A method to reduce radiation injury to intestine—a preliminary report

Abstract

Radiotherapy in the management of pelvic tumours leads to an incidence of morbidity and mortality. Acute reactions are common and may be troublesome, but with appropriate management they settle without mortality. Late reactions, however, though less frequent may lead to permanent disability and death. The increasing use of radiation therapy combined with the longer survival of patients treated has increased the importance of the prevention of radiation injury. Careful planning to avoid areas of high dose, an overall dose limitation together with a restriction of the volume for irradiation and a careful selection of patients, recognizing such predisposing factors as extensive abdominal surgery, previous radiotherapy and co-existing intestinal disease, can reduce the incidence of post-radiation morbidity. However, such a policy may lead to an inadequate dosage being attained for eradication of all tumour and a denial of radiotherapy for patients where the risk of radiation injury is considered to be too high. The rectum and lower portion of the pelvic colon must inevitably be included in the area of radiotherapy when pelvic tumours are irradiated. However, attempts have been made to exclude the small intestine and remaining large intestine. Omentum may be positioned across the pelvis and prevent small intestine from entering it, but unfortunately this is only occasionally possible. Jelliffe (pers. commun.) has employed a temporary pneumoperitoneum in the management of bladder tumours, however, problems with respiratory embarrassment in the elderly and in the positioning of patients to maintain an elevated pelvis did not allow a continuation of the work. We have attempted to exclude the small and part of the large intestine from the pelvis with the use of a soft bag distended with sterile saline. There is extensive experience in the use of fluidcontaining bags for breast replacement, and devices made of a silicone elastomer are generally extremely well tolerated. From those available appliances a Silastic percutaneous skin expander (Lapin design) was chosen for use in this preliminary study as it can be filled with 500 ml of sterile saline and is a simple bag, unlike other prostheses which distend to a breast shape [1]. To introduce the fluid a 23 gauge needle is inserted in a self-sealing silicone valve which is located in the prosthesis; behind the valve is a thin stainless steel cone which acts as a needle stop to prevent further puncture of the bag. The bag is filled with 500 ml of sterile saline. At laparotomy the bag is placed within the pelvis and