The treatment of radiation-induced rectovaginal fistulas and rectal strictures is individualized ( Table 34-2 ). Suitability for major pelvic surgery must be determined, as well as the presence of locally recurrent or widely disseminated cancer. Anal manometry may provide useful insight as to whether the native rectum can adequately function as a storage reservoir. Compliance is measured by instilling sequential volumes of air into a balloon placed inside the rectal vault while assessing intrarectal pressure and patient sensation. Most normal patients are able to feel as little as 15 to 30 ml of air within the rectum and can tolerate up to 200 ml without having excessive discomfort. The urge to defecate usually occurs at 60 ml of air. The noncompliant radiated rectum cannot
TABLE 34-2 -- Surgical Treatment Methods in Patients with Radiation Injury of the Rectum
Low anterior resection Coloanal anastomosis
Colonic J-pouch-anal anastomosis
Sigmoid on-lay patch (Bricker-Johnston)
Transperineal flap accommodate increasing volumes of air without substantial and inappropriate rises in intrarectal pressure. Furthermore, the patient may experience significant discomfort shortly after the threshold sensation for a bowel movement is reached. The presence of a noncompliant rectum, therefore, may argue for resectional procedures rather than local repair of a rectovaginal fistula or stricture. The benefit gained from doing so is correction of the underlying problem, increased compliance and storage capability of the neorectum, and improved quality of life. The price to pay, however, is a procedure that may be accompanied by significant blood loss and the potential for other complications, such as genitourinary dysfunction and anastomotic leak.
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