Late radiogenic small bowel damage: guidelines for the general surgeon

The majority of late radiogenic small bowel injuries presents with obstruction or peritonitis. Owing to an average latency period of years, many of these patients are admitted to community hospitals and treated by general surgeons, who in turn see only a few pertinent patients in their professional lifetime. This study intends to provide the general surgeon with comprehensive guidelines for safer surgical management.

Forty-one publications were analyzed in a search for clinical, procedural and outcome data.

After a mean interval of 3.4 years following radiotherapy, patients with a mean age of 57 years present with obstruction (71%), fistula (17%), perforation (10%) or hemorrhage (2%) due to small bowel radiation injury. 22% have associated colorectal injury. The intestinal compartments most frequently affected are lower ileum, cecum and rectosigmoid, whereas the midgut and transverse colon are usually free. Consequently, the dehiscence rate of resection and ileoileostomy is 26%, jejunoileostomy 12%, ileoascendostomy 9% and ileotransversostomy 4%, and the pertinent 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 insufficiency 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 disease, 37% die from progressive radiation injury and 63% from tumor progression.

If resection is warranted, a reasonably extended ileal resection, right hemicolectomy and ileotransversostomy, is safe. Likewise, ileotransverse anastomosis is the best choice for bypass. Lysis should not be enforced in radiation-injured bowel compartments. Terminal enterostomy with distal mucous fistula alleviates otherwise untreatable fistulae.