1
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Chi MS, Hsieh PH, Huang SH, Hsu HC, Chi KH. Chronic radiation proctitis refractory to steroid enema was successfully treated by metformin and sodium butyrate: a case report. J Med Case Rep 2024; 18:239. [PMID: 38725071 PMCID: PMC11083804 DOI: 10.1186/s13256-024-04551-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Radiation proctitis (RP) is a significant complication of pelvic radiation. Effective treatments for chronic RP are currently lacking. We report a case where chronic RP was successfully managed by metformin and butyrate (M-B) enema and suppository therapy. CASE PRESENTATION A 70-year-old Asian male was diagnosed with prostate cancer of bilateral lobes, underwent definitive radiotherapy to the prostate of 76 Gy in 38 fractions and six months of androgen deprivation therapy. Despite a stable PSA nadir of 0.2 ng/mL for 10 months post-radiotherapy, he developed intermittent rectal bleeding, and was diagnosed as chronic RP. Symptoms persisted despite two months of oral mesalamine, mesalamine enema and hydrocortisone enema treatment. Transition to daily 2% metformin and butyrate (M-B) enema for one week led to significant improvement, followed by maintenance therapy with daily 2.0% M-B suppository for three weeks, resulting in continued reduction of rectal bleeding. Endoscopic examination and biopsy demonstrated a good therapeutic effect. CONCLUSIONS M-B enema and suppository may be an effective treatment for chronic RP.
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Affiliation(s)
- Mau-Shin Chi
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- Institute of Veterinary Clinical Science, School of Veterinary Medicine, National Taiwan University, Taipei, Taiwan
| | - Ping-Hsun Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Shu-Han Huang
- Department of Pathology and Laboratory Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Ho-Chi Hsu
- Department of General Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Kwan-Hwa Chi
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
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2
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Berntsson H, Thien A, Hind D, Stewart L, Mahzabin M, Tung WS, Bradburn M, Kurien M. Interventions for Managing Late Gastrointestinal Symptoms Following Pelvic Radiotherapy: a Systematic Review and Meta-analysis. Clin Oncol (R Coll Radiol) 2024; 36:318-334. [PMID: 38431427 DOI: 10.1016/j.clon.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/04/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
AIMS Pelvic radiotherapy can induce gastrointestinal injury and symptoms, which can affect quality of life. We assessed interventions for managing these symptoms. MATERIALS AND METHODS A review of randomised controlled trials published between January 1990 and June 2023 from databases including MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, ISRCTN and grey literature sources was conducted. Meta-analyses were carried out using the DerSimonian and Laird random effects model to produce overall treatment differences with 95% confidence intervals. RESULTS Twenty-eight studies (2392 participants) of varying methodological quality were included. 4% formalin was superior to sucralfate for improving gastrointestinal symptom score (standardised mean difference [SMD] -1.07, 95% confidence interval -1.48 to -0.65). Argon plasma coagulation (APC) was inferior to sucralfate (SMD 1.22, 95% confidence interval 0.84 to 1.59). Counselling positively influenced symptom score (SMD -0.53, 95% confidence interval -0.76 to -0.29), whereas hyperbaric oxygen therapy showed conflicting results. Sucralfate combined with APC increased endoscopic markers of moderate-severe bleeding versus APC alone (risk ratio 2.26, 95% confidence interval 1.12 to 4.55). No definite conclusions on pain, incontinence, diarrhoea, tenesmus or quality of life interventions were confirmed. CONCLUSIONS Small study sizes, methodological quality and heterogeneity limit support of any individual intervention. APC and 4% formalin seem to be promising interventions, with further larger randomised controlled trials now warranted.
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Affiliation(s)
- H Berntsson
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK.
| | - A Thien
- Department of General Surgery, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei
| | - D Hind
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - L Stewart
- The Medical School, University of Sheffield, Sheffield, UK
| | - M Mahzabin
- The Medical School, University of Sheffield, Sheffield, UK
| | - W S Tung
- The Medical School, University of Sheffield, Sheffield, UK
| | - M Bradburn
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - M Kurien
- The Medical School, University of Sheffield, Sheffield, UK
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3
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Pietrzak A, Banasiewicz T. Applicability of sodium butyrate preparations from a surgeon's and gastroenterologist's perspective. POLISH JOURNAL OF SURGERY 2024; 96:68-73. [PMID: 38629276 DOI: 10.5604/01.3001.0054.4152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
In recent years, much has been written about the possibilities of using exogenous sodium butyrate in the prevention and treatment of gastrointestinal diseases, in prehabilitation, in peri- and postoperative treatment, as well as its local application. It became possible thanks to the development of a special formulation (microencapsulation technique) enabling the delivery of unstable butyrate compounds to the large intestine, where it is used primarily as a source of energy. It also plays a key role in maintaining body homeostasis by maintaining the integrity of the intestinal epithelium and stimulating the intestinal immune system. There is growing evidence of the effectiveness of sodium butyrate in various areas of health. The following article discusses the possibilities of using microencapsulated sodium butyrate in the prevention and treatment of gastrointestinal diseases from the perspective of a gastroenterologist and gastrointestinal surgeon.
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Affiliation(s)
- Anna Pietrzak
- 2nd Department of Gastroenterology, Centre of Postgraduate Medical Education, Warsaw, Poland; Department of Gastroenterology, Bielanski Hospital in Warsaw, Poland
| | - Tomasz Banasiewicz
- Chair and Department of General Surgery, Endocrine and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
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4
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Kim MS, Yang SJ, Jung SY, Lee TY, Park JK, Park YG, Woo SY, Kim SE, Lee RA. Combination of phytochemicals, including ginsenoside and curcumin, shows a synergistic effect on the recovery of radiation-induced toxicity. PLoS One 2024; 19:e0293974. [PMID: 38241326 PMCID: PMC10798472 DOI: 10.1371/journal.pone.0293974] [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: 06/22/2023] [Accepted: 10/20/2023] [Indexed: 01/21/2024] Open
Abstract
Radiotherapy is commonly used to treat solid cancers located in the pelvis. A considerable number of patients experience proctitis of varying severity, even for a considerable period after radiotherapy. These side effects are often long-lasting or progressively worsen despite multiple therapeutic efforts and are a primary cause of an unexpectedly low quality of life, even after successful cancer treatment. Therefore, this study evaluated the individual and combined efficacy of ginsenoside, curcumin, butyric acid, and sucralfate compounds in treating radiation-induced proctitis. While the candidate compounds did not affect the proliferation and migration of cancer cells, they promoted the recovery of cell activity, including motility. They exhibited anti-inflammatory effects on human dermal fibroblasts or human umbilical vein endothelial cells within in vitro disease models. When each compound was tested, curcumin and ginsenoside were the most effective in cell recovery and promoted the migration of human dermal fibroblasts and cell restoration of human umbilical vein endothelial cells. The combination of ginsenoside and curcumin resulted in cell migration recovery of approximately 54%. In addition, there was a significant improvement in the length of the endothelial tube, with an increase of approximately 25%, suggesting that the ginsenoside-curcumin-containing combination was the most effective against radiation-induced damage. Furthermore, studies evaluating the effects of combined treatments on activated macrophages indicated that the compounds effectively reduced the secretion of inflammatory cytokines, including chemokines, and alleviated radiation-induced inflammation. In conclusion, our study provides valuable insights into using curcumin and ginsenoside as potential compounds for the effective treatment of radiation-induced injuries and highlights the promising therapeutic benefits of combining these two compounds.
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Affiliation(s)
- Min-Sung Kim
- Central Research Center, CORESTEMCHEMON Inc., Seoul, South Korea
| | - Su-Jeong Yang
- Central Research Center, CORESTEMCHEMON Inc., Seoul, South Korea
| | - Seo-Yeong Jung
- Central Research Center, CORESTEMCHEMON Inc., Seoul, South Korea
| | - Tae-Yong Lee
- Central Research Center, CORESTEMCHEMON Inc., Seoul, South Korea
| | - Jin-Kyung Park
- Central Research Center, CORESTEMCHEMON Inc., Seoul, South Korea
| | - Yun-Gyeong Park
- Central Research Center, CORESTEMCHEMON Inc., Seoul, South Korea
| | - So-Youn Woo
- Department of Microbiology, Ewha Womans University, College of Medicine, Seoul, South Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, South Korea
| | - Ryung-Ah Lee
- Department of Surgery, Ewha Womans University, College of Medicine, Seoul, South Korea
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5
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Yan X, Li J, Wu D. The Role of Short-Chain Fatty Acids in Acute Pancreatitis. Molecules 2023; 28:4985. [PMID: 37446647 DOI: 10.3390/molecules28134985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/17/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Acute pancreatitis (AP) is a digestive emergency and can develop into a systematic illness. The role of the gut in the progression and deterioration of AP has drawn much attention from researchers, and areas of interest include dysbiosis of the intestinal flora, weakened intestinal barrier function, and bacterial and endotoxin translocation. Short-chain fatty acids (SCFAs), as one of the metabolites of gut microbiota, have been proven to be depleted in AP patients. SCFAs help restore gut homeostasis by rebuilding gut flora, stabilizing the intestinal epithelial barrier, and regulating inflammation. SCFAs can also suppress systematic inflammatory responses, improve the injured pancreas, and prevent and protect other organ dysfunctions. Based on multiple beneficial effects, increasing SCFAs is an essential idea of gut protective treatment in AP. Specific strategies include the direct use of butyrate or indirect supplementation through fiber, pre/pro/synbiotics, or fecal microbiota transplantation as a promising adjective therapy to enteral nutrition.
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Affiliation(s)
- Xiaxiao Yan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
- Eight-Year Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jianing Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Dong Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
- Clinical Epidemiology Unit, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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6
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Abu-Sbeih H, Tang T, Ali FS, Ma W, Shatila M, Luo W, Tan D, Tang C, Richards DM, Ge PS, Thomas AS, Wang Y. Clinical Features and Management of Acute and Chronic Radiation-Induced Colitis and Proctopathy. Cancers (Basel) 2023; 15:3160. [PMID: 37370770 DOI: 10.3390/cancers15123160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/03/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND RICAP is a recognized adverse effect of radiation therapy (RT) that can adversely affect cancer patients' quality of life. Data on the clinical characteristics and outcomes of RICAP are scarce. We aimed to analyze the clinical and endoscopic characteristics of acute or chronic radiation-induced colitis and proctopathy (ARICAP and CRICAP) based on symptom onset after RT (≤ or >45 days, respectively). METHODS This is a retrospective observational study of a single tertiary cancer center, from January 2010 and December 2018, of cancer patients with endoscopically confirmed ARICAP and CRICAP. We conducted univariate and multivariate logistic regression analyses to associate clinical variables with endoscopic and medical outcomes. RESULTS One hundred and twelve patients were included (84% Caucasian; 55% female; median age of 59 years); 46% had ARICAP with non-bloody diarrhea as the predominant symptom, whereas 55% had CRICAP with mostly bloody diarrhea. Neovascularization was the most frequent finding on endoscopy, followed by bleeding. ARICAP patients more often received medical management (p < 0.001), whereas CRICAP patients with bleeding more often received argon plasma coagulation (APC) (p = 0.002). Female sex and undergoing less-intense RT treatments were more associated with medical treatment; bleeding clinically and during the endoscopy was more associated with APC treatment. However, APC treatment did not significantly reduce bleeding recurrence or RICAP symptoms. CONCLUSION Patients with ARICAP and CRICAP experience different symptoms. Medical management should be considered before endoscopic therapy. APC may be useful in patients with endoscopically apparent bleeding.
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Affiliation(s)
- Hamzah Abu-Sbeih
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Internal Medicine, University of Missouri, Kansas City, MO 65211, USA
| | - Tenglong Tang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Faisal S Ali
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas Health Science Center, Houston, TX 77030, USA
| | - Weijie Ma
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Malek Shatila
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Wenyi Luo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Dongfeng Tan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - David M Richards
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Phillip S Ge
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Anusha S Thomas
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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7
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Polese L, Giugliano E, Cadrobbi R, Boemo DG. Diode Laser Therapy for Radiation-Induced Vascular Ectasia: Long-Term Results and Cost Analysis. Life (Basel) 2023; 13:life13041025. [PMID: 37109554 PMCID: PMC10144337 DOI: 10.3390/life13041025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Collateral damage to surrounding healthy tissues has been reported in patients who undergo radiation therapy for pelvic malignancies. This study aimed to evaluate the safety, efficacy and cost efficiency of endoscopic diode laser therapy in patients diagnosed with chronic radiation proctitis (CRP). METHODS The data of 24 patients (median age 78, range 67-90 years) who presented rectal bleeding and were diagnosed with CRP after undergoing high-dose radiotherapy for prostatic cancer and underwent diode laser therapy were evaluated retrospectively. Non-contact fibers were used in the patients who underwent the procedure without sedation in an outpatient setting. RESULTS The patients underwent a median of two sessions; overall, a mean of 1591 J of laser energy per session was used. No complications were noted during or after the procedures. Bleeding was completely resolved in 21/24 (88%) patients, and two patients showed improvement (96%). It was not necessary to suspend antiplatelet (six patients) or anticoagulant (four patients) therapy during the treatment course. The mean cost per session was EUR 473.4. CONCLUSIONS The study findings demonstrated that endoscopic non-contact diode laser treatment in CRP patients is safe, effective and cost efficient. For this procedure, antiplatelet and anticoagulant therapy suspension, intraprocedural sedation and hospital admission are not required.
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Affiliation(s)
- Lino Polese
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Emilia Giugliano
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Roberto Cadrobbi
- First Surgical Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
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8
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Zhu T, Wang Z, He J, Zhang X, Zhu C, Zhang S, Li Y, Fan S. D-galactose protects the intestine from ionizing radiation-induced injury by altering the gut microbiome. JOURNAL OF RADIATION RESEARCH 2022; 63:805-816. [PMID: 36253108 PMCID: PMC9726703 DOI: 10.1093/jrr/rrac059] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/18/2022] [Indexed: 05/12/2023]
Abstract
This article aims to investigate the protection of the intestine from ionizing radiation-induced injury by using D-galactose (D-gal) to alter the gut microbiome. In addition, this observation opens up further lines of research to further increase therapeutic potentials. Male C57BL/6 mice were exposed to 7.5 Gy of total body irradiation (TBI) or 13 Gy of total abdominal irradiation (TAI) in this study. After adjustment, D-gal was intraperitoneally injected into mice at a dose of 750 mg/kg/day. Survival rates, body weights, histological experiments and the level of the inflammatory factor IL-1β were observed after TBI to investigate radiation injury in mice. Feces were collected from mice for 16S high-throughput sequencing after TAI. Furthermore, fecal microorganism transplantation (FMT) was performed to confirm the effect of D-gal on radiation injury recovery. Intraperitoneally administered D-gal significantly increased the survival of irradiated mice by altering the gut microbiota structure. Furthermore, the fecal microbiota transplanted from D-gal-treated mice protected against radiation injury and improved the survival rate of recipient mice. Taken together, D-gal accelerates gut recovery following radiation injury by promoting the growth of specific microorganisms, especially those in the class Erysipelotrichia. The study discovered that D-gal-induced changes in the microbiota protect against radiation-induced intestinal injury. Erysipelotrichia and its metabolites are a promising therapeutic option for post-radiation intestinal regeneration.
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Affiliation(s)
| | | | - Junbo He
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Department of Radiation Injury Treatment, Institute of Radiation Medicine Chinese Academy of Medical Sciences and Peking Union Medical College, 238 Baidi Road, Tianjin 300192, China
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong’ An Road, Shanghai 200032, PR China
| | - Xueying Zhang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Department of Radiation Injury Treatment, Institute of Radiation Medicine Chinese Academy of Medical Sciences and Peking Union Medical College, 238 Baidi Road, Tianjin 300192, China
| | - Changchun Zhu
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Department of Radiation Injury Treatment, Institute of Radiation Medicine Chinese Academy of Medical Sciences and Peking Union Medical College, 238 Baidi Road, Tianjin 300192, China
| | - Shuqin Zhang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Department of Radiation Injury Treatment, Institute of Radiation Medicine Chinese Academy of Medical Sciences and Peking Union Medical College, 238 Baidi Road, Tianjin 300192, China
| | - Yuan Li
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Department of Radiation Injury Treatment, Institute of Radiation Medicine Chinese Academy of Medical Sciences and Peking Union Medical College, 238 Baidi Road, Tianjin 300192, China
| | - Saijun Fan
- Corresponding author. Saijun Fan, Institute of Radiation Medicine Chinese Academy of Medical Sciences and Peking Union Medical College.
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9
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Dalsania RM, Shah KP, Stotsky-Himelfarb E, Hoffe S, Willingham FF. Management of Long-Term Toxicity From Pelvic Radiation Therapy. Am Soc Clin Oncol Educ Book 2021; 41:1-11. [PMID: 33793314 DOI: 10.1200/edbk_323525] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pelvic radiation therapy is an integral component in the treatment of various gastrointestinal, gynecologic, and genitourinary cancers. As survival rates from these malignancies improve, the prevalence of toxicity secondary to pelvic radiation has increased. Gastrointestinal toxicities are the most common complications and greatly impact quality of life. Toxicities can present in acute or late stages; although symptoms may be similar during both, the management may differ. Acute toxicities represent an inflammatory reaction in response to the radiation exposure, whereas late toxicities may arise as a result of small vessel disease, ischemia, and fibrosis. Currently, there are no large clinical trials and only limited guidelines on the management of late gastrointestinal radiation toxicities. Therapy is generally approached in a stepwise manner from medical to endoscopic to surgical methods. Several endoscopic therapies, such as the treatment of radiation proctitis with argon plasma coagulation and dilation of radiation bowel strictures, may prevent the need for surgical intervention, which may be associated with high morbidity and mortality. Given that late toxicities can occur years after radiation therapy, they are often difficult to recognize and diagnose. Successful management of late toxicities requires recognition, an understanding of the underlying pathophysiology, and a multidisciplinary approach. More dedicated research could clarify the prevalence of gastrointestinal pelvic radiation toxicities, permit a better understanding of the efficacy and safety profile of current therapies, and allow for the development of novel therapeutic approaches.
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Affiliation(s)
- Raj M Dalsania
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kevin P Shah
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA
| | | | | | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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10
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Salminen S, Collado MC, Endo A, Hill C, Lebeer S, Quigley EMM, Sanders ME, Shamir R, Swann JR, Szajewska H, Vinderola G. The International Scientific Association of Probiotics and Prebiotics (ISAPP) consensus statement on the definition and scope of postbiotics. Nat Rev Gastroenterol Hepatol 2021; 18:649-667. [PMID: 33948025 PMCID: PMC8387231 DOI: 10.1038/s41575-021-00440-6] [Citation(s) in RCA: 625] [Impact Index Per Article: 208.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 02/03/2023]
Abstract
In 2019, the International Scientific Association for Probiotics and Prebiotics (ISAPP) convened a panel of experts specializing in nutrition, microbial physiology, gastroenterology, paediatrics, food science and microbiology to review the definition and scope of postbiotics. The term 'postbiotics' is increasingly found in the scientific literature and on commercial products, yet is inconsistently used and lacks a clear definition. The purpose of this panel was to consider the scientific, commercial and regulatory parameters encompassing this emerging term, propose a useful definition and thereby establish a foundation for future developments. The panel defined a postbiotic as a "preparation of inanimate microorganisms and/or their components that confers a health benefit on the host". Effective postbiotics must contain inactivated microbial cells or cell components, with or without metabolites, that contribute to observed health benefits. The panel also discussed existing evidence of health-promoting effects of postbiotics, potential mechanisms of action, levels of evidence required to meet the stated definition, safety and implications for stakeholders. The panel determined that a definition of postbiotics is useful so that scientists, clinical triallists, industry, regulators and consumers have common ground for future activity in this area. A generally accepted definition will hopefully lead to regulatory clarity and promote innovation and the development of new postbiotic products.
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Affiliation(s)
- Seppo Salminen
- grid.1374.10000 0001 2097 1371Functional Foods Forum, Faculty of Medicine, University of Turku, Turku, Finland
| | - Maria Carmen Collado
- grid.419051.80000 0001 1945 7738Institute of Agrochemistry and Food Technology-National Research Council (IATA-CSIC), Valencia, Spain
| | - Akihito Endo
- grid.410772.70000 0001 0807 3368Department of Food, Aroma and Cosmetic Chemistry, Faculty of Bioindustry, Tokyo University of Agriculture, Hokkaido, Japan
| | - Colin Hill
- grid.7872.a0000000123318773School of Microbiology, University College Cork, Cork, Ireland ,grid.7872.a0000000123318773APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - Sarah Lebeer
- grid.5284.b0000 0001 0790 3681Department of Bioscience Engineering, University of Antwerp, Antwerp, Belgium
| | - Eamonn M. M. Quigley
- Division of Gastroenterology and Hepatology, Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, TX USA
| | - Mary Ellen Sanders
- International Scientific Association for Probiotics and Prebiotics, Centennial, CO USA
| | - Raanan Shamir
- grid.414231.10000 0004 0575 3167Institute of Pediatric Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Center, Petach Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan R. Swann
- grid.5491.90000 0004 1936 9297School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK ,grid.7445.20000 0001 2113 8111Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Hania Szajewska
- grid.13339.3b0000000113287408Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Gabriel Vinderola
- grid.10798.370000 0001 2172 9456Instituto de Lactología Industrial (CONICET-UNL), Faculty of Chemical Engineering, National University of Litoral, Santa Fe, Argentina
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11
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O'Reilly M, Mellotte G, Ryan B, O'Connor A. Gastrointestinal side effects of cancer treatments. Ther Adv Chronic Dis 2020; 11:2040622320970354. [PMID: 33294145 PMCID: PMC7705778 DOI: 10.1177/2040622320970354] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/12/2020] [Indexed: 12/13/2022] Open
Abstract
Cancer survival rates have significantly improved over the last number of
years due to advancements in cancer therapies. Unfortunately this has
come at a cost. Therapeutic side effects are feared complications of
therapy that may result in decreased quality of life and early
cessation of the therapy, which can have knock-on effects on outcomes.
This article outlines the main gastrointestinal side effects seen with
radiation therapy, chemotherapy and immunotherapy, and discusses
appropriate investigation and management.
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Affiliation(s)
- Mary O'Reilly
- Department of Gastroenterology, Tallaght University Hospital/Trinity College Dublin, Ireland
| | - Gregory Mellotte
- Department of Gastroenterology, Tallaght University Hospital/Trinity College Dublin, Ireland
| | - Barbara Ryan
- Department of Gastroenterology, Tallaght University Hospital/Trinity College Dublin, Ireland
| | - Anthony O'Connor
- Department of Gastroenterology, Tallaght University Hospital/Trinity College Dublin, Belgard Road, Tallaght, Dublin, D24NR0A, Ireland
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Araujo IK, Muñoz-Guglielmetti D, Mollà M. Radiation-induced damage in the lower gastrointestinal tract: Clinical presentation, diagnostic tests and treatment options. Best Pract Res Clin Gastroenterol 2020; 48-49:101707. [PMID: 33317789 DOI: 10.1016/j.bpg.2020.101707] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/15/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Abstract
Radiation therapy is an important ally when treating malignant lesions in the pelvic area, but it is not exempt of adverse events. There are some measures that can be taken to reduce the possibility of these effects, but some are non-modifiable factors related to previous treatments, location of the lesions or comorbidities. There is a wide variety of clinical presentations that can be of an acute or chronic onset that go from mild to severe forms or that can have a great impact in the quality of life. Medical available therapies as metronidazole, sucralfate, mesalizine or probiotics, can be of aid although some lack of solid evidence of efficacy. Endoscopic treatment can be performed with argon plasma coagulation, bipolar cautery, radiofrequency, laser therapy or dilation. Hyperbaric therapy can be applied in refractory cases and surgery must be reserved to selected patients due to its high morbidity and mortality.
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Affiliation(s)
- Isis K Araujo
- Endoscopy and Motility Unit, Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
| | | | - Meritxell Mollà
- Radiation Oncology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
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Sultania S, Sarkar R, Das K, Dhali GK. Argon plasma coagulation is an effective treatment for chronic radiation proctitis in gynaecological malignancy: an observational study. Colorectal Dis 2019; 21:465-471. [PMID: 30585689 DOI: 10.1111/codi.14541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 11/12/2018] [Indexed: 12/31/2022]
Abstract
AIM Chronic radiation proctitis (CRP) develops in 5-15% of patients after pelvic radiation therapy, with rectal bleeding being the main symptom. Reports suggest that argon plasma coagulation (APC) can be an effective therapy for CRP following radiotherapy for prostate cancer, but there is less information about how useful it is after radiotherapy for gynaecological malignancy. The aim of this work therefore was to study the efficacy of APC for CRP after radiotherapy for gynaecological malignancy. METHOD This was a prospective study of consecutive patients with CRP following radiotherapy for gynaecological malignancy at IPGME&R, SDLD, Kolkata, India; symptoms included rectal bleeding grade (RBG) ≥ 2. APC was performed at monthly intervals to a maximum of four treatment sessions. Severity of disease at baseline was graded (endoscopically) by the total colonoscopic severity score (TCSS) and treatment response was assessed by reduction in RBG from ≥ 2 to ≤ 1 measured at > 6 months after cessation of APC. RESULTS Seventy patients [90% with cervical cancer, 10% with endometrial cancer; mean age 51.93 ± 9.15 years; median RBG 3 (range 2-4)] received APC. Seven patients died due to underlying malignancy and seven patients were lost to follow-up. Fifty-six (85.7%) patients responded to therapy after a median of 2 (range 1-4) treatment sessions. Multivariate analysis demonstrated that a lower haemoglobin at the start of treatment predicted failure of therapy (P < 0.05). CONCLUSION APC is an effective management option for CRP in female patients with gynaecological malignancy. However, the more anaemic the patient the less likely it is to be successful.
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Affiliation(s)
- S Sultania
- Department of Gastroenterology, CKS Hospitals, Jaipur, Rajasthan, India
| | - R Sarkar
- Department of Gastroenterology, School of Digestive and Liver disease, Kolkata, West Bengal, India
| | - K Das
- Department of Gastroenterology, School of Digestive and Liver disease, Kolkata, West Bengal, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver disease, Kolkata, West Bengal, India
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Wu T, Grootaert C, Pitart J, Vidovic NK, Kamiloglu S, Possemiers S, Glibetic M, Smagghe G, Raes K, Van de Wiele T, Van Camp J. Aronia (Aronia melanocarpa) Polyphenols Modulate the Microbial Community in a Simulator of the Human Intestinal Microbial Ecosystem (SHIME) and Decrease Secretion of Proinflammatory Markers in a Caco-2/endothelial Cell Coculture Model. Mol Nutr Food Res 2018; 62:e1800607. [DOI: 10.1002/mnfr.201800607] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/30/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Ting Wu
- Department of Food Technology; Safety and Health; Ghent University; 9000 Ghent Belgium
| | - Charlotte Grootaert
- Department of Food Technology; Safety and Health; Ghent University; 9000 Ghent Belgium
| | | | - Nevena Kardum Vidovic
- Center of Research Excellence in Nutrition and Metabolism; Institute for Medical Research; University of Belgrade; 11000 Belgrade Serbia
| | - Senem Kamiloglu
- Department of Food Technology; Safety and Health; Ghent University; 9000 Ghent Belgium
| | | | - Maria Glibetic
- Center of Research Excellence in Nutrition and Metabolism; Institute for Medical Research; University of Belgrade; 11000 Belgrade Serbia
| | - Guy Smagghe
- Department of Plants and Crops; Ghent University; 9000 Ghent Belgium
| | - Katleen Raes
- Department of Food Technology; Safety and Health; Ghent University Campus Kortrijk; 8500 Kortrijk Belgium
| | - Tom Van de Wiele
- Center for Microbial Ecology and Technology (CMET); Ghent University; 9000 Ghent Belgium
| | - John Van Camp
- Department of Food Technology; Safety and Health; Ghent University; 9000 Ghent Belgium
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15
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Chronic Radiation Proctitis. Dis Colon Rectum 2018; 61:1135-1140. [PMID: 30192320 DOI: 10.1097/dcr.0000000000001209] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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16
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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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Wu C, Guan L, Yao L, Huang J. Mesalazine suppository for the treatment of refractory ulcerative chronic radiation proctitis. Exp Ther Med 2018; 16:2319-2324. [PMID: 30186474 PMCID: PMC6122487 DOI: 10.3892/etm.2018.6464] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/25/2018] [Indexed: 12/21/2022] Open
Abstract
The aim of the present study was to investigate the safety and efficacy of mesalazine suppository in the treatment of refractory ulcerative chronic radiation proctitis (CRP). In total, 10 refractory ulcerative CRP patients who did not respond to previous medical treatments were recruited for the present study and were treated with mesalazine suppository (0.5 g) twice daily for 24 weeks. For each patient, the severity of clinical symptoms and endoscopic appearance was assessed before and after the treatment. For symptom scoring, the reductions in the mean total symptom score (pre- vs. post-treatment, 8.20 vs. 0.90; P<0.01), rectal bleeding score (2.40 vs. 0.30; P<0.01), rectal pain score (2.00 vs. 0.50; P<0.01), stool frequency score (2.00 vs. 0.10; P<0.01) and tenesmus score (1.80 vs. 0.00; P<0.01) were all statistically significant. For mucosal damage scoring, there was a reduction in the mean scores for total scores (9.22 vs. 5.22; P<0.01), telangiectasia (2.78 vs. 1.89; P=0.009), edema (2.89 vs. 1.78; P=0.001) and ulceration (2.44 vs. 0.89; P=0.003). However, statistically reductions in the median symptom scores were not observed for stenosis (0.78 vs. 0.67; P=0.347) and necrosis (0.33 vs. 0.00; P=0.081). Furthermore, no adverse events were observed during and after the treatment. The topical mesalazine suppository may be a safe and effective treatment for CRP, particularly for patients with deep ulcers. Adequately randomized controlled trials are required to confirm the results of the present study.
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Affiliation(s)
- Changliang Wu
- Department of Gastroenterology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530007, P.R. China
| | - Liyu Guan
- Department of Gastroenterology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530007, P.R. China
| | - Li Yao
- Department of Gastroenterology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530007, P.R. China
| | - Jiean Huang
- Department of Gastroenterology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530007, P.R. China
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Efficacy and Safety of Argon Plasma Coagulation for Hemorrhagic Chronic Radiation Proctopathy: A Systematic Review. Gastroenterol Res Pract 2018; 2018:3087603. [PMID: 29681929 PMCID: PMC5845516 DOI: 10.1155/2018/3087603] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/13/2017] [Accepted: 01/08/2018] [Indexed: 12/15/2022] Open
Abstract
Hemorrhagic chronic radiation proctopathy (CRP) is a common complication after pelvic radiotherapy in patients with prostate or gynecological cancers. This systematic review was conducted to evaluate the efficacy and safety of argon plasma coagulation (APC) in treating hemorrhagic CRP. The databases of PubMed, Embase, and Cochrane Library were searched for related studies from inception to July 2017. Finally, 33 studies were identified with a total of 821 hemorrhagic CRP patients. After APC treatment, hemoglobin levels increased from 7.7–13.4 g/L to 11–14 g/L (including 15 studies). All (n = 33) studies reported an effective rate in rectal bleeding, among which five studies had a rate of 100%. Short-term complications were reported in 31 studies, while long-term complications in 33 studies and no complication in 11 studies. As for the severe complications, perforation was reported by 2 out of 33 studies, and the incidences were 3.3% (1/30) and 3.7% (1/27), respectively. As for APC setting, argon gas flow rate (median 1.5 L/min) and electric power (median 50 W) had no significant influence on complications and hemostasis. In conclusion, current literature indicated that APC therapy was an effective and safe strategy for hemorrhagic CRP, and large-scale prospective studies are needed to warrant our study.
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van der Beek CM, Dejong CHC, Troost FJ, Masclee AAM, Lenaerts K. Role of short-chain fatty acids in colonic inflammation, carcinogenesis, and mucosal protection and healing. Nutr Rev 2017; 75:286-305. [PMID: 28402523 DOI: 10.1093/nutrit/nuw067] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Short-chain fatty acids (SCFAs), mainly acetate, propionate, and butyrate, produced by microbial fermentation of undigested food substances are believed to play a beneficial role in human gut health. Short-chain fatty acids influence colonic health through various mechanisms. In vitro and ex vivo studies show that SCFAs have anti-inflammatory and anticarcinogenic effects, play an important role in maintaining metabolic homeostasis in colonocytes, and protect colonocytes from external harm. Animal studies have found substantial positive effects of SCFAs or dietary fiber on colonic disease, but convincing evidence in humans is lacking. Most human intervention trials have been conducted in the context of inflammatory bowel disease. Only a limited number of those trials are of high quality, showing little or no favorable effect of SCFA treatment over placebo. Opportunities for future research include exploring the use of combination therapies with anti-inflammatory drugs, prebiotics, or probiotics; the use of prodrugs in the setting of carcinogenesis; or the direct application of SCFAs to improve mucosal healing after colonic surgery.
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Affiliation(s)
- Christina M van der Beek
- C.M. van der Beek, C.H.C. Dejong, F.J. Troost, A.A.M. Masclee, and K. Lenaerts are with Top Institute Food and Nutrition, Wageningen, the Netherlands. C.M. van der Beek, C.H.C. Dejong, and K. Lenaerts are with the Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands. C.H.C. Dejong is with the School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center+, Maastricht, the Netherlands. F.J. Troost and A.A.M. Masclee are with the Department of Internal Medicine, Division of Gastroenterology-Hepatology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Cornelis H C Dejong
- C.M. van der Beek, C.H.C. Dejong, F.J. Troost, A.A.M. Masclee, and K. Lenaerts are with Top Institute Food and Nutrition, Wageningen, the Netherlands. C.M. van der Beek, C.H.C. Dejong, and K. Lenaerts are with the Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands. C.H.C. Dejong is with the School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center+, Maastricht, the Netherlands. F.J. Troost and A.A.M. Masclee are with the Department of Internal Medicine, Division of Gastroenterology-Hepatology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Freddy J Troost
- C.M. van der Beek, C.H.C. Dejong, F.J. Troost, A.A.M. Masclee, and K. Lenaerts are with Top Institute Food and Nutrition, Wageningen, the Netherlands. C.M. van der Beek, C.H.C. Dejong, and K. Lenaerts are with the Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands. C.H.C. Dejong is with the School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center+, Maastricht, the Netherlands. F.J. Troost and A.A.M. Masclee are with the Department of Internal Medicine, Division of Gastroenterology-Hepatology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ad A M Masclee
- C.M. van der Beek, C.H.C. Dejong, F.J. Troost, A.A.M. Masclee, and K. Lenaerts are with Top Institute Food and Nutrition, Wageningen, the Netherlands. C.M. van der Beek, C.H.C. Dejong, and K. Lenaerts are with the Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands. C.H.C. Dejong is with the School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center+, Maastricht, the Netherlands. F.J. Troost and A.A.M. Masclee are with the Department of Internal Medicine, Division of Gastroenterology-Hepatology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Kaatje Lenaerts
- C.M. van der Beek, C.H.C. Dejong, F.J. Troost, A.A.M. Masclee, and K. Lenaerts are with Top Institute Food and Nutrition, Wageningen, the Netherlands. C.M. van der Beek, C.H.C. Dejong, and K. Lenaerts are with the Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands. C.H.C. Dejong is with the School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center+, Maastricht, the Netherlands. F.J. Troost and A.A.M. Masclee are with the Department of Internal Medicine, Division of Gastroenterology-Hepatology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, the Netherlands
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20
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Efficacy and safety of argon plasma coagulation in the management of extensive chronic radiation proctitis after pelvic radiotherapy for cervical carcinoma. Int J Colorectal Dis 2017; 32:1285-1288. [PMID: 28707144 DOI: 10.1007/s00384-017-2859-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Chronic radiation proctitis (CRP) usually develops 90 days or more after radiation. Currently, there is no standard available for the treatment of CRP. In argon plasma coagulation, monopolar diathermy is used to ionise the argon gas which coagulates the telengiectatic vessels in a noncontact fashion. However, there are very few studies which have reported its use in extensive CRP. We report the efficacy and safety of APC in seven patients with recurrent, extensive grade 3 radiation proctitis. MATERIALS AND METHODS This is a retrospective analysis of patients treated with argon plasma coagulation in our institute from June 2013 to June 2016. After adequate bowel preparation, patients underwent APC at an average power of 50 W with flow rate of 5 L/min. All the visible telangiectasia was ablated which required many sittings. RESULTS The median RPSAS symptom score for frequency of bleeding at enrolment was 5 (range 3-5). After completion of APC, the median RPSAS symptom score for frequency of bleeding decreased to 1. The median RPSAS symptom score for severity of bleeding was 5 (range 3-5). After completion of APC, the mean RPSAS symptom score for severity of bleeding decreased to 1. Mean haemoglobin level before treatment was 5.43 g/dl (SD 2.37). Mean haemoglobin level after treatment was10.04 g/dl (SD 2.0). Compared with pre-treatment levels after APC, there was a mean increase in haemoglobin of 4.61 + 1.78 [95% CI 2.97-6.25, p = 0.00]. CONCLUSION Argon plasma coagulation is a safe, well tolerated and effective treatment option in extensive chronic radiation proctitis which is refractory to medical management.
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Sahebnasagh A, Ghasemi A, Akbari J, Alipour A, Lashkardoost H, Ala S, Salehifar E. Successful Treatment of Acute Radiation Proctitis with Aloe Vera: A Preliminary Randomized Controlled Clinical Trial. J Altern Complement Med 2017; 23:858-865. [PMID: 28618234 DOI: 10.1089/acm.2017.0047] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Acute radiation proctitis (ARP) is a common side-effect that affects up to 50% of patients receiving radiotherapy. The aim of this study was to evaluate the role of a topical preparation of Aloe vera in the treatment of ARP induced by radiotherapy of pelvic area. SUBJECTS AND INTERVENTIONS In this double-blind placebo-controlled trial, 20 consecutive patients with ARP after external-beam radiation therapy (46-72 Gy) of pelvic malignancies were randomized to receive either Aloe vera 3% or placebo ointment, 1 g twice daily for 4 weeks. These patients presented with at least two of the following symptoms: rectal bleeding, abdominal/rectal pain, diarrhea, or fecal urgency. These symptoms were rated by the patients in terms of their severity (grade 0-4) for each of the symptoms mentioned earlier at baseline and then weekly for 4 weeks. A symptom index was calculated by the addition of the scores (16 most symptomatic). Radiation Therapy Oncology Group (RTOG) acute toxicity criteria and psychosocial status of the patients were also recorded weekly. The lifestyle impact of the symptoms was assessed by questionnaire grading from 0 (no effect on daily activity) to 4 (afraid to leave home). RESULTS There was a significant (p < 0.05) improvement in the symptom index (before treatment vs. after treatment with Aloe vera) for diarrhea (median score: 0.67 vs. 0.11), fecal urgency (median score: 0.89 vs. 0.11), clinical presentation total (median score: 4.33 vs. 1.22), RTOG total (median score: 2.89 vs. 0.89), and lifestyle (median score: 1.1 vs. 0.33). Hemorrhage and abdominal/rectal pain did not improve significantly. The odds ratios for advantage of Aloe vera over placebo for "clinical presentation total" and "RTOG total" were 3.97 (1.3-11.9) and 5.9 (1.6-21.6), respectively. CONCLUSION A substantial number of patients with radiation proctitis seem to benefit from therapy with Aloe vera 3% ointment.
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Affiliation(s)
- Adeleh Sahebnasagh
- 1 Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences , Sari, Iran
| | - Arash Ghasemi
- 2 Emam Khomeini Hospital, Mazandaran University of Medical Sciences , Sari, Iran
| | - Jafar Akbari
- 3 Pharmaceutical Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences , Sari, Iran
| | - Abbas Alipour
- 4 Faculty of Medicine, Community Medicine Department, Mazandaran University of Medical Sciences , Sari, Iran
| | - Hossein Lashkardoost
- 5 School of Public Health, North Khorasan University of Medical Sciences , Bojnurd, Iran
| | - Shahram Ala
- 3 Pharmaceutical Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences , Sari, Iran
| | - Ebrahim Salehifar
- 6 Gastrointestinal Cancer Research Center, Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences , Sari, Iran
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Jensen MM, Jia W, Isaacson KJ, Schults A, Cappello J, Prestwich GD, Oottamasathien S, Ghandehari H. Silk-elastinlike protein polymers enhance the efficacy of a therapeutic glycosaminoglycan for prophylactic treatment of radiation-induced proctitis. J Control Release 2017; 263:46-56. [PMID: 28232224 DOI: 10.1016/j.jconrel.2017.02.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 02/15/2017] [Accepted: 02/19/2017] [Indexed: 12/17/2022]
Abstract
Radiation-induced proctitis (RIP) is the most common clinical adverse effect for patients receiving radiotherapy as part of the standard course of treatment for ovarian, prostate, colon, and bladder cancers. RIP limits radiation dosage, interrupts treatment, and lowers patients' quality of life. A prophylactic treatment that protects the gastrointestinal tract from deleterious effects of radiotherapy will significantly improve patient quality of life and may allow for higher and more regular doses of radiation therapy. Semi-synthetic glycosaminoglycan (GAG), generated from the sulfation of hyaluronic acid, are anti-inflammatory but have difficulty achieving therapeutic levels in many tissues. To enhance the delivery of GAG, we created an in situ gelling rectal delivery system using silk-elastinlike protein polymers (SELPs). Using solutions of SELP 815K (which contains 6 repeats of blocks comprised of 8 silk-like units, 15 elastin-like units, and 1 lysine-substituted elastin-like unit) with GAG GM-0111, we created an injectable delivery platform that transitioned in <5min from a liquid at room temperature to a hydrogel at body temperature. The hydrogels released 50% of their payload within 30min and enhanced the accumulation of GAG in the rectum compared to traditional enema-based delivery. Using a murine model of radiation-induced proctitis, the prophylactic delivery of a single dose of GAG from a SELP matrix administered prior to irradiation significantly reduced radiation-induced pain after 3, 7, and 21days by 53±4%, 47±10%, and 12±6%, respectively. Matrix-mediated delivery of GAG by SELP represents an innovative method for more effective treatment of RIP and promises to improve quality of life of cancer patients by allowing higher radiotherapy doses with improved safety.
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Affiliation(s)
- Mark Martin Jensen
- Department of Bioengineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA
| | - Wanjian Jia
- Division of Urology, Section of Pediatric Urology, University of Utah, Salt Lake City, UT 84113, USA
| | - Kyle J Isaacson
- Department of Bioengineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA
| | - Austin Schults
- Division of Urology, Section of Pediatric Urology, University of Utah, Salt Lake City, UT 84113, USA
| | - Joseph Cappello
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT 84112, USA
| | - Glenn D Prestwich
- Department of Medicinal Chemistry, University of Utah, Salt Lake City, UT 84112, USA
| | - Siam Oottamasathien
- Division of Urology, Section of Pediatric Urology, University of Utah, Salt Lake City, UT 84113, USA; Department of Surgery and Division of Pediatric Urology, Primary Children's Hospital, Salt Lake City, UT 84113, USA.
| | - Hamidreza Ghandehari
- Department of Bioengineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center for Nanomedicine, Nano Institute of Utah, 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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Yuan ZX, Ma TH, Zhong QH, Wang HM, Yu XH, Qin QY, Chu LL, Wang L, Wang JP. Novel and Effective Almagate Enema for Hemorrhagic Chronic Radiation Proctitis and Risk Factors for Fistula Development. Asian Pac J Cancer Prev 2017; 17:631-8. [PMID: 26925655 DOI: 10.7314/apjcp.2016.17.2.631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Radiation proctitis is a common complication after radiotherapy for pelvic malignant tumors. This study was conducted to assess the efficacy of novel almagate enemas in hemorrhagic chronic radiation proctitis (CRP) and evaluate risk factors related to rectal deep ulcer or fistula secondary to CRP. All patients underwent a colonoscopy to confirm the diagnosis of CRP and symptoms were graded. Typical endoscopic and pathological images, risk factors, and quality of life were also recorded. A total of 59 patients were enrolled. Gynecological cancers composed 93.1% of the primary malignancies. Complete or obvious reduction of bleeding was observed in 90% (53/59) patients after almagate enema. The mean score of bleeding improved from 2.17 to 0.83 (P<0.001) after the enemas. The mean response time was 12 days. No adverse effects were found. Moreover, long-term successful rate in controlling bleeding was 69% and the quality of life was dramatically improved (P=0.001). The efficacy was equivalent to rectal sucralfate, but the almagate with its antacid properties acted more rapidly than sucralfate. Furthermore, we firstly found that moderate to severe anemia was the risk factor of CRP patients who developed rectal deep ulcer or fistulas (P= 0.015). We also found abnormal hyaline-like thick wall vessels, which revealed endarteritis obliterans and the fibrosis underlying this disease. These findings indicate that almagate enema is a novel effective, rapid and well-tolerated method for hemorrhagic CRP. Moderate to severe anemia is a risk factor for deep ulceration or fistula.
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Affiliation(s)
- Zi-Xu Yuan
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China E-mail : , wangl9@mail. sysu.edu.cn,
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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: 1.3] [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: 20] [Impact Index Per Article: 2.5] [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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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: 1.6] [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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van de Wetering FT, Verleye L, Andreyev HJN, Maher J, Vlayen J, Pieters BR, van Tienhoven G, Scholten RJPM. Non-surgical interventions for late rectal problems (proctopathy) of radiotherapy in people who have received radiotherapy to the pelvis. Cochrane Database Syst Rev 2016; 4:CD003455. [PMID: 27111831 PMCID: PMC7173735 DOI: 10.1002/14651858.cd003455.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND This is an update of a Cochrane review first published in 2002, and previously updated in 2007. Late radiation rectal problems (proctopathy) include bleeding, pain, faecal urgency, and incontinence and may develop after pelvic radiotherapy treatment for cancer. OBJECTIVES To assess the effectiveness and safety of non-surgical interventions for managing late radiation proctopathy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 11, 2015); MEDLINE (Ovid); EMBASE (Ovid); CANCERCD; Science Citation Index; and CINAHL from inception to November 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing non-surgical interventions for the management of late radiation proctopathy in people with cancer who have undergone pelvic radiotherapy for cancer. Primary outcomes considered were: episodes of bowel activity, bleeding, pain, tenesmus, urgency, and sphincter dysfunction. DATA COLLECTION AND ANALYSIS Study selection, 'Risk of bias' assessment, and data extraction were performed in duplicate, and any disagreements were resolved by involving a third review author. MAIN RESULTS We identified 1221 unique references and 16 studies including 993 participants that met our inclusion criteria. One study found through the last update was moved to the 'Studies awaiting classification' section. We did not pool outcomes for a meta-analysis due to variation in study characteristics and endpoints across included studies.Since radiation proctopathy is a condition with various symptoms or combinations of symptoms, the studies were heterogeneous in their intended effect. Some studies investigated treatments targeted at bleeding only (group 1), some investigated treatments targeted at a combination of anorectal symptoms, but not a single treatment (group 2). The third group focused on the treatment of the collection of symptoms referred to as pelvic radiation disease. In order to enable some comparison of this heterogeneous collection of studies, we describe the effects in these three groups separately.Nine studies assessed treatments for rectal bleeding and were unclear or at high risk of bias. The only treatments that made a significant difference on primary outcomes were argon plasma coagulation (APC) followed by oral sucralfate versus APC with placebo (endoscopic score 6 to 9 in favour of APC with placebo, risk ratio (RR) 2.26, 95% confidence interval (CI) 1.12 to 4.55; 1 study, 122 participants, low- to moderate-quality evidence); formalin dab treatment (4%) versus sucralfate steroid retention enema (symptom score after treatment graded by the Radiation Proctopathy System Assessments Scale (RPSAS) and sigmoidoscopic score in favour of formalin (P = 0.001, effect not quantified, 1 study, 102 participants, very low- to low-quality evidence), and colonic irrigation plus ciprofloxacin and metronidazole versus formalin application (4%) (bleeding (P = 0.007, effect not quantified), urgency (P = 0.0004, effect not quantified), and diarrhoea (P = 0.007, effect not quantified) in favour of colonic irrigation (1 study, 50 participants, low-quality evidence).Three studies, of unclear and high risk of bias, assessed treatments targeted at something very localised but not a single pathology. We identified no significant differences on our primary outcomes. We graded all studies as very low-quality evidence due to unclear risk of bias and very serious imprecision.Four studies, of unclear and high risk of bias, assessed treatments targeted at more than one symptom yet confined to the anorectal region. Studies that demonstrated an effect on symptoms included: gastroenterologist-led algorithm-based treatment versus usual care (detailed self help booklet) (significant difference in favour of gastroenterologist-led algorithm-based treatment on change in Inflammatory Bowel Disease Questionnaire-Bowel (IBDQ-B) score at six months, mean difference (MD) 5.47, 95% CI 1.14 to 9.81) and nurse-led algorithm-based treatment versus usual care (significant difference in favour of the nurse-led algorithm-based treatment on change in IBDQ-B score at six months, MD 4.12, 95% CI 0.04 to 8.19) (1 study, 218 participants, low-quality evidence); hyperbaric oxygen therapy (at 2.0 atmospheres absolute) versus placebo (improvement of Subjective, Objective, Management, Analytic - Late Effects of Normal Tissue (SOMA-LENT) score in favour of hyperbaric oxygen therapy (HBOT), P = 0.0019) (1 study, 150 participants, moderate-quality evidence, retinol palmitate versus placebo (improvement in RPSAS in favour of retinol palmitate, P = 0.01) (1 study, 19 participants, low-quality evidence) and integrated Chinese traditional plus Western medicine versus Western medicine (grade 0 to 1 radio-proctopathy after treatment in favour of integrated Chinese traditional medicine, RR 2.55, 95% CI 1.30 to 5.02) (1 study, 58 participants, low-quality evidence).The level of evidence for the majority of outcomes was downgraded using GRADE to low or very low, mainly due to imprecision and study limitations. AUTHORS' CONCLUSIONS Although some interventions for late radiation proctopathy look promising (including rectal sucralfate, metronidazole added to an anti-inflammatory regimen, and hyperbaric oxygen therapy), single small studies provide limited evidence. Furthermore, outcomes important to people with cancer, including quality of life (QoL) and long-term effects, were not well recorded. The episodic and variable nature of late radiation proctopathy requires large multi-centre placebo-controlled trials (RCTs) to establish whether treatments are effective. Future studies should address the possibility of associated injury to other gastro-intestinal, urinary, or sexual organs, known as pelvic radiation disease. The interventions, as well as the outcome parameters, should be broader and include those important to people with cancer, such as QoL evaluations.
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Affiliation(s)
- Fleur T van de Wetering
- Julius Center for Health Sciences and Primary Care / University Medical Center UtrechtDutch Cochrane CentrePO Box 85500UtrechtNetherlands3508 GA
| | - Leen Verleye
- Belgian Health Care Knowledge CentreKruidtuinlaan 55BrusselsBelgium1000
| | | | - Jane Maher
- Mount Vernon HospitalDepartment of Radiotherapy and OncologyRickmansworth RoadNorthwoodMiddlesexUKHA6 2RN
| | - Joan Vlayen
- Belgian Health Care Knowledge CentreKruidtuinlaan 55BrusselsBelgium1000
| | - Bradley R Pieters
- Academic Medical Center / University of AmsterdamDepartment of Radiation OncologyMeibergdreef 9AmsterdamNetherlands1105
| | - Geertjan van Tienhoven
- Academic Medical CenterRadiation Oncology and HyperthermiaP.O. Box 22700Meibergdreef 9AmsterdamNetherlands1100 DE
| | - Rob JPM Scholten
- Julius Center for Health Sciences and Primary Care / University Medical Center UtrechtDutch Cochrane CentrePO Box 85500UtrechtNetherlands3508 GA
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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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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: 4.3] [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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Rustagi T, Corbett FS, Mashimo H. Treatment of chronic radiation proctopathy with radiofrequency ablation (with video). Gastrointest Endosc 2015; 81:428-36. [PMID: 24973172 DOI: 10.1016/j.gie.2014.04.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 04/21/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic radiation proctopathy (CRP) is a common sequela occurring even many years after pelvic radiation. Current ablative therapies for bleeding ectatic vessels have the potential for deep tissue injury leading to ulcerations, perforation, and fistulas. Radiofrequency ablation (RFA) therapy avoids deep tissue injury and is a promising treatment for CRP. OBJECTIVE To assess the long-term safety and efficacy of RFA for the treatment of CRP. DESIGN Multicenter, retrospective analysis of a prospectively collected database. SETTING Veterans Affairs Boston Healthcare System, Massachusetts; Sarasota Memorial Hospital and Suncoast Endoscopy of Sarasota, Florida. PATIENTS A total of 39 consecutive patients with CRP. INTERVENTIONS Endoscopic RFA of CRP. MAIN OUTCOME MEASUREMENTS The primary endpoint of the study was complete resolution of rectal bleeding. Secondary endpoints included visually scored improvement of CRP on endoscopic follow-up by using a rectal telangiectasia density (RTD) grading score, improvement in hemoglobin level, and adverse events related to the procedure. RESULTS A total of 39 male patients (mean [± standard deviation {SD}] age 72.9 ± 6.6 years) were included in the study. The mean number of RFA sessions was 1.49 (median 1, interquartile range [IQR] 1-2, range 1-4), with a mean interval of 18 weeks between sessions. Rectal bleeding stopped completely in all patients during the mean follow-up of 28 months (range 7-53 months). A significant improvement occurred in the mean (± SD) hemoglobin level from 11.8 ± 2 to 13.5 ± 1.6 g % (P < .0001). Endoscopic severity also improved significantly with an improvement in the median RTD score from 3 (IQR 2-3) to 0 (IQR 0-1) (P < .0001). Treatment with RFA led to discontinuation of blood transfusion and iron therapy in 92% and 82% patients, respectively. LIMITATIONS Retrospective analysis, lack of control group. CONCLUSION RFA therapy led to complete resolution of rectal bleeding in all treated CRP patients, with improvement in clinical and endoscopic indices without any major adverse events. Further controlled studies are needed to establish RFA as the endoscopic therapy of choice for treatment of CRP.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - F Scott Corbett
- Florida Digestive Health Specialists, Sarasota Memorial Hospital, Sarasota, Florida, USA
| | - Hiroshi Mashimo
- Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
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31
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Pfaendler KS, Wenzel L, Mechanic MB, Penner KR. Cervical cancer survivorship: long-term quality of life and social support. Clin Ther 2015; 37:39-48. [PMID: 25592090 PMCID: PMC4404405 DOI: 10.1016/j.clinthera.2014.11.013] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/25/2014] [Accepted: 11/25/2014] [Indexed: 11/12/2022]
Abstract
PURPOSE Surgery, radiotherapy, and chemotherapy are the mainstays of cervical cancer treatment. Many patients receive multiple treatment modalities, each with its own long-term effects. Given the high 5-year survival rate for cervical cancer patients, evaluation and improvement of long-term quality of life are essential. METHODS Pertinent articles were identified through searches of PubMed for literature published from 1993 to 2014. We summarize quality of life data from long-term follow-up studies of cervical cancer patients. We additionally summarize small group interviews of Hispanic and non-Hispanic cervical cancer survivors regarding social support and coping. FINDINGS Data are varied in terms of the long-term impact of treatment on quality of life, but consistent in suggesting that patients who receive radiotherapy as part of their treatment have the highest risk of increased long-term dysfunction of bladder and bowel, as well as sexual dysfunction and psychosocial consequences. Rigorous investigations regarding long-term consequences of treatment modalities are lacking. IMPLICATIONS Continued work to improve treatment outcomes and survival should also include a focus on reducing adverse long-term side effects. Providing supportive care during treatment and evaluating the effects of supportive care can reduce the prevalence and magnitude of long-term sequelae of cervical cancer, which will in turn improve quality of life and quality of care.
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Affiliation(s)
- Krista S Pfaendler
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California at Irvine Medical Center, Orange, California
| | - Lari Wenzel
- Program in Public Health, University of California, Irvine, Irvine, California; Department of Medicine and Program in Public Health, Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
| | - Mindy B Mechanic
- Department of Psychology, California State University, Fullerton, Fullerton, California
| | - Kristine R Penner
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California at Irvine Medical Center, Orange, California.
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Late rectal toxicity after low-dose-rate brachytherapy: incidence, predictors, and management of side effects. Brachytherapy 2014; 14:148-59. [PMID: 25516492 DOI: 10.1016/j.brachy.2014.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 12/20/2022]
Abstract
As clinical outcomes for patients with clinically localized prostate cancer continue to improve, patients and physicians are increasing making treatment decisions based on concerns regarding long-term morbidity. A primary concern is late radiation proctitis, a clinical entity embodied by various signs and symptoms, ranging from diarrhea to rectal fistulas. Here, we present a comprehensive literature review examining the clinical manifestations and pathophysiology of late radiation proctitis after low-dose-rate brachytherapy (BT), as well as its incidence and predictors. The long-term risks of rectal bleeding after BT are on the order of 5-7%, whereas the risks of severe ulceration or fistula are on the order of 0.6%. The most robust predictor appears to be the volume of rectum receiving the prescription dose. In certain situations (e.g., salvage setting, for patients with increased radiosensitivity, and following aggressive biopsy after BT), the risk of these severe toxicities may be increased by up to 10-fold. A variety of excellent management options exist for rectal bleeding, with endoscopic methods being the most commonly used.
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Patel A, Pathak R, Deshpande V, Patel SH, Wickremesinghe PC, Vadada D. Radiofrequency ablation using BarRx for the endoscopic treatment of radiation proctopathy: a series of three cases. Clin Exp Gastroenterol 2014; 7:453-60. [PMID: 25525377 PMCID: PMC4266256 DOI: 10.2147/ceg.s66534] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Radiation proctopathy is a complication of pelvic radiotherapy, which occurs in patients treated for carcinoma of the prostate, rectum, urinary bladder, cervix, uterus, and testes. If it presents within 6 weeks to 9 months after therapy, it is called acute radiation proctitis/proctopathy (ARP), and if it occurs 9 months to a year after treatment, it is classified as chronic radiation proctitis/proctopathy (CRP). CRP occurs in 5%–20% of patients receiving pelvic radiation, depending on the radiation dose and the presence or absence of chemotherapy. In many cases, CRP resolves spontaneously, but in some, it can lead to persistent rectal bleeding. Other symptoms of CRP include diarrhea, mucoid discharge, urgency, tenesmus, rectal pain, and fecal incontinence. Despite the availability of several therapies, many patients fail to respond, and continue to suffer in their quality of life. Radiofrequency ablation (RFA) is a newer endoscopic technique that uses radiofrequency energy to ablate tissue. This is an emerging way to treat radiation proctopathy and other mucosal telangiectasia. We present three cases of radiation proctopathy treated with RFA at our institute and review the literature on treatment modalities for CRP. We were also able to find 16 other cases of CRP that used RFA, and review their literature as well as literature on other treatment modalities.
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Affiliation(s)
- Anish Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Rahul Pathak
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Vrushak Deshpande
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Sunil H Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | | | - Deepak Vadada
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
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34
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Abstract
The optimal management of radiation proctitis is ill defined. A variety of alternatives are available and include topical agents (ie, sucralfate enemas, formalin), oral agents (ie, pentoxyfylline, vitamin A), hyperbaric oxygen, and endoscopic interventions (ie, argon plasma coagulation). It is prudent to manage patients conservatively and to intervene only when necessary with the option least likely to exacerbate the proctitis. Rectal biopsies should be avoided as they may precipitate a complication. More aggressive measures, such as argon laser coagulation, should be employed only when more conservative approaches fail.
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35
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Laterza L, Cecinato P, Guido A, Mussetto A, Fuccio L. Management of radiation-induced rectal bleeding. Curr Gastroenterol Rep 2014; 15:355. [PMID: 24101202 DOI: 10.1007/s11894-013-0355-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pelvic radiation disease is one of the major complication after radiotherapy for pelvic cancers. The most commonly reported symptom is rectal bleeding which affects patients' quality of life. Therapeutic strategies for rectal bleeding are generally ignored and include medical, endoscopic, and hyperbaric oxygen treatments. Most cases of radiation-induced bleeding are mild and self-limiting, and treatment is normally not indicated. In cases of clinically significant bleeding (i.e. anaemia), medical therapies, including stool softeners, sucralfate enemas, and metronidazole, should be considered as first-line treatment options. In cases of failure, endoscopic therapy, mainly represented by argon plasma coagulation and hyperbaric oxygen treatments, are valid and complementary second-line treatment strategies. Although current treatment options are not always supported by high-quality studies, patients should be reassured that treatment options exist and success is achieved in most cases if the patient is referred to a dedicated centre.
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Affiliation(s)
- Liboria Laterza
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S.Orsola-Malpighi University Hospital, Via Massarenti 9, 40138, Bologna, 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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37
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Hogan NM, Kerin MJ, Joyce MR. Gastrointestinal complications of pelvic radiotherapy: medical and surgical management strategies. Curr Probl Surg 2013; 50:395-407. [PMID: 23930906 DOI: 10.1067/j.cpsurg.2013.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Niamh M Hogan
- Department of Colorectal Surgery, University College Hospital Galway, Ireland
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Karamanolis G, Psatha P, Triantafyllou K. Endoscopic treatments for chronic radiation proctitis. World J Gastrointest Endosc 2013; 5:308-12. [PMID: 23858374 PMCID: PMC3711061 DOI: 10.4253/wjge.v5.i7.308] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 05/29/2013] [Accepted: 06/18/2013] [Indexed: 02/05/2023] Open
Abstract
Chronic radiation proctitis is a complication that occurs in patients who receive radiation therapy for pelvic malignancies. The common presentation is with rectal bleeding, but also rectal pain, diarrhea, tenesmus and even passage of mucus can occur. The optimal treatment of bleeding due to radiation proctitis remains unclear. Among various therapeutic options, medical management is generally ineffective and surgical intervention has a high incidence of morbidity. Promising advances have been made in endoscopic therapy, including argon plasma coagulation (APC), formalin application as well as new techniques such as radiofrequency ablation and cryoablation. APC is a safe, highly effective and long-lasting therapy in patients with rectal bleeding associated with radiation proctitis. It has been shown that several sessions of APC reduce the rate of bleeding and therefore the blood transfusion requirements. Moreover, the effect of treatment is long lasting. However, best results are achieved in patients with mild to moderate radiation proctitis, leaving space for alternative treatments for patients with more severe disease. In patients with severe or refractory radiation proctitis intra rectal formalin application is an appropriate treatment option. Radiofrequency ablation and cryoablation have shown efficacy as alternative methods in a limited number of patients with refractory chronic radiation proctitis.
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Stacey R, Green JT. Nonendoscopic therapies for the management of radiation-induced rectal bleeding. Curr Opin Support Palliat Care 2013; 7:175-82. [DOI: 10.1097/spc.0b013e32835f3e00] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Havenaar R. Intestinal health functions of colonic microbial metabolites: a review. Benef Microbes 2013; 2:103-14. [PMID: 21840809 DOI: 10.3920/bm2011.0003] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This review tries to find a scientific answer on the following two questions: (1) to what extent do we understand the specific role of colonic microbial metabolites, especially short-chain fatty acids (SCFA), in maintaining the health status and prevention of diseases of the colon and the host; (2) to what extent can we influence or even control the formation of colonic microbial metabolites which are beneficial for the health status. The review focuses on the following topics: energy source, intestinal motility, defence barrier, oxidative stress with special attention for antiinflammatory and anti-carcinogen functions, and satiety. Also the risk of overproduction of SCFA is discussed. Reviewing the literature as present today, it can be concluded that physiological levels of SCFA are vital for the health and well-being of the host and that the presence of carbohydrates (dietary fibre, prebiotics) is essential to favour the metabolic activity in the direction of carbohydrate fermentation. For optimal motor activity of the ileum and colon, to regulate the physiological intestinal mobility, steadily fermentable dietary fibres or prebiotics are crucial. The formation of SCFA, especially propionate and butyrate, up to high physiological levels in the colon, much likely also contributes to the defence mechanisms of the intestinal wall. No final answer can be given yet about the role of SCFA in anti-inflammation and anti-carcinogenicity, but recently published research shows possible mechanisms in this field. The intake of prebiotics or specific dietary fibres promotes the formation of SCFA within the physiological range, and more or less specifically increases the levels of propionate and butyrate. In this way, they provide benefit to the host, especially the natural regulation of the digestive system.
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Eddi R, DePasquale JR. Radiofrequency ablation for the treatment of radiation proctitis: a case report and review of literature. Therap Adv Gastroenterol 2013; 6:69-76. [PMID: 23320051 PMCID: PMC3539292 DOI: 10.1177/1756283x12456895] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Radiation proctitis is a frequent complication of pelvic radiation for cancer. This condition can present acutely within several weeks of radiation, or chronically many months or years after radiation, leading to rectal bleeding and transfusion-dependent anemia. Various medical and endoscopic therapies have been described to treat this condition; however, some patients fail to respond to the current standard therapies. Here we present a case of refractory radiation proctitis, with suboptimal response to other therapies, treated successfully with a novel method, radiofrequency ablation.
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Affiliation(s)
- Rodney Eddi
- Seton Hall University, School of Health and Medical Sciences – St. Michael’s Medical Center, Department of Medicine, Division of Gastroenterology, 111 Central Avenue, Newark, NJ 07102, USA
| | - Joseph R. DePasquale
- Seton Hall University, School of Health and Medical Sciences – St. Michael’s Medical Center, Department of Medicine, Division of Gastroenterology, Newark, USA
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Fuccio L, Guido A, Andreyev HJN. Management of intestinal complications in patients with pelvic radiation disease. Clin Gastroenterol Hepatol 2012; 10:1326-1334.e4. [PMID: 22858731 DOI: 10.1016/j.cgh.2012.07.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/22/2012] [Accepted: 07/20/2012] [Indexed: 02/07/2023]
Abstract
Gastrointestinal toxicity after radiotherapy for pelvic cancer is a major complication-the most commonly reported symptoms include rectal bleeding, diarrhea, and fecal incontinence, which substantially impair patients' quality of life. Management of these symptoms can be a challenge, although available treatment strategies generally are ignored or underused. Radiation-induced symptoms have multiple mechanisms of pathogenesis; the first step for the correct management is to identify the mechanism that is causing the symptoms. Optimal management requires close liaisons among physicians, gastroenterologists with specialist interests, radiotherapists, oncologists, dieticians, nurses, and surgeons. Patients should be reassured that treatment options (medical, endoscopic, and surgical) exist and are in most cases successful if patients are referred to experts in pelvic radiation disease. However, although new therapeutic approaches are not yet always supported by high-quality trials, research projects are underway to improve management of patients. Clinicians should focus on using proven treatments correctly and avoiding misuse.
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Affiliation(s)
- Lorenzo Fuccio
- Department of Clinical Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy.
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Abstract
BACKGROUND Chronic radiation proctopathy is associated with significant morbidity. The effectiveness of endoscopic and medical therapies has not been evaluated. OBJECTIVES The aim of this study was to conduct a systematic review of the effectiveness of endoscopic and comparative medical therapies for chronic radiation proctopathy. DATA SOURCES A comprehensive search Medline and PubMed was performed. STUDY SELECTION A comprehensive literature search was performed for studies of endoscopic and medical therapy for clinical and endoscopic improvement in chronic radiation proctopathy from January 1990 until December 2010. The quality of the overall evidence was rated according to the Grading of Recommendations, Assessment, Development, and Evaluation Working Group. SETTING Patients in both inpatient and outpatient settings were assessed. PATIENTS Patients experiencing chronic radiation proctopathy were included. INTERVENTIONS Patients had undergone medical or endoscopic treatments for chronic radiation proctopathy. MAIN OUTCOME MEASUREMENTS The primary outcomes measured were the resolution or improvement in symptoms. RESULTS A total of 39 studies were found, of which 27 evaluated endoscopic therapy and 12 evaluated medical therapy chronic radiation proctopathy. Overall, there is low-level evidence for the effectiveness of endoscopic therapy with argon plasma coagulation in reducing short-term (≤6 weeks) symptoms of chronic radiation proctopathy and insufficient evidence for long-term improvement. There is moderate-level evidence for the use of sucralfate enemas and low-level evidence for use of short-chain fatty acid enemas and hyperbaric oxygen. There is insufficient evidence for other agents: topical formalin, 5-aminosalicylic acid compounds, sulfasalazine, vitamin A, and pentoxifylline. LIMITATIONS Individual authors were not contacted, and the search was limited to English language journals only. CONCLUSION Endoscopic treatment with argon plasma coagulation appears effective in the short-term outcome of chronic radiation proctopathy. There is a moderate level of evidence for the use of sucralfate enemas. Large, randomized, placebo-controlled studies evaluating endoscopic and medical therapies for chronic radiation proctopathy are needed.
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Daram SR, Lahr C, Tang SJ. Anorectal bleeding: etiology, evaluation, and management (with videos). Gastrointest Endosc 2012; 76:406-17. [PMID: 22817792 DOI: 10.1016/j.gie.2012.03.178] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/13/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Sumanth R Daram
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA
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Lam MCW, Parliament M, Wong CKW. Argon plasma coagulation for the treatment of hemorrhagic radiation colitis. Case Rep Gastroenterol 2012; 6:446-51. [PMID: 22933988 PMCID: PMC3398092 DOI: 10.1159/000339462] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Radiation colitis is a common consequence of pelvic radiation. Its complications may include anemia due to chronic bleeding requiring transfusions. Many of these patients are managed with rectal medications which are often inadequate for control. Argon plasma coagulation (APC) has been well described for its efficacy in treating radiation proctitis. Here we present two cases in whom APC therapy was used to treat severe radiation colitis. We reviewed two cases originally seen at the regional cancer center (Cross Cancer Institute) in Edmonton, Alberta, Canada. Both patients received pelvic radiation for recurrent endometrial cancers and were referred for active bleeding secondary to radiation colitis that had required numerous transfusions. Radiation-induced telangiectasias were found from 10–50 cm in the sigmoid colon. Both patients had significant improvement of symptoms after one session of APC treatment set at 40–60 W and gas flow of 2.0 l/min. There were no complications from the procedures. Neither patient required blood transfusions after the treatment with improvement in their hemoglobin levels and were doing well at 3- and 6-month follow-up. APC can be used effectively to provide immediate and sustained resolution of symptoms in patients with radiation colitis.
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Affiliation(s)
- Mindy C W Lam
- Cross Cancer Institute and Royal Alexandra Hospital, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alta., Canada
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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: 5.6] [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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Rustagi T, Mashimo H. Endoscopic management of chronic radiation proctitis. World J Gastroenterol 2011; 17:4554-62. [PMID: 22147960 PMCID: PMC3225092 DOI: 10.3748/wjg.v17.i41.4554] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 05/14/2011] [Accepted: 05/21/2011] [Indexed: 02/06/2023] Open
Abstract
Chronic radiation proctopathy occurs in 5%-20% of patients following pelvic radiotherapy. Although many cases resolve spontaneously, some lead to chronic symptoms including diarrhea, tenesmus, urgency and persistent rectal bleeding with iron deficiency anemia requiring blood transfusions. Treatments for chronic radiation proctitis remain unsatisfactory and the basis of evidence for various therapies is generally insufficient. There are very few controlled or prospective trials, and comparisons between therapies are limited because of different evaluation methods. Medical treatments, including formalin, topical sucralfate, 5-amino salicylic acid enemas, and short chain fatty acids have been used with limited success. Surgical management is associated with high morbidity and mortality. Endoscopic therapy using modalities such as the heater probe, neodymium:yttrium-aluminium-garnet laser, potassium titanyl phosphate laser and bipolar electrocoagulation has been reported to be of some benefit, but with frequent complications. Argon plasma coagulation is touted to be the preferred endoscopic therapy due to its efficacy and safety profile. Newer methods of endoscopic ablation such as radiofrequency ablation and cryotherapy have been recently described which may afford broader areas of treatment per application, with lower rate of complications. This review will focus on endoscopic ablation therapies, including such newer modalities, for chronic radiation proctitis.
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Seo EH, Kim TO, Kim TG, Joo HR, Park J, Park SH, Yang SY, Moon YS, Park MJ, Ryu DY, Song GA. The efficacy of the combination therapy with oral and topical mesalazine for patients with the first episode of radiation proctitis. Dig Dis Sci 2011; 56:2672-7. [PMID: 21365239 DOI: 10.1007/s10620-011-1637-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 02/14/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Radiation proctitis is a common complication of pelvic radiation for which an optimal treatment remains undetermined. We assessed the efficacy of oral and topical mesalazine combination therapy for patients with naive radiation proctitis. METHODS A total of 23 patients with radiation proctitis were enrolled in the study over a period of 2 years. Three of these patients were excluded due to severe bleeding during the study. Twenty patients (mean age 60.3 years; two males, 18 females) were treated with oral mesalazine (3 × 1 g per day) plus a daily mesalazine suppository (1 g per day at bedtime) for 4 weeks. The efficacy of treatment was assessed according to the Subjective Objective Management Analytic (SOMA) scale for alleviation of clinical symptoms of rectal toxicity and sigmoidoscopic findings. RESULTS The mean bleeding score improved significantly from 2.10 to 1.70 (p = 0.002) with mesalazine treatment. However, scores were not improved for pain (0.30-0.20, p = 0.163), tenesmus (0.50-0.45, p = 0.577), or stool frequency (0.35-0.30, p = 0.577). The improvements in the mean telangiectasia score (1.80-1.45, p = 0.005), bleeding point score (1.60-1.05, p < 0.001), and friable mucosa score (1.35-1.00, p = 0.005) were all statistically significant. No side-effects were noted in any of the patients. CONCLUSIONS The combination of oral and topical mesalazine therapy for radiation proctitis may be a safe and effective treatment for naive radiation proctitis, especially for hemorrhagic proctitis. A large, randomized controlled trial is required to confirm the results of this pilot study.
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Affiliation(s)
- Eun Hee Seo
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University School of Medicine, 1435 Jwa-dong, Haeundae-gu, Busan 612-030, Republic of Korea
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Hou JK, Abudayyeh S, Shaib Y. Treatment of chronic radiation proctitis with cryoablation. Gastrointest Endosc 2011; 73:383-9. [PMID: 21295650 DOI: 10.1016/j.gie.2010.10.044] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 10/25/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic radiation proctitis (CRP) is a common problem in patients receiving pelvic radiation. Current therapies have the potential for deep tissue injury with ulcerations, perforation, and fistula formation. Cryospray ablation therapy offers superficial ablation of mucosa and is a potential method to endoscopically treat CRP safely and effectively. OBJECTIVE To determine tolerability of and response to cryotherapy in patients with radiation proctitis. DESIGN Prospective case-series pilot study. SETTING Baylor College of Medicine, Michael E. DeBakey Medical Center, Houston, Texas. PATIENTS Ten patients were prospectively recruited with chronic hemorrhagic radiation proctitis. INTERVENTIONS Endoscopic cryoablation of CRP. MAIN OUTCOME MEASUREMENTS Symptom severity of CRP was obtained by using the Radiation Proctitis Severity Assessment Scale (RPSAS). Endoscopic assessment was obtained using the rectal telangiectasia density grade. The primary endpoint of the study was endoscopic improvement of CRP based on the change in rectal telangiectasia density at 3-month follow-up. Secondary endpoints included symptomatic improvement based on RPSAS and adverse events at 3 months. RESULTS Ten patients with hemorrhagic radiation proctitis were treated with endoscopic cryoablation. Endoscopic severity improved as measured by rectal telangiectasia density from 2.7 to 1.7 (P=.004). Overall subjective clinical scores improved as determined by the Radiation Proctitis Severity Assessment Scale from 27.7 to 13.6 (P=.003). Endoscopic improvement correlated with symptom improvement. LIMITATIONS Nonpowered case series pilot study. CONCLUSIONS Cryoablation improved clinical and endoscopic indices in CRP. Further controlled studies are needed to identify the safety and efficacy of cryoablation for CRP.
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Affiliation(s)
- Jason K Hou
- Baylor College of Medicine, Michael E. Debakey Veterans Affairs Hospital, Houston, TX 77030, USA
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Appalaneni V, Fanelli RD, Sharaf RN, Anderson MA, Banerjee S, Ben-Menachem T, Decker GA, Fisher L, Fukami N, Harrison ME, Strohmeyer L, Friis C, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Dominitz JA. The role of endoscopy in patients with anorectal disorders. Gastrointest Endosc 2010; 72:1117-23. [PMID: 21111864 DOI: 10.1016/j.gie.2010.04.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 04/14/2010] [Indexed: 02/08/2023]
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