Treatment of severe actinic rectitis
Surgery Department,
Hospital A .
C .Camargo e Fundafao
Antonio Prudente - sao Paulo, Brazil
B a c k g ro u n d : T h e a u th o rs re p o rt th e tre a tm e n t o f th re e fe m a le p a tie n ts w ith se ve re a ctin ic re ctitis, w ith ste n o sis o r p e rfo ra tio n , su b m itte d to a n te rio r p ro cto sig m o id e cto m y a n d tra n sa n a l co lo a n a l a n a sto m o sis. M e th o d s : In a ll ca se s su rg e ry co n siste d o f to ta l p ro cto sig m o id e cto m y, m u co se cto m y o f th e a n a l ca n a l, lo w e rin g o f th e le ft co lo n th ro u g h th e p e lvis a n d tra n sa n a l a n a sto m o sis p e rfo rm e d m a n u a lly a t th e le ve l o f th e p e ctin e a l lin e u sin g se p a ra te a b so rb a b le su tu re s. A p ro te ctive in te stin a l sh u n t w a s p e rfo rm e d in a ll ca se s. R e s u lts : T h e th re e p a tie n ts d id n o t p re se n t tra n so p e ra tive o r im m e d ia te p o sto p e ra tive co m p lica tio n s, b u t th e first p a tie n t d e ve lo p e d d e e p ve n o u s th ro m b o sis o f th e le g th a t w a s su b m itte d to su cce ssfu l clin ica l tre a tm e n t. T h e in te stin a l sh u n ts w e re la te r clo se d in a ll th re e ca se s. S p h in cte r fu n ctio n w a s co n sid e re d ve ry g o o d in th e first ca se a n d re g u la r in th e re m a in in g tw o . C o n c lu s io n : T h e su rg ica l te ch n iq u e u tilize d w a s co n sid e re d to b e a d e q u a te fo r th e ca se s re p o rte d a n d is th e first o p tio n fo r th e m a in te n a n ce o f tra n sit in p a tie n ts w ith se ve re a ctin ic re ctitis sin ce th e a n a sto m o sis is p e rfo rm e d u sin g n o n -irra d ia te d co lo n w ith th e p e ctin e a l lin e , p ra ctica lly o u tsid e th e p e lvis.
U N IT E R M S : A ctin ic re ctitis. C o lo a n a l a n a sto m o sis. P ro ctitis. S u rg e ry. S p h in cte r p re se rva tio n . C e rvix ca rcin o m a .
IN T R O D U C T IO N
T
he sequelaetract representof radiotherapya problem of difficult solution evenin the gastrointestinalafter control of the prim ary tum or (I).T he dam age
of ionizing radiation is progressive and cum ulative and is
caused b y hyalinization of the arterial vascularization of
the affected organ, leading to chronic ischem ia w ith
vascular neoform ation of the telangiectasia type, w hich
m ay be an attem pt to com pensate for the lack of oxygen
A d d re ss fo r co rre sp o n d e n ce : B e n e d ito M a u ro R o ssi
H o sp ita l A . C . C a m a rg o - D e p a rta m e n to d e C iru rg ia R u a P ro fQ A n to n io P ru d e n te , 2 1 1
S a o P a u lo /S P - B ra zil- C E P 0 1 5 0 9 -0 1 0
in tissues. T his phenom enon, how ever, is responsible for
the bleeding observed in patients w ith actinic sequelae
(2,3). D uring the acute phase or the chronic phase, clinical
treatm ent consists of sym ptom atic relief and palliative
m easures. Surgical resection of the affected organ is
indicated in cases w ith m ore severe alterations, such as
stenoses, fistulae or intractable bleeding (4 ).
P A T IE N T S A N D M E T H O D S
Surgery w as indicated for patients w ith no evidence
of active neoplasias, in adequate clinical condition, w ith
good sphincter function and aw are of the operative risks,
including the possibility of needing a perm anent intestinal
shunt.
R O S S I, 8 .M .; N A K A G A W A , W .T .; F E R N A N D E S , J.A .P .; L O P E S , A ; P A E G L E , L .D . - T re a tm e n t o f se ve re a ctin ic re ctitis
Surgery consisted of rectosigm oidectom y, including
m ucosectom y of the anal canal, low ering of the left colon
through the pelvis and its m anual anastom osis at the level
of the pectineal line using separate absorbable sutures.
Since this is a high-risk anastom osis, a protective intestinal.
shunt w as perform ed and closed as soon as the patient
w as in adequate clinical condition. A nal endoscopy,
peranal contrasted radiologic exam ination and clinical
evaluation of sphincter function w ere perform ed before
shunt closure in order to diagnose possible fistulae or other
alterations that m ight contraindicate the reconstruction
of intestinal transit. Patient follow -up by a nurse w ith
specialization in stom otherapy w as of fundam ental
im portance.
C A S E R E P O R T S A N D R E S U L T S
Case 1
A 41 year old w om an w ith spinocellular carcinom a
(SC C ) of the cervix invading the param etrium up to the
pelvic w all (clinical stage Illb) w as treated in 1981
exclusively w ith radiotherapy. The total dose w as 7500
cG y at point A (tum or), w ith 4000 cG y applied externally
to the pelvis using a 4 M eV linear accelerator and 3500
cG y w ith Fletcher intravaginal applicators. The source
w as cesium 137. In February 1989 she presented hem aturia
w hich w as treated clinically, w ith im provem ent of signs
and sym ptom s. In M arch 1990 she presented an increased
num ber of evacuations w ith cram ps, m ucus and blood in
the feces. R ectosigm oidoscopy show ed m ucosa w hich w as
friable to instrum ent touch, w ith edem a and vascular
neoform ation of the telangiectasia type. She w as subm itted
to clinical dietary treatm ent. In M arch 1992, sym ptom s
and endoscopic appearance becam e w orse. A biopsy
revealed actinic recti tis. In M ay 1993 she presented acute
abdom inal pain. Exploratory laparotom y revealed sigm oid
necrosis and perforation. A nterior sigm oidectom y w as
perform ed, the rectum w as closed and a term inal
colostom y w as carried out. In D ecem ber 1993 the
endoscopic appearance of the rectum w as unchanged but
the patient had no sym ptom s. In N ovem ber 1994 the
patient stated that she w ould not accept her colostom y
condition w hile having no tum oral activity. W e proposed
surgery and explained its risks to the patient, w ho accepted
the procedure. She w as then subm itted to anterior resection
of the rectum w ith m anual transanal coloanal anastom osis
and protective ileostom y. H er im m ediate postoperative
course w as free from com plications. A natom opathological
exam ination of the surgical piece revealed chronic rectitis.
In D ecem ber 1994 she developed deep venous throm bosis
in a leg w hich w as treated clinically. The ileostom y w as
closed in February 1995, w ith no com plications.
She currently has good sphincter function and
sensitivity to solid or liquid feces and gases, w ith no
nocturnal losses and 1 to 2 evacuations a day. She
continues to have actinic cystitis w ith sporadic dysuria
and hem aturia, controlled by clinical treatm ent.
Case
2A 71-year old w om an w ith cervical SC C , w ith
invasion of the param etrium up to the pelvic w all (clinical
stage Illb), w as subm itted to exclusive radiotherapy in
O ctober 1978. The total dose w as 8500 cG y at point A
(tum or), w ith 4000 cG y applied to the pelvis w ith a 4
M eV linear accelerator and 4500 cG y w ith Fletcher
intravaginal applicators. The source w as cesium 137. In
June 1993 she presented an increased num ber of daily
evacuations, w ith liquid feces w ithout blood or m ucus
and w as subm itted to clinical treatm ent. In M ay 1995, a
colonoscopy revealed actinic rectitis w ith thickening of
the m ucosa, w hich w as pale, w ith vascular neoform ation
of the telangiectasia type, easy bleeding upon instrum ent
touch and stenosis of the rectosigm oid transition. In
A ugust 1995, in the absence of tum oral activity of the
cervical SC C , the patient w as subm itted to anterior
rectosigm oidectom y w ith m anual transanal coloanal
anastom osis and protective colostom y. H er postoperative
course w as free from com plications. A natom opathological
exam ination revealed chronic rectitis w ith vascular
hyalinization and intense fibrosis. The colostom y w as
closed in D ecem ber 1995 w ith no com plications. She
currently has regular intestinal function w ith 3 to 4
evacuations a day and feces varying in consistency
according to the diet. She presents no diurnal incontinence,
w ith control of gases and feces. A t night she has sporadic
involuntary losses, especially w hen the feces are liquid.
She sporadically presents urinary sym ptom s, dysuria or
hem aturia, w hich are controlled by clinical treatm ent.
Case
3A 49-year old w om an w ith a cervical SC C w ith
invasion up to the pelvic w all (clinical stage Illb) w as
treated in N ovem ber 1992 by exclusive radiotherapy w ith
8 0 0 0 c G y a t p o in t A ( tu m o r ) , w ith 4 5 0 0 c G y a p p lie d to th e p e lv is w ith a 4 M e V lin e a r a c c e le r a to r a n d 3 5 0 0 c G y a p p lie d w ith F le tc h e r in tr a v a g in a l a p p lic a to r s , u s in g c e s iu m 1 3 7 . I n A u g u s t 1 9 9 5 s h e f e lt a b d o m in a l c r a m p s a c c o m p a n ie d b y v o m itin g a n d a c u te d ia r r h e a . C o lo n o s c o p y r e v e a le d a r e c tu m w ith th ic k e n e d m u c o s a , o b lite r a tio n o f s u b m u c o s a l v e s s e ls , e a s y b le e d in g u p o n in s tr u m e n t to u c h a n d s te n o s is a t th e le v e l o f th e r e c to s ig m o id tr a n s itio n p r e v e n tin g p a s s a g e o f th e in s tr u m e n t. T h e in te s tin a l s u b o c c lu s io n im p r o v e d w ith c lin ic a l tr e a tm e n t. I n D e c e m b e r 1 9 9 5 s h e w a s s u b m itte d to lo o p s ig m o id o s to m y d u e to a c u te in te s tin a l o b s tr u c tio n , w ith im p r o v e m e n t o f s ig n s a n d s y m p to m s . I n A p r il 1 9 9 6 , in th e a b s e n c e o f tu m o r a l a c tiv ity o f th e c e r v ic a l
s e c ,
s h e w a s s u b m itte d to a n te r io r r e c to s ig m o id e c to m y w ith m a n u a l tr a n s a n a l c o lo a n a l a n a s to m o s is a n d p r o te c tiv e tr a n s v e r s o to m y . H e r p o s to p e r a tiv e c o u r s e w a s g o o d a n d h e r c o lo s to m y w a s c lo s e d in M a y 1 9 9 6 w ith n o c o m p lic a tio n s . S h e c u r r e n tly h a s r e g u la r in te s tin a l f u n c tio n w ith o u t in c o n tin e n c e a n d w ith s e n s itiv ity f o r f e c e s a n d g a s e s .C O M M E N T S
A p p r o x im a te ly h a lf th e p a tie n ts w ith m a lig n a n t n e o p la s ia s a r e s u b m itte d to r a d io th e r a p y a t s o m e tim e d u r in g tr e a tm e n t, a n d c h r o n ic c o m p lic a tio n s m a y o c c u r in 2 to
50/0
o f th e s e c a s e s ( 5 ) . I n te s tin a l c h a n g e s m a y o c c u rf r o m 3 to 1 5 y e a r s a f te r r a d io th e r a p y . ( 6 ) .
S o m e f a c to r s h a v e b e e n r e p o r te d to b e p r e d is p o s in g to p o s t- th e r a p y c o m p lic a tio n s , a m o n g th e m p r e v io u s la p a r o to m y , a r te r ia l h y p e r te n s io n , d ia b e te s o r e m a c ia tio n
( 7 ) . C o m p lic a tio n s s h o u ld b e m a in ly p r e v e n te d b y
a p p r o p r ia te tr e a tm e n t p la n n in g , p r e f e r a b ly w ith th e a id o f a c o m p u te r , r e s p e c tin g th e m a x im u m d o s e to le r a te d b y th e s m a ll in te s tin e ( 4 5 0 0 c G y ) a n d b y th e r e c tu m ( 5 5 0 0
c G y ) o n . T h e u s e o f tis s u e - p r o te c tin g s u b s ta n c e s s e e m s to h a v e p r o d u c e d g o o d r e s u lts in e x p e r im e n ta l s tu d ie s ( 9 ) .
M o s t p e lv ic c o m p lic a tio n s a f te r r a d io th e r a p y a r e d u e to c a r c in o m a o f th e c e r v ix ( 1 ,5 ,1 0 ,1 1 ) , w h ic h is m o r e c o m m o n
in c o u n tr ie s w h e r e s o c io e c o n o m ic c o n d itio n s f a v o r th e d e v e lo p m e n t o f th is ty p e o f tu m o r . T h e r e s e e m s to b e n o s ig n if ic a n t c o r r e la tio n w ith th e o c c u r r e n c e o f a s e c o n d p r im a r y tu m o r a m o n g p a tie n ts s u b m itte d to p e lv ic r a d io th e r a p y , a lth o u g h a g r e a te r in c id e n c e o f tu m o r s o f th e r e c tu m a n d b la d d e r a n d o f le u k e m ia a p p e a r s to te n d to o c c u r a m o n g th e s e p a tie n ts ( 1 2 ) .
T h e m a jo r s ig n s a n d s y m p to m s o f th e th r e e p a tie n ts d e s c r ib e d h e r e a r e th e s a m e a s th o s e r e p o r te d in th e I i te r a tu r e , i.e ., a b d o m in a l p a in , d ia r r h e a , b le e d in g a n d in te s tin a l s te n o s is ( 1 3 ) . T h e c la s s if ic a tio n o f th e s e r e c ta l
s y m p to m s m a y b e c lin ic a l, s u c h a s th a t p r o p o s e d b y A e b e r h a r d ( 1 4 ) ( T a b le 1 ) , o r e n d o s c o p ic , s u c h a s th a t
p r o p o s e d b y S h e r m a n ( 1 5 ) in 1 9 5 4 , in w h ic h g r a d e s I a n d
I I a r e c h a r a c te r iz e d b y e d e m a , e a s y b le e d in g a n d s u p e r f ic ia l u lc e r s o f th e m u c o s a , a n d g r a d e s I I a n d I V a r e c h a r a c te r iz e d b y im p o r ta n t b le e d in g a n d d e e p u lc e r s th a t m a y e v e n le a d to th e d e v e lo p m e n t o f f is tu la e o r s te n o s is . T a b le 2 s h o w s a c lin ic a l- e n d o s c o p ic c la s s if ic a tio n u s e d in th is D e p a r tm e n t f o r a c tin ic r e titis .
U r in a r y s y m p to m s s u c h a s d y s u r ia a n d h e m a tu r ia u s u a lly a c c o m p a n y th e p ic tu r e o f r e c titis , a s d e s c r ib e d f o r tw o o f th e th r e e c a s e s p r e s e n te d h e r e , a n d c a n b e c lin ic a lly c o n tr o lle d in a p a llia tiv e m a n n e r s in c e th e ir e v o lu tio n is a ls o c h r o n ic a n d o f d if f ic u lt tr e a tm e n t, a s is th e c a s e f o r th e r e c tu m ( 9 ) . F u r th e r m o r e , th e r e m a y b e s y m p to m s r e la te d to
th e s m a ll in te s tin e s u c h a s c r a m p s a n d a b d o m in a l d is c o m f o r t. I n c a s e s in w h ic h th e te r m in a l ile u m is s e v e r e ly in v o lv e d , s u r g e r y m a y b e in d ic a te d , s u c h a s ile u m r e s e c tio n to g e th e r w ith th e r ig h t c o lo n a n d ile u m - tr a n s v e r s e c o lo n a n a s to m o s is ( 1 6 ) . I n c a s e s o f s m a ll in te s tin e o b s tr u c tio n ,
w h e n e v e r p o s s ib le it is b e tte r to p e r f o r m a b y p a s s th a n a s e g m e n ta l r e s e c tio n w ith a n a s to m o s is , s in c e th e f o r m e r p r o c e d u r e s e e m s to h a v e a lo w e r c o m p lic a tio n r a te ( 1 7 ,1 8 ) .
G r a d e 1 G r a d e 2 G r a d e 3
G r a d e 4
G r a d e 5
T a b le 1
C lin ic a l s y s te m u s e d to s c o r e th e m o r b id ity o f r a d io th e r a p y
F e w s y m p to m s r e q u ir in g n o tr e a tm e n t
T r e a tm e n t w ith n o n e e d fo r h o s p ita liz a tio n o r a c h a n g e in p a tie n t life s ty le Im p o r ta n t s y m p to m s th a t c h a n g e p a tie n t life s ty le , r e q u ir in g h o s p ita liz a tio n fo r
tr e a tm e n t, in c lu d in g s m a ll s u r g e r ie s .
S y m p to m s r e q u ir in g m a jo r s u r g e r y ( c o lo s to m y , la p a r o to m y ) o r p r o lo n g e d h o s p ita liz a tio n
F a ta l c o m p lic a tio n
R O S S I, 8 .M .; N A K A G A W A , W .T .; F E R N A N D E S , J .A .P .; L O P E S , A ; P A E G L E , L .D . - T r e a tm e n t o f s e v e r e a c tin ic r e c titis
Table 2
Clinical and endoscopic classification used in the Department of Surgery for actinic rectitis
G r a d e 1
G r a d e 2
G r a d e 3
G r a d e 4
S lig h t s y m p to m s o f e a s y c lin ic a l c o n tr o l
E d e m a o f th e r e c ta l m u c o s a /o b lite r a tio n o f s u b m u c o s a l v e s s e ls M o d e r a te s y m p to m s w ith a g o o d r e s p o n s e to c lin ic a l tr e a tm e n t E a s y b le e d in g u p o n e n d o s c o p ic e x a m in a tio n /s u p e r fic ia l u lc e r s M a r k e d s y m p to m s o f d iffic u lt c lin ic a l c o n tr o l
D iffu s e b le e d in g o f r e c ta l m u c o s a /d e e p a n d d iffu s e u lc e r s C lin ic a lly u n c o n tr o lla b le s y m p to m s
F is tu la e /s te n o s e s
T r e a tm e n t o f s e v e r e a c tin ic r e c titis s y m p to m s s im p ly b y a n in te s tin a l s h u n t m a y im p r o v e th e c lin ic a l p ic tu r e , b u t th e tis s u e p r o c e s s in th e ir r a d ia te d a r e a c o n tin u e s a n d w h e n th e s h u n t is c lo s e d th e s y m p to m s c o m e b a c k , a t tim e s m o r e e x a c e r b a te d th a n b e f o r e ( 1 ,1 9 ) .
T r e a tm e n t o f r e c ta l b le e d in g w ith in tr a lu m in a l f o r m a lin m a y b e in d ic a te d , e s p e c ia lly in a c u te a n d u n c o n tr o lla b le c a s e s , b u t m a y a ls o le a d to s te n o s is , w ith o u t c h a n g in g th e c h r o n ic p o s t- ir r a d ia tio n p r o c e s s ( 2 0 ,2 1 ) . L a s e r m a y b e u s e d in c a s e s o f m o d e r a te a c tin ic r e c titis in o r d e r to c o n tr o l lo c a liz e d b le e d in g in a r e a s o f te la n g ie c ta s ia ( 5 ) .
T h e u s e o f s y s te m ic c o r tic o id s m a y a ls o b e in d ic a te d in s e le c te d c a s e s o f a c tin ic r e c titis ( 2 2 ) .
P r o c to s ig m o id e c to m y w ith p e r a n a l c o lo a n a l a n a s to m o s is is d e f in itiv e in r e la tio n to a c tin ic a lte r a tio n s a s th e lo w e r e d c o lo n is n o t ir r a d ia te d . T h e te c h n iq u e w a s f ir s t d e s c r ib e d b y P a r k s ( 2 3 ) a n d la te r u s e d f o r tr e a tm e n t o f
c a n c e r o f th e r e c tu m ( 2 4 ,2 5 ,2 6 ) . I t is a te c h n iq u e o f d if f ic u lt e x e c u tio n , e s p e c ia lly in te r m s o f p e lv ic d is s e c tio n s in c e s ig n if ic a n t p e lv ic f ib r o s is w ith o u t d e f in e d a n a to m ic a l
lim its is u s u a lly p r e s e n t y e a r s a f te r r a d io th e r a p y , a n d b e s id e s th is , th e r e is a n in c r e a s e d p o s t- o p e r a tiv e in f e c tio n r a te ( 1 ,2 7 ) .T h e r a te s o f o p e r a tiv e c o m p lic a tio n s m a y b e h ig h , o f te n w ith th e n e e d f o r th e p a tie n t to k e e p a p e r m a n e n t in te s tin a l s h u n t d e s p ite s u r g e r y (27,2R). I n th e th r e e p a tie n ts r e p o r te d h e r e th e c o m p lic a tio n s w e r e n o t s ig n if ic a n t b u t, in v ie w o f th e s m a ll n u m b e r o f c a s e s , th is r e s u lt s h o u ld b e c o n s id e r e d w ith c a u tio n .
I n c o n c lu s io n , p r o c to s ig m o id e c to m y in c lu d in g th e m u c o s a o f th e a n a l c a n a l a n d r e c o n s tr u c tio n o f in te s tin a l tr a n s it w ith a p e r a n a l c o lo a n a l a n a s to m o s is is th e f ir s t tr e a tm e n t o p tio n f o r p a tie n ts w ith s e v e r e a c tin ic r e c titis . T h e p h y s ic ia n s h o u ld a lw a y s ta k e in to c o n s id e r a tio n th e a b s e n c e o f . tu m o r a c tiv ity , th e c lin ic a l c o n d itio n o f th e p a tie n t a n d h is /h e r w illin g n e s s to s u b m it to th e s u r g e r y p r o p o s e d a f te r b e in g f u lly in f o r m e d a b o u t a ll o f its p o s s ib le c o m p lic a tio n s , in c lu d in g k e e p in g a p e r m a n e n t in te s tin a l s h u n t, o r th e p r e s e n c e o f s u c h in te n s e p e lv ic f ib r o s is th a t th e p r o c e d u r e p r o p o s e d c a n n o t b e c a r r ie d o u t.
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