Chronic Radiation Proctopathy Research Articles

Risk factors associated to argon plasma coagulation treatment failure in patients with chronic radiation proctopathy.

argon plasma coagulation (APC) is the current endoscopic treatment of choice for patients who develop chronic radiation proctopathy. The aim of this study was to identify risk factors associated with treatment failure. one hundred and ninety-nine patients treated with argon plasma coagulation in a single center were retrospectively analyzed. twenty-four (12.06 %) patients were classified as APC treatment failures. Requirement of red blood cells transfusion and/or hemoglobin < 7 g/dl (OR 12.19, 95 % CI: 2.78-53.45, p < 0.001) and severe bleeding frequency (OR 2.76, 95 % CI: 1.13-6.72, p = 0.03) at diagnosis and prior to endoscopic therapy were associated with argon plasma coagulation treatment failure. Nineteen patients of the successful therapy group developed bleeding recurrence; no risk factors were associated with a shorter recurrence-free time. More than four APC sessions were associated to a higher risk of surgical intervention for bleeding control (OR 87.00, 95 % CI: 10.23-740.18, p < 0.001). requirement of red blood cells transfusion and/or hemoglobin < 7 g/dl and a severe bleeding frequency (more than five days per week) were identified as the most important risk factors for treatment failure in patients with chronic radiation proctopathy.

Laparoscopic Proximally Extended Colorectal Resection With Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Late Complications of Chronic Radiation Proctopathy.

BackgroundChronic radiation proctopathy (CRP) is a common complication after radiation therapy for pelvic malignancies. Compared with diversion surgery, resection surgery removes the damaged tissue completely to avoid the risks of recurrence and improve patients' outcome. Hence, resection surgery could be an optimal surgical approach when CRP is complicated by late complications. This study aimed to describe a modified surgical procedure of resection surgery and report its preliminary efficacy and safety in treating patients with CRP with late complications.MethodsWe retrospectively reviewed the patients who were diagnosed with CRP with late complications and underwent the modified surgical procedure of laparoscopic proximally extended colorectal resection with two-Stage Turnbull-Cutait pull-through coloanal anastomosis (PE-Bacon) between November 2019 and October 2020 in the Sixth Affiliated Hospital of Sun Yat-sen University.ResultsA total of 15 patients were performed the modified laparoscopic procedure of PE-Bacon, of which 1 patient underwent conversion from laparoscopic to open operation for intraoperative massive hemorrhage. Overall, the major (Clavien-Dindo III-V) postoperative complications occurred in 1 patient, anastomotic leakage was observed in 2 (13.3%) patients, and anastomotic stricture was observed in 4 (26.7%) patients. No patient had to be reoperated and died. Up to now, at the average follow-up of (524.40 ± 108.39) days, the preoperative symptoms of 93.3% (14/15) patients were relieved, with nine patients achieved complete remission, five patients only suffered minor symptoms. Because of the progression of radiation uropathy, one patient still had a vesicovaginal fistula as pre-operative complication. Colostomy reversal has been performed on 8 (53.3%) patients at an average postoperative duration of 299.5 ± 92.68 days, among whom only 2 patients suffered from major Low Anterior Resection Syndrome (LARS) until now.ConclusionsLaparoscopic PE-Bacon surgery is a safe and feasible surgical procedure for late complications of CRP with low morbidity and high symptom remission rate.

Feasibility and safety of laparoscopic Parks procedure for chronic radiation proctopathy

Objective: To preliminarily evaluate the feasibility and safety of laparoscopic Parks procedure for chronic radiation proctopathy (CRP). Methods: A descriptive cohort study was carried out. The clinical and follow-up data of 19 patients who received laparoscopic Parks procedure due to CRP in the Sixth Affiliated Hospital of Sun Yat-sen University from July 2013 to March 2019 were retrospectively analyzed. Inclusion criteria: (1) serious late complications occurred after pelvic radiotherapy, e.g.serious intractable hematochezia (hemoglobin <70 g/L), intractable anal pain (numerical rating scale >7), rectostenosis, perforation, and fistula. (2) imaging examinations including colonoscopy, pelvic MRI and/or chest, abdomen and pelvic CT were performed before surgery to confirm the lesions. Exclusion criteria: (1) preoperative or intraoperative diagnosis of tumor recurrence; (2) only ostomy was performed after laparoscopic exploration; (3) after neoadjuvant radiotherapy for rectal cancer; (4) incomplete medical records. Surgical procedures: (1) Laparoscopic exploration: tumor recurrence was excluded, and the range of radioactive damage in the intestine was determined. Marks were made on the proximal sigmoid colon without grossly obvious edema, thickening or radioactive injuries. (2) Abdominal operation: the right mesentery of sigmoid colon and rectum was opened, inferior mesenteric vein and inferior mesenteric artery were divided and the Toldt gap was expanded inwards and cephalad. The outside of left hemicolon was freed, the gastrocolic ligament was opened, the splenic flexure was fully mobilized, and the rectum was separated from the rear, side and front to the lowest point. Then perineal operation was performed. (3) Perineal operation: the whole layer of rectum wall was cut thoroughly at 1cm below the lesion's lower margin, the space around the rectum was fully separated, the rectum and sigmoid colon was pulled out through the anus and cut off at the site of the grossly normal intestine, the diseased bowel was removed and a coloanal anastomosis was made. (4) A protective stoma was performed. Conditions of operation, complication and symptom relief were summarized. A descriptive statistic method was used to analyze the results. Results: All the 19 patients were female with a median age of 53 (interquartiles, 50, 56) years old, of whom 18 patients had primary cervical cancer. Surgical indications: 9 cases were rectovaginal fistula; 9 cases were intractable anal pain, among whom 7 were complicated with deep rectal ulcer; and 1 case was intractable hematochezia with deep rectal ulcer. Eighteen cases completed laparoscopic Parks procedure, while 1 case was converted to laparotomy. The median operative time was 215 (131, 270) minutes, the median bleeding volume was 50 (50, 100) ml, and the median hospital stay was 12 (11, 20) days. There was no perioperative death. Ten cases had postoperative complications, including 3 cases of serious complications (CD grade IIIb and above) within 30 days after operation, of whom one case developed pelvic infection caused by rectovaginal, rectovesical and rectourethral fistula and acute renal failure (IVa); 2 cases developed orifice prolapse and parastomal hernia (IIIb). Seven cases had anastomosis-related complications, including 4 cases of grade A anastomotic leakage and 3 cases of anastomotic stenosis. Symptoms of CRP in the whole group were significantly relieved or disappeared after one year of the operation. Five cases achieved stoma closure. Conclusions: Laparoscopic Parks procedure for chronic radiation proctopathy is safe and feasible, and can effectively improve symptoms. However, the incidence of anastomotic complications is high, so the surgical indications should be strictly controlled.

PDGFC signaling is a potential therapeutic target for radiation proctopathy.

e24105 Background: Radiation proctopathy(RP), with acute or chronic rectal dysbiosis, arises as one of the most crucial complications of radiation therapy for pelvic malignancies. Common symptoms of RP patients include rectal breeding, incontinence and so on. However, its efficacy is disappointing due to lack of specific therapeutic drugs. Moreover, limitied scientific studies have been carried out to elucidate the mechanism of RP progression. Herein, we aim to study the underlying mechanism of RP with mouse model and clinical samples, and dig out its potential therapy. Methods: Firstly, chronic radiation proctopathy(CRP) mouse model is established by administering 25 Gy γ-irradiation in the pelvic region shielding the rest of bodies with lead blocks. Eight weeks later, the mice are harvested, and their colorectal tissues are used for RT-qPCR, western blot, immunostaining and transcriptome sequence analysis. Secondly, the outcomes of irradiated Pdgfc+/+ and Pdgfc−/− mice are compared and gene set enrichment analysis(GSEA) is used to further clarify the differences between these two groups. Lastly, crenolanib, a selective inhibitor of PDGFR, is subjected to mice before or after γ-irradiation to study its potential role in RP prevention and treatment. Results: In our RP mouse model, pdgfc and fibrosis markers are shown to highly express in the distal colorectal tissues after irradiation, Similarily, accumulation of PDGFC and fibrosis-related proteins is observed in RP patients’ tissues and serum. Besides, pdgfc appears in the list of cytokine and cytokine receptor interaction gene set which is the most enriched one in the radiation group. Furthermore, pdgfc knockout significantly alleviates radiation induced colorectal injuries in vivo, including mucosal lesions, submucosal thickening, and hyperplasia and edema of muscular layer. Moreover, GSEA reveals that pdgfc knockout may suppress RP progression through repression of pro-inflammatory cytokines and chemokines. Finally, crenolanib overcomes irradiation-induced injuries in the colorectal region of mice. Conclusions: PDGFC is an important regulator of RP progression, which may serve as a potentially therapeutic target for RP treatment.

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

BACKGROUNDChronic 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.AIMTo study feasibility of optical coherence tomography angiography (OCTA) for investigating subsurface vascular alterations in CRP and response to RFA treatment.METHODSTwo patients with normal rectum and 8 patients referred for, or undergoing endoscopic RFA treatment for CRP were imaged with a prototype ultrahigh-speed optical coherence tomography (OCT) system over 15 OCT/colonoscopy visits (2 normal patients, 5 RFA-naïve 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, without requiring 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.RESULTSOCTA/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 > 200 μm in diameter were visualized in the rectal submucosa. Abnormal mucosal vasculature occurred in 0 of 2 normal patients and 3 of 5 RFA-naïve patients, while abnormal submucosal vasculature occurred more often, in 1 of 2 normal patients and 5 of 5 RFA-naïve 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.CONCLUSIONOCTA 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.

Management of radiation proctopathy: a focus on the role of endoscopy

Chronic radiation proctopathy (CRP) affects a significant proportion of patients who undergo radiation treatment for cancer. It manifests in many ways, including pain, diarrhoea and rectal bleeding. It is often with rectal bleeding and related problems, such as anaemia, that these individuals present to the endoscopy department. Various treatments do exist for CRP. They include medical therapies, such as sucralfate or formalin enemas, endoscopic treatment and surgical intervention, which is reserved for refractory cases. Argon plasma coagulation (APC) is the mainstay of endoscopic treatment, but it can carry risks of ulceration and stricture formation. In response to this, other endoscopic therapies, such as radiofrequency ablation (RFA) and cryotherapy, have been proposed and tried. This clinical review explores the available evidence and provides a guide to the decision-making process that a member of the endoscopy team may undergo in order to achieve a satisfactory outcome for the patient.

10-year series studies of chronic radiation proctopathy from The Sixth Affiliated Hospital of Sun Yat-sen University

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).

Efficacy and Safety of Argon Plasma Coagulation for Hemorrhagic Chronic Radiation Proctopathy: A Systematic Review.

Hemorrhagic chronic radiation proctopathy (CRP) is a common complication after pelvic radiotherapy in patients with prostate or gynecological cancers. This systematic review was conducted to evaluate the efficacy and safety of argon plasma coagulation (APC) in treating hemorrhagic CRP. The databases of PubMed, Embase, and Cochrane Library were searched for related studies from inception to July 2017. Finally, 33 studies were identified with a total of 821 hemorrhagic CRP patients. After APC treatment, hemoglobin levels increased from 7.7–13.4 g/L to 11–14 g/L (including 15 studies). All (n = 33) studies reported an effective rate in rectal bleeding, among which five studies had a rate of 100%. Short-term complications were reported in 31 studies, while long-term complications in 33 studies and no complication in 11 studies. As for the severe complications, perforation was reported by 2 out of 33 studies, and the incidences were 3.3% (1/30) and 3.7% (1/27), respectively. As for APC setting, argon gas flow rate (median 1.5 L/min) and electric power (median 50 W) had no significant influence on complications and hemostasis. In conclusion, current literature indicated that APC therapy was an effective and safe strategy for hemorrhagic CRP, and large-scale prospective studies are needed to warrant our study.

Attach importance to standardized treatment of chronic radiation proctopathy

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.

Long-Term Endoscopic Follow-Up of Patients with Chronic Radiation Proctopathy after Brachytherapy for Prostate Cancer.

Background. Chronic radiation proctopathy (CRP) is late toxicity and associated with morbidity. Aim. To investigate the predictors of prognosis in patients with CRP after brachytherapy (BT). Methods. One hundred four patients with prostate cancer were treated with BT or BT followed by external-beam radiotherapy (BT + EBRT). We retrospectively investigated the 5-year incidence of rectal bleeding and endoscopic findings of CRP using the Vienna Rectoscopy Score (VRS). Twenty patients with VRS ≥ 1 were divided into the improved VRS group without treatment, unchanged VRS group, and treated group. The parameters associated with alteration of VRS were analyzed. Results. The incidence of rectal bleeding was 24%. The risk of rectal bleeding was higher in patients treated with BT + EBRT compared to those treated with BT (p < 0.0001). The incidence of superficial microulceration was higher in the improved VRS group than in the unchanged VRS group (p < 0.05). The incidence of multiple confluent telangiectasia or superficial ulcers > 1 cm2 was higher in the treated group than in both the improved and unchanged VRS groups (p < 0.05). Conclusions. Patients treated with BT + EBRT have a high risk of CRP. Endoscopic findings were useful for prognostic prediction of CRP.

PWE-113 One Year Experience of A New Chronic Radiation Proctopathy Specialist Service

Introduction Chronic radiation proctopathy (CRP) is a recognised complication of pelvic radiotherapy. Symptoms include diarrhoea, rectal pain, bleeding and tenesmus. In 2014, we set up an enhanced, dedicated, multidisciplinary, specialist service for managing the gastro-intestinal (GI) complications of CRP, based on The Royal Marsden Protocol. 1 Here we review the management of CRP at a tertiary referral centre over one year. Methods Patients with CRP reported at lower GI endoscopy (December 2014–15), were identified by an Endoscopy Database search for ‘radiation’. Case notes were reviewed. Indication for procedure, previous cancer and radiotherapy, endoscopy findings, treatment and outcomes were recorded. Results 86 patients had endoscopic evidence of CRP. M:F ratio 8:1. Cancer history: prostate 87% (75), cervical 6% (5), rectal 4% (3), bladder 1% (1), ovarian 1% (1), endometrial 1% (1). Mean time since radiotherapy: 4.5 years (range: 1–13 years). 24% (21) were referred via the 2 WW pathway and 16% (14) by the bowel cancer screening program (BCSP). 23% (20) were identified during surveillance colonoscopies for cancer/ polyps or colitis. 36% (31) were referred from GI clinic. Indications: rectal bleeding 47% (40), change in bowel habit 5% (4), iron deficiency anaemia (IDA) 8% (7) and faecal occult blood 16% (14). 41% (35) were asymptomatic. 27% (23) required intervention for CRP (haemorrhagic angiectasia with rectal bleeding causing anaemia and/or significant impact on quality of life). Sucralfate enemas 2 g bd, ± metronidazole oral 400 mg tds, ± Normacol were prescribed. 65% (15/23) were referred to a Specialist Nurse for follow up, 53% (8/15), of which, responded to medical therapy within 8 weeks. One patient was unable to tolerate sucralfate enemas. 13% (3/23) patients required escalation to rectal formalin instillation. ‘ Off protocol’, 7% (6) were treated with Argon Plasma Coagulation (APC) as their index therapy. A solitary rectal ulcer was found in 5% (4) of patients, two were a complication of APC. Two patients were referred for hyperbaric oxygen therapy. 62% of patients did not require any therapeutic intervention. Conclusion A significant number of patients with CRP are now referred via 2 WW and BCSP. Full colonoscopic assessment is appropriate to exclude other pathology, however, the majority do not require medical or endoscopic intervention, many are asymptomatic and few have IDA. For patients that require intervention for CRP, a multidisciplinary approach should be employed, medical therapy is effective and well tolerated, endoscopic intervention should be reserved for individuals who fail medical treatment. APC should only be used in carefully selected cases due to risk of ulceration. CRP services should be audited to ensure appropriate management and minimise complications. Reference 1 Frontline Gastroenterol (2015) 6 (1): 53–72. Disclosure of Interest None Declared

Sa1743 Endoscopic Long-Term Follow-Up of Chronic Radiation Proctopathy After Brachytherapy for Prostate Cancer

Sa1743 Endoscopic Long-Term Follow-Up of Chronic Radiation Proctopathy After Brachytherapy for Prostate Cancer

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 morbid-mortality. 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.

Hyperbaric oxygen therapy for radiation-induced injury: evidence is needed

Hyperbaric oxygen therapy for radiation-induced injury: evidence is needed

Emerging indications of endoscopic radiofrequency ablation.

Radiofrequency ablation (RFA) is a well-validated treatment of dysplastic Barrett's esophagus. Other indications of endoscopic RFA are under evaluation. Four prospective studies (total 69 patients) have shown that RFA achieved complete remission of early esophageal squamous intra-epithelial neoplasia at a rate of 80%, but with a substantial risk of stricture. In the setting of gastric antral vascular ectasia, two prospective monocenter studies, and a retrospective multicenter study, (total 51 patients), suggest that RFA is efficacious in terms of reducing transfusion dependency. In the setting of chronic hemorrhagic radiation proctopathy, a prospective monocenter study and a retrospective multicenter study (total 56 patients) suggest that RFA is an efficient treatment. A retrospective comparative study (64 patients) suggests that RFA improves stents patency in malignant biliary strictures. Endoscopic RFA is an upcoming treatment modality in early esophageal squamous intra-epithelial neoplasia, as well as in gastric, rectal, and biliary diseases.

Mo2027 Comparison of Chronic Radiation Proctopathy After Brachytherapy Alone and in Combination With External-Beam Radiotherapy for Prostate Cancer

Mo2027 Comparison of Chronic Radiation Proctopathy After Brachytherapy Alone and in Combination With External-Beam Radiotherapy for Prostate Cancer

Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.

Chronic proctitis refers to persistent or relapsing inflammation of the rectum, which results from a wide range of etiologies with various pathogenic mechanisms. The patients may share similar clinical presentations. Ulcerative proctitis, chronic radiation proctitis or proctopathy, and diversion proctitis are the 3 most common forms of chronic proctitis. Although the diagnosis of these disease entities may be straightforward in the most instances based on the clinical history, endoscopic, and histologic features, differential diagnosis may sometimes become problematic, especially when their etiologies and the disease processes overlap. The treatment for the 3 forms of chronic proctitis is different, which may shed some lights on their pathogenetic pathway. This article provides an overview of the latest data on the clinical features, etiologies, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.

Continuing Medical Education Exam: February 2015

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Ridtitid W, Schmidt SE, Al-Haddad MA, et al. Performance characteristics of EUS for locoregional evaluation of ampullary lesions. Gastrointest Endosc 2015;81:380-8. Choi IJ, Lee JH, Kim YI, et al. Long-term outcome comparison of endoscopic resection and surgery in early gastric cancer meeting the absolute indication for endoscopic resection. Gastrointest Endosc; 2015;81:333-41. Navaneethan U, Jegadeesan R, Nayak S, et al. ERCP-related adverse events in patients with primary sclerosing cholangitis. Gastrointest Endosc 2015;81:410-9. Rustagi T, Corbett FS, Mashimo H. Treatment of chronic radiation proctopathy with radiofrequency ablation. Gastrointest Endosc 2014:;81:428-36 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

A randomized controlled clinical trial of formalin for treatment of chronic hemorrhagic radiation proctopathy in cervical carcinoma patients.

Chronic hemorrhagic radiation proctopathy is not uncommon after radiotherapy for cervical carcinoma. The outcomes of several treatments have been variable. Many studies demonstrate that topical treatment with 4 % formalin is effective and safe. However, a nonrandomized control study showed a high response rate and good tolerance in chronic radiation proctopathy patients treated with 10 % formalin. The optimal concentration of formalin therefore remains unclear. To compare the effectiveness and safety of 4 and 10 % formalin for the treatment of chronic hemorrhagic radiation proctopathy, a prospective trial was conducted at the Department of Gynecology of the Affiliated Hospital of Binzhou Medical College from January 2009 to December 2012. One hundred and twenty patients with chronic hemorrhagic radiation proctopathy following radiotherapy for cervical carcinoma were recruited and randomized to receive 4 or 10 % formalin. A standard protocol was followed for formalin application. Symptom and rectoscopy scores were evaluated before and at 12 weeks after treatment. In the 4 % formalin group, 49 (86.0 %) and 53 (91.4 %) patients showed an improvement in symptom score and rectoscopy score, respectively (P = 0.36). Symptom and rectoscopy scores decreased significantly after treatment in both the 4 % formalin group and the 10 % formalin group (P < 0.001). Symptom score was correlated with rectoscopy score (P < 0.001). More patients in the 10 % group suffered treatment-related complications than did those in the 4 % group (P = 0.03). For the treatment of chronic hemorrhagic radiation proctopathy, 4 % should be the preferred formalin concentration.

Treatment of chronic radiation proctopathy with radiofrequency ablation (with video)

Chronic radiation proctopathy (CRP) is a common sequela occurring even many years after pelvic radiation. Current ablative therapies for bleeding ectatic vessels have the potential for deep tissue injury leading to ulcerations, perforation, and fistulas. Radiofrequency ablation (RFA) therapy avoids deep tissue injury and is a promising treatment for CRP. To assess the long-term safety and efficacy of RFA for the treatment of CRP. Multicenter, retrospective analysis of a prospectively collected database. Veterans Affairs Boston Healthcare System, Massachusetts; Sarasota Memorial Hospital and Suncoast Endoscopy of Sarasota, Florida. A total of 39 consecutive patients with CRP. Endoscopic RFA of CRP. The primary endpoint of the study was complete resolution of rectal bleeding. Secondary endpoints included visually scored improvement of CRP on endoscopic follow-up by using a rectal telangiectasia density (RTD) grading score, improvement in hemoglobin level, and adverse events related to the procedure. A total of 39 male patients (mean [± standard deviation {SD}] age 72.9 ± 6.6 years) were included in the study. The mean number of RFA sessions was 1.49 (median 1, interquartile range [IQR] 1-2, range 1-4), with a mean interval of 18 weeks between sessions. Rectal bleeding stopped completely in all patients during the mean follow-up of 28 months (range 7-53 months). A significant improvement occurred in the mean (± SD) hemoglobin level from 11.8 ± 2 to 13.5 ± 1.6 g % (P< .0001). Endoscopic severity also improved significantly with an improvement in the median RTD score from 3 (IQR 2-3) to 0 (IQR 0-1) (P< .0001). Treatment with RFA led to discontinuation of blood transfusion and iron therapy in 92% and 82% patients, respectively. Retrospective analysis, lack of control group. RFA therapy led to complete resolution of rectal bleeding in all treated CRP patients, with improvement in clinical and endoscopic indices without any major adverse events. Further controlled studies are needed to establish RFA as the endoscopic therapy of choice for treatment of CRP.