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1
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Zhang H, Zhang Z, Yuan S. Chinese clinical practice guidelines for the prevention and treatment of radiation-induced rectal injury. PRECISION RADIATION ONCOLOGY 2023; 7:237-255. [PMID: 40336868 PMCID: PMC11935203 DOI: 10.1002/pro6.1217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 05/09/2025] Open
Abstract
Although radiotherapy plays an important role in the treatment of cancer, it may have negative effects in some individuals. Rectal injury is a common adverse effect of abdominal and pelvic radiotherapy. This injury is caused by administering radiation to the abdomen. Appropriate treatment techniques can be determined if doctors have a better understanding of the incidence, risk factors, and clinical symptoms of radiation-induced rectal injuries. Studies on the underlying pathophysiology of radiation-induced rectal injury may aid in the development of effective treatment and prevention strategies. The implementation of efficient preventive measures can improve the quality of life of patients with cancer and make it easier for them to complete their treatment. Therefore, comprehensive and accurate assessments are crucial for developing holistic and individualized treatment plans for patients who have already developed symptoms, with early intervention being a priority.
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Affiliation(s)
- Hui Zhang
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghaiChina
| | - Zhen Zhang
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghaiChina
- China Anti‐Cancer Association Tumor Support Therapy Committee
- China Anti‐Cancer Association Tumor Radiation Protection Committee
- Chinese Radiation Therapy Oncology Group
| | - Shuanghu Yuan
- China Anti‐Cancer Association Tumor Support Therapy Committee
- China Anti‐Cancer Association Tumor Radiation Protection Committee
- Chinese Radiation Therapy Oncology Group
- Department of RadiologyShandong Cancer HospitalJinanChina
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2
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Pattarajierapan S, Amornwichet N, Khomvilai S. Rectal irrigation as rescue therapy for refractory and severe hemorrhagic radiation proctitis: A case report. Clin Case Rep 2021; 9:e04985. [PMID: 34721856 PMCID: PMC8529883 DOI: 10.1002/ccr3.4985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 11/06/2022] Open
Abstract
Rectal irrigation may be considered in refractory and severe hematochezia from chronic radiation proctitis before performing other invasive treatments. It prevents superimposed infection and effectively reduces bleeding.
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Affiliation(s)
- Sukit Pattarajierapan
- Surgical Endoscopy Colorectal Division, Department of SurgeryFaculty of Medicine, Chulalongkorn UniversityBangkokThailand
| | - Napapat Amornwichet
- Division of Radiation Oncology, Department of RadiologyFaculty of Medicine, Chulalongkorn UniversityBangkokThailand
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of SurgeryFaculty of Medicine, Chulalongkorn UniversityBangkokThailand
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3
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Botulinum Toxin Injection for the Treatment of the Recurrent Rectovaginal Fistulas in Combination with Surgical Repair. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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4
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Steinhauff D, Jensen M, Talbot M, Jia W, Isaacson K, Jedrzkiewicz J, Cappello J, Oottamasathien S, Ghandehari H. Silk-elastinlike copolymers enhance bioaccumulation of semisynthetic glycosaminoglycan ethers for prevention of radiation induced proctitis. J Control Release 2021; 332:503-515. [PMID: 33691185 DOI: 10.1016/j.jconrel.2021.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/17/2021] [Accepted: 03/01/2021] [Indexed: 12/22/2022]
Abstract
Radiation-induced proctitis (RIP) is a debilitating adverse event that occurs commonly during lower abdominal radiotherapy. The lack of prophylactic treatment strategies leads to diminished patient quality of life, disruption of radiotherapy schedules, and limitation of radiotherapy efficacy due to dose-limiting toxicities. Semisynthetic glycosaminoglycan ethers (SAGE) demonstrate protective effects from RIP. However, low residence time in the rectal tissue limits their utility. We investigated controlled delivery of GM-0111, a SAGE analogue with demonstrated efficacy against RIP, using a series of temperature-responsive polymers to compare how distinct phase change behaviors, mechanical properties and release kinetics influence rectal bioaccumulation. Poly(lactic acid)-co-(glycolic acid)-block-poly(ethylene glycol)-block-poly(lactic acid)-co-(glycolic acid) copolymers underwent macroscopic phase separation, expelling >50% of drug during gelation. Poloxamer compositions released GM-0111 cargo within 1 h, while silk-elastinlike copolymers (SELPs) enabled controlled release over a period of 12 h. Bioaccumulation was evaluated using fluorescence imaging and confocal microscopy. SELP-415K, a SELP analogue with 4 silk units, 15 elastin units, and one elastin unit with lysine residues in the monomer repeats, resulted in the highest rectal bioaccumulation. SELP-415K GM-0111 compositions were then used to provide localized protection from radiation induced tissue damage in a murine model of RIP. Rectal delivery of SAGE using SELP-415K significantly reduced behavioral pain responses, and reduced animal mass loss compared to irradiated controls or treatment with traditional delivery approaches. Histological scoring showed RIP injury was ameliorated for animals treated with GM-0111 delivered by SELP-415K. The enhanced bioaccumulation provided by thermoresponsive SELPs via a liquid to semisolid transition improved rectal delivery of GM-0111 to mice and radioprotection in a RIP model.
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Affiliation(s)
- D Steinhauff
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - M Jensen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - M Talbot
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - W Jia
- Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - K Isaacson
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - J Jedrzkiewicz
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
| | - J Cappello
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT 84112, USA
| | - S Oottamasathien
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - H Ghandehari
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA; Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT 84112, USA.
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5
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Huang X, Zhong Q, Wang H, Zhao J, Kuang Y, Guan Q, He Y, Qin Q, Wang H, Ma T. Diverting colostomy is an effective procedure for ulcerative chronic radiation proctitis patients after pelvic malignancy radiation. BMC Surg 2020; 20:267. [PMID: 33143666 PMCID: PMC7607838 DOI: 10.1186/s12893-020-00925-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/22/2020] [Indexed: 02/06/2023] Open
Abstract
Background Chronic radiation proctitis (CRP) with rectal ulcer is a common complication after pelvic malignancy radiation, and gradually deteriorating ulcers will result in severe complications such as fistula. The aim of this study was to evaluate effect of colostomy on ulcerative CRP and to identify associated influence factors with effectiveness of colostomy. Methods Between November 2011 to February 2019, 811 hospitalized patients were diagnosed with radiation-induced enteritis (RE) in Sun Yat-sen University Sixth Affiliated Hospital, among which 284 patients presented with rectal ulcer, and 61 ulcerative CRP patients were retrospectively collected and analyzed. Results The overall effective rate of colostomy on ulcerative CRP was 49.2%, with a highest effective rate of 88.2% within 12 to 24 months after colostomy. 9 (31.1%) CRP patients with ulcers were cured after colostomy and 12 (19.67%) patients restored intestinal continuity, among which including 2 (3.3%) patients ever with rectovaginal fistula. 100% (55/55) patients with rectal bleeding and 91.4% (32/35) patients with anal pain were remarkably alleviated. Additionally, multivariable analysis showed the duration of stoma [OR 1.211, 95% CI (1.060–1.382), P = 0.005] and albumin (ALB) level post-colostomy [OR 1.437, 95% CI (1.102–1.875), P = 0.007] were two independent influence factors for the effectiveness of colostomy on the rectal ulcer of CRP patients. Conclusions Colostomy was an effective and safe procedure for treating rectal ulcer of CRP patients, and also a potential strategy for preventing and treating fistula. Duration of stoma for 12–24 months and higher ALB level could significantly improve the effectiveness of colostomy on ulcerative CRP patients.
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Affiliation(s)
- Xiaoyan Huang
- Guangdong Institute of Gastroenterology, Sun Yat-Sen University Sixth Affiliated Hospital, Guangzhou, 510655, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-Sen University Sixth Affiliated Hospital, Guangzhou, 510655, Guangdong, China
| | - Qinghua Zhong
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China.,Department of Endoscopic Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China
| | - Huaiming Wang
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China
| | - Jie Zhao
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China
| | - Yingyi Kuang
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China
| | - Qi Guan
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China
| | - Yanjiong He
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China
| | - Qiyuan Qin
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China
| | - Hui Wang
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China.
| | - Tenghui Ma
- Department of Colorectal Surgery, Sun Yat-Sen University Sixth Affiliated Hospital, No. 26 Yuancun Erheng Road, Guangzhou, 510655, Guangdong, China.
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6
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Ryoo SB, Oh HK, Ha HK, Han EC, Kwon YH, Song I, Moon SH, Choe EK, Park KJ. Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences. Ann Surg Treat Res 2019; 97:149-156. [PMID: 31508396 PMCID: PMC6722290 DOI: 10.4174/astr.2019.97.3.149] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/04/2019] [Accepted: 07/19/2019] [Indexed: 12/30/2022] Open
Abstract
Purpose Rectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures. Methods Between 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted. Results The median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058). Conclusion Radiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.
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Affiliation(s)
- Seung-Bum Ryoo
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Heung-Kwon Oh
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Division of Colorectal Surgery, Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Heon-Kyun Ha
- Division of Colorectal Surgery, Department of Surgery, Myongji Hospital, Goyang, Korea
| | - Eon Chul Han
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Division of Colorectal Surgery, Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Yoon-Hye Kwon
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Song
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hui Moon
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Choe
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Kyu Joo Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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7
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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.
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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
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8
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Emphasis on Repair, Not Just Avoidance of Injury, Facilitates Prudent Stereotactic Ablative Radiotherapy. Semin Radiat Oncol 2017; 27:378-392. [DOI: 10.1016/j.semradonc.2017.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Zhong Q, Yuan Z, Ma T, Wang H, Qin Q, Chu L, Wang J, Wang L. Restorative resection of radiation rectovaginal fistula can better relieve anorectal symptoms than colostomy only. World J Surg Oncol 2017; 15:37. [PMID: 28153025 PMCID: PMC5288935 DOI: 10.1186/s12957-017-1100-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/12/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Radiation-induced rectovaginal fistula (RVF) is a severe and difficult complication after pelvic malignancy radiation. This study was to retrospectively compare the outcomes of restorative resection and colostomy only in remission of anorectal symptoms. METHODS We enrolled a cohort of 26 consecutive cases who developed RVF after pelvic radiation. Two main procedures for these patients in our institution were used: one was restorative resection and pull-through coloanal anastomosis with a prophylactic colostomy, and another was a simple colostomy without resection. Thus, we divided these patients into these two groups. Anorectal symptoms including rectal pain, bleeding, tenesmus, and perineal mucous discharge were recorded and scored prior to surgery and at postoperative multiple time points. RESULTS The baseline was similar among the two groups. All patients acquired good efficacy with improved symptoms at postoperative 6, 12, and 24 months, when compared to baseline. In addition, the resection group showed a better remission of tenesmus (6 months 33.3 vs 0%; 12 months 66.7 vs 16.7%) and perineal mucous discharge (6 months 88.9 vs 6.7%; 12 months 77.8 vs 15.4%; 24 months 85.7 vs 25.0%). Furthermore, three (30%) patients in the resection group successfully reversed stomas while no stoma was closed in the simple colostomy group. CONCLUSIONS Both restorative resection procedure and colostomy only can improve anorectal symptoms of radiation-induced RVF, but restorative resection can completely relieve anorectal symptoms in selected cases.
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Affiliation(s)
- Qinghua Zhong
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zixu Yuan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - Tenghui Ma
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Huaiming Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qiyuan Qin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Lili Chu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jianping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor, Sun Yat-sen University, No.26, Road Yuancun ErHeng Road, Tianhe District, Guangzhou, 510655, China
| | - Lei Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor, Sun Yat-sen University, No.26, Road Yuancun ErHeng Road, Tianhe District, Guangzhou, 510655, China.
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10
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Weiner J, Schwartz D, Martinez M, Safdieh J, Aytaman A, Schreiber D. Long-term results on the efficacy of argon plasma coagulation for patients with chronic radiation proctitis after conventionally fractionated, dose-escalated radiation therapy for prostate cancer. Pract Radiat Oncol 2016; 7:e35-e42. [PMID: 27663931 DOI: 10.1016/j.prro.2016.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/23/2016] [Accepted: 07/27/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE This study was designed to assess the efficacy and outcomes of argon plasma coagulation (APC) in the management of chronic radiation proctitis after conventionally fractionated, dose-escalated radiation therapy (≥7560 cGy). METHODS AND MATERIALS We retrospectively reviewed the charts on all patients treated with external beam radiation therapy (minimum dose, 7560 cGy) for histologically confirmed prostate cancer at our institution from 2003 to 2011. Five hundred patients met these criteria; of these, 35 patients (7.0%) developed radiation proctitis necessitating intervention with APC. Indications for APC treatment were either the need for blood transfusions resulting from proctitis-related anemia or refractory bleeding despite medical management. RESULTS The median follow-up from the completion of radiation treatment was 78 months (range, 19-129) and the median follow up from the most recent APC treatment was 56 months (range, 3-112). Fifteen men (42.9%) needed blood transfusions because of proctitis-related anemia. For 19 patients (54.3%), bleeding was controlled after 1 or 2 treatments. Eventual bleeding control was obtained in 30 patients (85.7%). The median number of sessions per patient was 2 (range, 1-13). Post-APC ulceration was noted in 8 cases (22.9%). Two patients (5.7%) developed colovesicular fistulas, with 1 patient dying from this complication. A short interval between treatments (≤35 days) was associated with an increased risk of ulcer or fistula formation. CONCLUSIONS APC is an effective treatment for patients with medically refractive radiation proctitis after dose-escalated radiation therapy, frequently controlling bleeding after only one or two sessions. However, rectal ulceration is a common complication, along with a small risk of life-threatening toxicity.
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Affiliation(s)
- Joseph Weiner
- Department of Radiation Oncology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York.
| | - David Schwartz
- Department of Radiation Oncology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Manuel Martinez
- Department of Gastroenterology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Gastroenterology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Joseph Safdieh
- Department of Radiation Oncology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Ayse Aytaman
- Department of Gastroenterology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York
| | - David Schreiber
- Department of Radiation Oncology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, New York; Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, New York
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Nelamangala Ramakrishnaiah VP, Krishnamachari S. Chronic haemorrhagic radiation proctitis: A review. World J Gastrointest Surg 2016; 8:483-491. [PMID: 27462390 PMCID: PMC4942748 DOI: 10.4240/wjgs.v8.i7.483] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 01/06/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023] Open
Abstract
Chronic haemorrhagic radiation proctitis (CHRP) is a difficult problem faced by the patients following radiation for pelvic malignancy. There is no standard treatment for this condition, but many methods of treatment are available. The aim of this study was to review the literature to see whether there is an improvement in the available evidence in comparison with previously published systematic reviews in treating patients with CHRP. The PubMed/Medline database and Google Scholar search was selectively searched. Studies, which treated patients with rectal bleeding due to chronic radiation proctitis or CHRP, were included. Seventy studies were finally selected out of which 14 were randomized controlled clinical trials. Though these studies could not be compared, it could be seen that there was an improvement in the methodology of the studies. There was an objective assessment of symptoms, signs and an objective assessment of outcomes. But, still, there were only a few studies that looked into the quality of life following treatment of CHRP. To increase recruitment to trials, a national registry of cases with established late radiation toxicity would facilitate the further improvement of such studies. Some of the conclusions that could be reached based on the available evidence are 4% formalin should be the first line treatment for patients with CHRP. Formalin and argon plasma coagulation (APC) are equally effective, but formalin is better for severe disease. Refractory patients, not responding to formalin or APC, need to be referred for hyperbaric oxygen therapy or surgery. Radio-frequency ablation is a promising modality that needs to be studied further in randomized trials.
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12
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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: 1.4] [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.
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13
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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.
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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
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14
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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: 3.9] [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.
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Pigò F, Bertani H, Manno M, Mirante VG, Caruso A, Conigliaro RL. Radiofrequency ablation for chronic radiation proctitis: our initial experience with four cases. Tech Coloproctol 2014; 18:1089-1092. [PMID: 24915942 DOI: 10.1007/s10151-014-1178-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 05/31/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic radiation proctitis (CRP) occurs up to 20 % of patients after pelvic radiotherapy, with rectal bleeding as the main presenting complaint. Radiofrequency ablation (RFA) has recently been used in the management of Barrett's esophagus, but its efficacy in CRP has to be studied. The aim of this case series was to describe four cases of patients with CRP treated with RFA that demonstrate the efficacy and safety of the technique. METHODS All the procedures were performed with HALO 90 or HALO 90 Ultra ablation catheter fitted on the distal end of a standard flexible endoscope. For each patient, the severity of symptoms was assessed at baseline and after the last treatment session. RESULTS At least two sessions of RFA (maximum 4) were necessary, at three-month intervals, to completely control the symptoms. No major complications were observed. CONCLUSIONS RFA was effective and safe for control bleeding in this case series. Adequately powered randomized controlled trials are needed to establish the safety and efficacy of RFA for CRP.
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Affiliation(s)
- F Pigò
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Modena, Italy,
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Abstract
Radiation damage to the rectum following radiotherapy for pelvic malignancies can range from acute dose-limiting side effects to major morbidity affecting health-related quality of life. No standard guidelines exist for diagnosis and management of radiation proctitis. This article reviews the definitions, staging, and clinical features of radiation proctitis, and summarizes the modalities available for the treatment of acute and chronic radiation proctitis. Because of the paucity of well-controlled, blinded, randomized studies, it is not possible to fully assess the comparative efficacy of the different approaches to management. However, the evidence and rationale for use of the different strategies are presented.
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Affiliation(s)
- Ankit Sarin
- Division of Colon and Rectal Surgery, University of California-San Francisco, San Francisco, CA, USA
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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: 5.2] [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.
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Abstract
Radiation therapy is commonly utilized as a major component in the treatment of pelvic malignancy. Unfortunately, secondary toxicity to the lower gastrointestinal tract can occur. This most commonly affects the rectum, although injuries to the colon and small intestine are not uncommon. The presentation can be acute or chronic, and different mechanisms are responsible for each. Symptomatology is quite variable but can result in significant compromise for the patient. Numerous preventive and treatment strategies have been applied to this disease process. This article presents a summary of the current knowledge regarding radiation injury to the lower gastrointestinal tract with special emphasis on treatment options for radiation proctitis.
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Affiliation(s)
- Gregory D Kennedy
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin 53792-7375, USA
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19
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Bowel perforation from bevacizumab for the management of colorectal cancer. Anticancer Drugs 2009; 20 Spec No 2:S19-21. [PMID: 19352105 DOI: 10.1097/01.cad.0000349759.64373.e9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bevacizumab (Avastin) is a recently developed monoclonal antibody, which targets the vascular endothelial growth factor receptor pathway, and is currently used in combination with cytotoxic agents as first-line or second-line therapy for patients with metastatic colon cancer. Common complications from administration of bevacizumab include hypertension, proteinuria, and diarrhea. These complications are typically managed conservatively. More serious complications of bevacizumab administration include venous thromboembolism, bleeding, and bowel perforation. Although these complications are much more infrequent, prompt recognition is imperative for adequate and timely management. In this report, we discuss a patient with bowel perforation from bevacizumab for the treatment of metastatic colorectal cancer.
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Affiliation(s)
- Norio KAWAMURA
- Department of Internal Medicine, Cancer Institute Hospital, Tokyo, Japan
| | - Tomoko ISHIBASHI
- Department of Internal Medicine, Cancer Institute Hospital, Tokyo, Japan
| | - Kouichi KOIZUMI
- Department of Internal Medicine, Cancer Institute Hospital, Tokyo, Japan
| | - Shunkichi KAI
- Department of Internal Medicine, Cancer Institute Hospital, Tokyo, Japan
| | - Takao TAKEKOSHI
- Department of Internal Medicine, Cancer Institute Hospital, Tokyo, Japan
| | - Masakazu MARUYAMA
- Department of Internal Medicine, Cancer Institute Hospital, Tokyo, Japan
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21
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Petersen S, Jongen J, Petersen C, Sailer M. Radiation-induced sequelae affecting the continence organ: incidence, pathogenesis, and treatment. Dis Colon Rectum 2007; 50:1466-74. [PMID: 17661143 DOI: 10.1007/s10350-007-0296-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Incontinence is a late complication that causes symptoms years after radiation treatment and is difficult to deal with; it poses a particular challenge for care-providing physicians. REVIEW This review looks at our current knowledge of the incidence, symptoms, and treatment of fecal incontinence induced by radiation treatment. An approximate estimation based on retrospective data suggests an incidence of fecal incontinence of up to one-third of patients. The mechanism that causes incontinence are changes in anal resting tone, squeeze pressure, and rectal volume or rectal compliance. The other associated aspects of incontinence include such further disorders as proctitis, colitis, and other disturbances involving the lower digestive tract. The therapeutic options mainly comprise the treatment of associated aspects, such as proctitis or diarrhea. CONCLUSION Surgical treatment should be the absolute exception. If the creation of a stoma is being considered, a resective procedure offering freedom from symptoms seems to be the more advantageous option.
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Affiliation(s)
- Sven Petersen
- Department of Surgery, Bethesda General Hospital Hamburg Bergedorf, Glindersweg 80, 21029, Hamburg, Germany.
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Heinzerling JH, Huerta S. Bowel perforation from bevacizumab for the treatment of metastatic colon cancer: incidence, etiology, and management. ACTA ACUST UNITED AC 2006; 63:334-7. [PMID: 16971205 DOI: 10.1016/j.cursur.2006.06.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2006] [Revised: 06/14/2006] [Accepted: 06/14/2006] [Indexed: 12/19/2022]
Abstract
Avastin (Bevacizumab) is a recently developed monoclonal antibody against vascular endothelial growth factor (VEGF) receptor that increases survival in patients with metastatic colorectal cancer. Bowel perforation is a known risk factor of unknown etiology associated with the use of Avastin. In this report, the incidence, risk factors, typical presentation, and management of patients with this complication is described.
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Affiliation(s)
- John H Heinzerling
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Tomori H, Yasuda T, Shiraishi M, Isa T, Muto Y, Egawa H. Radiation-associated ischemic coloproctitis: report of two cases. Surg Today 1999; 29:1088-92. [PMID: 10554336 DOI: 10.1007/s005950050650] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Radiation-associated ischemic coloproctitis is a rare clinical entity caused by vascular insufficiency to the rectosigmoid colon. It most commonly occurs after radiotherapy for gynecological cancer. We present herein the cases of two patients who developed radiation-associated coloproctitis with transmural necrosis and eventual perforation. Perforation of the rectosigmoid colon occurred 3.5 years after radiotherapy in case 1, a 46-year-old woman, and presented as a well-defined small area of transmural necrosis. Conversely, in case 2, a 55-year-old woman, it occurred 1.5 years after radiotherapy, and presented as segmental, diffuse transmural necrosis. The lesion in case 1 had been caused by intramural vascular obliteration due to marked fibrosis of the bowel wall, while that in case 2 had been caused by occlusion of the mesenteric artery with thrombosis. Both patients underwent Hartmann's resection without rectal excision, and survived the perforative event.
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Affiliation(s)
- H Tomori
- Department of Surgery I, Clinical Laboratory Medicine, Faculty of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa 903-0215, Japan
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Affiliation(s)
- M R Yates
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, The Mayo Clinic, Rochester, Minnesota, USA
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25
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Rossi BM, Nakagawa WT, Fernandes JA, Lopes A, Paegle LD. Treatment of severe actinic rectitis. SAO PAULO MED J 1998; 116:1629-33. [PMID: 9699386 DOI: 10.1590/s1516-31801998000100007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The authors report the treatment of three female patients with severe actinic rectitis, with stenosis or perforation, submitted to anterior proctosigmoidectomy and transanal coloanal anastomosis. METHODS In all cases surgery consisted of total proctosigmoidectomy, mucosectomy of the anal canal, lowering of the left colon through the pelvis and transanal anastomosis performed manually at the level of the pectineal line using separate absorbable sutures. A protective intestinal shunt was performed in all cases. RESULTS The three patients did not present transoperative or immediate postoperative complications, but the first patient developed deep venous thrombosis of the leg that was submitted to successful clinical treatment. The intestinal shunts were later closed in all three cases. Sphicter function was considered very good in the first case and regular in the remaining two. CONCLUSION The surgical technique utilized was considered to be adequate for the cases reported and is the first option for the maintenance of transit in patients with severe actinic rectitis since the anastomosis is performed using non-irradiated colon with the pectineal line, practically outside the pelvis.
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Affiliation(s)
- B M Rossi
- Surgery Department, Hospital A.C. Camargo e Fundação Antônio Prudente-São Paulo, Brazil
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Abstract
Although radiation has proven itself valuable in the treatment of a variety of pelvic malignancies, it is not without serious morbidity. This article has outlined the incidence of acute and chronic injury, ways to prevent the occurrence of complications, and the use of new medical and surgical treatments.
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