Arteriodigestive fistula: a complication associated with intraoperative and external beam radiotherapy following surgery for gastric cancer

Treatment experience of delayed massive gastrointestinal bleeding caused by intra-abdominal arteriointestinal fistula in gastric cancer patients after radical gastrectomy

BACKGROUND

Gastric cancer (GC) remains one of the leading causes of cancer-related death. Arteriointestinal fistula is a very rare but lethal postoperative complication in GC patients after gastrectomy. However, very few reports associated with arteriointestinal fistula have been published, and there is no matured diagnosis and treatment consensus for arteriointestinal fistula. Herein, we will investigate the etiology, clinical feature, diagnostic method, treatment, and prognosis by summarizing two patients we treated and consulting related cases reported in recent years.

CASE PRESENTATION

A 61-year-old male and 75-year-old female with advanced gastric cancer of gastric antrum underwent radical distal gastrectomy and D2 regional lymphadenectomy. Residual gastrojejunostomies by the Roux-en-Y method were performed. The two patients recovered well after gastrectomy, and they received postoperative adjuvant chemotherapy. However, both of them suffered sudden hematemesis and melena about 2 months after surgery, resulting in unstable vital signs. Emergency exploratory laparotomy and interventional embolotherapy by digital subtraction angiography were immediately respectively performed. During this process, arteriointestinal fistulas were found in both of them. Pseudoaneurysms of gastroduodenal artery and common hepatic artery were respectively ruptured and bleeding into the duodenum. Finally, the male patient recovered, while the female patient died because of rebleeding and hemorrhagic shock.

CONCLUSIONS

Arteriointestinal fistula, with low morbidity but high mortality, is an acute and fatal postoperative complication for GC patients after radical gastrectomy. DSA is the preferred method to diagnose arteriointestinal fistula. Embolotherapy by DSA should be performed immediately once arteriointestinal fistula is confirmed. Emergency laparotomy is another selection if the embolotherapy failed. We should pay more attention to perioperative preventive measures for formation of pseudoaneurysm, which is the leading cause of arteriointestinal fistula.

Adjuvant chemoradiotherapy with or without intraoperative radiotherapy for the treatment of resectable locally advanced gastric adenocarcinoma

PURPOSE

To document the long-term efficacy of intraoperative electron radiotherapy (IOERT) followed by concurrent chemotherapy and external-beam radiotherapy (EBRT) in the management of locally advanced gastric cancer.

MATERIALS AND METHODS

A total of 97 consecutive patients with T3/4 or N+ gastric adenocarcinoma were enrolled. Fifty-one patients received adjuvant chemoradiotherapy (EBRT group) and 46 received IOERT (dose range, 12-15 Gy) followed by chemoradiotherapy (EBRT+IOERT group).

RESULTS

The 5-year locoregional control rates were 50% and 35% in the two groups with or without IOERT, respectively (p=0.04). Two patients had recurrence within the IOERT field in the EBRT+IOERT group and 14 patients recurred in the same area in the EBRT group (p=0.02). Multivariate analyses revealed that adjuvant IOERT was an independent prognosticator for both local-regional control (p=0.02) and disease-free survival (p=0.05). G3/4 late toxicity was observed in 5 patients in the EBRT+IOERT group, but none in the EBRT group (p=0.02).

CONCLUSIONS

Higher radiation dose may contribute to the improvement of local control, especially in the field encompassed by IOERT. The addition of IOERT to surgery and adjuvant chemoradiation deserves further investigation in a randomized trial.

[Radiological interventional procedures for the acute abdomen]

In patients with acute thrombo-embolic occlusion of the superior mesenteric artery, catheter-assisted thrombolytic therapy represents a procedure of increasing importance in addition to surgery and intensive care treatment. The thrombolytic drugs utilized for this purpose are urokinase, streptokinase and recombinant tissue plasminogen activator (rtPA).Therapeutic embolization is predominantly used in the treatment of arterial bleeding from the gastro-intestinal tract, the liver, the intestines (due to an aneurysm or vascular malformation) and in bleeding from intestinal anastomoses. Polyvinyl alcohol particles, embospheres, gelfoam and microcoils can be utilized as embolic agents. Percutaneous transhepatic cholangiodrainage and stent implantation are applied in patients with biliary obstructions caused by inoperable tumors of the gall bladder or bile ducts, of the pancreatic head or duodenum and by metastases located in the liver parenchyma or hepatic hilum.Image-guided percutaneous drainage is a valuable option in the management of abscesses in the peritoneal cavity; less common indications are lymphoceles, biliomas, urinomas, hematomas, necrosis and pseudocysts.

Primary aorto-duodenal fistula as a late complication of radiotherapy: report of a case and review of the literature

Primary aorto-duodenal fistula (PADF) is a rare condition that may result in rapid exsanguination if untreated. PADF due to radiotherapy appears to be extremely rare with only a few cases reported in the medical literature. We report the case of a 61-year-old man who presented with massive gastrointestinal bleeding 25 years after surgery and radiotherapy for seminoma of the testicle and was successfully treated at our institution. We also review the literature on this very uncommon condition. A Medline search was conducted for the period from 1966 to June 2006 to identify case reports of PADF following radiotherapy. Only 7 cases of PADF due to radiotherapy were identified in addition to our own, 4 males and 3 females, aged 40 to 73 years, all treated for various forms of abdominal malignancies. The latency period ranged from 2 weeks to 25 years. None of the aortas were aneurysmatic. One patient died before he could be taken to the operating room. 5 patients underwent surgical repair and 4 survived. 2 patients underwent endovascular treatment but did not survive. PADF may develop up to 25 years after radiotherapy. Diagnosis should be considered when massive upper gastrointestinal bleeding develops in a patient who had previous abdominal radiotherapy, no matter how long before the episode of bleeding. Prompt surgical repair offers a reasonable chance of cure. Endovascular procedures do not appear to be efficacious.

Long-term results after intraoperative radiation therapy for gastric cancer

PURPOSE

We retrospectively analyzed the impact of intraoperative radiation therapy (IORT) on long-term survival in patients with resectable gastric cancer.

METHODS AND MATERIALS

From 1991 to 2001, a total of 84 patients with gastric neoplasms underwent gastectomy or subtotal resection with IORT (23 Gy, 6-15 MeV; IORT-positive [IORT(+)] group). Patients with a history of additional neoadjuvant chemotherapy, histologically confirmed R1 or R2 resection, or reoperation with curative intention after local recurrence were excluded from further analysis. The remaining 61 patients were retrospectively matched with 61 patients without IORT (IORT-negative [IORT(-)] group) for Union Internationale Contre le Cancer (UICC) stage, patient age, histologic grading, extent of surgery, and level of lymph node dissection. Subgroups included postoperative UICC Stages I (n = 31), II (n = 11), III (n = 14), and IV (n = 5).

RESULTS

Mean follow-up was 4.8 years in the IORT(+) group and 5.0 years in the IORT(-) group. The overall 5-year patient survival rate was 58% in the IORT(+) group vs. 59% in the IORT(-) group (p = 0.99). Subgroup analysis showed no impact of IORT on 5-year patient survival for those with UICC Stages I/II (76% vs. 80%; p = 0.87) and III/IV (21% vs. 14%, IORT(+) vs. IORT(-) group; p = 0.30). Perioperative mortality rates were 4.9% and 4.9% in the IORT(+) vs. IORT(-) group. Total surgical complications were more common in the IORT(+) than IORT(-) group (44.3% vs. 19.7%; p < 0.05). The locoregional tumor recurrence rate was 9.8% in the IORT(+) group.

CONCLUSIONS

Use of IORT was associated with low locoregional tumor recurrence, but had no benefit on long-term survival while significantly increasing surgical morbidity in patients with curable gastric cancer.

Evaluation of intraoperative radiotherapy for gastric carcinoma with D2 and D3 surgical resection

AIM: To study the proper sites and doses of intraoperative radiotherapy (IORT) for gastric carcinoma and the effects of this treatment.

METHODS: A total of 106 patients with stageI-IV gastric carcinoma who received D2 or D3 radical operation combined with IORT were analyzed. Sixty-seven patients with gastric cancer of the antrum and body underwent distal gastrectomy. The sites of irradiation were at the celiac artery and hepatoduodenal ligment area. Another 39 patients with carcinoma of the cardia and upper part of the gastric body and whole stomach underwent proximal gastrectomy or total gastrectomy. The sites of irradiation for this group were the upper margin of the pancreas and the regional para-aorta. The therapeutic effects (including survival and complications) of these 106 cases received operation combined with IORT (IORT group) were compared with 441 cases treated during the same time period by a radical operation alone (operation group).

RESULTS: The radiation dose below 30 Gy was safe. The therapeutic method of the operation combined with IORT did not prolong the survival of patients with stage I and IV gastric cancer, but the 5-year survival rates of patients with stage II and III gastric cancers were significantly improved. The 5-year survival rates of the stages III cancer patients receiving D2 resection combined with IORT were markedly improved, while for those receiving D3 radical resection, only the postoperative 3- or 4-year survival rates were improved (P < 0.005-0.001). The 5-year survival rate for those patients was raised only by 4.7% (P > 0.05).

CONCLUSION: The 5-year survival rates of patients with stages II and III gastric carcinoma who received D2 lymphadenectomy combined with IORT were improved, and there was no influence on the postoperative complications and mortality.

Perioperative high-dose-rate brachytherapy in locally advanced and recurrent gynecologic cancer: Initial results of a phase II trial

BACKGROUND

This study was undertaken to determine the feasibility of perioperative high-dose-rate brachytherapy (PHDRB) as an adjunct to salvage surgery in primary advanced or recurrent gynecologic cancer.

METHODS

Twenty-five patients with either locally advanced (n = 4) or recurrent (n = 21) gynecologic cancer suitable for salvage surgery were included. Unirradiated patients were treated with preoperative chemoradiation followed by salvage surgery and PHDRB (R0 and R1 resections receiving 16 or 24 Gy, respectively). Previously irradiated patients were treated with salvage surgery and PHDRB alone with 32 or 40 Gy for R0 or R1 resections, respectively.

RESULTS

Resections were categorized as R0 in 9 patients (36.0%) and R1 in 16 (64.0%). Four previously irradiated patients suffered fatal pelvic bleeding between 8 and 13 months after surgery and PHDRB. After a median follow-up of 20 months (3-55+), the 4-year actuarial local and pelvic controls were 88.1% and 80.8%, respectively. The 4-year distant metastases-free survival was 40.9%. Four-year actuarial overall survival was 34.0%, with a median survival of 27.1 months (95% confidence interval: 17.5-36.8).

CONCLUSIONS

Local and pelvic control results are excellent for this very high-risk-disease population. PHDRB dose in previously irradiated patients has been shifted to the closest lower level due to unacceptable vascular toxicity.

intraoperative radiation therapy part 2. Clinical results

Intraoperative radiation therapy (IORT) has been used for over 30 years in Asia, Europe and America as a supplementary activity in the treatment of cancer patients with promising results. Modern IORT is carried out with electron beams (IOERT) produced by a linear accelerator generally used for external beam irradiation (EBRT) or a specialized mobile electron accelerator. HDR brachytherapy (HDR-IORT) has also been applied on selected locations. Retrospective analysis of clinical experiences in cancer sites such as operable pancreatic tumour, locally advanced/recurrent rectal cancer, head and neck carcinomas, sarcomas and cervical cancer are consistent with local tumour control promotion compared to similar clinical experiences without IORT. New emerging indications such as the treatment of breast cancer are presented. The IORT component of the therapeutical approach allows intensification of the total radiation dose without additional exposure of healthy tissues and improves dose-deposit homogeneity and precision. Results of the application of IORT on selected disease sites are presented with an analysis on future possibilities. To improve the methodology, clinical trials are required with multivariate analysis including patient, tumour and treatment characteristics, prospective evaluation of early and late toxicity, patterns of tumour recurrence and overall patient outcome.

Pattern of failures in gastric cancer patients with lymph node involvement treated by surgery, intraoperative and external beam radiotherapy

AIMS

High local failure rates in gastric cancer have been reported, up to 67%. To achieve a better local control, we evaluated intraoperative radiotherapy (IORT) and external beam radiotherapy (EBRT) in association with surgery for gastric cancer patients with lymph node involvement. We report here the analysis of the patterns of failure for patients involved in this IORT protocol.

MATERIAL AND METHODS

Forty-two positive lymph node (N+) gastric cancer patients were operated on (31 total, three subtotal and eight extended gastrectomies) with IORT procedure between 1985 and 1997 (33 males, nine females, mean age 61.3 years). IORT was focused on coeliac area (mean dose 15 Gy), followed by EBRT (46 Gy) in 36 patients. Ten patients were pN1 and 32 were pN2. A concurrent systemic chemotherapy (five Fluoro-Uracil and Cisplatinum) was performed in 14 patients.

RESULTS

One patient died postoperatively. Actuarial pN+ 10 year survival rate was 44.8%. The 5 year actuarial local control and disease-free survival rates were 78.8 and 47.5%, respectively. As far as patterns of failure were explored, 5 patients have a local coeliac recurrence (12%) and 12 have distant metastases with no evidence of coeliac recurrence.

CONCLUSION

This retrospective analysis suggests a potential effect of IORT and/or EBRT in promoting local control and long-term survival in gastric cancer patients with lymph node involvement.

Curative treatment of gastric cancer: towards a multidisciplinary approach?

Despite marked decreases in incidence over the last century, particularly in developed countries, gastric cancer is still the second-most common tumor worldwide. Surgery remains the gold standard for the cure of locoregional disease. However, in most countries, the diagnosis is made at an advanced stage, and the 5-year survival for surgically resectable disease stays far below 50%. The efficacy of chemotherapy and/or radiation therapy in addition to surgery has been actively studied over the last 30 years. Unfortunately, with few exceptions, most studies of adjuvant therapy in gastric cancer have given deceiving results. The purpose of this review is to address the reasons for our failure to objectivate an improvement in the cure of gastric cancer with adjuvant treatment in most trials, and to consider potential solutions. The low efficacy of chemotherapy regimens available up to now may have hampered our progress. In addition, many previous studies suffered limitations of design or methodology (e.g. low accrual, inadequate disease stage selection, inadequate surgical treatment) that may have obscured a treatment effect. Furthermore, the reduced treatment tolerance of post-gastrectomy patients, perhaps due to their poor nutritional status, results in decreased or delayed adjuvant systemic therapy, with potential adverse consequences in its efficacy. Among potential solutions, the arrival of new drugs, taxanes and topoisomerase I inhibitors in particular, which have shown encouraging results in metastatic disease, may increase the impact of chemotherapy in a multidisciplinary treatment approach. Pre-treatment with chemotherapy and/or radiation therapy prior to surgery may also be advantageous, averting the problems associated with post-surgical treatment. Such an approach has been shown to be feasible in phase II studies, and is relatively well tolerated by patients. Several carefully designed randomized phase III trials are underway to answer this question.

Vascular-enteric fistulas associated with radiation therapy in patients with pancreatic adenocarcinoma

BACKGROUND

Irradiation therapy is being evaluated widely as an adjunct to therapy of resectable and unresectable pancreatic exocrine carcinoma. Exsanguinating haemorrhage has been an occasional late complication.

CASE OUTLINES

Two patients with unresectable cancer of the pancreas were treated by bypass, chemotherapy and both intra-operative and postoperative irradiation. Both patients died 5-11 months later of gastroduodenal haemorrhage from arterio-enteric fistulas, which were confirmed by autopsy but had been uncontrolled by selective embolisation. A third patient, for whom little other information was available, died of upper abdominal haemorrhage 5 months after a 'curative' resection combined with intra-operative and postoperative irradiation.

DISCUSSION

Judgement in management is difficult because of the poor prognosis from the underlying disease on the one hand versus the fact that site of bleeding has sometimes been from complicating benign disease. Better endovascular techniques of control of such haemorrhage may be developing.

Patterns of failure and long-term results in high-risk resected gastric cancer treated with postoperative radiotherapy with or without intraoperative electron boost

BACKGROUND

To evaluate the possible role of adjuvant radiotherapy in the management of high-risk resected gastric carcinoma.

METHODS

From 1982 to 1993, 62 patients surgically resected of a primary gastric cancer with adverse pathological features (serosal and/or regional lymph node involvement) were treated with postoperative radiotherapy with (Group I) or without (Group II) intraoperative electron boost to the surgical bed and coeliac axis (IORT).

RESULTS

After a median follow-up of 75.6 months (range 4-120+) for IORT patients and 91.2 months (range 6-149+) for non-IORT patients, overall relapse rates for Group I and Group II patients were 44.5% and 48.6% and local-regional relapse rates were 11.1% and 20%, respectively. Actuarial survival rates projected at the maximum follow-up were 41% and 38% in Groups I and II, respectively.

CONCLUSIONS

This retrospective analysis suggests a beneficial effect of adjuvant external radiotherapy in promoting local-regional control in high-risk resected gastric cancer.

Classification and pathophysiology of enterocutaneous fistulas

Enterocutaneous and aortoenteric fistulas arise from a diverse array of pathophysiologic states. Classification by anatomic, physiologic, and etiologic systems is critical to both nonoperative and operative treatment planning.