Chronic radiation proctopathy: A practical review of endoscopic treatment

Chronic radiation proctopathy(CRP) is a troublesome complication of pelvic radiotherapy. The most common presentation is rectal bleeding. CRP symptoms interfere with daily activities and decrease quality of life. Rectal bleeding management in patients with CRP represents a conundrum for practitioners. Medical therapy is ineffective in general and surgical approach has a high morbidmortality. Endoscopy has a role in the diagnosis,staging and treatment of this disease. Currently available endoscopic modalities are formalin,potassium titanyl phosphate laser,neodymium:yttrium-aluminum-garnet laser,argon laser,bipolar electrocoagulation(BiCAP),heater probe,band ligation,cryotherapy,radiofrequency ablation and argon plasma coagulation(APC). Among these options,APC is the most promising.

Treatment of hemorrhagic radiation-induced proctopathy with a 4% formalin application under perianal anesthetic infiltration

AIM:To evaluate the results of hemorrhagic radiation proctopathy treatment with a 4% formalin application.METHODS:A prospective study was performed.Over a three-year period,38 patients underwent 4% formalin application under perianal anesthetic infiltration for hemorrhagic radiation proctopathy.All patients included in the study were irradiated for prostate cancer.The patients ranged in age from 56-77 years(average 70 ± 5 years).All of the patients were referred for formalin therapy after noninvasive management had failed.Twenty-four(63.2%)patients underwent a single application,10(26.3%)patients underwent 2 applications,and 4(10.5%)patients underwent 3 applications.RESULTS:Two to 36 mo(average 12 ± 3 mo)following treatment,34 patients were interviewed(four were lost to follow-up).Twenty(58.8%)subjects reported complete cure,8(23.5%)subjects reported significant improvement,and 6(17.7%)subjects reported no change.One patient(who underwent a colostomy at a regional hospital with no specialized services available for previous bleeding episodes from radiation proctopathy)was cured,and the colostomy was closed.One patient(2.6%)developed rectal mucosal damage after the second application.CONCLUSION:A 4-min application of 4% formalin for hemorrhagic radiation-induced proctopathy under perianal anesthetic infiltration in patients who have received external radial radiation therapy for prostate cancer is simple,reasonably safe,inexpensive,generally well tolerated,and effective.

Assessment of chronic radiation proctopathy and radiofrequency ablation treatment follow-up with optical coherence tomography angiography: A pilot study

BACKGROUND Chronic radiation proctopathy(CRP) occurs as a result of pelvic radiation therapy and is associated with formation of abnormal vasculature that may lead to persistent rectal bleeding. While incidence is declining due to refinement of radiation delivery techniques, CRP remains one of the major complications of pelvic radiation therapy and significantly affects patient quality of life.Radiofrequency ablation(RFA) is an emerging treatment modality for eradicating abnormal vasculature associated with CRP. However, questions remain regarding CRP pathophysiology and optimal disease management.AIM To study feasibility of optical coherence tomography angiography(OCTA) for investigating subsurface vascular alterations in CRP and response to RFA treatment.METHODS Two patients with normal rectum and 8 patients referred for, or undergoing endoscopic RFA treatment for CRP were imaged with a prototype ultrahighspeed optical coherence tomography(OCT) system over 15 OCT/colonoscopy visits(2 normal patients, 5 RFA-na?ve patients, 8 RFA-follow-up visits). OCT and OCTA was performed by placing the OCT catheter onto the dentate line and rectum without endoscopic guidance. OCTA enabled depth-resolved microvasculature imaging using motion contrast from flowing blood, withoutrequiring injected dyes. OCTA features of normal and abnormal microvasculature were assessed in the mucosa and submucosa. Blinded reading of OCTA images was performed to assess the association of abnormal rectal microvasculature with CRP and RFA treatment, and rectal telangiectasia density endoscopic scoring.RESULTS OCTA/OCT images are intrinsically co-registered and enabled depth-resolved visualization of microvasculature in the mucosa and submucosa. OCTA visualized normal vascular patterns with regular honeycomb patterns vs abnormal vasculature with distorted honeycomb patterns and ectatic/tortuous microvasculature in the rectal mucosa. Normal arterioles and venules < 200 μm in diameter versus abnormal heterogenous enlarged arterioles and venules > 200μm in diameter were visualized in the rectal submucosa. Abnormal mucosal vasculature occurred in 0 of 2 normal patients and 3 of 5 RFA-na?ve patients,while abnormal submucosal vasculature occurred more often, in 1 of 2 normal patients and 5 of 5 RFA-na?ve patients. After RFA treatment, vascular abnormalities decreased, with abnormal mucosal vasculature observed in 0 of 8 RFA-follow-up visits and abnormal submucosal vasculature observed in only and 2 of 8 RFA-follow-up visits.CONCLUSION OCTA visualizes depth-resolved microvascular abnormalities in CRP, allowing assessment of superficial features which are endoscopically visible as well as deeper vasculature which cannot be seen endoscopically. OCTA/OCT of the rectum can be performed in conjunction with, or independently from endoscopy.Further studies are warranted to investigate if OCTA/OCT can elucidate pathophysiology of CRP or improve management.

Efficacy and complications of argon plasma coagulation for hemorrhagic chronic radiation proctitis

BACKGROUND Chronic radiation proctitis(CRP) is a complication which occurs in 1%-5% of patients who undergo radiotherapy for pelvic malignancies. Although a wide range of therapeutic modalities are available, there is no literature to date showing any particularly appropriate therapeutic modality for each disease stage. Argon plasma coagulation(APC) is currently recommended as the firstchoice treatment for hemorrhagic CRP, however, its indication based on longterm follow-up is still unclear. On the hypothesis that the long-term efficacy and safety of APC are not fully understood, we reviewed APC treatment for patients with hemorrhagic CRP from a single center.AIM To assess the long-term efficacy and safety of APC for hemorrhagic CRP.METHODS This is a retrospective study of consecutive patients treated with APC for hemorrhagic CRP from January 2013 to October 2017. Demographics, clinical variables, and typical endoscopic features were recorded independently. Success was defined as either cessation of bleeding or only occasional traces of bloody stools with no further treatments for at least 12 mo after the last APC treatment.We performed univariate and multivariate analyses to identify factors associated with success and risk factors for fistulas.RESULTS Forty-five patients with a median follow-up period of 24 mo(range: 12-67 mo)were enrolled. Fifteen(33.3%) patients required blood transfusion before APC.Successful treatment with APC was achieved in 31(68.9%) patients. The mean number of APC sessions was 1.3(1-3). Multivariate analysis showed that APC failure was independently associated with telangiectasias present on more than50% of the surface area [odds ratio(OR) = 6.53, 95% confidence interval(CI): 1.09-39.19, P = 0.04] and ulcerated area greater than 1 cm^2(OR = 8.15, 95%CI: 1.63-40.88, P = 0.01). Six(13.3%) patients had severe complications involving rectal fistulation. The only factor significantly associated with severe complications was ulcerated area greater than 1 cm^2(P = 0.035).CONCLUSION The long-term efficacy of APC for hemorrhagic CRP is uncertain in patients with telangiectasias present on > 50% of the surface area and ulceration > 1 cm^2.

Endoscopic and non-endoscopic approaches for the management of radiation-induced rectal bleeding

Pelvic radiation is a commonly utilized treatment for malignancy of the genitourinary and lower gastrointestinal tract. Radiation proctitis and the resultant clinical picture varies from asymptomatic to potentially life threatening. Similarly, treatment options also vary greatly, from medical therapy to surgical intervention. Commonly utilized medical therapy includes sucralfate enemas, antibiotics, 5-aminosalicylic acid derivatives, probiotics, antioxidants, short-chain fatty acids, formalin instillation and fractionated hyperbaric oxygen. More invasive treatments include endoscopic-based, focally ablative interventions such as dilation, heater and bipolar cautery, neodymium/yttrium aluminum garnet argon laser, radiofrequency ablation or argon plasma coagulation. Despite its relatively common frequency, there is a dearth of existing literature reporting headto-head comparisons of the various treatment options via a randomized controlled approach. The purpose of our review was to present the reader a consolidation of the existing evidence-based literature with the goal of highlighting the comparative effectiveness and risks of the various treatment approaches. Finally, we outline a pragmatic approach to the treatment of radiation proctitis. In light of the lack of randomized data, our goal is to pursue as least invasive an approach as possible, with escalation of care tailored to the severity of the patient's symptoms. For those cases that are clinicallyasymptomatic or only mildly symptomatic, observation or medical management can be considered. Once a patient fails such management or symptoms become more severe, invasive procedures such as endoscopically based focal ablation or surgical intervention can be considered. Although not all recommendations are supported by level I evidence, reported case series and single-institutional studies in the literature suggest that successful treatment with cessation of symptoms can be obtained in the majority of cases.

Hyperbaric oxygen therapy as a complementary treatment for radiation proctitis:Useless or useful?-A literature review

Radiotherapy(RT)is the backbone of multimodality treatment of more than half of cancer cases.Despite new modern RT techniques,late complications may occur such as radiation proctitis(RP).The natural history of RP is unpredictable.Minor symptoms may resolve spontaneously or require conservative treatment.On the other hand,for similar and uncomplicated clinical contexts,symptoms may persist and can even be refractory to the progressive increase in treatment measures.Over the last decades,an enormous therapeutic armamentarium has been considered in RP,including hyperbaric oxygen therapy(HBOT).Currently,the evidence regarding the impact of HBOT on RP and its benefits is conflicting.Additional prospective and randomised studies are necessary to validate HBOT’s effectiveness in the‘real world’clinical practice.This article reviewed the relevant literature on pathophysiology,clinical presentation,different classifications and discuss RP management including a proposal for a therapeutic algorithm with a focus on HBOT.

Pelvic radiation disease:Updates on treatment options

Pelvic cancers are among the most frequently diagnosed neoplasms and radiotherapy represents one of the main treatment options. The irradiation field usually encompasses healthy intestinal tissue,especially of distal large bowel,thus inducing gastrointestinal(GI) radiation-induced toxicity. Indeed,up to half of radiationtreated patients say that their quality of life is affected by GI symptoms(e.g.,rectal bleeding,diarrhoea). The constellation of GI symptoms- from transient to longterm,from mild to very severe- experienced by patients who underwent radiation treatment for a pelvic tumor have been comprised in the definition of pelvic radiation disease(PRD). A correct and evidence-based therapeutic approach of patients experiencing GI radiation-induced toxicity is mandatory. Therapeutic non-surgical strategies for PRD can be summarized in two broad categories,i.e.,medical and endoscopic. Of note,most of the studies have investigated the management of radiation-induced rectal bleeding. Patients with clinically significant bleeding(i.e.,causing chronic anemia) should firstly be considered for medical management(i.e.,sucralfate enemas,metronidazole and hyperbaric oxygen); in case of failure,endoscopic treatment should be implemented. This latter should be considered the first choice in case of acute,transfusion requiring,bleeding. More well-performed,high quality studies should be performed,especially the role of medical treatments should be better investigated as well as the comparative studies between endoscopic and hyperbaric oxygen treatments.