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Kohoutova D, Wilson A, Gee C, Elhusseiny R, Wanders L, Cunningham D. Intrarectal formalin treatment for haemorrhagic radiation-induced proctopathy: efficacy and safety. Colorectal Dis 2024; 26:932-939. [PMID: 38519847 DOI: 10.1111/codi.16956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/15/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024]
Abstract
AIM Pelvic radiotherapy is limited by dose-dependent toxicity to surrounding organs. The aim of this prospective study was to evaluate the efficacy and safety of intrarectal formalin treatment for radiotherapy-induced haemorrhagic proctopathy (RHP) at the Royal Marsden Hospital. METHOD Adult patients were enrolled. Haemoglobin was evaluated before and after formalin treatment. Antiplatelet and/or anticoagulation treatment and administration of transfusion were recorded. The interval between completion of radiotherapy and the first intrarectal 5% formalin treatment was assessed and the dose of radiotherapy was evaluated. Clinical assessment of the frequency and amount of rectal bleeding (rectal bleeding score 1-6) and endoscopic appearance (grade 0-3) were classified. Complications were recorded. RESULTS Nineteen patients were enrolled, comprising 13 men (68%) and 6 women. The mean age was 75 ± 9 years. The median time between completion of radiotherapy and the first treatment was 20 months [interquartile range (IQR) 15 months] and the median dose of radiotherapy was 68 Gy (IQR 14 Gy). Thirty-two procedures were performed (average 1.7 per patient). In total, 9/19 (47%) patients were receiving anticoagulation and/or antiplatelet medication and 5/19 (26%) received transfusion prior to treatment. The mean value of serum haemoglobin before the first treatment was 110 ± 18 g/L and afterwards it was 123 ± 16 g/L (p = 0.022). The median rectal bleeding score before the first treatment was 6 (IQR 0) and afterwards 2 (IQR 1-4; p < 0.001), while the median endoscopy score on the day of first treatment was 3 (IQR 0) compared with 1 (IQR 1-2) on the day of the last treatment 1 (p < 0.001). One female patient with a persistent rectal ulcer that eventually healed (18 months of healing) subsequently developed rectovaginal fistula (complication rate 1/19, 5%). CONCLUSIONS Treatment with intrarectal formalin in RHP is effective and safe.
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Affiliation(s)
| | - Ana Wilson
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
- St Mark's Hospital, London, UK
| | - Caroline Gee
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | - Linda Wanders
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
- Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
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Omer NNCDS, Araujo IDD, Cruz GMGD, Rodrigues FG. Therapeutics in Radiation-induced Proctopathy: A Systematic Review. JOURNAL OF COLOPROCTOLOGY 2022. [DOI: 10.1055/s-0041-1742258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractMalignant neoplasms are increasingly prevalent in the daily clinical practice. Up to 61% of patients with pelvic malignancies undergo pelvic radiotherapy in different doses, which may cause intestinal damage, and the rectum is the segment most frequently affected due to its fixed position in the pelvis. Currently, there are several strategies to minimize the effects of radiation on the tissues surrounding the neoplastic site; despite those strategies, radiotherapy can still result in serious damage to organs and structures, and these injuries accompany patients throughout their lives. One of the most common damages resulting from pelvic radiotherapy is acute proctitis.The diagnosis is confirmed by visualizing the rectal mucosa through rigid or flexible rectosigmoidoscopy and colonoscopy. The objective of the present study was to review the forms of radiation-induced proctopathytherapy, and to evaluate the results of each method to propose a standardization for the treatment of this pathology. Despite the prevalence of radiation-induced proctopathy, there is no definitive standardized treatment strategy so far. The first approach can be tried with local agents, such as mesalazine and formalin. For refractory cases, control can usually be achieved with argon plasma coagulation, hyperbaric oxygen, and radiofrequency ablation therapies. Regarding the study of radiation-induced proctopathy, there is a lack of robust studies with large samples and standardized therapies to be compared. There is a lack of double-blinded, randomized controlled studies to determine a definitive standard treatment algorithm.
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Affiliation(s)
| | - Ivana Duval de Araujo
- Doctor and Associate Professor IV, Department of Surgery, Universidade Federal de Minas Gerais, Brazil
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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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Long-Term Endoscopic Follow-Up of Patients with Chronic Radiation Proctopathy after Brachytherapy for Prostate Cancer. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2016; 2016:1414090. [PMID: 27378828 PMCID: PMC4917689 DOI: 10.1155/2016/1414090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/16/2016] [Indexed: 02/07/2023]
Abstract
Background. Chronic radiation proctopathy (CRP) is late toxicity and associated with morbidity. Aim. To investigate the predictors of prognosis in patients with CRP after brachytherapy (BT). Methods. One hundred four patients with prostate cancer were treated with BT or BT followed by external-beam radiotherapy (BT + EBRT). We retrospectively investigated the 5-year incidence of rectal bleeding and endoscopic findings of CRP using the Vienna Rectoscopy Score (VRS). Twenty patients with VRS ≥ 1 were divided into the improved VRS group without treatment, unchanged VRS group, and treated group. The parameters associated with alteration of VRS were analyzed. Results. The incidence of rectal bleeding was 24%. The risk of rectal bleeding was higher in patients treated with BT + EBRT compared to those treated with BT (p < 0.0001). The incidence of superficial microulceration was higher in the improved VRS group than in the unchanged VRS group (p < 0.05). The incidence of multiple confluent telangiectasia or superficial ulcers > 1 cm2 was higher in the treated group than in both the improved and unchanged VRS groups (p < 0.05). Conclusions. Patients treated with BT + EBRT have a high risk of CRP. Endoscopic findings were useful for prognostic prediction of CRP.
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Tsujinaka S, Baig MK, Gornev R, de la Garza C, Hwang JK, Sands D, Weiss EG, Nogueras JJ, Efron J, Vernava AM, Wexner SD. Formalin Instillation for Hemorrhagic Radiation Proctitis. Surg Innov 2016; 12:123-8. [PMID: 16034500 DOI: 10.1177/155335060501200209] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although formalin instillation has been proven to be an effective treatment of hemorrhagic radiation proctitis, different tech niques with varying success rates have been reported. The aim of this study was to assess our experience with formalin instillation for the treatment of radiation proctitis. After Institutional Review Board approval, all patients who presented with radiation proctitis and were treated with 4% formalin instillation were identified from a prospective database. Techniques of instillation were as follows: a formalin-soaked sponge stick was applied via a proctoscope (SS) and placed at each quadrant with a mean contact of 2.5 minutes (range, 0.5-3 minutes), or the formalin solution was introduced through a proctoscope in aliquots for a total of 350 to 400 mL irrigation (IR), with a mean contact time of 30 seconds in each aliquot. The patients were divided into two groups according to the method of formalin instillation and their outcomes were compared. Between March 1995 and September 2003, 21 patients who underwent formalin treatment were identified: 17 patients were in the SS and 4 patients were in the IR group. The mean age was 74.8 6.4 years and 70.5 6.8 years and the male/female ratio was 16:1 and 3:1 in the SS and IR groups, respectively. Indications for radiation therapy were prostate cancer in 19 patients: 16 (95.1%) SS patients and 3 (75%) IR patients. Four (23.5%) patients in the SS group were receiving anticoagulants or antiplatelet medications before the procedure. The mean duration of bleeding before formalin instillation was 11.7 months (range, 2-48 months) in the SS and 10.5 months (range, 7-12 months) in the IR group. Sixteen (94.1%) patients in the SS and 4 (100%) in the IR group had previous treatments for radiation proctitis, including hydrocortisone enema, 5-aminosalicylate mesalamine, and endoscopic coagulation. Eight (47.1%) patients in the SS and 2 (50%) in the IR group received a preprocedural blood transfusion, and 1 patient in the SS group required a blood transfusion after the formalin instillation. This patient subsequently underwent restorative proctosigmoidectomy because of persistent bleeding. The mean length of the procedure was 27.1 10.8 minutes in the SS group and 22.5 6.5 minutes in the IR group. The bleeding was successfully stopped on the first attempt in 14 patients (82.4%) in the SS group and 3 (75%) in the IR group. The instillation was repeated in 1 patient (5.9%) in the SS group and in 1 (25%) in the IR group. Four patients (23.5%) in the SS group experienced rectal pain after the procedure. One patient (5.9%) developed a new onset of fecal incontinence, while another (5.9%) had anococcygeal pain accompanied by worsening of fecal incontinence. One patient (25%) in the IR group developed acute colitis consistent with formalin instillation, which was managed by intravenous antibiotics. The patients were followed for a mean of 10 months (range, 1 to 38 months). Formalin instillation is effective in controlling refractory hemorrhage secondary to radiation proctitis.
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Affiliation(s)
- Shingo Tsujinaka
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Vanneste BGL, Van De Voorde L, de Ridder RJ, Van Limbergen EJ, Lambin P, van Lin EN. Chronic radiation proctitis: tricks to prevent and treat. Int J Colorectal Dis 2015; 30:1293-303. [PMID: 26198994 PMCID: PMC4575375 DOI: 10.1007/s00384-015-2289-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to give an overview of the measures used to prevent chronic radiation proctitis (CRP) and to provide an algorithm for the treatment of CRP. METHODS Medical literature databases including PubMed and Medline were screened and critically analyzed for relevance in the scope of our purpose. RESULTS CRP is a relatively frequent late side effect (5-20%) and mainly dependent on the dose and volume of irradiated rectum. Radiation treatment (RT) techniques to prevent CRP are constantly improving thanks to image-guided RT and intensity-modulated RT. Also, newer techniques like protons and new devices such as rectum spacers and balloons have been developed to spare rectal structures. Biopsies do not contribute to diagnosing CRP and should be avoided because of the risk of severe rectal wall damage, such as necrosis and fistulas. There is no consensus on the optimal treatment of CRP. A variety of possibilities is available and includes topical and oral agents, hyperbaric oxygen therapy, and endoscopic interventions. CONCLUSIONS CRP has a natural history of improving over time, even without treatment. This is important to take into account when considering these treatments: first be conservative (topical and oral agents) and be aware that invasive treatments can be very toxic.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands.
| | - Lien Van De Voorde
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
| | - Emile N van Lin
- Department of Radiation Oncology (MAASTRO Clinic), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 3035, 6202 NA, Maastricht, The Netherlands
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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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Samalavicius NE, Dulskas A, Kilius A, Petrulis K, Norkus D, Burneckis A, Valuckas KP. Treatment of hemorrhagic radiation-induced proctopathy with a 4% formalin application under perianal anesthetic infiltration. World J Gastroenterol 2013; 19:4944-4949. [PMID: 23946599 PMCID: PMC3740424 DOI: 10.3748/wjg.v19.i30.4944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 04/05/2013] [Accepted: 05/08/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the results of hemorrhagic radiation proctopathy treatment with a 4% formalin application.
METHODS: A prospective study was performed. Over a three-year period, 38 patients underwent 4% formalin application under perianal anesthetic infiltration for hemorrhagic radiation proctopathy. All patients included in the study were irradiated for prostate cancer. The patients ranged in age from 56-77 years (average 70 ± 5 years). All of the patients were referred for formalin therapy after noninvasive management had failed. Twenty-four (63.2%) patients underwent a single application, 10 (26.3%) patients underwent 2 applications, and 4 (10.5%) patients underwent 3 applications.
RESULTS: Two to 36 mo (average 12 ± 3 mo) following treatment, 34 patients were interviewed (four were lost to follow-up). Twenty (58.8%) subjects reported complete cure, 8 (23.5%) subjects reported significant improvement, and 6 (17.7%) subjects reported no change. One patient (who underwent a colostomy at a regional hospital with no specialized services available for previous bleeding episodes from radiation proctopathy) was cured, and the colostomy was closed. One patient (2.6%) developed rectal mucosal damage after the second application.
CONCLUSION: A 4-min application of 4% formalin for hemorrhagic radiation-induced proctopathy under perianal anesthetic infiltration in patients who have received external radial radiation therapy for prostate cancer is simple, reasonably safe, inexpensive, generally well tolerated, and effective.
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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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10
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Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment. Int J Colorectal Dis 2013; 28:261-6. [PMID: 22932907 DOI: 10.1007/s00384-012-1571-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically. Rectal instillation of formalin solution has been described as a successful treatment for chronic radiation-induced hemorrhagic proctitis resistant to medical treatment. We present our results in patients undergoing treatment with application of 4 % formalin for radiation-induced injury to the rectum. METHODS All patients were treated under anesthesia by direct application of 4 % formalin solution to the affected rectal areas. Patient gender, initial malignancy, grade of proctitis, need for blood transfusion, previous therapy, number of applications and response to treatment with formalin, complications, and length of follow-up were reviewed. RESULTS A total of 15 patients with a mean age of 68.9 (range, 48-77) years were followed for 31.3 (range, 18-51) months. The mean interval from the conclusion of radiotherapy and the onset of symptoms was 6.9 months. The mean duration of hemorrhagic proctitis before formalin application was 7.9 months. Ten patients had only one formalin application and five patients required a second application because of the persistent bleeding. Thirteen patients (87 %) had complete cessation of bleeding. No complications related to the formalin treatment were observed. CONCLUSIONS According to a revision of the literature and our experience, despite the small number of patients in our trial, we can state that the application of 4 % formalin solution is an effective, safe, and well-tolerated treatment for chronic radiation-induced hemorrhagic proctitis with minimal discomfort and no severe complications.
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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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12
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Placer C, Lizarazu A, Borda N, Elósegui JL, Enriquez Navascués JM. [Radiation proctitis and chronic and refractory bleeding. Experience with 4% formaldehyde]. Cir Esp 2012; 91:111-4. [PMID: 23036255 DOI: 10.1016/j.ciresp.2012.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/19/2012] [Accepted: 05/26/2012] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Bleeding is a common complication of proctitis secondary to radiotherapy of pelvic tumours. Between 5 and 10% may become severe and refractory to topical and endoscopic treatment. Experience with the application of 4% formaldehyde is presented. PATIENTS AND METHOD A retrospective and descriptive study was performed on a patient cohort with severe radiation proctitis admitted to the Hospital Universitario Donostia between January 2003 and September 2009. All patients were diagnosed by colonoscopy and admitted due to the severity of their treatment. Both 4% formaldehyde and the gauze technique were used, as well as using enemas, in cases refractory to topical and endoscopic treatment with argon. The technique was performed in theatre with regional anaesthetic. Clinical and endoscopic follow up was carried out. RESULTS The study included 25 males (73.5%) and 9 women (26.5%), with a mean age of 69 years (32-80) who had rectal bleeding due to radiation proctitis and required admission. All treatments failed in 6 (28.5%) patients, and 4% formaldehyde was used, with a complete response to the bleeding in all 6 patients, with 3 cases requiring one session, and the 3 others 2 sessions. The gauze technique was used in 4 patients and another 2 were given a formaldehyde enema due to the presence of stenosis. Pain appeared as the main complication in 2 (33.3%) patients. The median follow up was 60 months (interquartile range 26 to 67 months). CONCLUSIONS The use of 4% formaldehyde in bleeding due to radiation proctitis is an effective, easy to reproduce technique, with a low morbidity.
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Affiliation(s)
- Carlos Placer
- Sección de Cirugía Colorrectal, Hospital Universitario Donostia, San Sebastián, España.
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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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14
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Nelamangala Ramakrishnaiah VP, Javali TD, Dharanipragada K, Reddy KS, Krishnamachari S. Formalin dab, the effective way of treating haemorrhagic radiation proctitis: a randomized trial from a tertiary care hospital in South India. Colorectal Dis 2012; 14:876-82. [PMID: 22356304 DOI: 10.1111/j.1463-1318.2012.03008.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM Chronic radiation proctitis with bleeding is a common problem encountered following radiotherapy for pelvic malignancy. Sucralfate-steroid enema and formalin dab are two common nonsurgical treatments. A randomized trial was conducted to compare the efficacy of these two methods. METHOD This was a prospective randomized controlled trial conducted in the Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER) from August 2005 to May 2007. One-hundred and two patients with chronic radiation proctitis, presenting as rectal bleeding after radiotherapy for carcinoma of the cervix, were recruited and randomly allocated into two treatment groups: Group 1, formalin dab; and Group 2, sucralfate-steroid retention enema. The mean age of the patients was 51.3 ± 5.1 years. The mean interval between the end of radiotherapy and the onset of bleeding was 12.3 ± 3.5 months. Symptom score and sigmoidoscopic grade were assessed before, and at 1 month after, treatment. RESULTS Ninety per cent of patients in Group 1 and 74.5% of patients in Group 2 responded to treatment (P = 0.038). In spite of having a higher median symptom score before treatment, patients in Group 1 demonstrated a marked decrease in symptom score after treatment compared with patients in Group 2 and the difference once again was statistically significant (P = 0.000). Similarly, the median sigmoidoscopic grade was significantly lower for patients in Group 1 compared with patients in Group 2 after treatment (P = 0.000). There were no specific treatment-related complications in either group. CONCLUSIONS Formalin (4%) dab is superior to sucralfate-steroid retention enema for treatment of chronic haemorrhagic radiation proctitis.
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Teixeira FV, Denadai R, Ferraz RA, Goulart RDÁ, Saad-Hossne R. Instilação de formalina endoluminal como opção terapêutica da retite actínica hemorrágica. REVISTA BRASILEIRA DE COLOPROCTOLOGIA 2011. [DOI: 10.1590/s0101-98802011000100005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A retite actínica hemorrágica é um quadro grave que pode ocorrer em qualquer paciente submetido à radioterapia pélvica, por vezes, sendo necessária terapia transfusional e internação hospitalar. A abordagem terapêutica ainda é bastante controversa. Tanto para o tratamento inicial como para casos refratários, uma das opções é a aplicação de formalina. Este método é barato, facilmente disponível, de simples execução e eficaz no controle da hemorragia. Os autores relatam dois casos de retite actínica hemorrágica de pacientes tratados com instilação de formalina endoluminal, e sua eficácia terapêutica e complicações são discutidas
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Affiliation(s)
| | | | | | | | - Rogério Saad-Hossne
- Universidade Estadual Paulista; Sociedade Brasileira de Coloproctologia, Brasil
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Goldner G, Pötter R, Kranz A, Bluhm A, Dörr W. Healing of late endoscopic changes in the rectum between 12 and 65 months after external beam radiotherapy. Strahlenther Onkol 2011; 187:202-5. [PMID: 21347635 DOI: 10.1007/s00066-010-2211-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 10/06/2010] [Indexed: 01/12/2023]
Abstract
PURPOSE To evaluate the time course of late rectal mucosal changes after prostate cancer radiotherapy (RT). PATIENTS AND METHODS A rectosigmoidoscopy was performed at 12, 24, and 65 months after RT in 20 patients. Rectal mucosal changes (telangiectasia, congested mucosa, ulceration, stricture, and necrosis) were scored and documented according to the Vienna Rectoscopy Score (VRS, score 0-3). RESULTS VRS of 0 and 3, were found in 20% of patients (n = 4) and 5% of patients (n = 1), respectively at all time points. A shift of the VRS from 2 to 1 was found with incidence rates of 60% at 12 months and 20% at 65 months, which is equivalent to an improvement rate of 67%. Laser coagulation was required in 3 patients (15%) with rectal bleeding due to telangiectasia grade ≥2. CONCLUSION Late rectal mucosal changes are frequent after pelvic RT. Generally only the incidence rates corresponding to the initial diagnosis of the complications, independent of subsequent recovery, are reported. The results reported in the present study show that complications often improve over time. Hence, the usual reports of complication rates overestimate the proportion of patients presenting with side effects of certain grades.
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Affiliation(s)
- Gregor Goldner
- Department of Radiotherapy and Radiobiology, Vienna General Hospital, University of Vienna Medical School, Austria.
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17
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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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Abstract
Radiation therapy is commonly utilized as a major component in the treatment of pelvic malignancy. Unfortunately, secondary toxicity to the lower gastrointestinal tract can occur. This most commonly affects the rectum, although injuries to the colon and small intestine are not uncommon. The presentation can be acute or chronic, and different mechanisms are responsible for each. Symptomatology is quite variable but can result in significant compromise for the patient. Numerous preventive and treatment strategies have been applied to this disease process. This article presents a summary of the current knowledge regarding radiation injury to the lower gastrointestinal tract with special emphasis on treatment options for radiation proctitis.
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Affiliation(s)
- Gregory D Kennedy
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin 53792-7375, USA
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Phan J, Swanson DA, Levy LB, Kudchadker RJ, Bruno TL, Frank SJ. Late rectal complications after prostate brachytherapy for localized prostate cancer: incidence and management. Cancer 2009; 115:1827-39. [PMID: 19248043 DOI: 10.1002/cncr.24223] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This review of the literature on late rectal complications after prostate brachytherapy indicated that it is a highly effective treatment modality for patients with clinically localized prostate cancer but can cause chronic radiation proctitis. The most common manifestation of chronic radiation proctitis was anterior rectal wall bleeding, which often occurred within the first 2 years after brachytherapy. It is interesting to note that the rates of late rectal morbidity appear to have declined over time, which may reflect improvements in implantation techniques and imaging. Rectal biopsy as part of the workup to evaluate rectal bleeding can lead to rectal fistula and the need for colostomy, a rare but major complication. The authors recommend 1) screening colonoscopy before brachytherapy for patients who have not had a screening colonoscopy within the preceding 3 years to rule out colorectal malignancies and, thus, facilitate conservative management should rectal bleeding occur; 2) lifestyle modifications during treatment to limit exposure of the rectum to radiation; and 3) conservative management for rectal bleeding that occurs within 2 years after brachytherapy. Cancer 2009. (c) 2009 American Cancer Society.
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Affiliation(s)
- Jack Phan
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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20
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Radiation damage to the gastrointestinal tract: mechanisms, diagnosis, and management. Curr Opin Support Palliat Care 2008; 1:23-9. [PMID: 18660720 DOI: 10.1097/spc.0b013e3281108014] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW To summarize current knowledge about gastrointestinal radiation toxicity, with emphasis on mechanisms and clinical diagnosis and management. RECENT FINDINGS While there has been only modest change in cancer incidence and cancer mortality rates during the past 30 years, the number of cancer survivors has more than doubled. Moreover, the recognition of uncomplicated cancer cure as the ultimate goal in oncology has intensified efforts to prevent, diagnose, and manage side effects of radiation therapy. These efforts have been facilitated by recent insight into the underlying pathophysiology. SUMMARY The risk of injury to the intestine is dose limiting during abdominal and pelvic radiation therapy. Delayed bowel toxicity is difficult to manage and adversely impacts the quality of life of cancer survivors. More than 200,000 patients per year receive abdominal or pelvic radiation therapy, and the estimated number of cancer survivors with postradiation intestinal dysfunction is 1.5-2 million. Worthwhile progress towards reducing toxicity of radiation therapy has been made by dose-sculpting treatment techniques. Approaches derived from an improved understanding of the pathophysiology of bowel injury, however, will result in further advances. This article discusses the mechanisms of radiation-induced bowel toxicity and reviews current principles in diagnosis and management.
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Efficacy of argon plasma coagulation compared to topical formalin application for chronic radiation proctopathy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:129-32. [PMID: 18299729 DOI: 10.1155/2008/964912] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Chronic radiation proctopathy (CRP) is a troublesome complication of radiotherapy to the pelvis for which current treatment modalities are suboptimal. Currently, the application of formalin to the rectal mucosa (AFR) and thermal ablation with argon plasma coagulation (APC) are the most promising options. OBJECTIVE To compare the efficacy and safety of AFR with APC for CRP. PATIENTS AND METHODS Records of 22 patients (male to female ratio, 19:3; mean age, 74 years) who received either APC or AFR for chronic hematochezia caused by CRP, and who were evaluated and treated between May 1998 and April 2002, were reviewed. Complete evaluations were made three months after completion of each therapeutic modality. Patients were considered to be responders if there was a 10% increase in hemoglobin from baseline or complete normalization of hemoglobin (male patients, higher than 130 g/L; female patients, higher than 115 g/L) without the requirement for blood transfusion. RESULTS The mean hemoglobin level before therapy was 107 g/L. Patients received an average of 1.78 sessions for APC and 1.81 sessions for AFR. Eleven patients (50%) were treated with APC alone, eight patients (36%) with AFR alone and three (14%) with both modalities (two with AFR followed by APC, and one with APC followed by AFR). Eleven of 14 patients (79%) in the APC group were responders, compared with three of 11 patients (27%) in the AFR group (P=0.017). In the APC group, seven of 11 responders required only a single session, while in the AFR group, only one patient responded after a single session. Adverse events (nausea, vomiting, flushing, abdominal cramps, rectal pain and fever) occurred in two patients after APC and in nine patients after AFR (P=0.001). In the APC group, the mean hemoglobin level increase was 20 g/L at three months follow-up, compared with 14 g/L in the AFR group. CONCLUSION This retrospective study suggests that APC is more effective and safe than topical AFR to control hematochezia caused by CRP. Further studies are needed to confirm this observation.
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de Parades V, Bauer P, Marteau P, Chauveinc L, Bouillet T, Atienza P. Traitement non chirurgical des rectites radiques chroniques hémorragiques. ACTA ACUST UNITED AC 2007; 31:919-28. [DOI: 10.1016/s0399-8320(07)78299-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Mishra MV, Shirazi R, Barrett WL. Incidence and Clinical Course of Hemorrhagic Radiation Proctitis After Iodine-125 Prostate Brachytherapy. Clin Genitourin Cancer 2007; 5:397-400. [DOI: 10.3816/cgc.2007.n.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Leiper K, Morris AI. Treatment of radiation proctitis. Clin Oncol (R Coll Radiol) 2007; 19:724-9. [PMID: 17728120 DOI: 10.1016/j.clon.2007.07.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Accepted: 07/20/2007] [Indexed: 12/11/2022]
Abstract
Late complications of pelvic radiotherapy occur in 5-20% of patients, particularly chronic radiation proctitis (CRP). Rectal bleeding is the most common symptom. Other symptoms include difficulty in defaecation or tenesmus because of loss of distensibility of the rectum or rectal structuring. Treatment options of CRP include oral therapy (5-aminosalicylates, metronidazole), rectal instillation therapy (hydrocortisone, sucralfate, 5-aminosalicylates, formalin), thermal therapy (argon plasma coagulation, heater probe or laser) and hyperbaric oxygen. It is difficult to recommend evidence-based therapy. There are no adequately powered studies of the treatment of CRP and most data are uncontrolled, non-blinded observation studies from single sites. There are no standard evaluation tools (including endoscopic grading, symptom scores and quality-of-life scores), adequate description of preceding radiotherapy dose or adequate follow-up in most studies. Many studies have poor documentation of complications and few are carried out prospectively. A pragmatic approach is to use sucralfate enemas and oral metronidazole. Thermal methods seem to be effective and safe. Simple heater probe treatment or argon plasma coagulation are the preferred methods due to their better safety profile. Intra-rectal formalin seems to be effective, but possibly has a higher rate of complications. For resistant disease, hyperbaric oxygen may be an option.
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Affiliation(s)
- K Leiper
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK.
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25
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Abstract
PURPOSE The short-term safety and efficacy of 2 percent formalin administered as a retention enema for hemorrhagic radiation proctitis was studied. METHODS A group of 24 patients with hemorrhagic radiation proctitis who received radical radiotherapy were administered 2 percent formalin as a retention enema and the treatment was followed up from 1 to 29 (mean, 15.34) weeks. The enema was performed on an outpatient basis under sedation with pentazocine and promethazine with a retention time of two minutes. The symptoms and proctoscope findings were graded and converted into a numeric score, ranging from 1 to 4. The mean improvements in scores before treatment and after the last follow-up were analyzed for statistical significance by using the paired t-test. RESULTS There was complete cessation of bleeding in 47.8 percent of patients and very negligible bleeding in 30.4 percent. A total of 78.2 percent responded positively to treatment with 2 percent formalin retention enema. More than one application was required in 34.7 percent of the patients. The procedure was well tolerated and most of the side effects were mild. Side effects were diarrhea in 23.5 percent, abdominal pain and tenesmus in 8.8 percent, and fever with vomiting in 2.9 percent of patients. There was a statistically significant reduction in bleeding and proctoscopy scores (P<0.01). None of the patients in this study required surgery to palliate their symptoms. CONCLUSIONS Two percent formalin when given as a retention enema is a safe, inexpensive, and effective intervention for hemorrhagic radiation proctitis. Any trained health worker using simple precautions can perform this procedure. The long-term efficacy and safety of 2 percent formalin retention enemas need further assessment with randomized, controlled trials.
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Affiliation(s)
- Ramaiyer Raghu Raman
- Department of Radiation Oncology, MNJ Institute of Oncology & Regional Cancer Centre, Hyderabad, India.
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26
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Abstract
OBJECTIVE Topical formalin has been used as an effective treatment for haemorrhagic radiation proctitis. In the course of reviewing our experience with this modality, we identified two patients who developed anorectal cancer during the follow-up period. METHOD From 2001 to 2005, 49 patients who received pelvic radiation for treatment of prostate, rectal or endometrial cancer subsequently developed haemorrhagic radiation proctitis. Four percent formalin was applied in the office setting under direct visualization with a rigid proctoscope and without sedation. Response to treatment was then reviewed. RESULTS Seventy-eight per cent of patients reported a complete response to formalin application. Only 14% were refractory to formalin treatment. Two patients subsequently presented with anorectal cancer. CONCLUSION Topical formalin application in the outpatient setting appears to be an effective first-line treatment for haemorrhagic radiation proctitis. We report the first cases of anorectal cancer which developed subsequent to formalin application. Pelvic irradiation is known to increase the risk of developing a second malignancy, therefore it is impossible to determine what, if any, role formalin application played in the development of the second malignancies.
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Affiliation(s)
- D R Stern
- Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai School of Medicine, Mount Sinai Medical Center, New York, NY 10029, USA
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27
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AGRAWAL PP, BANSAL N, BAHADUR AK, SINGH K, RATHI AK. Management of chronic hemorrhagic radiation proctitis. Asia Pac J Clin Oncol 2007. [DOI: 10.1111/j.1743-7563.2006.00084.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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28
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Haas EM, Bailey HR, Faragher I. Application of 10 percent formalin for the treatment of radiation-induced hemorrhagic proctitis. Dis Colon Rectum 2007; 50:213-7. [PMID: 17080283 DOI: 10.1007/s10350-006-0707-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Rectal instillation of 4 percent formalin solution has been described as a successful treatment for hemorrhagic radiation proctitis recalcitrant to medical treatment. We present our experience with a new method of treatment involving the topical application of 10 percent buffered formalin, which is well tolerated and suitable for office use. METHODS Patients with marked or refractory rectal bleeding and clinical features consistent with radiation proctitis were reviewed. Treatment involved direct application of a 10 percent buffered formalin solution to the affected mucosa using a 16-inch cotton tip applicator applied through a proctoscope in the office setting. RESULTS A total of 100 patients with a mean age of 75 (range, 49-91) years were followed for 18 (range, 1-79) months. The interval from radiation exposure to formalin treatment was 21 months. Overall, 93 percent of patients had cessation of bleeding after an average of 3.5 formalin applications at two-week to four-week intervals. Patients with severe (Grade 3) proctitis and those taking aspirin required an average of 1.5 additional treatments. A total of eight patients rebled at a mean of 24 months from treatment; however, all responded to further applications of formalin. Three patients complained of anal pain and one experienced dizziness postprocedure for a complication rate of 1.1 percent. CONCLUSIONS We present a simple, cost-effective, and well-tolerated method of controlling hemorrhagic radiation proctitis. It is performed by using materials readily available in the office of a colon and rectal surgeon, eliminating the need for bowel preparation, anesthesia, or a surgical suite.
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Affiliation(s)
- Eric M Haas
- Department of Surgery, The Methodist Hospital, Houston, TX, USA.
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29
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Abstract
PURPOSE OF REVIEW Chronic radiation proctopathy is a complication of pelvic radiation therapy. The acute phase of radiation injury to the rectum occurs during or up to 3 months following radiation. Acute radiation injury can continue into a chronic phase or chronic radiation proctopathy may develop after a latent period of several months or years. Symptoms associated with the condition include diarrhea, rectal pain, bleeding, tenesmus, and stricture formation. Of the various symptoms, only bleeding from radiation-induced telangiectasias is amenable to endoscopic therapy. This paper summarizes the findings of experts in the field on endoscopic treatment of bleeding from chronic radiation proctopathy. RECENT FINDINGS Medical management is generally ineffective in controlling bleeding from chronic radiation proctopathy. Surgical intervention has a high incidence of morbidity. Promising advances have been made in endoscopic therapy, including formalin, neodymium/yttrium aluminum garnet, argon and potassium titanyl phosphate laser treatments, as well as argon plasma coagulation. Argon plasma coagulation presents an effective, efficient, inexpensive and reasonably safe noncontact method for destruction of radiation telangiectasias. SUMMARY Based on currently available data and trends, argon plasma coagulation is the favored treatment for bleeding from chronic radiation proctopathy.
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Affiliation(s)
- Sydney A Wilson
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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30
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Cullen SN, Frenz M, Mee A. Treatment of haemorrhagic radiation-induced proctopathy using small volume topical formalin instillation. Aliment Pharmacol Ther 2006; 23:1575-9. [PMID: 16696805 DOI: 10.1111/j.1365-2036.2006.02920.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Between 2 and 5% of patients undergoing pelvic radiotherapy develop chronic radiation proctopathy, occurring as a result of damage to the rectal mucosa during the treatment. Rectal bleeding of varying severity can occur as a consequence. There have been no formal trials of treatment for haemorrhagic radiation proctopathy and a variety of methods are currently used. AIM In a retrospective study of 20 patients treated at a single centre, we assessed the efficacy of small volume topical formalin instillation to control bleeding from radiation proctopathy. METHOD Patients were treated by a single operator using 20 mL of a 5% solution of formalin instilled into the rectum via a flexible sigmoidoscope for 3 min. Patients were followed up for an average of 22.7 months (range: 2-69). RESULTS A single session of formalin treatment was effective in 13 of 20 (65%) patients and a further four (20%) patients responded to a second treatment. No complications of the treatment was identified. CONCLUSION Small volume formalin instillation therapy appears to be safe and effective in the context of haemorrhagic radiation proctopathy. The technique is simple, inexpensive, quick and requires no sedation. We suggest that it should be considered as a first line for patients presenting with this distressing condition.
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Affiliation(s)
- S N Cullen
- Royal Berkshire Hospital, Reading, Berkshire, UK.
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31
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Vyas FL, Mathai V, Selvamani B, John S, Banerjee Jesudason SR. Endoluminal formalin application for haemorrhagic radiation proctitis. Colorectal Dis 2006; 8:342-6. [PMID: 16630241 DOI: 10.1111/j.1463-1318.2006.00950.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Radiation proctitis is a common complication following radiation therapy for pelvic malignancies. This is associated with significant morbidity which adversely affects the quality of life. Local application of formalin has been used effectively in the treatment of radiation proctitis. METHODOLOGY Thirty patients with haemorrhagic radiation proctitis who underwent endoluminal application of 4% formalin between January 1998 to October 2002 were followed up prospectively to assess the efficacy of the treatment. RESULTS The follow up ranged from 5 to 36 months (mean 18.1 months). Nineteen (63.3%) patients had complete response to formalin application while 7 (23.3%) patients had partial response. There were 4 (13.3%) failures. No procedure related complication was observed. CONCLUSION Local application of formalin is a simple, safe, inexpensive and fairly effective outpatient treatment modality for chronic radiation proctitis.
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Affiliation(s)
- F L Vyas
- Department of Surgery Unit 2, Christian Medical College and Hospital, Vellore 632004, India.
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Abstract
OBJECTIVE Radiation anorectal injury due to pelvic radiotherapy for non intestinal cancer is a significant cause of morbidity which may limit the treatment dose required. Conservative treatment options are of limited value and surgery is reserved only for the most severe complications. This review addresses radioprotection of the anorectum and aims to increase awareness amongst surgeons of the strategies that have been in practice in order to minimize the side-effects of radiotherapy while preserving its therapeutic efficacy. METHODS This review is based on a literature search (Medline and NLM PubMed) with manual cross-referencing of all articles related to anorectal radiation injury. RESULTS Optimization of radiation dose, the use of radioprotective agents and improvement in radiation delivery are the main areas of development. There are few data on the potential of altered fractionation schedules in reducing anorectal injury. A few phase I and II studies suggest that the pharmacological agents amifostine and misoprostol could be beneficial in limiting radiation damage but larger phase III studies are awaited. CONCLUSION The introduction of 3-dimensional conformal radiation therapy and intensity modulated radiation therapy has been the most significant advance in reducing radiation morbidity.
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Affiliation(s)
- F Abbasakoor
- Department of Surgery, Royal Free and University College Medical School, London, UK
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de Parades V, Etienney I, Bauer P, Bourguignon J, Meary N, Mory B, Sultan S, Taouk M, Thomas C, Atienza P. Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis--an effective but not risk-free procedure: a prospective study of 33 patients. Dis Colon Rectum 2005; 48:1535-41. [PMID: 15933799 DOI: 10.1007/s10350-005-0030-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE This prospective study evaluated the efficacy and safety of local formalin application in chronic refractory radiation-induced hemorrhagic proctitis. METHODS All patients were treated under anesthesia by direct application of 4 percent formalin to the affected rectal areas. RESULTS The study included 33 patients (17 women) and was conducted between January 1994 and December 2001. There were 11 anal cancers (33 percent), 11 prostate cancers, 9 cervical or endometrial cancers, 1 bladder cancer, and 1 rectal cancer. The mean number of daily rectal bleeds was 2.7 (range, 0.5-15). Nineteen patients (58 percent) were blood transfusion dependent. Twenty-three patients had only one formalin application and 10 patients required a second application because of the persistent bleeding. The treatment was effective in 23 cases (70 percent): 13 patients had complete cessation of bleeding and 10 patients had only minor bleeding. Six anal or rectal strictures occurred: 4 patients had been treated for anal cancer (36 percent) and 2 patients had been treated for other cancers (9 percent). None of the strictures was malignant. Anal incontinence worsened in 5 patients of the 11 who had been treated for anal cancer (45 percent) and occurred in 4 of the 22 other patients (18 percent). CONCLUSION Formalin application is an effective treatment for chronic radiation-induced hemorrhagic proctitis. However, local morbidity is not negligible. This result may be related to the high proportion of anal cancers in the series. In our opinion, therefore, formalin application should be reserved for severe hemorrhagic proctitis refractory to medical treatment and should be thoroughly discussed in cases of anorectal radiation-induced stricture, prior anal incontinence, or treated anal cancer.
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Affiliation(s)
- Vincent de Parades
- Proctologie Médico-Interventionnelle, Groupe Hospitalier Diaconesses-Croix Saint Simon, Paris, France
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Abstract
Several recent advances have been made in the evaluation and management of acute lower gastrointestinal bleeding. This review focuses on the management of lower gastrointestinal bleeding, especially acute severe bleeding. The aim of the study was to critically review the published literature on important management issues in lower gastrointestinal bleeding, including haemodynamic resuscitation, diagnostic evaluation, and endoscopic, radiologic, and surgical therapy, and to develop an algorithm for the management of lower gastrointestinal bleeding, based on this literature review. Publications pertaining to lower gastrointestinal bleeding were identified by searches of the MEDLINE database for the years 1966 to December 2004. Clinical trials and review articles were specifically identified, and their reference citation lists were searched for additional publications not identified in the database searches. Clinical trials and current clinical recommendations were assessed by using commonly applied criteria. Specific recommendations are made based on the evidence reviewed. Approximately, 200 original and review articles were reviewed and graded. There is a paucity of high-quality evidence to guide the management of lower gastrointestinal bleeding, and current endoscopic, radiologic, and surgical practices appear to reflect local expertise and availability of services. Endoscopic literature supports the role of urgent colonoscopy and therapy where possible. Radiology literature supports the role of angiography, especially after a positive bleeding scan has been obtained. Limited surgical data support the role of segmental resection in the management of persistent lower gastrointestinal bleeding after localization by either colonoscopy or angiography. There is limited high-quality research in the area of lower gastrointestinal bleeding. Recent advances have improved the endoscopic, radiologic and surgical management of this problem. However, treatment decisions are still often based on local expertise and preference. With increased access to urgent therapeutic endoscopy for the management of acute upper gastrointestinal bleeding, diagnostic and therapeutic colonoscopy can be expected to play an increasing role in the management of acute lower gastrointestinal bleeding.
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Affiliation(s)
- J J Farrell
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA 90095, USA.
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Konishi T, Watanabe T, Kitayama J, Shibahara J, Nagawa H. Endoscopic and histopathologic findings after formalin application for hemorrhage caused by chronic radiation-induced proctitis. Gastrointest Endosc 2005; 61:161-4. [PMID: 15672081 DOI: 10.1016/s0016-5107(04)02458-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Tsuyoshi Konishi
- Department of Surgical Oncology, Graduate School of Medicine, the University of Tokyo, Japan
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36
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Rubenstein EB, Peterson DE, Schubert M, Keefe D, McGuire D, Epstein J, Elting LS, Fox PC, Cooksley C, Sonis ST. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis. Cancer 2004; 100:2026-46. [PMID: 15108223 DOI: 10.1002/cncr.20163] [Citation(s) in RCA: 487] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Oral and gastrointestinal (GI) mucositis can affect up to 100% of patients undergoing high-dose chemotherapy and hematopoietic stem cell transplantation, 80% of patients with malignancies of the head and neck receiving radiotherapy, and a wide range of patients receiving chemotherapy. Alimentary track mucositis increases mortality and morbidity and contributes to rising health care costs. Consequently, the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology assembled an expert panel to evaluate the literature and to create evidence-based guidelines for preventing, evaluating, and treating mucositis. METHODS Thirty-six panelists reviewed literature published between January 1966 and May 2002. An initial meeting in January 2002 produced a preliminary draft of guidelines that was reviewed at a second meeting the same year. Thereafter, a writing committee produced a report on mucositis pathogenesis, epidemiology, and scoring (also included in this issue), as well as clinical practice guidelines. RESULTS Panelists created recommendations from higher levels of evidence and suggestions when evidence was of a lower level and there was a consensus regarding the interpretation of the evidence by the panel. Panelists identified gaps in evidence that made it impossible to recommend or not recommend use of specific agents. CONCLUSIONS Oral/GI mucositis is a common side effect of many anticancer therapies. Evidence-based clinical practice guidelines are presented as a benchmark for clinicians to use for routine care of appropriate patients and as a springboard to challenge clinical investigators to conduct high-quality trials geared toward areas in which data are either lacking or conflicting.
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Affiliation(s)
- Edward B Rubenstein
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Abstract
OBJECTIVE To review the management of radiotherapy- and chemotherapy-induced gastrointestinal mucositis. DATA SOURCE Articles and research studies. CONCLUSION Gastrointestinal damage is becoming a common dose-limiting toxicity. However, there is only limited research into the mechanism and possible treatment of this toxicity. IMPLICATIONS FOR NURSING PRACTICE It is important to document the frequency and severity of gastrointestinal mucositis, and to alleviate symptoms wherever possible.
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Affiliation(s)
- Dorothy M K Keefe
- Department of Medical Oncology, Royal Adelaide Hospital, South Australia
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O'Brien PC, Hamilton CS, Denham JW, Gourlay R, Franklin CIV. Spontaneous improvement in late rectal mucosal changes after radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2004; 58:75-80. [PMID: 14697423 DOI: 10.1016/s0360-3016(03)01445-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To describe the natural history of mucosal changes, in particular the development of telangiectases in the rectum, after radiotherapy (RT) for prostate cancer. METHODS AND MATERIALS Twenty patients undergoing local-field, nonconformal RT for prostate cancer underwent flexible sigmoidoscopy every 6 months for up to 3 years after RT completion. Telangiectasis was scored as absent, single, multiple, or multiple confluent. The site and circumferential extent were also documented. The patients filled in a diary to document the symptoms they were experiencing, including rectal bleeding. RESULTS Of the 20 patients, 12 developed multiple telangiectases, and 10 of these had rectal bleeding, which in all cases was mild. Telangiectasis was most commonly seen between 4 (anorectal junction) and 8 cm from the anal verge. In 5 patients, 4 of whom had multiple telangiectases, spontaneous resolution occurred. CONCLUSION Late radiation effects in the rectum do not appear to be permanent in all cases. This first prospective prolonged evaluation may provide an explanation for the observation that rectal bleeding resolves in a large proportion of patients with mild symptoms after RT. The reasons for improvement in the late radiation changes in the rectum compared with the permanent changes seen in organs such as the skin are unknown.
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Affiliation(s)
- Peter C O'Brien
- Department of Radiation Oncology, Newcastle Mater Hospital, Waratah, NSW, Australia.
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Cotti G, Seid V, Araujo S, Souza AHSE, Kiss DRR, Habr-Gama A. Conservative therapies for hemorrhagic radiation proctitis: a review. ACTA ACUST UNITED AC 2003; 58:284-92. [PMID: 14666326 DOI: 10.1590/s0041-87812003000500008] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Chronic radiation proctitis represents a challenging condition seen with increased frequency due to the common use of radiation for treatment of pelvic cancer. Hemorrhagic radiation proctitis represents the most feared complication of chronic radiation proctitis. There is no consensus for the management of this condition despite the great number of clinical approaches and techniques that have been employed. Rectal resection represents an available option although associated with high morbidity and risk of permanent colostomy. The effectiveness of nonoperative approaches remains far from desirable, and hemorrhagic recurrence represents a major drawback that leads to a need for consecutive therapeutic sessions and combination of techniques. We conducted a critical review of published reports regarding conservative management of hemorrhagic chronic radiation proctitis. Although prospective randomized trials about hemorrhagic radiation proctitis are still lacking, there is enough evidence to conclude that topical formalin therapy and an endoscopic approach delivering an argon plasma coagulation represent available options associated with elevated effectiveness for interruption of rectal bleeding in patients with chronic radiation proctitis.
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Affiliation(s)
- Guilherme Cotti
- Department of Gastroenterology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo/SP, Brazil
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Rotondano G, Bianco MA, Marmo R, Piscopo R, Cipolletta L. Long-term outcome of argon plasma coagulation therapy for bleeding caused by chronic radiation proctopathy. Dig Liver Dis 2003; 35:806-10. [PMID: 14674672 DOI: 10.1016/s1590-8658(03)00454-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Radiation-induced proctopathy is a serious complication of radiation therapy for pelvic malignancy. AIM To assess the safety and efficacy of argon plasma coagulation in the treatment of haemorrhagic radiation-induced proctopathy. PATIENTS Twenty-four patients with rectal bleeding due to radiation-induced proctopathy were prospectively enrolled in the study. METHODS Indications for treatment were iron deficiency anaemia (n = 16) and persistent bleeding, despite pharmacotherapy (n = 8). Argon flow and power used were 0.8-1.2 l/min and 40 W, respectively. An interval of at least 4 weeks was allowed between treatment sessions. Haemoglobin level, bleeding severity score, number of admissions and transfusion requirements were recorded after endoscopic coagulation and before 12 and 24 months. RESULTS A median of 2.5 therapeutic sessions per patient were performed (range 1-6). All patients reported clinical improvement and/or cessation of rectal bleeding. The mean value of the bleeding severity score decreased from 2.9 to 0.8 (P < 0.01), while average haemoglobin levels increased by a mean of 1.9 mg/dl at the end of the treatments (P < 0.05). During a minimum follow-up of 24 months (range 24-60), rectal bleeding recurred in two cases and was successfully retreated endoscopically. One patient developed a recto-vaginal fistula. CONCLUSIONS Argon plasma coagulation appears to be a safe and effective technique for management of rectal bleeding caused by radiation-induced proctopathy.
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Affiliation(s)
- G Rotondano
- Division of Gastroenterology and Digestive Endoscopy ASL NA5-Hospital Agostino Maresca, Torre del Greco, Italy
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Ramage JI, Gostout CJ. Endoscopic treatment of chronic radiation proctopathy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2003. [DOI: 10.1053/j.tgie.2003.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Zinicola R, Rutter MD, Falasco G, Brooker JC, Cennamo V, Contini S, Saunders BP. Haemorrhagic radiation proctitis: endoscopic severity may be useful to guide therapy. Int J Colorectal Dis 2003; 18:439-44. [PMID: 12677457 DOI: 10.1007/s00384-003-0487-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2003] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Management of haemorrhagic radiation proctitis remains controversial. Both endoscopically delivered argon plasma coagulation and rectal administration of formalin have been recommended. We evaluated the efficacy of argon plasma coagulation according to endoscopic severity of radiation proctitis. PATIENTS AND METHODS Fourteen patients treated with argon plasma coagulation for rectal bleeding due to radiation proctitis were reviewed. Patients were classified with a new endoscopic score for haemorrhagic radiation proctitis, comprising three factors: telangiectasia distribution, surface area involved, and presence of fresh blood. Seven patients were categorised as having grade A (mild), four grade B (moderate), and three grade C (severe) radiation proctitis. Rectal bleeding was assessed pre- and post-treatment using a five-point bleeding scale. RESULTS All patients with grade A and B radiation proctitis were treated successfully by argon plasma coagulation (mean 1.5 sessions). In one patient with grade C radiation proctitis argon plasma coagulation was successful after four sessions, but in the other two patients bleeding could not be controlled; a subsequent single formalin administration was successful in both. Overall in 12 patients (85.7%) bleeding ceased or improved significantly. The mean rectal bleeding scale reduced significantly from 2.6 to 0.9. One patient treated with argon plasma coagulation developed an asymptomatic rectosigmoid stenosis. CONCLUSION Argon plasma coagulation is a simple, safe and efficacious therapy for mild/moderate radiation proctitis. In patients with severe radiation proctitis several sessions are usually necessary, and success is not certain; in these cases, topical formalin administration may be more effective. Endoscopic severity of haemorrhagic radiation proctitis may be useful to guide appropriate therapy.
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Affiliation(s)
- Roberto Zinicola
- Wolfson Unit for Endoscopy, St. Mark's Hospital, Watford Road, Harrow, HA1 3UJ, UK
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Denton AS, Bentzen SM, Maher EJ. How useful are observational reports in the evaluation of interventions for radiation morbidity?: an analysis of formalin therapy for late radiation proctitis. Radiother Oncol 2003; 64:291-5. [PMID: 12242117 DOI: 10.1016/s0167-8140(02)00138-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Evidence-based medicine requires the systematic and critical evaluation of published and unpublished trials. Problems arise when a clinical condition is relatively rare and the only available data relate to experiential knowledge. The way forward would be to recommend the development of good quality randomized controlled studies. Until then, we are left with the situation where some information exists, albeit in the form of case reports and small series. Should this information be used and what features would determine its strength? METHODS Using the example of formalin therapy in haemorrhagic radiation proctitis, a treatment for a rare condition, we were able to identify 16 published studies, 13 of which were retrospective and three of which were prospective. The quality of reporting detail was assessed by comparison to the features in a 'proposed minimum dataset' for an uncontrolled study addressing this topic. RESULTS The mean score for quality of reporting detail for these studies was 50.6% (range 25-70%). Earlier studies reported a significantly higher response rate than subsequent studies and although there was a tendency for smaller studies to report higher response rates, this was not significant. The score for detail of reporting did not improve with year of publication and the correlation between the size of the study and the detail of reporting was not statistically significant. CONCLUSIONS The information presented is of exceedingly variable quality. If these studies are to be used, where insufficient controlled trials are available, they should be scored for methodology, and these scores used to assist interpretation of results. This would be facilitated if an accepted reporting format including specific criteria was available.
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Affiliation(s)
- A S Denton
- Centre for Cancer Treatment, Mount Vernon Hospital, Rickmansworth Road, Northwood, Middlesex, HA6 2RN, UK
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Chautems RC, Delgadillo X, Rubbia-Brandt L, Deleaval JP, Marti MCL, Roche B. Formaldehyde application for haemorrhagic radiation-induced proctitis: a clinical and histological study. Colorectal Dis 2003; 5:24-8. [PMID: 12780922 DOI: 10.1046/j.1463-1318.2003.00396.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Haemorrhagic radiation-induced proctitis is a serious complication of radiotherapy of pelvic organs. In severe cases, massive haemorrhage may necessitate hospitalization and repeated transfusions. Application of formaldehyde under direct vision is one of the most efficient treatments. The aim of this study was to evaluate the results of this treatment as well as the histological changes induced by formaldehyde on the rectal mucosa. MATERIAL AND METHODS From January 1991 to September 2001, 13 patients who presented a haemorrhagic radiation-induced proctitis have been treated in our outpatient clinic with 4% formaldehyde cotton soaked applications. They were followed up to one year after the treatment. Endoscopic biopsies were performed before, immediately after the application, 1 month later, as well as at the one-year follow-up. RESULTS In eight cases bleeding stopped after the first application. In two patients a second application was necessary to control the haemorrhage and in two other patients bleeding ceased definitively after the fourth application. Follow-up evaluation at 12 months showed no sign of acute proctitis or rebleeding. One asymptomatic patient had a mild stenosis of the rectum. Baseline biopsies showed signs of acute inflammation. Those performed after the application of formaldehyde showed fresh thromboses of the vessels of the mucosa. Biopsies at 1 month and 1 year showed only chronic changes secondary to the radiotherapy. CONCLUSION Local application of 4% formaldehyde for the treatment of haemorrhagic radiation-induced proctitis gives good results, is well tolerated and easy to perform. Formaldehyde applied selectively causes thromboses of the bleeding vessels, without deep lesions or extended necrosis.
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Affiliation(s)
- R C Chautems
- Outpatient Department, Unit of Proctology, University Hospital of Geneva, Micheli-du-Crest 24, 1211 Geneva 14, Switzerland
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Isomoto H, Hazama H, Shikuwa S, Omagari K, Mizuta Y, Murase K, Murata I, Kohno S. A case of haemorrhagic radiation proctitis: successful treatment with argon plasma coagulation. Eur J Gastroenterol Hepatol 2002; 14:901-4. [PMID: 12172416 DOI: 10.1097/00042737-200208000-00018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Argon plasma coagulation (APC) has been used extensively for a wide range of indications in gastrointestinal endoscopy. We describe a case of haemorrhagic radiation proctitis treated successfully with APC. A 54-year-old Japanese woman presented with daily rectal bleeding 4 months after cessation of radiotherapy for uterine cancer. Colonoscopic examination showed friable bleeding teleangiectasias in the rectum. Her haemoglobin level was decreased to 5.4 g/dl, requiring frequent blood transfusions. Endoscopic APC set at 1.2 l/min and 45 W was applied. After four treatment sessions without any complications, the patient showed complete resolution of haematochezia and subsequent haematological improvement. Standard and magnifying endoscopic follow-up revealed complete eradication of the vascular lesions and cicatrization of the treated areas, and mucosal covering with normal crypt lining. Endoscopic APC is an effective and well-tolerated treatment modality for the management of haemorrhagic proctitis.
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Affiliation(s)
- Hajime Isomoto
- Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan.
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Denton AS, Andreyev HJN, Forbes A, Maher EJ. Systematic review for non-surgical interventions for the management of late radiation proctitis. Br J Cancer 2002; 87:134-43. [PMID: 12107832 PMCID: PMC2376119 DOI: 10.1038/sj.bjc.6600360] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2001] [Revised: 04/03/2002] [Accepted: 04/12/2002] [Indexed: 12/11/2022] Open
Abstract
Chronic radiation proctitis produces a range of clinical symptoms for which there is currently no recommended standard management. The aim of this review was to identify the various non-surgical treatment options for the management of late chronic radiation proctitis and evaluate the evidence for their efficacy. Synonyms for radiation therapy and for the spectrum of lower gastrointestinal radiation toxicity were combined in an extensive search strategy and applied to a range of databases. The included studies were those that involved interventions for the non-surgical management of late radiation proctitis. Sixty-three studies were identified that met the inclusion criteria, including six randomised controlled trials that described the effects of anti-inflammatory agents in combination, rectal steroids alone, rectal sucralfate, short chain fatty acid enemas and different types of thermal therapy. However, these studies could not be compared. If the management of late radiation proctitis is to become evidence based, then, in view of its episodic and variable nature, placebo controlled studies need to be conducted to clarify which therapeutic options should be recommended. From the current data, although certain interventions look promising and may be effective, one small or modest sized study, even if well-conducted, is insufficient to implement changes in practice. In order to increase recruitment to trials, a national register of cases with established late radiation toxicity would facilitate multi-centre trials with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data.
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Affiliation(s)
- A S Denton
- Center for Cancer Treatment, Mount Vernon Hospital, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK
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Luna-Pérez P, Rodríguez-Ramírez SE. Formalin instillation for refractory radiation-induced hemorrhagic proctitis. J Surg Oncol 2002; 80:41-4. [PMID: 11967906 DOI: 10.1002/jso.10095] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Radiation proctitis is a common complication after pelvic irradiation. One to five percent of these patients will develop intractable or massive hemorrhagic radiation proctitis that will require repeated hospital admissions and blood transfusions. We evaluated the benefits of instillation of 4% formalin in the management of refractory hemorrhagic radiation-induced proctitis. METHODS From January 1998 to May 1999, 20 female patients who failed with administration of topical steroids and/or mesalazine were treated with 500 ml of 4% formalin instilled into the rectum in 50-ml aliquots. RESULTS Median age was 58 years. Eighteen patients had cervical cancer and two, endometrial cancer. These patients received a mean of 7,500 rads to the pelvis. The symptoms began at a mean of 8 months after termination of radiotherapy. Median time of symptomatic rectal hemorrhage was 8 months. Median of blood units previously transfused was six (range: 2-11). Hemorrhage immediately ceased after the 4% formalin instillation in 17 patients. Three patients required formalin instillation repetition with success in one. Overall success was 90%. Median follow-up was 20 months. Five patients had moderate pelvic pain after instillation and one developed rectosigmoideal necrosis that required resection plus Hartmann procedure. Two patients developed rectovaginal fistula and required colostomy, and one thereafter, required abdominoperineal resection en bloc with the posterior wall of the vagina due to pelvis sepsis. CONCLUSIONS Rectal instillation of 4% formalin is a simple, inexpensive, and efficient treatment for refractory hemorrhagic radiation proctitis.
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Affiliation(s)
- Pedro Luna-Pérez
- Colorectal Service, Surgical Oncology Department, Hospital de Oncología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México, D.F., Mexico
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Denton A, Forbes A, Andreyev J, Maher EJ. Non surgical interventions for late radiation proctitis in patients who have received radical radiotherapy to the pelvis. Cochrane Database Syst Rev 2002:CD003455. [PMID: 11869662 DOI: 10.1002/14651858.cd003455] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic radiation proctitis (inflammation of the rectum) may develop after the completion of pelvic radiotherapy. Presently there is no recommended standard management. OBJECTIVES To assess the effects of various non-surgical treatment options for the management of late chronic radiation proctitis. SEARCH STRATEGY We searched the Cochrane Controlled Trials Register, issue 1, 2001, MEDLINE 1966 to 2001, EMBASE 1980 to 2001, CANCERCD 1980 to 2001, Science Citation Index 1991 to 2001, CINAHL 1982 to 2001, as well as sources of grey literature. We also hand searched relevant textbooks and contacted experts in the field. SELECTION CRITERIA Studies (preferentially randomised controlled trials) of interventions for the non-surgical management of late radiation proctitis in patients who have undergone pelvic radiotherapy as part of their cancer treatment. DATA COLLECTION AND ANALYSIS The inclusion criteria were independently applied by two of the reviewers (AD and EJM) and where there was disagreement this was resolved by involving a third reviewer to form a consensus. MAIN RESULTS Six randomised controlled trials were included. None of the trials compared anti-inflammatories with placebo. However rectal sucralfate showed greater clinical improvement for proctitis than anti-inflammatories (odds ratio 14.00, 95% confidence interval 1.46 to 134.26; n=1 study), though no difference was seen for endoscopic improvement (odds ratio 2.74, 95% confidence interval 0.64 to 11.76, n=1 study). The addition of metronidazole to the anti-inflammatory regime also appeared to improve the response rate, as measured by the reduction in rectal bleeding, diarrhoea, erythema and ulceration (n=1 study). Similarly rectal hydrocortisone appeared to be more effective than rectal betamethasone for clinical improvement although no difference was seen in endoscopic improvement (n=1 study). Short chain fatty acid enemas did not appear to be effective compared to placebo (n=2 studies). In the comparison of the heater probe and bipolar electrocautery (n=1 study), there was no discernible difference for severe bleeding after one year, but the heater probe demonstrated a greater increase in the haematocrit and reduced transfusion requirements. REVIEWER'S CONCLUSIONS Late radiation complications are a relatively rare manifestation, with many potential carers and poor diagnostic criteria. Although certain interventions look promising and may be effective (such as rectal sucralfate, adding metronidazole to the anti-inflammatory regime and heater probes), single small studies (even if well conducted) provide insufficient evidence. The episodic and variable nature of late radiation proctitis also requires placebo controlled studies to establish whether particular treatments are effective. Regional or centralised registers of radiation toxicity should be established so that interventions can be administered in the setting of multi-centre trials with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data including quality of life evaluations.
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Affiliation(s)
- A Denton
- Centre for Cancer Treatment, Mount Vernon Hospital, Rickmansworth Rd, Northwood, Middlesex, UK, HA6 2RN.
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Tjandra JJ, Sengupta S. Argon plasma coagulation is an effective treatment for refractory hemorrhagic radiation proctitis. Dis Colon Rectum 2001; 44:1759-65; discussion 1771. [PMID: 11742157 DOI: 10.1007/bf02234451] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Chronic radiation proctitis complicating pelvic radiotherapy can be debilitating. It commonly presents with rectal bleeding, which can be difficult to control. Medical management of hemorrhagic radiation proctitis is not very successful, although surgery carries high risks. Thus, endoscopic treatments are preferred. The aim of this study is to assess the efficacy of argon plasma coagulation applied endoscopically to treat hemorrhagic radiation proctitis that has been refractory to topical formalin therapy. METHODS Twelve patients who had ongoing bleeding from radiation proctitis, after previously failed formalin therapy, underwent endoscopic treatment using argon plasma coagulation. The efficacy of treatment was assessed by grading the frequency and severity of bleeding (0-4, 0 being no bleeding), hemoglobin level, and transfusion requirements. RESULTS At a median follow-up of 11 months, ten patients (83 percent) had a significant reduction in the severity and frequency of bleeding, with complete cessation in six (50 percent). The presence of coexistent radiation-induced sigmoiditis in two patients was associated with reduced but persistent bleeding, because of difficulty in targeting the bleeding sites in the sigmoid colon. The median number of treatment sessions per patient was two (range, 1-3), with the number of sessions correlated with the extent of the proctitis. All patients had an improvement in their hemoglobin level, with the mean increasing from 11.2 to 12.3 g/dl. In the six months before starting therapy, all patients had been taking iron supplements, and four had required blood transfusions (median 3 units, range, 2-6). Iron supplements were ceased four weeks after the completion of therapy in all cases, and no further transfusions were required during the study period. None of the patients experienced any significant side effects or complications. CONCLUSIONS Argon plasma coagulation is an effective and safe treatment for hemorrhagic radiation proctitis that has been refractory to topical formalin therapy.
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Affiliation(s)
- J J Tjandra
- Department of Surgery, Colorectal Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria 3050, Australia
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Taïeb S, Rolachon A, Cenni JC, Nancey S, Bonvoisin S, Descos L, Fournet J, Gérard JP, Flourié B. Effective use of argon plasma coagulation in the treatment of severe radiation proctitis. Dis Colon Rectum 2001; 44:1766-71. [PMID: 11742159 DOI: 10.1007/bf02234452] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Chronic radiation proctitis, a well described complication of pelvic radiation therapy, can result in severe bleeding that is refractory to conventional treatment. Argon plasma coagulation is an effective treatment for hemorrhagic lesions of the gastrointestinal tract. The aim of this study was to assess the efficacy and safety of argon plasma coagulation in the management of severe radiation proctitis resistant to medical treatment. METHODS Eleven patients (10 males) aged between 54 and 86 years (mean +/- standard error of the mean, 73 +/- 3 years), with chronic radiation proctitis after radiotherapy for prostate (n = 9), uterine (n = 1) or rectal (n = 1) cancer were enrolled in this prospective study. Traditional therapies had failed including mainly topical steroids, 5-aminosalicylic acid and sometimes sucralfate. All patients had active bleeding from diffuse telangiectasias responsible for chronic anemia and seven of them required blood transfusions. The mean duration of the sessions was 20 minutes and one to five sessions (mean, 3.2 +/- 0.4), usually without anesthesia, were required to stop bleeding. Mean follow-up time was 19 +/- 2 (range, 7-30) months. RESULTS Rectal bleeding disappeared in nine patients and was greatly reduced in two. All the patients were free of transfusions during the mean follow-up of 19 months. The mean hemoglobin level was 7.7 +/- 2.8 g/dl at the first session and increased significantly (P = 0.003) to 11.5 +/- 2.6 g/dl after treatment. In two patients, a rectal stenosis appeared 7 and 11 months after the first session. CONCLUSION Argon plasma coagulation is a simple, inexpensive and effective treatment for severe refractory radiation proctitis with telangiectasias. Follow-up supervision is in progress to evaluate long term benefits and the risk of rectal stenosis.
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Affiliation(s)
- S Taïeb
- Hepato-Gastroenterology Units, Centre Hospitalier Lyon Sud, Chemin du Grand Revoyet, 69495 Pierre Bénite, France
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