Chronic radiation proctopathy (CRP) is the delayed adverse effect after radiotherapy for pelvic malignancies. It is characterized as progressive fibrosis in pathology. The symptoms are usually unspecific which include rectal bleeding, perianal pain, tenesmus, stool frequencies and so on. The course of CRP can present from months to years after radiation. Severe complications can occur in the late stage and will greatly affect the quality of life. Currently, there is no standard guides for diagnosis and treatment of CRP. For advancing the knowledge and proposing new treatment modalities of CRP, this article summarizes our 10-year experience as follows: (1) Except the existence of vessel damage, interstitial fibrosis, mucous ulcer, edema and inflammatory cell infiltration in the radiation-injury area, the capillary count was obviously reduced in mucous substratum and angiostatin expression up-regulated remarkably in above area, resulting in the continuous development of compensatory capillary expansion and interstitial fibrosis in mucous layer. (2) Rectal ultrasound examination was used the first time to diagnose CRP. According to thickness change of rectal wall layer and increase of blood signal, severity of CRP activity was evaluated with good diagnostic value. (3) For slight-moderate rectal bleeding, moderate-heavy bleeding and heavy bleeding, application of retention enema with compound preparation based on mucoprotective agents, regional perfusion hemostasis with formaldehyde and proximal colostomy gained satisfactory efficacy. (4) Improved Parks operation should be recommended for CRP patients with advanced complications. (5) For rectal cancer patients receiving neoadjuvant chemoradiotherapy, "proximal extended excision" should be performed innovatively to decrease the risk of anastomotic complications (Tianhe Procedure).

Radiation proctopathy represents the feared injury of rectum resulting from radiotherapy to pelvic malignancy. Interstitial fibrosis is the major histopathologic feature of chronic radiation proctopathy, whose symptoms may improve over time without any management. Treatment decisions should be based on the pattern and severity of symptoms and endoscopic findings. Non-surgical interventions are generally used to relieve major symptoms and prevent severe complications. Surgery is reserved for patients with refractory complications. Diverting stoma and restorative resection are suggested for selected patients to promote rehabilitation. Overall management should target on the improvement of patients′ long-term quality-of-life.

Objective: To explore clinical features and prognosis factors of surgical complications after intersphincteric resection (ISR) for low rectal cancer following neoadjuvant chemoradiotherapy. Methods: The clinical data of 132 patients with low rectal cancer who underwent ISR following neoadjuvant chemoradiotherapy from September 2010 to June 2017 at Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University were retrospectively reviewed. There were 100 males and 32 females, with the age of (52.9±11.4) years and distance to anal verge of 3.9 cm. Records of perioperative complication (POC) within 30 days after surgery, anastomotic leakage (AL), and anastomotic stenosis (AS) were analyzed. POC was recorded according to the Clavien-Dindo classification. AL was graded by ISREC system and classified into the early AL within 30 days after surgery and delayed AL beyond 30 days. AS was defined as narrowing of the bowel lumen at the anastomosis that prevented passage through a colonoscope with a 12 mm diameter. According to the shape of narrowing, AS was recorded as the stenosis in situ or stenosis with long-segment bowel above. Univariate and multivariate analysis were used to identify risk factors of anastomotic complications. Results: Among the 132 patients, full-dose radiotherapy and diverting stoma were performed in 128 (97.0%) patients, respectively. In entire cohort, AL was found in 41 (31.1%) patients, including 32 patients with clinical leakage (24.2%). The median time for diagnosis of AL was 37 days (2 to 214 days) after surgery. There were 25 patients (18.9%) who were diagnosed with delayed AL beyond 30 days. Chronic presacral sinus formation was detected in 22 of 129 (17.1%) patients at 12 months from surgery. Among the 128 eligible patients, 36 (28.1%) were diagnosed as AS, including 24 (18.8%) patients with stenosis in situ and 12 (9.4%) patients with bowel stenosis above. After a median follow-up of 26 months, 7(5.3%) patients received permanent colostomy and the other 20(15.2%) patients retained a persistent ileostomy, owing to anastomotic complications. Results of multivariate analysis showed that radiation colitis was an independent prognosis factor of AL after ISR (OR=5.04, 95% CI: 2.05 to 12.43, P=0.000); male gender (OR=5.19, 95% CI: 1.24 to 21.75, P=0.024) and AL (OR=8.49, 95% CI: 3.32 to 21.70, P=0.000) were independent prognosis factors of AS after ISR. Conclusions Surgical complications are common after ISR for low rectal cancer patients with neoadjuvant chemoradiotherapy. A high rate of AL is observed after long-term follow-up, which is associated with AS. Increasing awareness of anastomotic complications after ISR should be raised, especially for male patients with radiation colitis.

Radiation-induced bowel injury is a common complication of radiation therapy for pelvic malignancy. Given the huge number of patients diagnosed with pelvic malignancy, the number of patients diagnosed with radiation-induced bowel injury increased year by year, which put a great burden on the clinical diagnosis and treatment of radiation-induced bowel injury. In particular, chronic radiation-induced bowel injury, which is manifested in the process of prolonged, repeated and progressive aggravation, seriously affects the physical and mental health of patients and makes clinical diagnosis and treatment difficult. However, due to insufficient attention and understanding from doctors and patients, standardized diagnosis and treatment of radiation-induced bowel injury still have a long way to go. Radiation-induced bowel injury is self-limited but irreversible. During diagnosis, we should pay attention to overall evaluation of the stage of disease based on clinical symptoms, endoscopic examination, imaging examination, pathology and nutritional risk. The treatment methods include health education, drug therapy, enema therapy, formalin local treatment, endoscopic treatment and surgical treatment, etc. The treatment decision-making should be based on clinical symptoms, endoscopic or imaging findings to alleviate the clinical symptoms of patients as the primary goal and to improve the long-term quality of life of patients as the ultimate goal.

OBJECTIVEThe aim of this study is to introduce a new type of cross suture in closing peritoneal incision after abdominoperineal resection (APR) for rectal cancer.

METHODSThis new type of cross suture was firstly proposed and applied in a small cohort in our hospital. In this study, we reported its efficacy and safety. From Feb 2018 to May 2018, 8 cases (5 male, 3 female) of rectal cancer from the Sixth Affiliated Hospital of Sun Yat-Sen University receiving APR with new cross suture, were analyzed retrospectively. The median age was 45.5 years and the median distance between tumor distant border and anal verge was 2.5 cm. Three patients received neoadjuvant therapy. The detailed procedures of new cross suture are listed as follows: (1)Marking the margin: an oval circle around the anus is designed. The anterior incision reaches middle peritoneum, and the posterior incision is close to the coccyx apex. Two triangle incisions are made at the 3 and 9 point directions of lithotomy position, respectively. (2)Tumor resection: purse string suture is made to close the anus, then cut open the peritoneal skin and fatty tissue according to the principles of total mesorectal resection(TME). Reserve the fatty tissue in the ischiorectal space as much as possible. R0 resection is required. Approximate the pelvic muscles and fatty tissue in the ischiorectal space to reduce residual cavity; (3)Close the peritoneal incision by absorbable stitch: Two intracutaneous stiches in the anterior and posterior parts of the incision are made. Then four intracutaneous circle stiches along the two triangles are performed. The incision appears like a "cross" after tighting these stiches. A drainage was placed in presacral space.

RESULTSAll procedures were successfully conducted in 8 cases and no severe complication occurred after surgery. The median volume of whole surgery bleeding was 100 ml and the median time of the peritoneal surgery was 50 minutes. The median volume of drainage was 95 ml in the first 3 postoperative days. The median time of drainage removal was 5 days. Seven cases received primary wound healing without superficial(wound infection and dehiscence) or deep perineal wound(perineal abscess and presacral abscess) complications. Presacral abscess occurred in one case. The median time of primary wound healing was 11 days.

CONCLUSIONThe new cross suture for perineal incision after APR procedure is simple with satisfying efficacy. The drainage of residue cavity in the presacral space is complete. The cross suture reduces the time of primary wound healing and decreases scars.

Female ; Humans ; Male ; Middle Aged ; Perineum ; surgery ; Rectal Neoplasms ; surgery ; Retrospective Studies ; Suture Techniques ; Sutures

Objective: To investigate the effect of irradiation to anastomosis from preoperative radiotherapy for patients with rectal cancer by studying the pathological changes. Methods: In this retrospective study, patients enrolled in the FOWARC study from January 2011 to July 2014 in the Sixth Affiliated Hospital of Sun Yat-Sen University were included. In the FOWARC study, enrolled patients with local advanced rectal cancer were randomly assigned to receive either neoadjuvant chemo-radiotherapy or chemotherapy. Among these patients, 23 patients were selected as radiation proctitis (RP)group, who fulfilled these conditions: (1) received neoadjuvant chemo-radiotherapy followed by sphincter-preserving surgery; (2) developed radiation proctitis as confirmed by preoperative imaging diagnosis; (3) had intact clinical samples of surgical margins. Twenty-three patients who had received neoadjuvant chemo-radiotherapy but without development of radiation proctitis were selected as non-radiation proctitis (nRP) group. Meanwhile, 23 patients received neoadjuvant chemotherapy only were selected as neoadjuvant chemotherapy (CT) group. Both nRP and CT cases were selected by ensuring the basic characteristics such as sex, age, tumor site, lengths of proximal margin and distal margin all maximally matched to the RP group. Both proximal and distal margins were collected for further analysis for all selected cases. Microscopy slices were prepared for hematoxylin & eosin staining and Masson staining to show general pathological changes, and also for immunohistochemistry with anti-CD-34 as primary antibody to reveal the microvessel. Microvessel counting in submucosal layer and proportion of macrovessel with stenosis were used to evaluate the blood supply of the proximal and distal end of anastomosis. A modified semi-quantitative grading approach was used to evaluate the severity of radiation-induced injury. Either ANOVA analysis, Kruskal-Wallis rank-sum test or χ² test was used for comparison among three groups, and Mann-Whitney U test was used for comparison between two groups. Results: Compared to group of neoadjuvant chemotherapy only, patients receiving neoadjuvant chemo-radiotherapy had lower microvessel count in both proximal and distal margins (M(Q_R): proximal, 25.5 (19.6) vs. 50.0 (25.0), Z=3.915, P=0.000; distal, 20.5 (17.5) vs. 49.0 (28.0), Z=3.558, P=0.000), higher proportions of macrovessel with stenosis (proximal, 9.5% (23.8%) vs. 0, Z=3.993, P=0.000; distal, 11.5%(37.3%) vs. 0 (2.0%), Z=2.893, P=0.004), higher histopathologic score (proximal, 4.0 (2.0) vs. 1.0 (2.0), Z=6.123, P=0.000; distal, 5.0 (3.0) vs. 2.0 (1.0), Z=4.849, P=0.000). In patients receiving neoadjuvant chemo-radiotherapy, compared to nRP group, RP group had lower microvessel count in both proximal and distal margins (proximal, 19.0 (23.0) vs. 30.4 (38.0), Z=2.845, P=0.004; distal, 19.0 (13.0) vs. 30.0(29.1), Z=2.022, P=0.043), higher proportions of macrovessel with stenosis (proximal, 23.0% (40.0%) vs. 0(11.0%), Z=3.248, P=0.001; distal, 27.0% (45.0%) vs. 3.0% (19.0%), Z=2.164, P=0.030). Rate of anastomotic leakage for CT, nRP and RP group were 8.7% (2/23), 30.4% (7/23), and 52.2% (12/23), and the differences among three groups were statistically significant (χ²=10.268, P=0.007). Conclusion Radiation-induced injury existed on both margins of the resected rectal site after preoperative radiotherapy, and those diagnosed as radiation proctitis had more severe microvascular injury.

Objective: To investigate the safety and efficacy of surgical treatment for chronic radiation intestinal injury. Methods: A descriptive cohort study was performed. Clinical data of 73 patients with definite radiation history and diagnosed clinically as chronic radiation intestinal injury, undergoing operation at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from January 1, 2012 to February 28, 2019, were reviewed and analyzed retrospectively. Patients did not undergo operation or only received adhesiolysis were excluded. All the patients had preoperative examination and overall evaluation of the disease. According to severity of intestinal obstruction and patients′ diet, corresponding nutritional support and conservative treatment were given. Surgical methods: The one-stage bowel resection and anastomosis was the first choice for surgical treatment of chronic radiation intestinal injury. Patients with poor nutritional condition were given enterostomy and postoperative enteral nutrition and second-stage stoma closure and intestinal anastomosis if nutritional condition improved. For those who were unable to perform stoma closure, a permanent stoma should be performed. Patients with severe abdominal adhesion which was difficult to separate, enterostomy or bypass surgery after adhesiolysis would be the surgical choice. For patients with tumor metastasis or recurrence, enterostomy or bypass surgery should be selected. Observation parameters: the overall and major (Clavien-Dindo grades III to V) postoperative complication within 30 days after surgery or during hospitalization; mortality within postoperative 30 days; postoperative hospital stay; time to postoperative recovery of enteral nutrition; time to removal of drainage tube. Results: Of the 73 patients who had been enrolled in this study, 10 were male and 63 were female with median age of 54 (range, 34-80) years. Preoperative evaluation showed that 61 patients had intestinal stenosis, 63 had intestinal obstruction, 11 had intestinal perforation, 20 had intestinal fistula, 3 had intestinal bleeding, and 6 had abdominal abscess, of whom 64(87.7%) patients had multiple complications. Tumor recurrence or metastasis was found in 15 patients. A total of 65(89.0%) patients received preoperative nutritional support, of whom 35 received total parenteral nutrition and 30 received partial parenteral nutrition. The median preoperative nutritional support duration was 8.5 (range, 6.0-16.2) days. The rate of one-stage intestine resection was 69.9% (51/73), and one-stage enterostomy was 23.3% (17/73). In the 51 patients undergoing bowel resection, the average length of resected bowel was (50.3±49.1) cm. Among the 45 patients with intestinal anastomosis, 4 underwent manual anastomosis and 41 underwent stapled anastomosis; 36 underwent side-to-side anastomosis, 5 underwent end-to-side anastomosis, and 4 underwent end-to-end anastomosis. Eighty postoperative complications occurred in 39 patients and the overall postoperative complication rate was 53.4% (39/73), including 39 moderate to severe complications (Clavien-Dindo grade III-V) in 20 patients (27.4%, 20/73) and postoperative anastomotic leakage in 2 patients (2.7%, 2/73). The mortality within postoperative 30 days was 2.7% (2/73); both patients died of abdominal infection, septic shock, and multiple organ failure caused by anastomotic leakage. The median postoperative hospital stay was 13 (11, 23) days, the postoperative enteral nutrition time was (7.2±6.9) days and the postoperative drainage tube removal time was (6.3±4.2) days. Conclusions Surgical treatment, especially one-stage anastomosis, is safe and feasible for chronic radiation intestine injury. Defining the extent of bowel resection, rational selection of the anatomic position of the anastomosis and perioperative nutritional support treatment are the key to reduce postoperative complications.

Chronic radiation intestinal injury denotes the repeated and prolonged damage of intestine caused by radiotherapy to pelvic malignancy, which usually occurs after three months of radiotherapy. Surgical intervention is indicated when the progressive intestinal injury leads to the development of massive intestinal hemorrhage, obstruction, perforation, fistula and other late complications. However, there is no consensus on the surgical procedures. We illustrate the dilemma in surgical treatment from the points of pathological mechanism and the frequent sites of radiation intestinal injury. Meanwhile, we discuss the surgical alternatives of radiation intestinal injury based on the literature and our experience. The pathological mechanism of chronic radiation injury is progressive occlusive arteritis and parenchymal fibrosis. The frequently involved sites are distal ileum, sigmoid colon and rectum based on the radiotherapy region. The morbidity and mortality are high in surgery of chronic radiation injury due to poor ability of tissue healing, pelvic fibrosis, multiple organ damage, and poor physical condition. Definitive intestinal resection is one of the most common surgical procedures. Extended resection of diseased bowel to ensure that there is no radiation damage in at least one end of the anastomotic bowels is the key to decrease the risk of complications related to anastomotic sites.

Chronic radiation intestinal injury denotes the repeated and prolonged damage of intestine caused by radiotherapy to pelvic malignancy, which usually occurs after three months of radiotherapy. Surgical intervention is indicated when the progressive intestinal injury leads to the development of massive intestinal hemorrhage, obstruction, perforation, fistula and other late complications. However, there is no consensus on the surgical procedures. We illustrate the dilemma in surgical treatment from the points of pathological mechanism and the frequent sites of radiation intestinal injury. Meanwhile, we discuss the surgical alternatives of radiation intestinal injury based on the literature and our experience. The pathological mechanism of chronic radiation injury is progressive occlusive arteritis and parenchymal fibrosis. The frequently involved sites are distal ileum, sigmoid colon and rectum based on the radiotherapy region. The morbidity and mortality are high in surgery of chronic radiation injury due to poor ability of tissue healing, pelvic fibrosis, multiple organ damage, and poor physical condition. Definitive intestinal resection is one of the most common surgical procedures. Extended resection of diseased bowel to ensure that there is no radiation damage in at least one end of the anastomotic bowels is the key to decrease the risk of complications related to anastomotic sites.

Objective:To investigate the clinical efficacy of redo rectal resection and coloanal anastomosis.Methods:The retrospective and descriptive study was conducted. The clinicopatholo-gical data of 49 patients who underwent redo rectal resection and coloanal anastomosis for the treatment of local recurrence of tumors and failure of colorectal or coloanal anastomosis after rectal resection in the Sixth Affiliated Hospital of Sun Yat-sen University from November 2012 to December 2021 were collected. There were 32 males and 17 females, aged 57(range,31-87)years. Redo rectal resection and coloanal anastomosis was performed according to the patient′s situations. Observa-tion indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distri-bution were represented as M( Q1, Q3) or M(range). Count data were described as absolute numbers or percentages. Results:(1) Surgical situations. All 49 patients underwent redo rectal resection and coloanal anastomosis successfully, with the interval between the initial surgery and the reopera-tion as 14.2(7.1,24.3)months. The operation time and volume of intraoperative bold loss of 49 patients in the redo rectal resection and coloanal anastomosis was 313(251,398)minutes and 125(50,400)mL, respectively. Of the 49 patients, there were 38 cases receiving laparoscopic surgery including 12 cases with transanoscopic laparoscopic assisted surgery, 11 cases receiving open surgery including 2 cases as conversion to open surgery, there were 20 cases undergoing Bacon surgery, 14 cases undergoing Dixon surgery, 12 cases undergoing Parks surgery, 2 cases undergoing intersphincter resection and 1 case undergoing Kraske surgery, there were 20 cases undergoing rectum dragging out excision and secondary colonic anastomosis, 13 cases undergoing dragging out excision single anastomosis, 12 cases undergoing rectum dragging out excision double anastomosis, 4 cases undergoing first-stage manual anastomosis, there were 21 cases with enterostomy before surgery, 16 cases with prophylactic enterostomy after surgery, 12 cases without prophylactic enterostomy after surgery. The duration of postoperative hospital stay of 49 patients was (14±7)days. (2) Postoperative situations. Fifteen of 49 patients underwent postoperative complications, including 8 cases with grade Ⅱ Clevien-Dindo complications and 7 cases with ≥grade Ⅲ Clevien-Dindo complications. None of 49 patient underwent postoperative transferring to intensive care unit and no patient died during hospitalization. Results of postoperative histopathological examination in 23 patients with tumor local recurrence showed negative incision margin of the surgical specimen. (3) Follow-up. All 49 patients underwent post-operative follow-up of 90 days. There were 42 cases undergoing redo rectal resection and coloanal anastomosis successfully and 7 cases failed. Of the 37 patients with enterostomy, 20 cases failed in closing fistula, and 17 cases succeed. There were 46 patients receiving follow-up with the median time as 16.1(7.5,34.6)months. The questionnaire response rate for low anterior resection syndrome (LARS) score was 48.3%(14/29). Of the patients who underwent redo coloanal anastomosis and closure of stoma successfully, there were 9 cases with mild-to-moderate LARS.Conclusion:Redo rectal resection and coloanal anastomosis is safe and feasible for patients undergoing local recurr-ence of tumors and failure of colorectal or coloanal anastomosis after rectal resection, which can successfully restore intestinal continuity in patients and avoid permanent enterostomy.