Late radiogenic small bowel damage: Guidelines for the general surgeon

Background/Aims: The majority of late radiogenic small bowel injuries prese nts with obstruction or peritonitis. Owing to an average latency period of years, many of these patients are admitted to community hospitals and treat ed by general surgeons, who in turn see only a few pertinent patients in th eir professional lifetime. This study intends to provide the general surgeo n with comprehensive guidelines for safer surgical management. Material and Methods: Forty-one publications were analyzed in a search for clinical, pr ocedural and outcome data. Results: After a mean interval of 3.4 years foll owing radiotherapy, patients with a mean age of 57 years present with obstr uction (71%), fistula (17%), perforation (10%) or hemorrhage (2%) due to sm all bowel radiation injury. 22% have associated colorectal injury. The inte stinal compartments most frequently affected are lower ileum, cecum and rec tosigmoid, whereas the midgut and transverse colon are usually free. Conseq uently, the dehiscence rate of resection a nd ileoileostomy is 26%, jejunoi leostomy 12%, ileoascendostomy 9% and ileotransversostomy 4%, and the perti nent rate of progressive radiation injury is 9.1%. Bypass procedures yield an overall dehiscence rate of 9%, ileotransverse bypass 1.6%, and the rate of progressive radiation injury is 37%. The lethality of suture line insuff iciency is 85%. Lysis carries a lethal perforation rate of 6%. Only 58% of patients survive over 2 years, and of those not succumbing to unrelated dis ease, 37% die from progressive radiation injury and 63% from tumor progress ion. Conclusion: If resection is warranted, a reasonably extended ileal res ection, right hemicolectomy and ileotransversostomy, is safe. Likewise, ile otransverse anastomosis is the best choice for bypass. Lysis should not be inforced in radiation-injured bowel compartments. Terminal enterostomy with distal mucous fistula alleviates otherwise untreatable fistulae.