Good morning, I'm posting to get the group's opinions on a case of severe post-radiation rectitis on a 74 years-old male patient.
- Jul 2021 prostate external beam irradiation with 7360 cGy for prostate cancer Gleason 7 (3+4). Patient free of cancer ever since.
- Six months later he starts having daily rectal bleeding. Does not accept medical treatment with sucralfate enemas.
- Aug 2023 hospitalized for endoscopic control with APC of persistent rectal bleeding. Rehospitalized one month later with life threatening rectal bleeding (Hct 40% -> 18%). Endoscopic hemostasis.
- Has daily anal pain and about 15 bowel movements with mucus per day.
- The pain is well controlled with paracetamol, Lyrica and Tramal. Has tried sucralfate enemas and cortisol enemas without any improvement.
- His last rectosigmoidoscopy on Dec 2023 confirms the persistence of ischemic rectitis with a normal sigmoid mucosa (photos). The pelvic MRI does not show any significant damage outside of the rectal wall.
- Has comorbidities with AF, COPD, depression. Has started eating normal and gained some weight after having lost 18% of his weight in 2 months (BMI 21,5).
What are your thoughts?
Any conservative measures to propose? (there's no experience with hyperbaric O2 treatment in our practice)
If you operated what would you choose? Hartmann colostomy? Parks procedure? Resection with coloanal pull-through anastomosis? Abdominoperineal amputation (Miles)?
When comparing excision to diversion, a Chinese meta-analysis (https://www.ncbi.nlm.nih.gov/pubmed/34823303) gives a higher complication rate for excision (35.1% vs. 15.9%, OR=2.67, 95% CI: 1.58 to 4.53) but also a better symptom improvement ((94.2% vs. 64.1%, OR=6.19, 95% CI: 2.47 to 15.52)
Thank you in advance for sharing your experience and posting your thoughts.