Pelvic peritoneal reconstruction to prevent radiation enteritis in rectal carcinoma

Some patients with rectal cancer who undergo exenterative surgery may require radiation therapy as an adjuvant treatment for recurrent or residual disease. A common devastating side effect of this treatment modality is radiation enteritis, a radiation-induced small bowel injury. Hence, the prevention of such a complication is essential for both the surgeon and the radiation oncologist. A new surgical method using the posterior rectus sheath and peritoneum to partition the abdominal cavity at the level of the umbilicus to the sacral promontory seems to accomplish this purpose, keeping the small bowel away from the pelvic cavity. After removal of the rectal lesion [eight abdominoperineal resections (APRs), nine Hartmann's procedures, and one low anterior resection (LAR)] in 18 patients with rectal cancer, this new surgical procedure was performed. One of the patients had an early postoperative intestinal obstruction, and all but one of the patients received postoperative adjuvant radiation therapy. In addition, a small bowel series was performed before the radiation therapy and six months and one year after surgery. Upon examination, most of these patients still had their small bowel kept intact in the abdominal cavity. During the follow-up period of 10 months to 2 years with an average of 18 months, two late complications of intestinal obstruction were noted. Exploratory laparotomy of these two patients revealed radiation enteritis of the small bowel. Therefore, the failure rate of the following procedure is 12 percent, since 2 of the 17 patients received small bowel injury. Although the follow-up period for this surgical method is short, the results have encouraged us to continue the use of this procedure on advanced rectal cancer patients who require postoperative radiation therapy.