The surgical treatment of the radiation-damaged rectum

Details are given of 37 consecutive patients with radiation damage to the rectum. Twenty-eight presented with rectovaginal fistulas, 3 with haemorrhage from ulcerative proctitis, 3 with low rectal strictures, 2 with a painful rectal ulcer and 1 with a rectal carcinoma. Thirty-five of the 37 had been treated for carcinoma of the cervix, and of these, 30 were Black South African women in whom this disease forms approximately 70 per cent of all malignancies. Associated pathology in these patients included urinary fistulas, small bowel fistulas or stenoses and a variable degree of fibrosis of the pelvic cellular tissue. Treatment involved subtotal rectal resection with restoration of continuity by means of a peranal sleeve anastomosis between healthy colon and the rectal stump denuded of its mucosa. Technical success was achieved in 35 of the 37 patients, with no mortality. The functional results were assessed both subjectively and objectively in 31 patients followed up for more than 6 months. Full continence was achieved in 54 per cent initially, improving to 75 per cent (21 of 28) at 1 year postoperatively. At 1 year, variable degrees of incontinence for a liquid stool persisted in 7 of 9 patients who had low fistulas with a low anastomosis at dentate line level. Where anastomosis was possible at a higher level, all 19 patients cured of fistula, ulcer, stenosis or haemorrhagic proctitis were fully continent at 1 year.