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Entero-anal fistula: A rare complication after abdomino perineal resection and radiotherapy—Case report
European Journal of Radiology Extra 61 (2007) 53–55
Entero-anal fistula: A rare complication after abdomino perineal resection and radiotherapy—Case report Madhup Rastogi a,∗ , Kirti Srivastava a , Madanlal B. Bhatt a , Madhu Srivastava a , Mohan C. Pant a , Luv Kakkar b a
Department of Radiotherapy, King George’s Medical University, Chowk, Lucknow 226003, UP, India b Department of Gastroenterology, King George’s Medical University, Lucknow, UP, India Received 27 June 2006; received in revised form 21 October 2006; accepted 23 October 2006
Abstract Abdominoperineal resection (APR) is the surgery most commonly performed for cancers involving lower third of the rectum. It is an extensive resection surgery resulting in the disturbed anatomy of pelvic fossa. With the introduction of chemo radiotherapy, the control rate and survival figures have gone up with the associated increase in the treatment related toxicities. We present an extremely unusual complication of entero-anal fistula following APR and radiation therapy in a 40-year-old male with rectal carcinoma. The present report describes the possible cause for the development of this rare event along with highlighting some of the important issues that needs to be considered under such conditions. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Entero-anal fistula; Abdominoperineal resection; Radiation therapy
1. Introduction Abdominoperineal resection (APR) is the surgery most commonly performed for cancers involving lower third of the rectum. It is an extensive resection surgery that results in vacant rectal fossa thus causing displacement of other pelvic organs. We present an extremely unusual complication of entero-anal fistula following APR and radiation therapy in a 40-year-old male with rectal carcinoma. The present case report describes the possible cause for the development of this rare event along with highlighting some of the important issues that needs to be considered under such conditions.
2. Case history A 40-year-old male, chronic smoker, beetle chewer and alcoholic referred to our OPD in November 2003 with chief complaints of altered bowel habits for the past 6 months. ∗
Corresponding author. Tel.: +91 522 2240016. E-mail address: [email protected] (M. Rastogi).
1571-4675/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2006.10.014
There was history of melena for the past 3 months. Endoscopy revealed a friable growth at lower third of rectum. Biopsy from the growth was suggestive of adenocarcinoma. Patient underwent APR surgery with terminal colostomy and closure of anal opening under general anesthesia. Postoperative histology revealed adenocarcinoma of rectum infiltrating to deeper muscular layer. Patient was referred to us for adjuvant treatment in the form of chemo radiotherapy. All the baseline investigations including complete hemogram, liver function test, renal function test, X-ray chest, ultrasound abdomen and contrast enhanced cat scan pelvis were well within normal limits. In view of the above findings patient received three cycles of 5-FU and Leucovorin IV prior to radiotherapy. A total of 60 Gy radiotherapy was given in two phases (phase 1: 50 Gy in 25 fractions by four field box technique and phase 2: 10 Gy boost in five fractions by three field technique to the pelvis). Radiotherapy was well tolerated and patient kept on regular follow-up. Patient remained disease free for about 2 years. In November 2005 he reported again with an unusual complaints of continuously passing watery discharge with fecal matters from the previously closed anal opening. At the same
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M. Rastogi et al. / European Journal of Radiology Extra 61 (2007) 53–55
Fig. 1. Barium meal follows through film showing collection of contrast in the small bowel and a narrow enterocutaneous tract up to anal verge forming entero-anal fistula.
time fecal matter output from the colostomy was noticeably decreased. Imaging studies like USG abdomen and CECT did not show any conclusive finding however there was no evidence of local recurrence. Our oncology team postulated a hypothesis regarding the possible rupture of small bowel as a late complication of radiation thus resulting an enteocutaneous fistulous tract, which finally reached up to anal verge. To prove it, a Barium-meal-follow through study was performed, which revealed collection of contrast in the small bowel and a narrow fistulous tract up to anal verge confirming the hypothesis (Fig. 1). It was essentially due to the rupture of previously irradiated small bowel loop as a late complication of radiation therapy, which has formed an enterocutaneous tract up to the anal verge thus resulting in entero-anal fistula. Patient was re-explored and a side to end anastomses performed successfully.
3. Discussion Since Miles [1] described in1908, APR has been the gold standard for treatment of the distal rectal cancer. Despite improvements in operative and perioperative care it is associated with significant morbidity. Various series report mortality rates of 2–6% [2,3] and complication rates of over 50% [4]. Several studies have demonstrated an increase in both disease-free interval and overall survival when radiation therapy is combined with chemotherapy following surgical resection [5,6]. The addition of radiation and chemotherapy further adds up the morbidity. APR, as the name suggests, involve two phases: an abdominal phase and a perineal phase, done synchronously. This
extensive surgical procedure is performed in a confined space with wide anatomic variations in most cases on large tumors. It involves en bloc resection of the rectosigmoid, the rectum, and the anus along with the surrounding mesentery, mesorectum, and perianal soft tissues together with closure of anal opening and end colostomy thus resulting in iatrogenic vacant rectal fossa. This vacant rectal fossa may result in displacement of other pelvic organs. For instance, the urinary bladder tends to fall posteriorly and occupies a presacral and/or precoccygeal location with the seminal vesicles or uterus, and loops of the small bowel can be present in the vacant fossa [7,8]. Posterior displacement of pelvic organs is a major concern if radiation therapy is planned. If no proper precautions are being taken these displaced small bowel loops will get irradiated during radiation therapy and will under go acute and late morbidities of radiation. One of the surgical techniques to prevent the posterior displacement of pelvic organs is the peritonization of the raw area during surgery. But many surgeons do not prefer this technique routinely [9]. And such patients like the present case are at a higher risk of developing radiation enteritis that may some time result in fistula formation. Improved radiation planning and techniques can be used to minimize treatment-related complications. These techniques include the use of multiple pelvic fields, prone positioning, customized bowel immobilization molds (belly boards), bladder distention, visualization of the small bowel through oral contrast, and the incorporation of three-dimensional or comparative treatment planning [10].
4. Conclusion Today we see the high successful outcome of combined modality treatment comprising of surgery followed by adjuvant chemo radiotherapy in lower rectal cancers. The present case report is an example of extreme manifestation of radiation induced small bowel injury resulting in unusual entero-anal fistula which could have been prevented by surgical technique (peritonization of raw area or use of a biodegradable mesh) and with the use of better radiation planning techniques. Thus focus is on the avoidance of treatment related complications to ensure a better quality of life to the patient.
References [1] Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 1908;2:1812–3. [2] Rosen L, Veidenheimer MC, Coller JA, et al. Mortality, morbidity, and patterns of recurrence after abdominoperineal resection for cancer of the rectum. Dis Colon Rectum 1982;25:202–8. [3] Enker WE, Laffer UT, Block GE. Enhanced survival of patients with colon and rectal cancer is based upon wide anatomic resection. Ann Surg 1979;190:350–60.
M. Rastogi et al. / European Journal of Radiology Extra 61 (2007) 53–55 [4] Fitzgibbons Jr RJ, Harkrider Jr WW, Cohn Jr I. Review of abdominoperineal resections for cancer. Am J Surg 1977;134:624–9. [5] Krook JE, Moertel CG, Gunderson LL, et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. New England J Med 1991;324(11):709–15. [6] Fisher B, Wolmark N, Rockette H, et al. Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP protocol R-01. J Natl Cancer Inst 1988;80(1):21–9. [7] Carrington B. Postoperative and postradiation pelvis. In: Hricak H, Carrington BM, editors. MRI of the pelvis: a text atlas. London, England: Dunitz; 1991. p. 519–55.
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[8] Lee JK, Stanley RJ, Sagel SS, Levitt RG, McClennan BL. CT appearance of the pelvis after abdomino-perineal resection for rectal carcinoma. Radiology 1981;141:737–41. [9] Faith S, Hulten L, Ojerskog B. Ommission of pelvic peritoneal closure after abdominoperineal rectal excision. Ann Chir Gynaecol 1977;66(4):181–3. [10] Koelbl O, Richter S, Flentje M. Influence of patient positioning on dosevolume histogram and normal tissue complication probability for small bowel and bladder in patients receiving pelvic irradiation: a prospective study using a 3D planning system and a radiobiological model. Int J Radiat Oncol, Biol, Phys 1999;45(5):1193–8.
Entero-anal fistula: A rare complication after abdomino perineal resection and radiotherapy—Case report Madhup Rastogi a,∗ , Kirti Srivastava a , Madanlal B. Bhatt a , Madhu Srivastava a , Mohan C. Pant a , Luv Kakkar b a
Department of Radiotherapy, King George’s Medical University, Chowk, Lucknow 226003, UP, India b Department of Gastroenterology, King George’s Medical University, Lucknow, UP, India Received 27 June 2006; received in revised form 21 October 2006; accepted 23 October 2006
Abstract Abdominoperineal resection (APR) is the surgery most commonly performed for cancers involving lower third of the rectum. It is an extensive resection surgery resulting in the disturbed anatomy of pelvic fossa. With the introduction of chemo radiotherapy, the control rate and survival figures have gone up with the associated increase in the treatment related toxicities. We present an extremely unusual complication of entero-anal fistula following APR and radiation therapy in a 40-year-old male with rectal carcinoma. The present report describes the possible cause for the development of this rare event along with highlighting some of the important issues that needs to be considered under such conditions. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Entero-anal fistula; Abdominoperineal resection; Radiation therapy
1. Introduction Abdominoperineal resection (APR) is the surgery most commonly performed for cancers involving lower third of the rectum. It is an extensive resection surgery that results in vacant rectal fossa thus causing displacement of other pelvic organs. We present an extremely unusual complication of entero-anal fistula following APR and radiation therapy in a 40-year-old male with rectal carcinoma. The present case report describes the possible cause for the development of this rare event along with highlighting some of the important issues that needs to be considered under such conditions.
2. Case history A 40-year-old male, chronic smoker, beetle chewer and alcoholic referred to our OPD in November 2003 with chief complaints of altered bowel habits for the past 6 months. ∗
Corresponding author. Tel.: +91 522 2240016. E-mail address: [email protected] (M. Rastogi).
1571-4675/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2006.10.014
There was history of melena for the past 3 months. Endoscopy revealed a friable growth at lower third of rectum. Biopsy from the growth was suggestive of adenocarcinoma. Patient underwent APR surgery with terminal colostomy and closure of anal opening under general anesthesia. Postoperative histology revealed adenocarcinoma of rectum infiltrating to deeper muscular layer. Patient was referred to us for adjuvant treatment in the form of chemo radiotherapy. All the baseline investigations including complete hemogram, liver function test, renal function test, X-ray chest, ultrasound abdomen and contrast enhanced cat scan pelvis were well within normal limits. In view of the above findings patient received three cycles of 5-FU and Leucovorin IV prior to radiotherapy. A total of 60 Gy radiotherapy was given in two phases (phase 1: 50 Gy in 25 fractions by four field box technique and phase 2: 10 Gy boost in five fractions by three field technique to the pelvis). Radiotherapy was well tolerated and patient kept on regular follow-up. Patient remained disease free for about 2 years. In November 2005 he reported again with an unusual complaints of continuously passing watery discharge with fecal matters from the previously closed anal opening. At the same
54
M. Rastogi et al. / European Journal of Radiology Extra 61 (2007) 53–55
Fig. 1. Barium meal follows through film showing collection of contrast in the small bowel and a narrow enterocutaneous tract up to anal verge forming entero-anal fistula.
time fecal matter output from the colostomy was noticeably decreased. Imaging studies like USG abdomen and CECT did not show any conclusive finding however there was no evidence of local recurrence. Our oncology team postulated a hypothesis regarding the possible rupture of small bowel as a late complication of radiation thus resulting an enteocutaneous fistulous tract, which finally reached up to anal verge. To prove it, a Barium-meal-follow through study was performed, which revealed collection of contrast in the small bowel and a narrow fistulous tract up to anal verge confirming the hypothesis (Fig. 1). It was essentially due to the rupture of previously irradiated small bowel loop as a late complication of radiation therapy, which has formed an enterocutaneous tract up to the anal verge thus resulting in entero-anal fistula. Patient was re-explored and a side to end anastomses performed successfully.
3. Discussion Since Miles [1] described in1908, APR has been the gold standard for treatment of the distal rectal cancer. Despite improvements in operative and perioperative care it is associated with significant morbidity. Various series report mortality rates of 2–6% [2,3] and complication rates of over 50% [4]. Several studies have demonstrated an increase in both disease-free interval and overall survival when radiation therapy is combined with chemotherapy following surgical resection [5,6]. The addition of radiation and chemotherapy further adds up the morbidity. APR, as the name suggests, involve two phases: an abdominal phase and a perineal phase, done synchronously. This
extensive surgical procedure is performed in a confined space with wide anatomic variations in most cases on large tumors. It involves en bloc resection of the rectosigmoid, the rectum, and the anus along with the surrounding mesentery, mesorectum, and perianal soft tissues together with closure of anal opening and end colostomy thus resulting in iatrogenic vacant rectal fossa. This vacant rectal fossa may result in displacement of other pelvic organs. For instance, the urinary bladder tends to fall posteriorly and occupies a presacral and/or precoccygeal location with the seminal vesicles or uterus, and loops of the small bowel can be present in the vacant fossa [7,8]. Posterior displacement of pelvic organs is a major concern if radiation therapy is planned. If no proper precautions are being taken these displaced small bowel loops will get irradiated during radiation therapy and will under go acute and late morbidities of radiation. One of the surgical techniques to prevent the posterior displacement of pelvic organs is the peritonization of the raw area during surgery. But many surgeons do not prefer this technique routinely [9]. And such patients like the present case are at a higher risk of developing radiation enteritis that may some time result in fistula formation. Improved radiation planning and techniques can be used to minimize treatment-related complications. These techniques include the use of multiple pelvic fields, prone positioning, customized bowel immobilization molds (belly boards), bladder distention, visualization of the small bowel through oral contrast, and the incorporation of three-dimensional or comparative treatment planning [10].
4. Conclusion Today we see the high successful outcome of combined modality treatment comprising of surgery followed by adjuvant chemo radiotherapy in lower rectal cancers. The present case report is an example of extreme manifestation of radiation induced small bowel injury resulting in unusual entero-anal fistula which could have been prevented by surgical technique (peritonization of raw area or use of a biodegradable mesh) and with the use of better radiation planning techniques. Thus focus is on the avoidance of treatment related complications to ensure a better quality of life to the patient.
References [1] Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 1908;2:1812–3. [2] Rosen L, Veidenheimer MC, Coller JA, et al. Mortality, morbidity, and patterns of recurrence after abdominoperineal resection for cancer of the rectum. Dis Colon Rectum 1982;25:202–8. [3] Enker WE, Laffer UT, Block GE. Enhanced survival of patients with colon and rectal cancer is based upon wide anatomic resection. Ann Surg 1979;190:350–60.
M. Rastogi et al. / European Journal of Radiology Extra 61 (2007) 53–55 [4] Fitzgibbons Jr RJ, Harkrider Jr WW, Cohn Jr I. Review of abdominoperineal resections for cancer. Am J Surg 1977;134:624–9. [5] Krook JE, Moertel CG, Gunderson LL, et al. Effective surgical adjuvant therapy for high-risk rectal carcinoma. New England J Med 1991;324(11):709–15. [6] Fisher B, Wolmark N, Rockette H, et al. Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP protocol R-01. J Natl Cancer Inst 1988;80(1):21–9. [7] Carrington B. Postoperative and postradiation pelvis. In: Hricak H, Carrington BM, editors. MRI of the pelvis: a text atlas. London, England: Dunitz; 1991. p. 519–55.
55
[8] Lee JK, Stanley RJ, Sagel SS, Levitt RG, McClennan BL. CT appearance of the pelvis after abdomino-perineal resection for rectal carcinoma. Radiology 1981;141:737–41. [9] Faith S, Hulten L, Ojerskog B. Ommission of pelvic peritoneal closure after abdominoperineal rectal excision. Ann Chir Gynaecol 1977;66(4):181–3. [10] Koelbl O, Richter S, Flentje M. Influence of patient positioning on dosevolume histogram and normal tissue complication probability for small bowel and bladder in patients receiving pelvic irradiation: a prospective study using a 3D planning system and a radiobiological model. Int J Radiat Oncol, Biol, Phys 1999;45(5):1193–8.