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©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 28, 2020; 26(8): 850-864
Published online Feb 28, 2020. doi: 10.3748/wjg.v26.i8.850
Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy
Zi-Xu Yuan, Qi-Yuan Qin, Miao-Miao Zhu, Qing-Hua Zhong, Alessandro Fichera, Hui Wang, Huai-Ming Wang, Xiao-Yan Huang, Wu-Teng Cao, Ye-Biao Zhao, Lei Wang, Teng-Hui Ma
Zi-Xu Yuan, Qi-Yuan Qin, Miao-Miao Zhu, Qing-Hua Zhong, Hui Wang, Huai-Ming Wang, Xiao-Yan Huang, Ye-Biao Zhao, Lei Wang, Teng-Hui Ma, Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
Zi-Xu Yuan, Qi-Yuan Qin, Qing-Hua Zhong, Hui Wang, Huai-Ming Wang, Ye-Biao Zhao, Lei Wang, Teng-Hui Ma, 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
Wu-Teng Cao, Department of Radiology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
Author contributions: Yuan ZX, Qin QY, Ma TH, Wang L, and Wang H conceived of and designed the study; Yuan ZX, Zhu MM, Zhong QH, Zhao YB, Huang XY, and Cao WT collected the data and followed the patients; Yuan ZX, Qin QY, Huang XY, and Wang H analyzed and interpreted the data; Yuan ZX, Qin QY, and Ma TH drafted the manuscript; Yuan ZX, Wang H, Fichera A, and Ma TH made critical revisions to the manuscript.
Supported by National Natural Science Foundation of China, No. 8157120115 and No. 81803163; Natural Science Foundation of Guangdong PhD Start Grant, No. 2018A030310320 and No. 2018A030310319; 5010 Project of Sun Yat-Sen University; and Johnson & Johnson Grant for Excellent Surgeons.
Institutional review board statement: This study was approved by the Ethical Committee of The Sixth Affiliated Hospital of Sun Yat-Sen University and also according to the provisions of the World Medical Association’s Declaration of Helsinki in 1995 (updated in Tokyo, 2004).
Informed consent statement: Informed consent of this study was waived due to its retrospective nature. Patients agreed to undergo treatment by written consent.
Conflict-of-interest statement: There are no conflicts of interest to report.
STROBE statement: All items that should be included in reports of cohort studies have been included.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Teng-Hui Ma, MD, Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Road, Guangzhou 510655, Guangdong Province, China. austin_2004@163.com
Received: October 10, 2019
Peer-review started: October 30, 2019
First decision: November 22, 2019
Revised: December 4, 2019
Accepted: February 15, 2020
Article in press: February 15, 2020
Published online: February 28, 2020
ARTICLE HIGHLIGHTS
Research background
Chronic radiation proctopathy (CRP) is a common and sometimes difficult issue after radiotherapy for pelvic malignancies. Severe and refractory bleeding is hard to manage. Diverting fecal diversion is very effective and fast in remission of rectal bleeding in the management of severe CRP bleeding in our previous study, but diverting stoma is usually thought to be permanent according to the literature. The anorectal function and quality of life after stoma reversal remain unclear.
Research motivation
During the past 3 years, we have successfully performed colostomy reversals in a larger cohort of CRP patients with severe bleeding and followed patients after colostomy reversals. In this series study, we will report the efficacy of colostomy, the rate of stoma closure of diverting colostomy, and anorectal function after reversals.
Research objectives
The aim of this study was to evaluate the efficacy of colostomy and the rate of stoma reversals in severe hemorrhagic CRP.
Research methods
Patients with severe hemorrhagic CRP who underwent colostomy or conservative treatment were enrolled retrospectively. Rectal bleeding, hemoglobin (Hb), endoscopic features, endo-ultrasound (EUS), rectal manometry, and MRI scans were recorded. Anorectal functions and quality of life before stoma and after stoma reversal were scored with EORTC-QOL-C30 questionnaires.
Research results
After screening 738 continual CRP patients, 14 patients in the colostomy group and 25 patients in the conservative group as controls were enrolled. The Hb was gradually increased to normal levels in two years after colostomy, while no significant increase was observed in the conservative group. All of 14 patients obtained complete remission of bleeding and colostomy was successfully reversed in 13 of 14 (93%), except one with very old age. Improved endoscopic telangiectasia and bleeding, decreased vascularity by EUS, increased presarcal space, and thickened rectal wall by MRI were observed. Anorectal functions and quality of life were significantly improved after stoma reverse.
Research conclusions
Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP. Meanwhile, stoma can be reversed and anorectal functions can be recovered after reversal.
Research perspectives
Preventative diverting colostomy can relieve refractory bleeding before it progresses to severe life-threatening anemia and patients can obtain dramatic benefit. Thus, we have started a prospective clinical trial to enroll severe hemorrhagic CRP patients who are suitable for diverting colostomy (Clinical Trial No. NCT03397901), which will provide more evidence to the usage of colostomy in severe CRP patients.
