed a marked decrease in bleeding and objective signs of proctitis in all patients. Complete cessation of bleeding was achieved in five patients. Possible complications to the treatment detected in our study were the following: anorectal pain, tenesmus, incontinence, diarrhea, and mucous rectal discharge. No signs of neoplasia were found. CONCLUSIONS The formalin treatment had a very good effect on chronic radiation proctitis. Possible complications were detected. Except in the case of anorectal pain, these are all of a questionable nature and can possibly be attributed to chronic radiation proctitis itself rather than the formalin treatment. Further study is warranted to confirm long-term effects of the formalin and to exclude possible complications, especially secondary anorectal cancer.
Collapse
Affiliation(s)
- P L Eriksen
- Abdominal Surgery Ward (Department P), Aarhus University Hospital, Aarhus, Denmark
| | | | | |
Collapse
|
32
|
Clavo B, Ceballos D, Gutierrez D, Rovira G, Suarez G, Lopez L, Pinar B, Cabezon A, Morales V, Oliva E, Fiuza D, Santana-Rodriguez N. Long-term control of refractory hemorrhagic radiation proctitis with ozone therapy. J Pain Symptom Manage 2013; 46:106-12. [PMID: 23102757 DOI: 10.1016/j.jpainsymman.2012.06.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 06/21/2012] [Accepted: 07/01/2012] [Indexed: 11/26/2022]
Abstract
CONTEXT Persistent or severe hemorrhagic radiation proctitis (HRP) has limited therapeutic options. OBJECTIVES To describe our experience with ozone therapy (O3T) in the management of refractory HRP. METHODS Patients (n=17; median age 69 years [range 42-80 years]) previously irradiated for prostate or uterine cancer and suffering persistent or severe HRP without response to conventional treatment were enrolled to receive an O3/O2 gas mixture via rectal insufflations and topical application of ozonized oil. Most of the patients (83%) had Grade 3 or Grade 4 toxicity. Median follow-up post-O3T was 40 months (range 3-56 months). RESULTS Endoscopic treatments required were: 43 (median 1; range 0-10) pre-O3T; 17 (median 0; range 0-8; P=0.063) during O3T; and five (median 0; range 0-2; P=0.008) during follow-up. Hemoglobin levels were 10.35g/dL (7-14g/dL) pre-O3T and 13g/dL (9-15g/dL) (P=0.001) post-O3T. Median toxicity grades were 3 (range 2-4) pre-O3T, 1 (range 0-2; P<0.001) at the end of O3T, and 0 (range 0-1; P<0.001) at the last follow-up. CONCLUSION Persistent advanced HRP was significantly improved with O3T. The addition of O3T can be useful as a complementary treatment in the long-term management of HRP and, as such, merits further evaluation.
Collapse
Affiliation(s)
- Bernardino Clavo
- Radiation Oncology Department, Dr. Negrin University Hospital, Las Palmas, Spain.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Stacey R, Green JT. Nonendoscopic therapies for the management of radiation-induced rectal bleeding. Curr Opin Support Palliat Care 2013; 7:175-82. [DOI: 10.1097/spc.0b013e32835f3e00] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
34
|
Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment. Int J Colorectal Dis 2013; 28:261-6. [PMID: 22932907 DOI: 10.1007/s00384-012-1571-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically. Rectal instillation of formalin solution has been described as a successful treatment for chronic radiation-induced hemorrhagic proctitis resistant to medical treatment. We present our results in patients undergoing treatment with application of 4 % formalin for radiation-induced injury to the rectum. METHODS All patients were treated under anesthesia by direct application of 4 % formalin solution to the affected rectal areas. Patient gender, initial malignancy, grade of proctitis, need for blood transfusion, previous therapy, number of applications and response to treatment with formalin, complications, and length of follow-up were reviewed. RESULTS A total of 15 patients with a mean age of 68.9 (range, 48-77) years were followed for 31.3 (range, 18-51) months. The mean interval from the conclusion of radiotherapy and the onset of symptoms was 6.9 months. The mean duration of hemorrhagic proctitis before formalin application was 7.9 months. Ten patients had only one formalin application and five patients required a second application because of the persistent bleeding. Thirteen patients (87 %) had complete cessation of bleeding. No complications related to the formalin treatment were observed. CONCLUSIONS According to a revision of the literature and our experience, despite the small number of patients in our trial, we can state that the application of 4 % formalin solution is an effective, safe, and well-tolerated treatment for chronic radiation-induced hemorrhagic proctitis with minimal discomfort and no severe complications.
Collapse
|
35
|
Muls AC, Watson L, Shaw C, Andreyev HJN. Managing gastrointestinal symptoms after cancer treatment: a practical approach for gastroenterologists. Frontline Gastroenterol 2013; 4:57-68. [PMID: 28839701 PMCID: PMC5369780 DOI: 10.1136/flgastro-2012-100218] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 07/12/2012] [Accepted: 07/12/2012] [Indexed: 02/07/2023] Open
Abstract
The percentage of the population living with a diagnosis of cancer is rising. By 2030, there will be 4 million cancer survivors in the UK. One quarter of cancer survivors are left with physical symptoms, which affect their quality of life. Gastrointestinal (GI) symptoms are the most common of all chronic physical side-effects of cancer treatment and have the greatest impact on daily activity. Cancer therapies induce long-term changes in bowel function due to alterations to specific GI physiological functions. In addition, the psychological effect of a cancer diagnosis, new GI disease or pre-existing underlying conditions, may also contribute to new symptoms. Twenty-three upper GI symptoms have been identified as occurring after pelvic radiotherapy. After upper GI cancer treatment, the most troublesome symptoms include reflux, abdominal pain, indigestion, diarrhoea and fatigue. Often, several symptoms are present simultaneously and women experience more symptoms than men. The symptoms which patients rate as most difficult are urgency, wind, diarrhoea, incontinence, abdominal pain and rectal bleeding. Recent UK Guidance on managing GI symptoms suggests that these symptoms can be treated especially if gastroenterological advice is combined with dietetic and nursing input to optimise investigations and management. However, as different pathological processes can result in identical symptoms; a systematic, 'algorithmic' approach to assess and treat these symptoms is required. This paper aims to illustrate the value of such an approach to investigate and treat the most common GI symptoms that trouble patients. The algorithm allows clinicians to institute a comprehensive medical management plan.
Collapse
Affiliation(s)
- Ann C Muls
- The GI unit, Department of Medicine, The Royal Marsden Hospital, London and Sutton, UK
| | - Lorraine Watson
- The Department of Nutrition and Dietetics, The Royal Marsden Hospital, London and Sutton, UK
| | - Clare Shaw
- The Department of Nutrition and Dietetics, The Royal Marsden Hospital, London and Sutton, UK
| | - H Jervoise N Andreyev
- The GI unit, Department of Medicine, The Royal Marsden Hospital, London and Sutton, UK
| |
Collapse
|
36
|
Eddi R, DePasquale JR. Radiofrequency ablation for the treatment of radiation proctitis: a case report and review of literature. Therap Adv Gastroenterol 2013; 6:69-76. [PMID: 23320051 PMCID: PMC3539292 DOI: 10.1177/1756283x12456895] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Radiation proctitis is a frequent complication of pelvic radiation for cancer. This condition can present acutely within several weeks of radiation, or chronically many months or years after radiation, leading to rectal bleeding and transfusion-dependent anemia. Various medical and endoscopic therapies have been described to treat this condition; however, some patients fail to respond to the current standard therapies. Here we present a case of refractory radiation proctitis, with suboptimal response to other therapies, treated successfully with a novel method, radiofrequency ablation.
Collapse
Affiliation(s)
- Rodney Eddi
- Seton Hall University, School of Health and Medical Sciences – St. Michael’s Medical Center, Department of Medicine, Division of Gastroenterology, 111 Central Avenue, Newark, NJ 07102, USA
| | - Joseph R. DePasquale
- Seton Hall University, School of Health and Medical Sciences – St. Michael’s Medical Center, Department of Medicine, Division of Gastroenterology, Newark, USA
| |
Collapse
|
37
|
Placer C, Lizarazu A, Borda N, Elósegui JL, Enriquez Navascués JM. [Radiation proctitis and chronic and refractory bleeding. Experience with 4% formaldehyde]. Cir Esp 2012; 91:111-4. [PMID: 23036255 DOI: 10.1016/j.ciresp.2012.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/19/2012] [Accepted: 05/26/2012] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Bleeding is a common complication of proctitis secondary to radiotherapy of pelvic tumours. Between 5 and 10% may become severe and refractory to topical and endoscopic treatment. Experience with the application of 4% formaldehyde is presented. PATIENTS AND METHOD A retrospective and descriptive study was performed on a patient cohort with severe radiation proctitis admitted to the Hospital Universitario Donostia between January 2003 and September 2009. All patients were diagnosed by colonoscopy and admitted due to the severity of their treatment. Both 4% formaldehyde and the gauze technique were used, as well as using enemas, in cases refractory to topical and endoscopic treatment with argon. The technique was performed in theatre with regional anaesthetic. Clinical and endoscopic follow up was carried out. RESULTS The study included 25 males (73.5%) and 9 women (26.5%), with a mean age of 69 years (32-80) who had rectal bleeding due to radiation proctitis and required admission. All treatments failed in 6 (28.5%) patients, and 4% formaldehyde was used, with a complete response to the bleeding in all 6 patients, with 3 cases requiring one session, and the 3 others 2 sessions. The gauze technique was used in 4 patients and another 2 were given a formaldehyde enema due to the presence of stenosis. Pain appeared as the main complication in 2 (33.3%) patients. The median follow up was 60 months (interquartile range 26 to 67 months). CONCLUSIONS The use of 4% formaldehyde in bleeding due to radiation proctitis is an effective, easy to reproduce technique, with a low morbidity.
Collapse
Affiliation(s)
- Carlos Placer
- Sección de Cirugía Colorrectal, Hospital Universitario Donostia, San Sebastián, España.
| | | | | | | | | |
Collapse
|
38
|
Daram SR, Lahr C, Tang SJ. Anorectal bleeding: etiology, evaluation, and management (with videos). Gastrointest Endosc 2012; 76:406-17. [PMID: 22817792 DOI: 10.1016/j.gie.2012.03.178] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/13/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Sumanth R Daram
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA
| | | | | |
Collapse
|
39
|
Nelamangala Ramakrishnaiah VP, Javali TD, Dharanipragada K, Reddy KS, Krishnamachari S. Formalin dab, the effective way of treating haemorrhagic radiation proctitis: a randomized trial from a tertiary care hospital in South India. Colorectal Dis 2012; 14:876-82. [PMID: 22356304 DOI: 10.1111/j.1463-1318.2012.03008.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM Chronic radiation proctitis with bleeding is a common problem encountered following radiotherapy for pelvic malignancy. Sucralfate-steroid enema and formalin dab are two common nonsurgical treatments. A randomized trial was conducted to compare the efficacy of these two methods. METHOD This was a prospective randomized controlled trial conducted in the Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER) from August 2005 to May 2007. One-hundred and two patients with chronic radiation proctitis, presenting as rectal bleeding after radiotherapy for carcinoma of the cervix, were recruited and randomly allocated into two treatment groups: Group 1, formalin dab; and Group 2, sucralfate-steroid retention enema. The mean age of the patients was 51.3 ± 5.1 years. The mean interval between the end of radiotherapy and the onset of bleeding was 12.3 ± 3.5 months. Symptom score and sigmoidoscopic grade were assessed before, and at 1 month after, treatment. RESULTS Ninety per cent of patients in Group 1 and 74.5% of patients in Group 2 responded to treatment (P = 0.038). In spite of having a higher median symptom score before treatment, patients in Group 1 demonstrated a marked decrease in symptom score after treatment compared with patients in Group 2 and the difference once again was statistically significant (P = 0.000). Similarly, the median sigmoidoscopic grade was significantly lower for patients in Group 1 compared with patients in Group 2 after treatment (P = 0.000). There were no specific treatment-related complications in either group. CONCLUSIONS Formalin (4%) dab is superior to sucralfate-steroid retention enema for treatment of chronic haemorrhagic radiation proctitis.
Collapse
|
40
|
Radiation proctitis: current strategies in management. Gastroenterol Res Pract 2011; 2011:917941. [PMID: 22144997 PMCID: PMC3226317 DOI: 10.1155/2011/917941] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 06/15/2011] [Accepted: 08/23/2011] [Indexed: 12/11/2022] Open
Abstract
Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically, and an understanding of the available modalities is crucial in the management of these patients. In this paper, we focus on the current treatments of radiation proctitis.
Collapse
|
41
|
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: 1.8] [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
|
42
|
Teixeira FV, Denadai R, Ferraz RA, Goulart RDÁ, Saad-Hossne R. Instilação de formalina endoluminal como opção terapêutica da retite actínica hemorrágica. REVISTA BRASILEIRA DE COLOPROCTOLOGIA 2011. [DOI: 10.1590/s0101-98802011000100005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A retite actínica hemorrágica é um quadro grave que pode ocorrer em qualquer paciente submetido à radioterapia pélvica, por vezes, sendo necessária terapia transfusional e internação hospitalar. A abordagem terapêutica ainda é bastante controversa. Tanto para o tratamento inicial como para casos refratários, uma das opções é a aplicação de formalina. Este método é barato, facilmente disponível, de simples execução e eficaz no controle da hemorragia. Os autores relatam dois casos de retite actínica hemorrágica de pacientes tratados com instilação de formalina endoluminal, e sua eficácia terapêutica e complicações são discutidas
Collapse
Affiliation(s)
| | | | | | | | - Rogério Saad-Hossne
- Universidade Estadual Paulista; Sociedade Brasileira de Coloproctologia, Brasil
| |
Collapse
|
43
|
Appalaneni V, Fanelli RD, Sharaf RN, Anderson MA, Banerjee S, Ben-Menachem T, Decker GA, Fisher L, Fukami N, Harrison ME, Strohmeyer L, Friis C, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Dominitz JA. The role of endoscopy in patients with anorectal disorders. Gastrointest Endosc 2010; 72:1117-23. [PMID: 21111864 DOI: 10.1016/j.gie.2010.04.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 04/14/2010] [Indexed: 02/08/2023]
|
44
|
Jongen J, Peleikis HG, Eberstein A, Bock JU, Kahlke V. Proktitis aus Sicht der Proktologie*. COLOPROCTOLOGY 2010. [DOI: 10.1007/s00053-010-0116-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
45
|
Hazewinkel M, Sprangers M, van der Velden J, van der Vaart C, Stalpers L, Burger M, Roovers J. Long-term cervical cancer survivors suffer from pelvic floor symptoms: A cross-sectional matched cohort study. Gynecol Oncol 2010; 117:281-6. [DOI: 10.1016/j.ygyno.2010.01.034] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 01/17/2010] [Accepted: 01/25/2010] [Indexed: 10/19/2022]
|
46
|
Patel P, Subhas G, Gupta A, Chang YJ, Mittal VK, McKendrick A. Oral vitamin A enhances the effectiveness of formalin 8% in treating chronic hemorrhagic radiation proctopathy. Dis Colon Rectum 2009; 52:1605-9. [PMID: 19690489 DOI: 10.1007/dcr.0b013e3181afbe3a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Chronic radiation proctopathy occurs in 5 to 20% of patients receiving radiation therapy, with rectal bleeding as its most common presentation. Although formalin treatment for rectal bleeding is promising, improvement is possible. Given the success of vitamin A in other radiation-induced treatments, we studied the efficacy of combining formalin with vitamin A in controlling bleeding symptoms of chronic radiation proctopathy. METHODS A retrospective review (1993-2007) was performed of patients presenting with features of chronic radiation proctopathy. Formalin 8% in a buffered solution was applied to the affected mucosa with use a tip applicator, and 10,000 units of vitamin A were given orally on a daily basis. Formalin treatments were repeated at three-week to four-week intervals until symptoms resolved. RESULTS A comparison was made between patients who received formalin alone (n = 30) and those who received formalin in combination with vitamin A (n = 34). The 64 patients had a mean age of 79 years (range, 54-90 years). The combination group required fewer treatments (mean, 1.9) and a shorter time (11 weeks) for resolution of symptoms compared with the formalin-alone group (mean, 5.2 and 31 weeks, respectively) (P < 0.001). The overall success rate in controlling bleeding was only 64% in the formalin-alone group when compared with 94% in the combination group. CONCLUSIONS When vitamin A was added to the regimen, a significant reduction was observed in the number of treatments and the time needed for resolution of symptoms, and there was an increased overall success rate. This combination represents a simple, effective, and well tolerated method of controlling hemorrhagic chronic radiation proctopathy.
Collapse
Affiliation(s)
- Purnal Patel
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan 48075, USA
| | | | | | | | | | | |
Collapse
|
47
|
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
|
48
|
Abstract
PURPOSE OF REVIEW Radiotherapy frequently results in persistent effects on gastrointestinal function adversely impacting on the quality of life of patients cured of their malignant disease. Long-term effects on gastrointestinal function remain prevalent despite the advent of three-dimensional techniques of radiotherapy because higher radiation doses and more combined modality treatments are prescribed to improve cure rates. RECENT FINDINGS Chronic elevation of cytokine levels and implication of the cyclooxygenase-2 pathway in radiation bowel injury in animals, and the involvement of the Rho/Rho kinase pathway in the fibrogenic differentiation of smooth muscle cells of patients with late radiation enteritis, suggest a role for inhibition of these pathways. The importance of limiting acute gastrointestinal toxicity by dietary, pharmacological and physical interventions and of optimizing radiotherapy techniques and prescriptions is underscored by increasing evidence that a component of the long-term effects of radiotherapy on gastrointestinal function is a consequence of acute damage. SUMMARY Strategies to control acute toxicity are important in reducing the impact of long-term effects of radiotherapy on gastrointestinal function. Further research into genetic profiling to characterize individual risk of radiation bowel damage and the pathways implicated in fibrogenic differentiation is needed to reduce and prevent bowel complications.
Collapse
|
49
|
Huang H, Lu JG, Cao YQ. [Advances in treatment of radiation proctitis]. ZHONG XI YI JIE HE XUE BAO = JOURNAL OF CHINESE INTEGRATIVE MEDICINE 2008; 6:975-978. [PMID: 18782547 DOI: 10.3736/jcim20080921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- He Huang
- Department of Anorectal Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China.
| | | | | |
Collapse
|
50
|
Abbas MA. Intramural formalin injection for rectal ulcer refractory to medical and endoscopic treatment. Dis Colon Rectum 2008; 51:1160-1; author reply 1162. [PMID: 18317840 DOI: 10.1007/s10350-008-9245-0] [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: 08/10/2007] [Revised: 08/20/2007] [Accepted: 09/23/2007] [Indexed: 02/08/2023]
|