The surgical treatment of the radiation-damaged rectum

Abstract

Details are given of 37 consecutive patients with radiation damage to the rectum. Twenty-eight presented with rectovaginal fistulas, 3 with haemorrhage from ulcerative proctitis, 3 with low rectal strictures, 2 with a painful rectal ulcer and 1 with a rectal carcinoma. Thirty-five of the 37 had been treated for carcinoma of the cervix, and of these, 30 were Black South African women in whom this disease forms approximately 70 per cent of all malignancies. Associated pathology in these patients included urinary fistulas, small bowel fistulas or stenoses and a variable degree of fibrosis of the pelvic cellular tissue. Treatment involved subtotal rectal resection with restoration of continuity by means of a peranal sleeve anastomosis between healthy colon and the rectal stump denuded of its mucosa. Technical success was achieved in 35 of the 37 patients, with no mortality. The functional results were assessed both subjectively and objectively in 31 patients followed up for more than 6 months. Full continence was achieved in 54 per cent initially, improving to 75 per cent (21 of 28) at 1 year postoperatively. At 1 year, variable degrees of incontinence for a liquid stool persisted in 7 of 9 patients who had low fistulas with a low anastomosis at dentate line level. Where anastomosis was possible at a higher level, all 19 patients cured of fistula, ulcer, stenosis or haemorrhagic proctitis were fully continent at 1 year.

Pathophysiology and Therapy of Chronic Radiation-Induced Injury to the Colon

“…Other authors describe the results in 37 women treated for chronic radiation injury to the rectum with a Parks pull-through anastomosis [33]. The indication for surgery in the majority of cases was large recto-vaginal fistulas.…”

Management of chronic hemorrhagic radiation proctitis

“…94,95 Due to radiation-induced fibrosis, obliteration of tissue planes and ischemia, surgery is not only technically difficult but also carries high morbidity of 10-80% and mortality up to 47%. 94,95 Deitel and Vasic in 1979 noted an anastomotic leak rate of 25% and an overall surgical mortality of 19%. 6 Galland and Spencer showed mortality of 53% and anastomotic leak rate of 65% in their study in 1979.…”

Management of Late Complications of Pelvic Radiation in the Rectum and Anus

“…It is usually confined to the mucosa with histology showing normal submucosa, but thickened and edematous lamina propria with patchy fibroblastic proliferation and decreased mitotic rate within the mucosa. The risk of development of rectal cancer after radiation treatment is approximately tripled 22 and may be reflected by the fact that aneuploid cells have been discovered in the rectum of patients with radiation proctitis. 18 The mucosal capillaries attempt to compensate developing telangiectasia with friable vessels that are prone to bleeding, the most common presentation.…”

“…129,133,134 Other methods described include creation of an ileocecal reservoir anastomosed to anorectal ring 125 and the use of colonic J-pouches. * Two had recurrent disease but declined further surgery.…”