Aggressive initial surgery for chronic radiation enteritis: long-term results of resection vs non-resection in 44 consecutive cases

Clinical features, outcome and risk factors in cervical cancer patients after surgery for chronic radiation enteropathy

Background

Radical hysterectomy and radiotherapy have long been mainstays of cervical cancer treatment. Early stage cervical cancer (FIGO stage IB1–IIA) is traditionally treated using radical surgery combined with radiotherapy, while locally advanced cervical cancer is treated using radiotherapy alone or chemoradiotherapy. In this retrospective study, we describe and analyse the presenting clinical features and outcomes in our cohort and evaluate possible risk factors for postoperative morbidity in women who underwent surgery for chronic radiation enteropathy (CRE).

Methods

One hundred sixty-six eligible cervical cancer patients who underwent surgery for CRE were retrospectively identified between September 2003 and July 2014 in a prospectively maintained database. Among them, 46 patients received radical radiotherapy (RRT) and 120 received radical surgery plus radiotherapy (RS + RT). Clinical features, postoperative morbidity and mortality, and risk factors for postoperative morbidity were analysed.

Results

RS + RT group patients were more likely to present with RTOG/EORTC grade III late morbidity (76.1 % vs 92.5 %; p = 0.004), while RRT group patients tended to show RTOG/EORTC grade IV late morbidity (23.9 % vs 7.5 %; p = 0.004). One hundred forty patients (84.3 %) were treated with aggressive resection (anastomosis 57.8 % and stoma 26.5 %). Overall and major morbidity, mortality and incidence of reoperation in the RRT and RS + RT groups did not differ significantly (63 % vs 64.2 % [p = 1.000], 21.7 % vs 11.7 % [p = 0.137], 6.5 % vs 0.8 % [p = 0.065] and 6.5 % vs 3.3 % [p = 0.360], respectively). However, incidence of permanent stoma and mortality during follow-up was higher in the RRT group than in the RS + RT group (44.2 % vs 12.6 % [p = 0.000] and 16.3 % vs 3.4 % [p = 0.004], respectively). In multivariate analysis, preoperative anaemia was significantly associated with overall morbidity (p = 0.015), while severe intra-abdominal adhesion (p = 0.017), ASA grades III–V (P = 0.022), and RTOG grade IV morbidity (P = 0.018) were predicators of major morbidity.

Conclusions

Radiation-induced late morbidity tended to be severe in the RRT group with more patients suffering RTOG/EORTC grade IV morbidity, while there were no significant differences in postoperative morbidity, mortality and reoperation. Aggressive resection was feasible with acceptable postoperative outcomes. Severe intra-abdominal adhesion, ASA grades III–V and RTOG/EORTC grade IV late morbidity contributed significantly to major postoperative morbidity.

The prevalence of chronic radiation enteritis following radiotherapy for cervical or endometrial cancer and its impact on quality of life

BACKGROUND

Studies suggest that 50% of people may suffer from chronic radiation enteritis (CRE) (Andreyev, J., 2005. Gastrointestinal complications of pelvic radiotherapy: are they of any importance? Gut 54, 1051-1054). Gami et al. (Gami, B., Harrington, K., Blake, P., Dearnaley, D., Andreyev, H.J.N., 2003. How patients manage gastrointestinal symptoms after pelvic radiotherapy. Alimentary Pharmacology and Therapeutics 18, 987-994) argue that this is unimportant if quality of life is unaffected. The aim of this study was to identify how many women experience CRE following radiotherapy and to investigate whether women who have higher doses of radiotherapy or more advanced stage of cancer are more at risk.

METHODS

Women (=117) who had completed radiotherapy for cervical or endometrial cancer were asked to complete a validated questionnaire exploring bowel problems and quality of life. Responses were scored and compared to scores for women with known faecal incontinence (Bugg, G.J., Kiff, E.S., Hosker, G., 2001. A new condition-specific health-related quality of life questionnaire for the assessment of women with anal incontinence. British Journal of Obstetrics and Gynaecology 108 (10), 1057-1067).

RESULTS

Using a score of '0' to indicate no symptoms, 47% of women gained scores indicative of CRE (>0), range 20-85 (mean 34, SD 14.4). Younger women (p<0.001) and women with cervical cancer (p<0.05) were more likely to score for CRE. No significant relationship was observed between score and either radiotherapy dose or stage of cancer.

CONCLUSIONS

Scoring suggests that about half of woman treated with radiotherapy develop CRE. Quality of life is affected, particularly regarding tiredness and coping behaviours due to lack of warning signs for CRE.

Duodenocaval Fistula: A Late Complication of Retroperitoneal Irradiation and Vena Cava Replacement

Duodenocaval fistula (DCF), an unusual pathology, is associated with a 40% mortality rate in the 36 patients previously reported. Although migrating or ingested foreign bodies, trauma, and peptic ulcer disease are often described etiologies, 11 patients have been described who developed DCF after resection of retroperitoneal tumors, 9 of whom also had postoperative radiotherapy. We report two patients who developed DCF after resection of retroperitoneal tumors followed by radiation therapy. The first patient, a 56-year-old female, presented with upper gastrointestinal hemorrhage requiring transfusion caused by a duodenoprosthetic caval fistula 7 years after successful resection of a retroperitoneal leiomyosarcoma and replacement of the inferior vena cava followed by radiation and chemotherapy. The second patient, a 37-year-old male who had previously undergone resection of a retroperitoneal sarcoma followed by external radiotherapy, developed massive upper and lower gastrointestinal bleeding secondary to a duodenocaval fistula. The etiology, diagnosis, and treatment of DCF are analyzed with an emphasis on DCF following resection and irradiation of retroperitoneal tumors. In most patients, "spontaneous" DCF have occurred as a late complication of high-dose radiation for carcinoma of the right kidney or retroperitoneal structures.

Operative and long term results after surgery for chronic radiation enteritis

BACKGROUND

About one third of patients with chronic radiation enteritis will need to be operated on during follow-up. Morbidity and life expectancy after resection and conservative surgical management for chronic radiation enteritis have not been well documented.

METHODS

From 1984 to 1994, 109 patients were operated on with a mean follow-up of 40 months (range 1 to 293). Postoperative mortality, early and late morbidity, long-term survival were studied in patients after resection (n = 65) and after conservative surgical management (n = 42), and in patients after planned or emergency procedure. Existence of possible risk factors for reoperation after a first surgical procedure was analyzed.

RESULTS

Five (5%) patients died in the postoperative course. Operative mortality was significantly higher when the procedure was performed as an emergency (P <0.05). Although not statistically significant, mortality was higher in the resection group (5% versus 0%). Thirty-three (30%) patients experienced postoperative complications including anastomotic leak in 11. Morbidity was not statistically related to the nature of the treatment (ie, conservative versus resection) or to the indication (emergency versus elective). During follow-up, reoperation was required in 40% of the patients, because of recurrence of digestive symptoms suggestive of chronic radiation enteritis; the reoperation rate was higher in the patients of the conservative group (50% versus 34%). Overall survival, after a mean follow-up of 40 months in patients without cancer recurrence was 85% at 1 year and 69% at 5 years after surgery, respectively. Overall survival was influenced by the nature of the treatment with 51% and 71% 5-year survival after conservative and resection treatment, respectively.

CONCLUSIONS

Despite high initial mortality and morbidity rates, life expectancy in patients with chronic radiation enteritis without recurrence of their previous neoplastic disease was good. Resection seems to provide a smaller reoperation rate and a better 5-year survival, but a higher postoperative mortality.