Radiation Proctopathy Research Articles

The KTP Laser Is an Effective Treatment for Chronic Radiation Proctopathy

The KTP Laser Is an Effective Treatment for Chronic Radiation Proctopathy

Sucralfate Does Not Ameliorate Acute Radiation Proctitis: Randomised Study and Meta-analysis

During pelvic radiotherapy, many patients develop radiation-induced gastrointestinal symptoms, which may interfere with treatment. Prophylaxis during radiotherapy should ideally prevent acute reaction and the development of delayed injury. Sucralfate, an aluminium sucrose octasulphate, has been used for acute and delayed radiation side-effects. However, conflicting results have been published. We report here a prospective, randomised, placebo-controlled study of prophylactic sucralfate during pelvic radiotherapy. In addition, a meta-analysis of available data from the literature has been carried out. Fifty-one patients with localised pelvic tumours scheduled for curative conformal pelvic radiotherapy (total dose 64-70 Gy over 6.5-7 weeks in 2 Gy daily fractions) were included. Peroral sucralfate 2 g three times daily, or identically appearing placebo tablets, was given during the course of radiotherapy. Symptom registration, endoscopy and biopsies were carried out immediately before radiotherapy, 2 weeks and 6 weeks into the treatment course, and 2 weeks after completing radiotherapy. Mucosal cup forceps biopsies were obtained through a rigid proctoscope. Graded endoscopic appearance and quantitative histology were registered. On the basis of previously published negative reports, an unplanned interim analysis of 44 evaluable patients showed significantly increased diarrhoea in the sucralfate group and the trial was stopped. No difference was seen in other symptoms, endoscopic appearance or histology. A meta-analysis comprising five published studies showed no statistically significant beneficial effect of sucralfate on acute symptoms. Sucralfate cannot be recommended for prophylaxis of acute radiation proctopathy and may even worsen the symptoms.

Vitamin A Reduces Nonbleeding Symptoms of Chronic Radiation Proctopathy

Rectal bleeding associated with chronic radiation proctopathy can be managed easily by destroying telangiectasis with endoscopic therapy. However,

A Comparison of Argon Plasma Coagulation (APC) and KTP Laser in the Treatment of Chronic Radiation Proctopathy

A Comparison of Argon Plasma Coagulation (APC) and KTP Laser in the Treatment of Chronic Radiation Proctopathy

Are we making progress with argon plasma coagulation in chronic radiation proctopathy?

Are we making progress with argon plasma coagulation in chronic radiation proctopathy?

A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial of Retinol Palmitate (Vitamin A) for Symptomatic Chronic Radiation Proctopathy

This study was designed to determine whether oral retinol palmitate (vitamin A) can reduce the symptoms of radiation proctopathy. A randomized, double-blind trial comparing retinol palmitate (10,000 IU by mouth for 90 days) to placebo was conducted. Eligible patients were more than six months postpelvic radiotherapy and had significant symptoms as measured with the Radiation Proctopathy System Assessments Scale. Nineteen patients were randomized in total: ten to retinol palmitate and nine to placebo. The Radiation Proctopathy System Assessments Scale scores before and every 30 days for 90 days were measured. Five placebo nonresponders were crossed over to the retinol palmitate for another 90 days. Response was defined as a reduction in two or more symptoms by at least two Radiation Proctopathy System Assessments Scale points. Seven of ten retinol palmitate patients responded, whereas two of nine responded to placebo (P = 0.057). Mean pre-post-treatment change in Radiation Proctopathy System Assessments Scale (delta Radiation Proctopathy System Assessments Scale) in the retinol palmitate group was 11 +/- 5, whereas delta Radiation Proctopathy System Assessments Scale in the placebo group was 2.5 +/- 3.6 (P = 0.013, Mann-Whitney U test). Additionally, all five placebo nonresponders who were crossed over to treatment with retinal palmitate responded to treatment. In our trial, retinol palmitate significantly reduced rectal symptoms of radiation proctopathy, perhaps because of wound-healing effects. The current results can serve as the foundation for future trials examining retinol palmitate in the multi-institutional setting.

Efficacy and safety of argon plasma coagulation for the treatment of hemorrhagic radiation proctitis

To evaluate the efficacy, safety and medium-/long-term clinical course of patients undergoing endoscopic treatment with argon plasma coagulation for hemorrhagic radiation proctopathy. Descriptive, retrospective study with medium- and long-term follow-up. Ten patients were treated with argon plasma coagulation for hemorrhagic radiation proctopathy between July 1998 and February 2003. Inclusion criteria were: evidence of chronic rectal bleeding, consistent endoscopic findings, and absence of any other cause of hematochezia after a comprehensive ano-rectal examination and complete colonoscopy. The equipment used was a standard colonoscope, an argon delivery unit, an argon plasma coagulation probe 1.5 mm in internal diameter, and a high-frequency electrosurgical generator. Consecutive treatment sessions were programmed whenever it was considered necessary until all mucosal lesions had been treated. Clinical and evolutive follow-up was performed with a focus on tolerance, efficacy, and potential argon plasma coagulation-related complications. Data were updated by personal or telephonic interview. In all patients, chronic rectal bleeding stopped after the last treatment session. The mean number of treatment sessions to stop symptoms was 1.7. Mean follow-up was 31.1 months. All sessions were well tolerated, similarly to standard rectoscopy. In one case a recurrence of rectal bleeding was observed four months later, which required two repeat sessions. Four patients were anemic at inclusion. Three of them reported a resolved anemia at the end of the study. No delayed argon plasma coagulation-related complications such us ulcers or strictures were seen. Argon plasma coagulation appears to be a useful, effective and safe treatment for rectal bleeding resulting from chronic radiation proctitis when compared to standard medical and endoscopic treatments. These successful outcomes seem to persist even after long-term follow-up.

Argon plasma coagulation as first-line treatment for chronic radiation proctopathy.

Chronic radiation proctopathy is a troublesome complication of radiotherapy to the pelvis, for which current treatment modalities are unsatisfactory. The present prospective study was designed to determine the usefulness and safety of argon plasma coagulation in the management of chronic radiation proctopathy. Twenty-five consecutive patients (M:F 24:1, mean age: 69 years) with radiation proctopathy were prospectively included. All patients received argon plasma coagulation by a standard protocol. Response to treatment was assessed by symptom response, bleeding severity score, hematological parameters and transfusion requirements over a median 14-month follow up. Patients received a median of one treatment session with argon plasma coagulation. There was significant improvement in rectal bleeding in all patients, with complete cessation of bleeding in 21 (81%) of the patients. The median bleeding severity score fell from 3 to 0 (P < 0.0005). The mean hemoglobin level rose from 10.05 +/- 2.21 g/dL before treatment to 12.44 +/- 1.09 g/dL at 6 months following treatment (P < 0.002). There was also improvement in other symptoms such as urgency and diarrhea. Over the period of follow up, there was no recurrence of anemia and no complications were noted. These results suggest that argon plasma coagulation is a safe and effective modality in the treatment of chronic radiation proctopathy.

Comparison of Safety and Outcome Between Two Argon Plasma Coagulation Settings for Radiation Proctopathy in Patients with Prostate Cancer

Radiation proctopathy is a late complication of radiation therapy for prostate cancer. Argon plasma coagulation (APC) is an accepted endoscopic therapy, but there is no consensus for power settings and gas flow rate. We describe our experience with two different settings. Methods: Between January, 1997 and June, 2003, 124 patients were referred for endoscopic therapy for radiation proctopathy. The first exam was always a colonoscopy to rule out synchronous lesions. Repeat procedures were sigmoidoscopies. All procedures were performed by one endoscopist using an ERBE APC 300 and ICC 200 generator with end-firing probes. Early in the series, APC settings were 75W and 1.0 L/min. Later, these settings were changed to 40-60W and 1.0 L/min. Successful outcome was defined as cessation of bleeding. Failure was determined as need for surgical or other therapy. Results: 257 procedures were performed on 114 patients (93%) with a history of prostate cancer. The mean age was 71 years (range 51-84). 44 had external beam therapy (EBT, mean dose = 6227 cGy) ± hormonal blockade (HB), 18 had EBT (mean dose = 6115 cGy) + brachytherapy (BT), and 25 patients had BT ± HB. Brachytherapy doses were set according to American Association of Physicists in Medicine Task Group #43. 28 patients had an unspecified treatment regime. The mean procedures per patient was 2.2 (range 1-7). 63 patients received at least one APC treatment session at a setting of 75W. 51 patients had APC settings of 40-60W. The 75W group required an average of 2.6 procedures (range 2-7) to achieve success as compared to 1.6 procedures (range 1-4) for the 40-60W (p<0.001). Of the 33 patients who required 3 or more treatment sessions, 27 (82%) received APC at 75W for at least one session. This subset averaged 4 treatment sessions per patient and 66.7% of these were at the 75W setting. There were 3 complications (1.2%), all in the 75W group. Two patients had continued bleeding that required admission and transfusion. One of these patients underwent a diverting colostomy. A third patient had an asymptomatic rectal stricture. Conclusions: APC is a safe and effective procedure at a power setting of 60W or less. This study underscores the need for a grading system using endoscopic findings and radiation therapy parameters to most accurately compare treatment responses.

Endoscopic treatment of chronic radiation proctopathy

Radiation therapy for pelvic organ malignancy can result in chronic radiation proctopathy with significant morbidity. Treatments include medical and endoscopic techniques with surgical intervention reserved for resistant cases. There is limited efficacy data and no standardization of treatment regimens, which makes therapeutic recommendations somewhat anecdotal. The more frequently used endoscopic techniques are described in detail with recommendations for particular patient scenarios based on our experience.

Long-term outcome of argon plasma coagulation therapy for bleeding caused by chronic radiation proctopathy.

Radiation-induced proctopathy is a serious complication of radiation therapy for pelvic malignancy. To assess the safety and efficacy of argon plasma coagulation in the treatment of haemorrhagic radiation-induced proctopathy. Twenty-four patients with rectal bleeding due to radiation-induced proctopathy were prospectively enrolled in the study. Indications for treatment were iron deficiency anaemia (n = 16) and persistent bleeding, despite pharmacotherapy (n = 8). Argon flow and power used were 0.8-1.2 l/min and 40 W, respectively. An interval of at least 4 weeks was allowed between treatment sessions. Haemoglobin level, bleeding severity score, number of admissions and transfusion requirements were recorded after endoscopic coagulation and before 12 and 24 months. A median of 2.5 therapeutic sessions per patient were performed (range 1-6). All patients reported clinical improvement and/or cessation of rectal bleeding. The mean value of the bleeding severity score decreased from 2.9 to 0.8 (P < 0.01), while average haemoglobin levels increased by a mean of 1.9 mg/dl at the end of the treatments (P < 0.05). During a minimum follow-up of 24 months (range 24-60), rectal bleeding recurred in two cases and was successfully retreated endoscopically. One patient developed a recto-vaginal fistula. Argon plasma coagulation appears to be a safe and effective technique for management of rectal bleeding caused by radiation-induced proctopathy.

Oral vitamin A for the treatment of chronic radiation proctopathy: A randomized, controlled trial

Oral vitamin A for the treatment of chronic radiation proctopathy: A randomized, controlled trial

Complications of Argon Plasma Coagulation for Radiation Proctopathy

Argon plasma coagulation (APC) is known to effectively control bleeding from chronic radiation proctopathy, but few reports have described

Efficacy and complications of argon plasma coagulation for hematochezia related to radiation proctopathy

Background: Endoscopic treatments effectively control bleeding caused by radiation proctopathy. The aims of this study were to determine the efficacy and side effects of argon plasma coagulation in the treatment of this type of bleeding. Methods: Records of 21 consecutive patients in whom argon plasma coagulation was used to treat hemorrhagic radiation proctopathy were reviewed. Results: Pharmacologic measures had been unsuccessful in 12 patients. Endoscopic treatment had been unsuccessful in 5 patients. All patients were anemic and 4 had received blood transfusions. The mean number of treatment sessions was 1.7, and 10 patients were successfully treated in single session. Rectal bleeding resolved within 1 month of the last treatment in 19 patients, usually on the day of the last procedure. Bleeding resolved 2 months after cessation of therapy in another patient. Short-term side effects occurred in 3 (14%) patients (rectal pain, tenesmus, and/or abdominal distention); long-term complications (rectal pain, tenesmus, diarrhea) developed in 4 patients (19%). Conclusions: Hematochezia caused by radiation proctopathy is effectively controlled by argon plasma coagulation, in some cases after a single treatment session. Treatment may result in protracted bowel symptoms. (Gastrointest Endosc 2002;55:70-4.)

Review article: current therapeutic options for radiation proctopathy.

Radiation proctopathy is a common unfortunate complication following radiation therapy of pelvic malignancies. Symptoms of chronic radiation proctopathy include haematochezia, urgency, constipation, tenesmus, diarrhoea and rectal pain. Currently, a wide variety of pharmacological options, endoscopic cautery techniques and surgical procedures have been proposed for the treatment of chronic radiation proctopathy. Although these have been proposed primarily as treatment for rectal bleeding, the control of other symptoms has been noted with some of these agents. Pharmacological options include 5-aminosalicylic acid preparations, coticosteroid enemas, sucralfate (oral, enemas), formalin, short chain fatty acid enemas, oestrogen/progesterone, hyperbaric oxygen, antioxidants, sodium pentosan polysulphate and misoprostol rectal suppositories. Of these, sucralfate and formalin therapy appear to be effective for bleeding control. Misoprostol rectal suppositories and oral sucralfate may be useful in the prevention of acute and chronic symptoms of radiation proctopathy. Endoscopic cautery techniques have included the use of Nd:YAG laser and argon laser for coagulation of bleeding neovascular telangiectasias. Argon plasma coagulation offers a safe non-contact method of delivering haemostasis which has proven to be particularly useful in targeting difficult to reach lesions tangentially. Surgery is generally reserved for severe refractory cases involving ongoing haemorrhage, obstruction, stricture formation, fistulas and perforation. Given that formal randomized placebo-controlled studies are lacking for most treatments, the management of these patients is often challenging and unclear. Hence, there is a need for more research and education on radiation proctopathy.

Endoscopic argon plasma coagulation (APC) for radiation proctopathy

Radiation therapy for pelvic neoplasia is widely employed for both curative and palliative intent. Although safe and effective, 5|[ndash]|10% patients experience the undesirable complication of radiation proctitis (more properly called proctopathy). The rectal bleeding is typically intermittent but rarely presents as acute lower GI bleeding. Endoscopic evaluation reveals scattered vascular ectasias throughout the rectum|[sol]|distal sigmoid. The vascular ectasias are felt to arise from neoangiogenesis resultant from vascular wall fibrosis induced by radiation. Many modalities for treatment have been employed including topical application of various agents (formaldehyde, short-chain fatty acids, sulfasalazine, 5-ASA), endoscopic use of Nd:YAG laser, bipolar cautery and various surgical interventions. APC is a new endoscopic coagulation modality employing pressurized ionized argon gas delivered via polyethylene catheter to achieve superficial cauterization. Five patients diagnosed with symptomatic radiation proctopathy and anemia underwent APC at our institution within the past 18 months. One patient had been treated previously with YAG laser. During each endoscopic treatment session a flexible sigmoidoscopy was performed followed by ablation of rectal ectasias by APC. Routine APC application consisted of multiple, brief pulses from the APC device (ERBE) set at 60|[ndash]|65 watts applied by mucosal |[ldquo]|painting|[rdquo]| over focal areas of visible ectasias. Patients received a mean of 4.6 (range 2|[ndash]|7) treatment sessions (approx. one session every 3 wks). Hematocrit (Hct) values immediately preceding APC therapy and packed red blood cell transfusions (PRBC) during a 6 month interval prior to APC were compared to Hct and PRBC requirements during APC therapy. Hct values remained stable or improved while the need for PRBC was either eliminated or substantially decreased in all patients. Statistical significance was not achieved due to the limited sample size. All patients tolerated the procedure well with no complications noted.

KTP laser therapy for bleeding from chronic radiation proctopathy

Background: Endoscopic laser photocoagulation is commonly used to treat bleeding from the neovascular lesions of chronic radiation proctopathy. The KTP laser is an Nd/YAG–driven unit that emits light with a wavelength of 532 nm. This wavelength of energy is absorbed by hemoglobin and penetrates tissue to a depth of only 1 to 2 mm. Methods: Twenty-three patients were treated with KTP laser and followed for a median of 29 months (range 5 to 51 months); 21 had received radiation for prostate cancer and 2 for uterine cancer. The median age was 77 years (range 68 to 87 years). A median of 2 sessions (range 1 to 5 sessions) was performed using 4 to 10 Watts of power and a median energy of 816 Joules per session (range 204 to 2430 Joules). Results: After treatment there was a significant reduction in the frequency (p = 0.0005) of bleeding, increase in hematocrit level (p < 0.0001), improvement in activities of daily life (p = 0.01), and a reduction in use of health care resources (p < 0.0001). There was a trend toward decreased use of iron supplements (11 to 4 patients) and transfusions (4 to 0 patients). Two patients (9%) developed rectal ulcers after treatment. Conclusions: KTP laser photocoagulation is a safe and effective therapy for bleeding from chronic radiation proctopathy that improves activities of daily living and reduces use of health care resources. (Gastrointest Endosc 2000;52:353–7.)

Argon plasma coagulator treatment in the management of hematochezia secondary to chronic radiation proctopathy

Argon plasma coagulator treatment in the management of hematochezia secondary to chronic radiation proctopathy

Argon plasma coagulator treatment in the management of hematochezia secondary to chronic radiation proctopathy

Argon plasma coagulator treatment in the management of hematochezia secondary to chronic radiation proctopathy

Endoscopic argon plasma coagulation (APC) for radiation proctopathy

Endoscopic argon plasma coagulation (APC) for radiation proctopathy