The ileocecal reservoir for rectal replacement in complicated radiation proctitis

The surgical management of radiation proctopathy

BACKGROUND

There is sparse evidence guiding the optimum surgical management of patients with radiation proctopathy (RP). The purpose of this review is to analyse all the literature on the surgical management of RP in order to guide physicians and surgeons as to when and what surgery should be employed for these patients.

METHODS

A literature search of PubMed, EMBASE, MEDLINE, Ovid, and Cochrane Library using the MeSH terms "radiation proctopathy", "proctitis", "surgical management", and related terms as keywords was performed. The review included all articles that reported on the surgical management of patients with radiation proctopathy. All relevant articles were cross-referenced for further articles and any unavailable online were retrieved from hard-copy archive libraries. Eighteen studies including one prospective cohort study, fifteen retrospective cohort studies, and three small case series are included.

CONCLUSION

Surgery is indicated for patients with RP for rectal obstruction, perforation, fistulae, or a failure of medical measures to control the symptoms of RP. Surgery centres mainly on diversion version resection. Diversion alone does not remove the damaged tissue leaving the patient at risk of continued complications including bleeding, perforation, occlusion, and abscess formation; however, major resectional surgery carries higher risks. Morbidity and mortality vary 0-44% and 0-11% for diversion only versus 0-100% and 0-14% for resectional surgery. There is no universally agreed surgical first-line approach. The data supports both resection with defunctioning stoma or diversion only as reasonable first-line surgical options for patients requiring surgery for RP.

Radiofrequency ablation using BarRx for the endoscopic treatment of radiation proctopathy: a series of three cases

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.

Prospective randomised trial comparing ileocaecal interposition and colon-J-pouch as rectal replacement after total mesorectal excision

BACKGROUND

Ileocaecal interposition (ICI) is a technique of rectal replacement after total mesorectal excision (TME), but the method has never been evaluated in a randomised fashion. We performed a randomised, controlled trial to compare ICI and colon-J-pouch (CJP) for rectal replacements after TME for rectal cancer.

MATERIALS AND METHODS

Fifteen patients were enrolled into each treatment group of the trial according to the protocol. Follow-up evaluations were performed 3 months and 1 year after ileostomy closure and at a mean of 5 years after initial surgery.

RESULTS

Similar results between the groups were found for incontinence, urgency, constipation and quality of life at all follow-ups. The frequency of defecation was slightly lower in the CJP group at 3 months [3 (2-6) vs 5 (2-11) (p=0.043)] and at 1 year [3 (2-5) vs 5 (2-8) (p=0.034)]. However, this difference lost significance if patients who had postoperative radiotherapy were excluded from the analysis. Four out of the 15 patients treated with ICI experienced bowel obstruction, which required open surgery in two, endoscopic dilatation in one or maintenance of the ileostomy in one patient. None of the patients treated with CJP had similar complications.

CONCLUSIONS

ICI and CJP reconstruction result in a similar functional outcome and quality of life. As ICI did not show any benefit over CJP and tended to result in a higher frequency of defecation, it should not be used as a first choice treatment. In addition, ICI was associated with significant complications after radiotherapy. Therefore, it must not be used if postoperative radiochemotheray is intended.

Review article: current therapeutic options for radiation proctopathy

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

Anorectal injury following pelvic radiotherapy

BACKGROUND

Current knowledge of the effects of radiation on the anorectum is based on a limited number of studies. Variability in delivery techniques, both currently and historically, combined with a paucity of prospective and randomized studies makes interpretation of the literature difficult. This review presents the existing evidence and identifies areas that require further work.

METHODS

This review is based on a literature search (Medline and PubMed) and manual cross-referencing.

RESULTS AND CONCLUSION

More than three-quarters of patients receiving pelvic radiotherapy experience acute anorectal symptoms and up to one-fifth suffer from late-phase radiation proctitis. About 5 per cent develop other chronic complications, such as fistula, stricture and disabling faecal incontinence. The risk of rectal cancer may be increased. Conservative treatment options are of limited value. Surgery may be considered if symptoms are severe, provided sphincter function is adequate and recurrent disease is excluded. Large prospective studies with accurate dosimetric data and long-term follow-up are needed to provide meaningful information on which to base new strategies to minimize the side-effects from radiotherapy.

Colonic J pouch reconstruction of the radiation-damaged neorectum

BACKGROUND

Postoperative radiotherapy after restorative resection for rectal carcinoma can cause fibrosis, stricture and proctitis. There are few accounts in the literature of the surgical approach to the radiation-damaged neorectum.

METHODS

Reported are four patients who underwent resection of the radiation-damaged neorectum with colonic J pouch reconstruction between September 1996 and July 1997. The operative and postoperative course is described. Parameters of bowel function were assessed by standardized interview 6 months after ileostomy reversal. Ongoing follow up has occurred to the present time.

RESULTS

There was no mortality. Complications were splenic injury requiring splenectomy and a pelvic collection requiring percutaneous drainage. At 6 months after ileostomy reversal all patients had ongoing disturbance of bowel function, and two patients described some degree of incontinence. The mean frequency of bowel actions was four per day. Two patients have subsequently undergone further resection and formation of an end stoma.

CONCLUSIONS

Resection of the radiation-damaged neorectum with colonic J pouch reconstruction is technically feasible. Functional results in the present series were disappointing and half the patients went on to formation of a permanent stoma.

Argon beam coagulation for treatment of symptomatic radiation-induced proctitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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