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.

Questionnaire investigation of radiation rectal injury with anxiety, depression and somatic disorder / 中华胃肠外科杂志

Objective: To observe the incidence and treatment of radiation rectal injury complicated with anxiety, depression and somatic symptom disorder. Methods: A cross-sectional survey research method was carried out. Patients with radiation rectal injury managed by members of the editorial board of Chinese Journal of Gastrointestinal Surgery were the subjects of investigation. The inclusion criteria of the survey subjects: (1) patients suffered from pelvic tumors and received pelvic radiotherapy; (2) colonoscopy showed inflammatory reaction or ulcer in the rectum. Exclusion criteria: (1) patient had a history of psycho-somatic disease before radiotherapy; (2) patient was unable to use a smart phone, unable to read and understand the questions in the questionnaire displayed on the phone; (3) patient refused to sign an informed consent form. According to the SOMA self-rating scale, PHQ-15 self-rating scale, GAD-7 and PHQ-9 self-rating scale, the electronic questionnaire of "Psychological Survey of Radiation Proctitis" was designed. The questionnaire was sent to patients with radiation rectal injury managed by the committee through the WeChat group. Observational indicators: (1) radiation rectal injury symptom assessment: using SOMA self-rating scale, radiation rectal injury symptom classification: mild group (≤3 points), moderate group (4-6 points) and severe group (> 6 points); (2) incidence of anxiety, depression and physical disorder: using GAD-7, PHQ-9 and PHQ-15 self-rating scales respectively for assessment; (3) correlation of radiation rectal injury symptom grading with anxiety, depression, and somatic symptom disorder. Results: Seventy-one qualified questionnaires were collected, of which 41 (56.9%) were from Guangzhou. Among the 71 patients, 6 were males and 65 were females; the mean age was (55.7±9.3) years old and 48 patients (67.6%) were less than 60 years old; the median confirmed duration of radiation rectal injury was 2.0 (1.0, 5.0) years. (1) Evaluation of symptoms of radiation rectal injury: 18 cases of mild (25.4%), 27 cases of moderate (38.0%), and 26 cases of severe (36.6%). (2) Incidence of anxiety, depression and somatic disorder: 12 patients (16.9%) without comorbidities; 59 patients (83.1%) with anxiety, depression, or somatic disorder, of whom 2 patients only had anxiety, 1 patient only had depression, 9 only had somatic disorder, 2 had anxiety plus depression, 4 had anxiety plus somatic disorder, 2 had depression plus somatic disorder, and 40 had all three symptoms. (3) correlation of radiation rectal injury grading with anxiety, depression, and somatic symptom disorder: as compared to patients in mild group and moderate group, those in severe group had higher severity of anxiety and somatic symptom disorder (Z=-2.143, P=0.032; Z=-2.045, P=0.041), while there was no statistically significant difference of depression between mild group and moderate group (Z=-1.176, P=0.240). Pearson correlation analysis revealed that radiation rectal injury symptom score was positively correlated with anxiety (r=0.300, P=0.013), depression (r=0.287, P=0.015) and somatic symptom disorder (r=0.344, P=0.003). Conclusions: The incidence of anxiety, depression, and somatic symptom disorder in patients with radiation rectal injury is extremely high. It is necessary to strengthen the diagnosis and treatment of somatic symptom disorder, so as to alleviate the symptoms of patients with pelvic perineum pain and improve the quality of life.

Chronic radiation-induced rectal injury after adjuvant radiotherapy for pelvic malignant tumors: report based on a phase 3 randomized clinical trial / 中华胃肠外科杂志

Objective: Radiotherapy is one of the standard treatments for pelvic malignant tumors. However, researches associated with intestinal radiation injury and the quality of life (QoL) of patients receiving radiotherapy were lacking in the past. This study aims to analyze the occurrence of radiation-induced rectal injury after adjuvant radiotherapy for pelvic malignant tumors and call for more attention on this issne. Methods: A retrospectively observational study was conducted. Case data of cervical cancer patients from the database of STARS phase 3 randomized clinical trial (NCT00806117) in Sun Yat-sen University Cancer Center were analyzed. A total of 848 cervical cancer patients who received adjuvant radiation following hysterectomy and pelvic lymphadenectomy in Sun Yat-sen University Cancer Center from February 2008 to August 2015 were recruited. The pelvic radiation dosage was 1.8 Gy/day or 2.0 Gy/day, five times every week, and the total dosage was 40-50 Gy. Among 848 patients, 563 patients received radiation six weeks after surgery, of whom 282 received adjuvant radiation alone and 281 received concurrent chemoradiotherapy (weekly cisplatin); other 285 patients received sequential chemoradiotherapy (paclitaxel and cisplatin). Acute adverse events, chronic radiation damage of rectum, and QoL were collected and analyed. The digestive tract symptoms and QoL were evaluated based on EORTC QLQ-C30 questionnaires at one week after surgery (M0), during adjuvant therapy period (M1), and at 12 months and 24 months after the completion of treatments (M12 and M24), respectively. Higher scores in the functional catalog and overall quality of life indicated better quality of life, while higher scores in the symptom catalog indicated severe symptoms and worse QoL. Chronic radiation rectal injury was defined as digestive symptoms that were not improved within three months after radiotherapy. Grading standard of acute adverse events and chronic radiation rectal injury was according to the gastrointestinal part of National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0 (NCI-CTCAE Version 4.0). Results: The mean total radiation dosage of 848 patients was (47.8±4.6) Gy. During adjuvant therapy, the common symptoms of acute intestinal dysfunction were nausea (46.0%, 390/848), vomiting (33.8%, 287/848), constipation (16.3%, 138/848) and abdominal pain (10.3%, 87/848). At M12 and M24, the number of 0 QLQ-C30 questionnaires collected was 346 and 250, respectively. QLQ-C30 questionnaires showed that the scores of nausea or vomiting, appetite decrease, diarrhea, constipation, etc. were improved obviously at M12 or M24 compared with those at M0 or during M1 (all P<0.05). As the extension of the follow-up time, the score of the overall QoL of patients gradually increased [M0: 59.7 (0.0-100.0); M1: 63.1 (0.0-100.0); M12: 75.2 (0.0-100.0); M24: 94.1 (20.0-120.0); H=253.800, P<0.001]. Twelve months after the completion of treatments, the incidence of chronic radiation rectal injury was 9.8% (34/346), mainly presenting as abdominal pain, constipation, stool blood, diarrhea, mostly at level 1 to 2 toxicity (33/34, 97.1%). One patient (0.3%) developed frequent diarrhea (>8 times/d), which was level 3 toxicity. Twenty-four months after all treatments, the incidence of chronic radiation rectal injury was 9.6% (24/250), which was not decreased significantly compared to that in the previous period (χ(2)=0.008, P=0.927). The symotoms of one patient with level 3 toxicity was not relieved. Conclusions: The common symptoms of patients with pelvic maligant tumors during postoperative adjuvant radiotherapy include nausea, vomiting, constipation, abdominal pain and diarrhea. These symptoms are alleviated obviously at 12 and 24 months after adjuvant radiotherapy, and the QoL is significantly improved. However, a few patients may develop chronic radiation rectal injury which is not improved for years or even decades, and deserves attention in clinical practice.

Interpretation of Chinese expert consensus on multidisciplinary diagnosis and treatment of radiation rectal injury (2021 edition) / 中华胃肠外科杂志

Although pelvic radiotherapy has played an important role in the treatment of malignant tumors, it is still difficult to avoid radiation damage within a certain period of time. In 2021, under the joint promotion of Colorectal Surgery Group of Chinese Medical Association Surgery Branch, Colorectal Surgeons Committee of Chinese Medical Doctor Association Surgeons Branch, Colorectal Surgeons Committee of Chinese Medical Doctor Association, and Colorectal Cancer Professional Committee of Chinese Anti-Cancer Association, Expert Group on Diagnosis and Treatment of Radiation Intestinal Injury has updated and formulated the 2021 edition of the "Chinese expert consensus on the multidisciplinary diagnosis and treatment of radiation rectal injury" (hereinafter referred to as "Consensus"). This Consensus edition has major changes compared with the "Chinese consensus on the diagnosis and treatment of radiation proctitis (2018)", which mainly updates in the following aspects: (1) adjusting the name of radiation rectal injury: the term "radiation proctitis" was adjusted to "radiation rectal injury"; (2) advocating the concept of pelvic integral injury and the multidisciplinary diagnosis and treatment model; (3) putting forward the clinical classification of diseases: the classification of the chronic rectal injury includes telangiectasia, ulcer, stenosis and mixed type; (4) carrying out individualized treatment based on the characteristics of the above-mentioned disease classification, and adjusting the recommended level of non-surgical treatment; (5) proposing specific guiding principles and details of surgical treatment: "damage control" and "expanded resection" principles, etc. This new edition (2021) of Consensus further refines the disease analysis and treatment strategies, which not only improves the guiding value of clinical practice, but also provides an important reference for the standardized diagnosis and treatment of radiation rectal injury in China.

Chinese expert consensus on multidisciplinary diagnosis and treatment of radiation rectal injury (2021 edition) / 中华胃肠外科杂志

Radiation therapy plays a significant role in the integrated treatment for patients with pelvic malignancies, but may lead to radiation-induced rectal injury in some patients, which may affect their physical health and quality of life negatively. Patients with radiation-induced rectal injury are often complicated with pelvic multi-organ injury. Collaborative, multidisciplinary evaluation of pelvic injuries should be highlighted in clinical practices, including clinical, endoscopic, radiological and histopathologic evaluation. To determine the overall treatment strategy and develop individualized treatment strategy, it is necessary to assess the oncologic prognosis, severity and stage of radiation-induced rectal injury and clinical classification using different rating scales. Considering that the disease is self-limiting, non-surgical treatment should be performed for patients with early lesions, while surgical interventions should be performed as soon as possible for patients with severe complications. In terms of prevention of radiation-induced rectal injury, prevention should be targeted for patients at high risk of radiation-induced rectal injury through technique improvement, physical protection and drug prevention. This consensus aims to provide guidance for the clinical practice of radiation-induced rectal injury in China.

The report of 3 cases rectal injury during radical prostatectomy / 中华泌尿外科杂志

Objective To report the experience of rectal injury during laparoscopic radical prostatectomy(LRP).Methods The clinical data for 3 patients with iatrogenic rectal injury in LRP in our hospital between January 2015 and October 2018 were retrospectively analyzed.The data of these three patients were as follows:age 69-79 year,mean 74.3 year;BMI 25.6-28.6 kg/m2,mean 27.1 kg/m2;preoperative PSA 5.7-74.1 ng/ml,mean 32.7 ng/ml;prostate volume 55.2-80.3 ml,mean 65.3 ml;preoperative TMN stage T1b-3ａ N0M0,preoperative Gleason score 6-8.One patient received neoadjuvant hormonal therapy;one patient did HoLEP three month before LRP.Surgical method:When rectal injury was noted,we continued our dissection between the correct layers until prostatectomy was completed.Then the wound in the rectum was thoroughly checked and irrigated with diluted povidone iodine.The wound was trimmed according to the wound condition,and the suture was conducted by absorbable silk at three layers:the rectal mucosa layer,the outer layer of the rectal wall,the posterior layer of the fascia.Then we rinsed the wound with iodophor and completed the urethral reconstruction.Results The operative time was 138-210 min,mean 166.7 min,and repair time was 30-41 min,mean 34.3 min.The intraoperative blood loss was 110-215 ml,mean 158.3 ml.Rectal injury occurred during prostatic apical dissection in 1 patients,during dissection of Denonvilliers fascia in 2 patient.The size of the lesions was 1.0-1.5 cm,mean 1.2 cm.All of the rectal injuries were recognized during the operation,and three-layered sutures were used for the primary repair.None of the cases required ileostomy procedure.Diet recovery time was 6-7 d,mean 6.3 d.The duration of transurethral catheter insertion was 10-14 d,mean 12.3 d.The pathological stage was T2-3bN0M0,pathological Gleason score 6-9,and 1 case surgical margin positivity in the apical region of the prostate.No case occurred urorectal fistulas.2 cases received adjuvant androgen deprivation therapy.Conclusions Primary repair with laparoscopic three-layered suturing might be sufficient for the treatment of rectal injuries that occur during LRP if the lesion was small and the margin was clean.

Improper Use of Glycerol Enema and Rectal Ulcer(review) / 中国康复理论与实践

@#Glycerol enema, mainly composed of glycerol, sorbitol, and magnesium sulfate, was a kind of OCT caccagogue. The application of convenience, low prices made it used widely in patients with constipation. However, if the drug should not follow the indications and application of Methods , a series of improper consequences will be caused. The authors reviewed the application of Glycerol Enema, rectal injury and rectal ulcer in patients with constipation.

Management of Traumatic Injury to the Lower Rectum and Anal Sphincter Muscle Combined with Deep Perineal Laceration

Although rare, traumatic injuries to the lower rectum and anal sphincter muscle combined with deep perineal laceration present substantial diagnostic and management challenges for surgeons. Between February 2004 and February 2006, six patients were treated for traumatic injuries to the lower rectum and anal sphincter muscle combined with deep perineal laceration at the Department of Surgery, Chonnam National University Hospital. All six patients underwent a diverting colostomy, primary repair, and presacral a drainage, but only three cases underwentva a sphincteroplasty. Three patients who underwent a sphincteroplasty had normal findings on anorectal manometry. Traumatic injuries to the lower rectum and anal sphincter muscle combined with deep perineal laceration have a high morbidity rate and a great influence on the quality of life. Thus, such injuries require aggressive management, and treatment modalities should be tailored to the individual case.