Clincal practice of pelvic exenteration for late complications of pelvic radiation injury / 中华胃肠外科杂志

Pelvic radiation injury can potentially involve multiple pelvic organs, and due to its progressive and irreversible nature, its late stage can be complicated by fistulas, perforations, obstructions and other complications involved multiple pelvic organs, which seriously affect the long-term survival and the quality of life of patients. As a multidisciplinary surgical approach, pelvic exenteration has potential application in the treatment of late complications of pelvic radiation injury by completely removing the irradiated lesion, relieving symptoms and avoiding recurrence of symptoms. In clinical practice, we should advocate the concept of "pelvic radiation injury", emphasize multidisciplinary collaboration, fully evaluate the overall status of patients, primary tumor and pelvic radiation injury. We should follow the principles of "damage-control" and "extended resection", and follow the principle of enhanced recovery after surgery to achieve the goal of ensuring the surgical safety, relieving patients' symptoms and improving patients' quality of life and long-term survival.

Meta analysis of diseased bowel resection versus diversion enterostomy in the treatment of late severe complications of chronic radiation-induced rectal injury / 中华胃肠外科杂志

Objective: To investigate the efficacy and safety of diseased bowel resection and diversion enterostomy in the treatment of late severe complications of chronic radiation-induced late rectal injury (RLRI). Methods: Studies about comparison of diseased bowel resection and diversion enterostomy in the treatment of late severe complications of chronic RLRI were screened and retrieved from databases, including PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, CNKI, VIP, CBM and Wanfang. The following terms in Chinese were used to search [Title/Abstract]: radiation-induced intestinal injury, radiation proctitis, surgery. The following English terms were used to search: Radiation-induced intestinal injury, Bowel injury from radiation, Radiation proctitis, Surgery, Colostomy. Literature inclusion criteria: (1) studies with control groups, published at home and abroad publicly, about the postoperative effects of diseased bowel resection vs. diversion enterostomy on RLRI patients with late severe complications; (2) the period of the study performed in the literatures must be clear; (3) patients at the preoperative diagnosis for RLRI with refractory bleeding, narrow, obstruction, perforation or fistula, etc.; (4) diseased bowel resection included Hartmann, Dixon, Bacon and Parks; diversion enterostomy included colostomy and ileostomy; (5) if the studies were published by the same institution or authors at the same time, the study with the biggest sample size was chosen; studies conducted in different time with different subjects were simultaneously included; (6) at least one prognostic indicator of the following parameters should be included: the improvement of symptoms, postoperative complications, mortality, and reversed stomas rate. The stoma reduction rate was defined as the ratio of successful closure of colostomy after diseased bowel resection and diversion enterostomy. The method of direct calculation or the method of convert into direct calculation were used for stoma reduction rate. Exclusion criteria: (1) a single-arm study without control group; (2) RLRI patients did not undergo diseased bowel resection or diversion enterostomy at the first time; (3) RLRI patients with distant metastasis; (4) the statistical method in the study was not appropriate; (5) the information was not complete, such as a lack of prognosis in the observational indexes. After screening literatures according to criteria, data retrieval and quality evaluation were carried out. Review Manager 5.3 software was used for Meta-analysis. Sensitivity analysis was used to exam the stability of results. Funnel diagram was used to analyze the bias of publication. Results: A total of 11 literatures were enrolled, including 426 RLRI patients with late severe complications, of whom 174 underwent diseased bowel resection (resection group) and 252 underwent diversion enterostomy (diversion group), respectively. Compared with diversion group, although resection group had a higher morbidity of complication (35.1% vs. 15.9%, OR=2.67, 95% CI: 1.58 to 4.53, P<0.001), but it was more advantageous in symptom improvement (94.2% vs. 64.1%, OR=6.19, 95% CI: 2.47 to 15.52, P<0.001) and stoma reductions (62.8% vs. 5.1%, OR=15.17, 95% CI: 1.21 to 189.74, P=0.030), and the differences were significant (both P<0.05). No significant difference in postoperative mortality was found between the two groups (10.1% vs. 18.8%, OR=0.74, 95% CI: 0.21 to 2.59, P=0.640). There were no obvious changes between the two groups after sensitivity analysis for the prognostic indicators (the symptoms improved, postoperative complications, mortality, and reversed stomas rate) compared with the meta-analysis results before exclusion, suggesting that the results were robust and credible. Funnel diagram analysis suggested a small published bias. Conclusions: Chronic RLRI patients with late severe complications undergoing diseased bowel resection have higher risk of complication, while their long-term mortality is comparable to those undergoing diversion enterostomy. Diseased bowel resection is better in postoperative improvement of symptoms and stoma reduction rate.

Insuficiencia mesentérica crónica luego de radioterapia para aórtica / Surgical revascularization for treatment of chronic mesenteric ischemia secondary to radiotherapy

Background: Chronic mesenteric ischemia is observed in older people and is often due to atherosclerosis. Radiotherapy is an important risk factor for atherosclerosis. Aim: To report our experience with chronic mesenteric ischemia secondary to retroperitoneal radiotherapy. Material and methods: Review of medical records of four male patients aged 39 to 65 years, treated for chronic mesenteric ischemia secondary to para-aortic radiotherapy between 1993 and 2011. Results: All of them had the classic symptoms of ischemia characterized by post prandial abdominal pain and weight loss. One had also isolated diarrhea episodes. Revascularization was achieved with open or endovascular surgery, with good results during a follow up period ranging from two to 20 years. Conclusions: Surgical revascularization is a good treatment for chronic mesenteric ischemia secondary to radiotherapy.

Introducción: La insuficiencia mesentérica crónica es un diagnóstico infrecuente, generalmente secundario a enfermedad aterosclerótica, siendo considerada una enfermedad de pacientes añosos. Se sabe que la radioterapia es un factor de riesgo importante para aterosclerosis. Describimos nuestra experiencia en el manejo de la isquemia mesentérica crónica secundaria a radioterapia retroperitoneal. Materiales y métodos: Análisis retrospectivo de las fichas clínicas de los pacientes tratados en nuestro centro por insuficiencia mesentérica crónica posterior a radioterapia del territorio para-aórtico entre 1993 y 2011. Resultados: Un total de 4 pacientes de sexo masculino fueron identificados. Edad promedio: 49 +/- 12 años (rango 39-65). Todos presentaron los síntomas clásicos de insuficiencia mesentérica caracterizados por dolor abdominal postprandial y baja de peso. Uno de ellos además tenía episodios repetidos de diarrea. La revascularización mesentérica se obtuvo mediante cirugía abierta o endovascular con excelentes resultados a corto y largo plazo con un seguimiento promedio de 9,3 años (rango 2-20). Discusión: El curso acelerado de la aterosclerosis posterior a radioterapia se ha descrito en múltiples territorios vasculares. Síntomas de insuficiencia mesentérica crónica pueden ser malinterpretados en estos pacientes debido a su similitud con los síntomas observados en la ileitis actínica. Un diagnóstico y tratamiento oportuno son críticos para evitar complicaciones mayores y deterioro de calidad de vida de estos pacientes. Conclusión: La insuficiencia mesentérica crónica inducida por radioterapia es una condición infrecuente. El manejo con cirugía abierta o endovascular son seguras y otorgan resolución sintomática a largo plazo.

A Novel Approach for the Treatment of Radiation-Induced Hemorrhagic Cystitis with the GreenLight™ XPS Laser

The treatment of pelvic malignancies with radiotherapy can develop severe sequelae, especially radiation-induced hemorrhagic cystitis. It is a progressive disease that can lead to the need for blood transfusion, hospitalizations, and surgical interventions. This tends to affect the quality of life of these patients, and management can at times be difficult. We have evaluated the GreenLight Xcelerated Performance System (XPS) with TruCoag, although primarily used for management of benign prostatic hypertrophy (BPH), for the treatment of radiation-induced hemorrhagic cystitis.

Tratamento da úlcera escleral pós-cirurgia de pterígio e betaterapia por enxerto de esclera autóloga de espessura parcial / Partial thickness autologus scleral graft for treating scleral ulcers following pterygium excision and betatherapy

OBJETIVO: Avaliação dos resultados da utilização de enxerto de espessura parcial de esclera autóloga para o tratamento das úlceras esclerais profundas, como complicação tardia da exérese de pterígio associada à betaterapia. MÉTODOS: Foram tratados doze olhos de doze pacientes, nove femininos e três masculinos, com idade variando entre 48 e 82 anos, média 65,2 anos. RESULTADOS: Houve boa integração do enxerto em todos os casos, com resultado funcional e cosmético favorável e sem complicações. CONCLUSÃO: Várias técnicas de enxertia tem sido propostas para o tratamento da úlcera escleral: esclera e dura-máter homólogas, derme, cartilagem auricular e periósteo autólogos. No entanto, o procedimento com esclera autóloga apresenta reais vantagens em relaçâo aos enxertos empregados anteriormente. Não há referências na literatura quanto ao emprego de enxerto de esclera autóloga de espessura parcial para o tratamento da úlcera escleral.

OBJETICVE: The authors describes a surgical technique that utilizes autologus delaminated scleral graft for the management of deep scleral ulcers. METHODS: In this technique that were perfomed in 12 eyes of 12 patients, 9 female, 3 male, age from 48 to 82 years, mean age 65.2 years. RESULTS: Occurred good integration of the grafting in all cases without any complications. CONCLUSION: Many techniques have been proposed for the management of scleral ulcers: sclera and dura-mater, autologus derme, auricular cartilage and autologus periosteum.There is no reference in relation to autologus scleral grafting with partial thickness for the treatment of scleral ulcers, as proposed in this study.

Tratamento de lesão de tronco da artéria coronária esquerda após radioterapia do tórax / Treatment of left main coronary artery lesion after late thoracic radiotherapy

A prevenção de complicações cardiovasculares tardias após radioterapia (RT) para tratamento de um tumor maligno é um desafio. Relatamos o caso de um jovem paciente com linfoma de Hodgkin submetido a tratamento com RT que desenvolveu doença cardíaca isquêmica no seguimento, embora não apresentasse fatores de risco cardiovasculares. Concluímos que pacientes submetidos a RT que apresentam dor torácica deveriam ser criteriosamente avaliados em relação à doença arterial coronariana.

Prevention of late cardiovascular complications after radiation therapy (RT) for treatment of a malignant tumor is challenging. We report the case of a young male patient with Hodgkin's lymphoma treated with RT, who developed ischemic heart disease during follow-up, although he had no cardiovascular risk factors. We conclude that patients undergoing RT who experience chest pain should be fully investigated for coronary artery disease.

Complex ulcers due to radionecrosis - pathophysiology, diagnosis and treatment

The authors present a study on the pathophysiology of complex wounds induced by radiotherapy, describing their clinical aspects and histopathological findings.They go on to present six cases in which the lesion developed, and the clinical and surgical treatment established.

Tratamiento quirúrgico de las complicaciones intestinales de la radioterapia pélvica / Surgical treatment of intestinal complications of pelvic radiotherapy

One hundred forty patients treated for intestinal complications of pelvic irradiation are presented. The most common clinical expression was radiation rectitis, complicated with rectovaginal fistulas in 58 percent of cases. These patients were subjected to Parks procedure for fistula repair with satisfactory results. Half the operated patients remained with an ostomy as a definitive sequel and overall perioperative mortality in these patients was 10 percent. radiation enteritis has a high operative mortality due to delays in diagnosis and to severe septic complications. It must be suspected in irradiated patients presenting with chronic diarrhea and weigh loss. Urological complications and involvement of several intestinal segments are bad prognostic factors. Resections and anastomoses with undamaged segments are the safest surgical procedures. Improvements of radiation techniques and the use of a reabsorbable mesh to seal the pelvis during radiation therapy are adequate preventive measures

Anastomosis coloanal, operación de Parks, para el tratamiento de la rectitis actínica grave / Coloanal anastomosis coloanal, Parks surgery, in the treatment of severe radiation rectitis

Aim: To assess inmediate and late results of Prks operation in the treatment of severe radiation rectitis. Patients and methods: Retrospective review of clinical histories of 35 patients with uterine cervical cancer, 5 with endometrial cancer and 1 with vaginal cancer that received radiotherapy. Two years as a mean after radiotherapy, 14 women had rectal bleeding, 19 fistulae, 7 stenosis and 1 rectal ulceration. All were initially treated with a discharge colostomy and after a mean interval of 1.6 years, a Parks operation was performed. Results: One patient died after surgery (2.4 percent) due to peritonitis and sepsis. Early surgical complications were necrosis of descended colon in 2, intra-abdominal sbscess in 1, splenic rupture in 1 and postoperative bleeding in 1. Colostomy was closed in 37 patients 3 months after surgery. During late follow up (ranging from 3 to 64 months) rectal continence has been assessed as good in 30 patients, fair in 5 and bad in 2. Three women required a new colostomy. Conclusion: Parks operation is a viable therapeutic alternative for severe radiation rectitis

Actinic rectitis--the role of colostomy

From 4132 patients treated with radiation therapy due to gynecological malignancy from 1974 to 1988, 527 (12.75%) developed some grade of actinic rectitis with clinical manifestation. The authors analyzed the efficacy of colostomy in the management of 10 women with actinic rectitis grades I and II (Sherman classification) submitted to clinical treatment without response. Pelvic radiation therapy, clinical findings, proctoscopy and rectal biopsy were the basis for the diagnosis and staging of the actinic rectitis. All colostomies were made in the transverse colon and the median follow up from colostomy to last review was 53 months. Eight patients had complete remission of clinical findings after colostomy, but one had recurrence of symptoms 2 years later. One patient had incomplete remission but with clinical improvement and one patient had tumor recurrence. From 8 patients with complete clinical remission, 2 had the colostomies closed, but in 1 was restored 3 months later due to rectum-vaginal fistula

Reconstruçäo da parede torácica em radionecroses crônicas com retalhos cutâneos e miocutâneos / Reconstruction of the thoracic wall after chronic radionecrosis with cutaneous and miocutaneous grafts

Os autores descrevem sua experiencia com o tratamento de nove pacientes portadores de grave radionecrose da parede toracica decorrente de irradiacao da regiao apos cirurgia de mastectomia radical com linfadenectomia axilar. O tratamento consistiu na exerese completa das areas comprometidas e cobertura por retalhos de rotacao ou transposicao a distancia. Em dois casos foi utilizado pericardio bovino para reconstruir o plano pleural. Tres pacientes faleceram sendo que as demais permanecem em acompanhamento de 2 a 32 meses, sem sinais de recidiva tumoral ou complicacao operatoria

Enteritis actínica: resultados del tratamiento quirúrgico / Radiation enteropathy: results of surgical therapy

We reviewed the results of surgical therapy for radiation enteropathy in 18 consecutive patients. Fifteen (83%) were females and the age ranged from 31 to 81 years old. The indication for radiotherapy was cancer of the cervix in 10 patients (56). The mjean radiation dose was 5190 rads (range 4000 to 7000). Of 23 radiation lesions, 12 (52%) were located in the ileon, 10 in the rectum and 1 in the sigmoid. Fibrosis and stenosis was the most frequent lesion (70%) followed by fistulae (22%) and proctitis in 2 patients. Ressection or derivation was the surgical treatment employed in 22 of the 23 lesions. For lesions of the ileon, we performed ressection and anastomosis in 7 patients and derivation in 5. For rectal lesions we performed ressection, endoanal descent and colo-anal anastomosis in 7 patients anterior ressection in 2 and colostomy in 1. complications were observed in 5 patients (28%) and 1 patient died (5%). After a mean follow up of 56 months, 5 patients have died from recurrence of the original neoplastic lesions. We feel that surgical treatment allows improvement in quality of life of patients with radiation entreropathy

Atuaçäo da clínica de cirurgia plástica / Performance of the plastic surgery clinics

O autor tece consideraçöes sobre o atendimento de pacientes vítimas de acidentes com material radioativo, analisando näo sóo os procedimentos adotados para tratamento das lesöes sobre a pele e prevençäo das possíveis complicaçöes, mas principalmente os cuidados a serem adotados por toda a equipe cirúrgica no tratamento com este especial tipo de paciente. Enfatiza a necessidade de que sejam, a cada instante do ato cirúrgico, realizadas mediçöes, por pessoal especializado, dos níveis de radiaçöes, procedendo, sempre que estes se mostrem elevados, à troca de campos, luvas, capotes e à limpeza das áreas. Conclui apresentando as medidas que devem ser tomadas após realizaçöes das intervençöes cirúrgicas

Atuaçäo da clínica de cirurgia vascular / Performance of the vascular surgery clinics

A experiência da Clínica de Cirurgia Vascular do HNMD no tratamento dos pacientes irradiados com o Cési-137, provenientes de Goiânia, restringiu-se à realizaçäo de 18 cateterismos venosos profundos, utilizando cateteres convencionais de única luz, de duplo e triplo lumem e o acompanhamento de um caso de necrose de mäo direita. Os oito cateteres convencionais ocluiram nas primeiras 48 horas. Os dois cateteres de Hickman e os oito cateteres de triplo lumem mostram-se muito eficientes quanto à perviedade a longo prazo, facilidades perfusionais e tolerância do organismo. Näo foram observadas complicaçöes importantes com uso desses últimos. A vantagem do tipo "Multi-Med Catheter" se prende ao fato de poder o mesmo ser colocado por punçäo e orientado por guia metálico, facilitando a técnica. Com relaçäo às lesöes necróticas que ocorrem nesses pacientes ainda persiste dúvida se as mesmas decorrem da isquemia tissular ou se é conseqüência da açäo direta da radiaçäo sobre os tecidos. Nos parece que, a partir de uma determinada fase, há a somaçäo dos dois fatores causais

Atuaçäo da clínica de traumato-ortopedia / Performance of the traumatic orthopedy clinics

O trabalho procura orientar os cirurgiöes traumato - ortopedistas que possam vir a lidar com pacientes contaminados por materiais radioativos. Com esta finalidade, mostra as dificuldades encontradas por ocasiäo da amputaçäo de membro superior de uma das vítimas, mercê da insuficiência de dados bibliográficos em relaçäo à acidentes semelhantes e cita as particularidades do caso, que exigiu medidas de proteçäo e cuidados especializados, pela primeira vez postos em prática em nosso meio. Faz suscinta descriçäo dos dados clínicos do paciente, mencionando a evoluçäo, procedimentos diagnósticos utilizados, critérios adotados para indicaçäo da amputaçäo e o tratamento em suas etapas pré, per e pós operatórias, com detalhamento de vestimentas imprescindíveis, cuidados necessários e técnicas empregadas, realçando a importância da mediçäo constante dos índices de radioatividade por pessoal especializado e substituiçäo dos materiais em que os mesmos se mostraram acima dos considerados seguros