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©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 28, 2020; 26(8): 850-864
Published online Feb 28, 2020. doi: 10.3748/wjg.v26.i8.850
Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy
Zi-Xu Yuan, Qi-Yuan Qin, Miao-Miao Zhu, Qing-Hua Zhong, Alessandro Fichera, Hui Wang, Huai-Ming Wang, Xiao-Yan Huang, Wu-Teng Cao, Ye-Biao Zhao, Lei Wang, Teng-Hui Ma
Zi-Xu Yuan, Qi-Yuan Qin, Miao-Miao Zhu, Qing-Hua Zhong, Hui Wang, Huai-Ming Wang, Xiao-Yan Huang, Ye-Biao Zhao, Lei Wang, Teng-Hui Ma, Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
Zi-Xu Yuan, Qi-Yuan Qin, Qing-Hua Zhong, Hui Wang, Huai-Ming Wang, Ye-Biao Zhao, Lei Wang, Teng-Hui Ma, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases; Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
Alessandro Fichera, Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, United States
Wu-Teng Cao, Department of Radiology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510655, Guangdong Province, China
Author contributions: Yuan ZX, Qin QY, Ma TH, Wang L, and Wang H conceived of and designed the study; Yuan ZX, Zhu MM, Zhong QH, Zhao YB, Huang XY, and Cao WT collected the data and followed the patients; Yuan ZX, Qin QY, Huang XY, and Wang H analyzed and interpreted the data; Yuan ZX, Qin QY, and Ma TH drafted the manuscript; Yuan ZX, Wang H, Fichera A, and Ma TH made critical revisions to the manuscript.
Supported by National Natural Science Foundation of China, No. 8157120115 and No. 81803163; Natural Science Foundation of Guangdong PhD Start Grant, No. 2018A030310320 and No. 2018A030310319; 5010 Project of Sun Yat-Sen University; and Johnson & Johnson Grant for Excellent Surgeons.
Institutional review board statement: This study was approved by the Ethical Committee of The Sixth Affiliated Hospital of Sun Yat-Sen University and also according to the provisions of the World Medical Association’s Declaration of Helsinki in 1995 (updated in Tokyo, 2004).
Informed consent statement: Informed consent of this study was waived due to its retrospective nature. Patients agreed to undergo treatment by written consent.
Conflict-of-interest statement: There are no conflicts of interest to report.
STROBE statement: All items that should be included in reports of cohort studies have been included.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Teng-Hui Ma, MD, Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Road, Guangzhou 510655, Guangdong Province, China.
austin_2004@163.com
Received: October 10, 2019
Peer-review started: October 30, 2019
First decision: November 22, 2019
Revised: December 4, 2019
Accepted: February 15, 2020
Article in press: February 15, 2020
Published online: February 28, 2020
Processing time: 120 Days and 15.1 Hours
BACKGROUND
Severe chronic radiation proctopathy (CRP) is difficult to treat.
AIM
To evaluate the efficacy of colostomy and stoma reversal for CRP.
METHODS
To assess the efficacy of colostomy in CRP, patients with severe hemorrhagic CRP who underwent colostomy or conservative treatment were enrolled. Patients with tumor recurrence, rectal-vaginal fistula or other types of rectal fistulas, or who were lost to follow-up were excluded. Rectal bleeding, hemoglobin (Hb), endoscopic features, endo-ultrasound, rectal manometry, and magnetic resonance imaging findings were recorded. Quality of life before stoma and after closure reversal was scored with questionnaires. Anorectal functions were assessed using the CRP symptom scale, which contains the following items: Watery stool, urgency, perianal pain, tenesmus, rectal bleeding, and fecal/gas incontinence.
RESULTS
A total of 738 continual CRP patients were screened. After exclusion, 14 patients in the colostomy group and 25 in the conservative group were included in the final analysis. Preoperative Hb was only 63 g/L ± 17.8 g/L in the colostomy group compared to 88.2 g/L ± 19.3 g/L (P < 0.001) in the conservative group. All 14 patients in the former group achieved complete remission of bleeding, and the colostomy was successfully reversed in 13 of 14 (93%), excepting one very old patient. The median duration of stoma was 16 (range: 9-53) mo. The Hb level increased gradually from 75 g/L at 3 mo, 99 g/L at 6 mo, and 107 g/L at 9 mo to 111 g/L at 1 year and 117 g/L at 2 years after the stoma, but no bleeding cessation or significant increase in Hb levels was observed in the conservative group. Endoscopic telangiectasia and bleeding were greatly improved. Endo-ultrasound showed decreased vascularity, and magnetic resonance imaging revealed an increasing presarcal space and thickened rectal wall. Anorectal functions and quality of life were significantly improved after stoma reversal, when compared to those before stoma creation.
CONCLUSION
Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP. Stoma can be reversed, and anorectal functions can be recovered after reversal.
Core tip: This study evaluated the efficacy of colostomy and stoma reversal in severe chronic hemorrhagic radiation proctopathy. After screening 738 patients, 14 patients in the colostomy group and 25 in the conservative treatment group were included. All 14 colostomy patients achieved complete remission of bleeding, and the colostomy was reversed in 13 patients. The hemoglobin level increased gradually after the stoma. However, no bleeding cessation was observed in the conservative group. Anorectal functions and quality of life were improved after stoma reversal. In conclusion, diverting colostomy is an effective option and can be reversed in severe chronic hemorrhagic radiation proctopathy.
