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Gits HC, Dozois EJ, Houdek MT, Ho TP, Okuno SH, Guenzel RM, McGrath LA, Kraling AJ, Johnson JE, Lester SC. New school technology meets old school technique: Intensity modulated proton therapy and laparoscopic pelvic sling facilitate safe and efficacious treatment of pelvic sarcoma. Adv Radiat Oncol 2022; 7:101008. [PMID: 36034194 PMCID: PMC9404264 DOI: 10.1016/j.adro.2022.101008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose Small bowel tolerance may be dose-limiting in the management of some pelvic and abdominal malignancies with curative-intent radiation therapy. Multiple techniques previously have been attempted to exclude the small bowel from the radiation field, including the surgical insertion of an absorbable mesh to serve as a temporary pelvic sling. This case highlights a clinically meaningful application of this technique with modern radiation therapy. Methods and Materials A patient with locally invasive, unresectable high-grade sarcoma of the right pelvic vasculature was evaluated for definitive radiation therapy. The tumor immediately abutted the small bowel. The patient underwent laparoscopic placement of a mesh sling to retract the abutting small bowel and subsequently completed intensity modulated proton therapy. Results The patient tolerated the mesh insertion procedure and radiation therapy well with no significant toxic effects. The combination approach achieved excellent dose metrics, and the patient has no evidence of progression 14 months out from treatment. Conclusions The combination of mesh as a pelvic sling and proton radiation therapy enabled the application of a curative dose of radiation therapy and should be considered for patients in need of curative-intent radiation when the bowel is in close proximity to the target.
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Affiliation(s)
- Hunter C. Gits
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Eric J. Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Thanh P. Ho
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Scott H. Okuno
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Laura A. McGrath
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Alan J. Kraling
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Scott C. Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
- Corresponding author: Scott C. Lester, MD
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Rusli SM, Choo JM, Piozzi GN, Kim SH. Laparoscopic and robotic-assisted mesh pelvic closure for locally advanced and recurrent colorectal cancer. J Surg Case Rep 2021; 2021:rjab524. [PMID: 34858579 PMCID: PMC8634069 DOI: 10.1093/jscr/rjab524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/02/2021] [Indexed: 11/15/2022] Open
Abstract
Extensive resection that may be required in locally advanced and recurrent colorectal cancer result in formation of empty pelvic cavity that has the potential to cause small bowel descent into the pelvis. In patients with prior history of radiotherapy and multiple abdominal surgery, the risk of adhesion and subsequent small bowel obstruction can lead to increasing need for surgery and its resulting morbidity and mortality. We present five cases of locally advanced and recurrent colorectal cancer requiring laparoscopic and robotic-assisted pelvic closure with Gore-Tex Dual Mesh as prevention of small bowel descent into the pelvis. One out of the five cases had a history of small bowel obstruction after the surgery and wound-related infection occurred in one patient. There was no mesh-related complication or mortality. Pelvic closure using Gore-Tex Dual Mesh is feasible to prevent small bowel descent after surgery for locally advanced and recurrent colorectal cancer.
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Affiliation(s)
- Siti Mayuha Rusli
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jeong Min Choo
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Guglielmo Niccolò Piozzi
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Seon Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
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Foster JD, Tou S, Curtis NJ, Smart NJ, Acheson A, Maxwell-Armstrong C, Watts A, Singh B, Francis NK. Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement. Colorectal Dis 2018; 20 Suppl 5:5-23. [PMID: 30182511 DOI: 10.1111/codi.14348] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/16/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE). METHODS A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations. RESULTS Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications. CONCLUSION This position statement updates clinicians on current evidence around perineal closure after APE surgery.
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Affiliation(s)
- J D Foster
- Department of General Surgery, Poole Hospital NHS Foundation Trust, Poole, Dorset, UK
| | - S Tou
- Department of General Surgery, Royal Derby Hospital, Derby, UK
| | - N J Curtis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, Somerset, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - N J Smart
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - A Acheson
- Department of Colorectal Surgery, Nottingham University Hospital, Nottingham, UK
| | - C Maxwell-Armstrong
- Department of Colorectal Surgery, Nottingham University Hospital, Nottingham, UK
| | - A Watts
- Department of Surgery, Royal Devon and Exeter Hospital, Exeter, UK
| | - B Singh
- Department of General Surgery, Leicester General Hospital, Leicester, UK
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Abstract
Radiation enteritis continues to be a major health concern in recipients of radiation therapy. The incidence of radiation enteritis is expected to continue to rise during the coming years paralleling the unprecedented use of radiotherapy in pelvic cancers. Radiation enteritis can present as either an acute or chronic syndrome. The acute form presents within hours to days of radiation exposure and typically resolves within few weeks. The chronic form may present as early as 2 months or as long as 30 years after exposure. Risk factors can be divided into patient and treatment-related factors. Chronic radiation enteritis is characterized by progressive obliterative endarteritis with exaggerated submucosal fibrosis and can manifest by stricturing, formation of fistulae, local abscesses, perforation, and bleeding. In the right clinical context, diagnosis can be confirmed by cross-sectional imaging, flexible or video capsule endoscopy. Present treatment strategies are directed primarily towards symptom relief and management of emerging complications. Recently, however, there has been a shift towards rational drug design based on improved understanding of the molecular basis of disease in an effort to limit the fibrotic process and prevent organ damage.
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Affiliation(s)
- Ali H Harb
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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5
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Stacey R, Green JT. Radiation-induced small bowel disease: latest developments and clinical guidance. Ther Adv Chronic Dis 2014; 5:15-29. [PMID: 24381725 PMCID: PMC3871275 DOI: 10.1177/2040622313510730] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Ionizing radiation is commonly used to treat a number of malignancies. Although highly effective and now more targeted, many patients suffer side effects. The number of cancer survivors has increased and so there are more patients presenting with symptoms that have arisen as a result of radiotherapy. Radiation damage to small bowel tissue can cause acute or chronic radiation enteritis producing symptoms such as pain, bloating, nausea, faecal urgency, diarrhoea and rectal bleeding which can have a significant impact on patient's quality of life. This review outlines the pathogenesis of radiation injury to the small bowel along with the prevention of radiation damage via radiotherapy techniques plus medications such as angiotensin-converting enzyme inhibitors, statins and probiotics. It also covers the treatment of both acute and chronic radiation enteritis via a variety of medical (including hyperbaric oxygen), dietetic, endoscopic and surgical therapies.
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Affiliation(s)
- Rhodri Stacey
- Gastroenterology Registrar, University Hospital Llandough, Cardiff and Vale University Health Board, South Wales, UK
| | - John T Green
- Consultant Gastroenterologist, Department of Gastroenterology, University Hospital Llandough, Penlan Road, Penarth CF64 2XX, UK
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Galler AS, Petrelli NJ, Shakamuri SP. Rectal cancer surgery: A brief history. Surg Oncol 2011; 20:223-30. [DOI: 10.1016/j.suronc.2010.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2009] [Revised: 11/29/2009] [Accepted: 01/04/2010] [Indexed: 11/26/2022]
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Moreno-Sanz C, Manzanera-Díaz M, Cortina-Oliva FJ, de Pedro-Conal J, Clerveus M, Picazo-Yeste J. Pelvic reconstruction after abdominoperineal resection: a pilot study using an absorbable synthetic prosthesis. Tech Coloproctol 2011; 15:455-9. [PMID: 21960412 DOI: 10.1007/s10151-011-0763-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 09/09/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND Abdominoperineal resection (APR) is not free of complications, in particular complications due to the occupation of the pelvis by the small bowel after surgery. A number of surgical techniques have been described to prevent the small bowel from entering and adhering to the pelvis (pelvic partition), but there is no agreement concerning their use. The aim of this study was to evaluate the feasibility, effectiveness and safety of using an absorbable synthetic prosthetic material for pelvic partitioning after APR. METHODS A prospective non-randomised longitudinal pilot study was carried out on a series of 10 patients who underwent APR due to lower-third rectal cancer, in order to evaluate the feasibility, safety and efficacy of pelvic partitioning with an absorbable synthetic prosthetic material. RESULTS In all the patients, it was possible to perform a radical resection and to install the prosthesis. After a mean follow-up of 9 months (range: 4-18 months), no abdominal or perineal complications were detected. One patient (10%) suffered chronic pelvic pain. CONCLUSIONS Pelvic partition after APR of the rectum with an absorbable synthetic prosthesis is feasible, effective and safe.
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Affiliation(s)
- C Moreno-Sanz
- Department of Surgery, La Mancha Centro General Hospital, Avenida de la Constitución, s/n, 13600 Alcazar de San Juan, Ciudad Real, Spain.
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8
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Reconstrucción pélvica tras amputación abdominoperineal del recto. Cir Esp 2011; 89:77-81. [DOI: 10.1016/j.ciresp.2010.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 09/30/2010] [Accepted: 10/05/2010] [Indexed: 01/13/2023]
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Al-Sahaf O, El-Masry S. The use of porcine small intestinal submucosa mesh (SURGISIS) as a pelvic sling in a man and a woman with previous pelvic surgery: two case reports. J Med Case Rep 2009; 3:70. [PMID: 19236700 PMCID: PMC2654899 DOI: 10.1186/1752-1947-3-70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 02/23/2009] [Indexed: 12/03/2022] Open
Abstract
Introduction Closing the pelvic peritoneum to prevent the small bowel dropping into the pelvis after surgery for locally recurrent rectal cancer is important to prevent adhesions deep in the pelvis or complications of adjuvant radiotherapy. Achieving this could be difficult because sufficient native tissue is unavailable; we report on the use of small intestine submucosa extra-cellular matrix mesh in the obliteration of the pelvic brim. Case presentation We describe two cases in which submucosa extra-cellular matrix mesh was used to obliterate the pelvic brim following resection of a recurrent rectal tumour; the first patient, a 78-year-old Caucasian man, presented with small bowel obstruction caused by adhesions to a recurrent rectal tumour. The second patient, an 84-year-old Caucasian woman, presented with vaginal discharge caused by an entero-vaginal fistula due to a recurrent rectal tumour. Conclusion We report on the use of submucosa extra-cellular matrix mesh as a pelvic sling in cases where primary closure of the pelvic peritoneum is unfeasible. Its use had no infective complications and added minimal morbidity to the postoperative period. This is an original case report that would be of interest to general and colorectal surgeons.
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Affiliation(s)
- Osama Al-Sahaf
- Department of General Surgery, Our Lady of Lourdes Hospital, Drogheda, Co, Louth, Ireland.
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10
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All-trans-Retinoic Acid Attenuates Radiation-Induced Intestinal Fibrosis in Mice. J Surg Res 2008; 150:53-9. [DOI: 10.1016/j.jss.2007.12.762] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Revised: 10/15/2007] [Accepted: 12/06/2007] [Indexed: 11/20/2022]
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Joyce M, Thirion P, Kiernan F, Byrnes C, Kelly P, Keane F, Neary P. Laparoscopic pelvic sling placement facilitates optimum therapeutic radiotherapy delivery in the management of pelvic malignancy. Eur J Surg Oncol 2008; 35:348-51. [PMID: 18358678 DOI: 10.1016/j.ejso.2008.01.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Accepted: 01/31/2008] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Radiotherapy has a significant role in the management of pelvic malignancies. However, the small intestine represents the main dose limiting organ. Invasive and non-invasive mechanical methods have been described to displace bowel out of the radiation field. We herein report a case series of laparoscopic placement of an absorbable pelvic sling in patients requiring pelvic radiotherapy. METHODS Six patients were referred to our minimally invasive unit. Four patients required radical radiotherapy for localised prostate cancer, one was scheduled for salvage localised radiotherapy for post-prostatectomy PSA progression and one patient required adjuvant radiotherapy post-cystoprostatectomy for bladder carcinoma. All patients had excessive small intestine within the radiation fields despite the use of non-invasive displacement methods. RESULTS All patients underwent laparoscopic mesh placement, allowing for an elevation of small bowel from the pelvis. The presence of an ileal conduit or previous surgery did not prevent mesh placement. Post-operative planning radiotherapy CT scans confirmed displacement of the small intestine allowing all patients to receive safely the planned radiotherapy in terms of both volume and radiation schedule. CONCLUSION Laparoscopic mesh placement represents a safe and efficient procedure in patients requiring high-dose pelvic radiation, presenting with unacceptable small intestine volume in the radiation field. This procedure is also feasible in those that have undergone previous major abdominal surgery.
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Affiliation(s)
- M Joyce
- Division of Colorectal Surgery, Minimally Invasive Surgery, The Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland.
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12
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Kroshinsky D, Grossman ME, Fox LP. Approach to the Patient With Presumed Cellulitis. ACTA ACUST UNITED AC 2007; 26:168-78. [DOI: 10.1016/j.sder.2007.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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13
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Ihedioha U, Leung E, Chung L, Burgess G, Hendry D, O'dwyer PJ. A complex fistula caused by an eroding pelvic mesh sling. Hernia 2006; 11:75-8. [PMID: 17024307 DOI: 10.1007/s10029-006-0140-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Accepted: 08/14/2006] [Indexed: 11/30/2022]
Abstract
Pelvic mesh slings are increasingly used to create abdomino-pelvic partitions. This procedure is usually safe and carries low morbidity and mortality rates. However, we report a case of a 60-year-old male with a history of an abdomino-perineal resection for a low rectal carcinoma followed by adjuvant radiotherapy, who presented with an entero-vesicle-cutaneous fistula as a result of the polypropylene mesh eroding into his small bowel. He had to have a total cystectomy, small bowel resection and mesh removal in order to alleviate his symptoms.
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Affiliation(s)
- Ugo Ihedioha
- Professorial Unit of Surgery, Western Infirmary, Glasgow, G11 6NT, UK.
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14
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Guckenberger M, Flentje M. Late small bowel toxicity after adjuvant treatment for rectal cancer. Int J Colorectal Dis 2006; 21:209-20. [PMID: 16052309 DOI: 10.1007/s00384-005-0765-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND For locally advanced rectal cancer surgery as sole treatment results in poor local control and survival. After adjuvant radiotherapy for locally advanced rectal cancer, small bowel toxicity has been the most frequent and serious side effect. The gain in survival and local control was accompanied by severe late chronic toxicity reducing the benefit of adjuvant treatment. REVIEW Clinical factors, pathology and treatment of late small bowel toxicity after adjuvant radiotherapy for locally advanced rectal cancer will be discussed. This review will focus on different surgical and radiotherapeutic means reducing the risk of late small bowel damage.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, Klinik und Poliklinik für Strahlentherapie der Universität Würzburg, Josef-Schneider-Strasse 11, 97080 Würzburg, Germany.
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Onodera H, Nagayama S, Mori A, Fujimoto A, Tachibana T, Yonenaga Y. Reappraisal of Surgical Treatment for Radiation Enteritis. World J Surg 2005; 29:459-63. [PMID: 15770376 DOI: 10.1007/s00268-004-7699-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Although radiation enteritis is a well-recognized sequel of therapeutic irradiation, the standard surgical method is not universally agreed upon. Not only the short-term effect but also the long-term effect after a surgical intervention has been fairly well reported. To reassess the surgical therapy for radiation enteritis, we retrospectively analyzed 48 patients (5 males and 43 females, mean age 58.6 years) who had been operated on in our department. These patients were divided into two types according to the time of surgery or the clinical manifestation, and operative methods were analyzed. Patient's status such as bowel movement, body weight, and serum albumin value after surgery were analyzed, together with the patients survival. Our surgical methods were small intestinal resection for the intestinal obstruction, and pull-through reconstruction for proctitis. Two patients died of multiple organ failure caused by perforated peritonitis irrespective of emergent operation. Although the overall morbidity was 21.7%, there was no leakage when bowels were anastomosed. Overall survival after radiation-related complication in patients without previous neoplastic disease recurrence was 89%, 79%, and 69%, at 1, 3, and 5 years after surgery, respectively. Bowel motility, serum albumin level, and body weight recovered gradually soon after the operation and reached satisfactory levels within 6 months. Our analysis showed that small bowel injury should be treated by generous resection of the affected bowel followed by careful anastomosis of the disease-free ends, while rectal resection is best dealt with by restorative proctectomy. This may provide a good quality of life and minimize major postoperative complications such as leakage.
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Affiliation(s)
- Hisashi Onodera
- Department of Surgery & Surgical Basic Science, Kyoto University, 54 Shogoin Kawara cho, Sakyo ku, Kyoto 606-8507, Japan
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Reis ED, Vine AJ, Heimann T. Radiation damage to the rectum and anus: pathophysiology, clinical features and surgical implications. Colorectal Dis 2002; 4:2-12. [PMID: 12780647 DOI: 10.1046/j.1463-1318.2002.00282.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Radiation kills cancer cells by inducing various degrees of deoxyribonucleic acid fragmentation and disruption of intracellular membranes that lead to either immediate or delayed cell death. Although radiation can be effective in destroying cancer, its usefulness is limited by damage to normal tissues that surround the target tumour or those in the path of the radiation beam. The rectum and anus are damaged frequently during radiotherapy for abdominopelvic malignancy, including preresection therapy for rectal cancer. Such damage is often associated with lesions in the perineal skin, genitourinary tract, colon, and small intestine. Surgical intervention often is required for the most severe forms of these complications.
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Affiliation(s)
- E. D. Reis
- Department of Surgery, The Mount Sinai Medical Centre, New York, NY, USA
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17
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Burnett AF, Coe FL, Klement V, O'Meara AT, Muderspach LI, Roman LD, Morrow CP. The use of a pelvic displacement prosthesis to exclude the small intestine from the radiation field following radical hysterectomy. Gynecol Oncol 2000; 79:438-43. [PMID: 11104616 DOI: 10.1006/gyno.2000.5965] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The goal of this study was to develop a device which will elevate the small intestine out of the pelvic cavity during radiation after radical surgery. METHODS A prosthetic device of silicone plastic was designed which conforms to the pelvis. This device is filled with saline and renograffin for X-ray visualization. The capacity of the device is between 750 and 1500 cc. A small bowel contrast radiograph is performed prior to radiation to document exclusion from the radiation field. The device remains in place throughout radiation therapy and is then removed through a small incision after draining the contents of the prosthesis. RESULTS Seven devices have been placed to date. The patients' age ranged from 35 to 65 years. All women had stage Ib1 carcinoma of the cervix and all underwent a type III radical hysterectomy with bilateral pelvic and common iliac lymphadenectomy. The indication for placement of the device was deep invasion of tumor in five patients, close margin in one patient, and positive pelvic lymph nodes in one patient. The amount of fluid instilled in the device ranged from 960 to 1200 cc. All patients had a return to normal bowel function within 3 days of surgery. All had radiologically documented exclusion of the small intestine from the radiation field prior to beginning radiation. In the postoperative period there was one major complication: a pulmonary embolism documented by pulmonary angiogram on postoperative day 2. All seven patients completed planned radiotherapy. The devices have been removed, with no adhesions to the prosthesis. CONCLUSIONS The results of this study determine that the feasibility, safety, and efficacy of a prosthetic device in displacing the small bowel from the radiation field following radical surgery are sufficient to warrant a large-scale study. The device should be applicable to any and all tumors that require high dose pelvic radiation. It is expected that displacement of the small intestine from the radiation field will diminish overall complications and may allow delivery of radiation doses that approach colon and bladder tolerance.
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Affiliation(s)
- A F Burnett
- Division of Gynecologic Oncology, University of Southern California, Los Angeles, California 90033, USA
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Abstract
The treatment of rectal cancer typically involves a multidisciplinary approach. A minority of patients will have tumors that are full thickness, involve adjacent structures, or have metastatic disease to regional lymph nodes. The combination of adjuvant therapy and surgical resection is the mainstay of treatment for locally advanced carcinoma of the rectum. This article will review the role of adjuvant chemotherapy and radiotherapy in patients with high risk tumors. The operative considerations in advanced rectal cancers will be reviewed. In particular, the role of mesorectal excision and exenterative surgery will be discussed.
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Affiliation(s)
- A R Sasson
- Department of Surgical Oncology, Fox Chase Cancer Center, 7701 Burholme Avenue, Philadelphia, PA 19111, USA
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Waddell BE, Rodriguez-Bigas MA, Lee RJ, Weber TK, Petrelli NJ. Prevention of chronic radiation enteritis. J Am Coll Surg 1999; 189:611-24. [PMID: 10589598 DOI: 10.1016/s1072-7515(99)00199-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- B E Waddell
- Division of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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