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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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Pui WC, Chieng TH, Siow SL, Nik Abdullah NA, Sagap I. A Randomized Controlled Trial of Novel Treatment for Hemorrhagic Radiation Proctitis. Asian Pac J Cancer Prev 2020; 21:2927-2934. [PMID: 33112550 PMCID: PMC7798148 DOI: 10.31557/apjcp.2020.21.10.2927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Indexed: 12/30/2022] Open
Abstract
Background: Various methods have been used for treatment of hemorrhagic radiation proctitis (HRP) with variable results. Currently, the preferred treatment is formalin application or endoscopic therapy with argon plasma coagulation. Recently, a novel therapy with colonic water irrigation and oral antibiotics showed promising results and more effective compared to 4% formalin application for HRP. The study objective is to compare the effect of water irrigation and oral antibiotics versus 4% formalin application in improving per rectal bleeding due to HRP and related symptoms such as diarrhoea, tenesmus, stool frequency, stool urgency and endoscopic findings. Methods: We conducted a study on 34 patients with HRP and randomly assigned the patients to two treatment arm groups (n=17). The formalin group underwent 4% formalin dab and another session 4 weeks later. The irrigation group self-administered daily rectal irrigation at home for 8 weeks and consumed oral metronidazole and ciprofloxacin during the first one week. We measured the patients’ symptoms and endoscopic findings before and after total of 8 weeks of treatment in both groups. Results: Our study showed that HRP patients had reduced per rectal bleeding (p = 0.003) in formalin group, whereas irrigation group showed reduced diarrhoea (p=0.018) and tenesmus (p=0.024) symptoms. The comparison between the two treatment arms showed that irrigation technique was better than formalin technique for tenesmus (p=0.043) symptom only. Conclusion: This novel treatment showed benefit in treating HRP. It could be a new treatment option which is safe and conveniently self-administered at home or used as a combination with other therapies to improve the treatment outcome for HRP.
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Affiliation(s)
- Wei Chieng Pui
- Department of Surgery, Sibu Hospital, Sarawak, Malaysia.,Department of Surgery, Sarawak General Hospital(SGH), Sarawak, Malaysia
| | - Tiong How Chieng
- Department of Surgery, Sibu Hospital, Sarawak, Malaysia.,Department of Surgery, Sarawak General Hospital(SGH), Sarawak, Malaysia
| | - Sze Li Siow
- Department of Surgery, Sarawak General Hospital(SGH), Sarawak, Malaysia
| | | | - Ismail Sagap
- Colorectal Unit, Department of Surgery, Universiti Kebangsaan Malaysia(UKM), Kuala Lumpur, Malaysia
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Dziki Ł, Kujawski R, Mik M, Berut M, Dziki A, Trzciński R. Formalin therapy for hemorrhagic radiation proctitis. Pharmacol Rep 2015; 67:896-900. [PMID: 26398382 DOI: 10.1016/j.pharep.2015.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 02/02/2015] [Accepted: 03/11/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Radiotherapy within pelvis is a vital component of curative therapy for urological, gynecological and rectal malignances. Rectum is especially vulnerable to secondary radiation injury resulting in proctitis. The most common and life-threatening symptom is rectal hemorrhage. Formalin application into the rectum causes local cauterization of telangiectatic mucosal vessels. The aim of our study was to assess the efficacy of local formalin application in patients with hemorrhagic radiation proctitis. METHODS A solution of 4.0% formalin was used in the treatment of 20 patients with clinical and proctoscopic evidence of radiadion proctitis. Treatment involved direct application of 4.0% formalin into the rectum. All patients were followed-up in terms of complete resolution of symptoms or recurrences of bleeding. RESULTS A total of 20 patients with a mean age of 69.7 (range, 57-80) years were followed for 51.2 (range, 1-93) months. The mean duration of symptoms was 4.5 (range, 1-10) months and the interval between the end of radiotherapy and symptoms was mostly between 5 and 30 months. Patients required an average of 2 (range, 1-5) formalin treatments. Of the 20 patients, 10 had complete resolution of their symptoms after their first treatment. In 10 patients bleeding recurred and they were offered another formalin instillation and/or 5-ASA suppositories and argon therapy. Complete resolution of symptoms was achieved in all patients. CONCLUSIONS Topical formalin instillation is effective, safe, and well-tolerated method for the patients with radiation proctopathy. This therapy may be repeated in case of recurrent bleeding and combined with other methods of treatment.
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Affiliation(s)
- Łukasz Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Ryszard Kujawski
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Michał Mik
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Maciej Berut
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Adam Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland
| | - Radzisław Trzciński
- Department of General and Colorectal Surgery, Medical University of Lodz, Łódź, Poland.
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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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Eriksen PL, Tougaard RS, Tøttrup A. Clinical and proctoscopic evaluation of topical formalin application in the treatment of chronic radiation proctitis. Scand J Surg 2013; 102:96-100. [PMID: 23820684 DOI: 10.1177/1457496913482240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Chronic radiation proctitis is a disease associated with radiotherapy of cancer in the pelvic region. The main symptom is rectal bleeding. Several treatment modalities have been attempted, but few have demonstrated satisfactory effects. We present our experience with formalin applied locally to the rectal mucosa in the treatment of chronic radiation proctitis. Furthermore, we assess possible complications, the gravest suggested being cancer. Previous studies on the subject have reported good results, but often with a somewhat vaguely defined follow-up. Our evaluation of the treatment was based on both subjective symptoms and proctoscopic findings. MATERIAL AND METHODS A small study (N = 11) was conducted retrospectively. All patients treated for chronic radiation proctitis with formalin in our clinic were identified, and data concerning effect and complications were collected by studying the patients' records, with a questionnaire and a follow-up interview and proctoscopy. RESULTS The study showed a marked decrease in bleeding and objective signs of proctitis in all patients. Complete cessation of bleeding was achieved in five patients. Possible complications to the treatment detected in our study were the following: anorectal pain, tenesmus, incontinence, diarrhea, and mucous rectal discharge. No signs of neoplasia were found. CONCLUSIONS The formalin treatment had a very good effect on chronic radiation proctitis. Possible complications were detected. Except in the case of anorectal pain, these are all of a questionable nature and can possibly be attributed to chronic radiation proctitis itself rather than the formalin treatment. Further study is warranted to confirm long-term effects of the formalin and to exclude possible complications, especially secondary anorectal cancer.
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Affiliation(s)
- P L Eriksen
- Abdominal Surgery Ward (Department P), Aarhus University Hospital, Aarhus, Denmark
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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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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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Al-Amin A, Cowley R, Scott N. Formalin dab for treatment of haemorrhagic radiation proctitis. BMJ Case Rep 2011; 2011:bcr.05.2011.4255. [PMID: 22689607 DOI: 10.1136/bcr.05.2011.4255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors present a case of a 75-year-old man who underwent 2 months of radiotherapy for prostate cancer. He developed rectal bleeding 6 months later. A colonoscopy showed radiation proctitis with no other abnormalities up to the caecum. He was treated with a variety of medical therapies and argon beam laser with minimal effect. He was treated with epinephrine injection after a subsequent flexible sigmoidoscopy. He required multiple blood transfusions because of the resulting anaemia. He was finally treated with topical formalin dab therapy over three sessions, after which his rectal bleeding subsided and haemoglobin levels eventually reached normal levels.
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Affiliation(s)
- Azzam Al-Amin
- Department of Vascular Surgery, Royal Blackburn Hospital, Blackburn, UK.
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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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López Rodríguez M, Martín Martín M, Cerezo Padellano L, Marín Palomo A, Ibáñez Puebla Y. Gastrointestinal toxicity associated to radiation therapy. Clin Transl Oncol 2010; 12:554-61. [DOI: 10.1007/s12094-010-0553-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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[Nonsurgical treatment of chronic radiation-induced hemorrhagic proctitis]. Presse Med 2008; 37:1113-20. [PMID: 18077130 DOI: 10.1016/j.lpm.2007.07.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Revised: 07/22/2007] [Accepted: 07/27/2007] [Indexed: 12/25/2022] Open
Abstract
The incidence of radiation-induced chronic hemorrhagic proctitis is less than 10 to 20%. The onset of this proctitis is delayed relative to the radiation therapy and generally develops from 6 to 24 months later. There are numerous predisposing factors, the most important of which is the radiation therapy dose: risk increases exponentially above 40-45 Gy. Its pathophysiology involves progressive obliterating endarteritis and transmural interstitial fibrosis, which induce chronic ischemia that is irreversible and progressive during the years after radiation therapy. Its diagnosis depends most often on the combination of clinical history and typical endoscopic appearance (congestive mucosa and/or telangiectases). Topical administrative of sucralfate or corticosteroids as well as argon plasma coagulation, with formalin treatment if necessary, provides relief for most patients.
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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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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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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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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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Ng SSM, Ng NC, Lee JFY, Yiu RYC, Li JCM, Leung KL. Formalin dab for refractory radiation proctitis: Preliminary Hong Kong experience. SURGICAL PRACTICE 2006. [DOI: 10.1111/j.1744-1633.2006.00316.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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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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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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