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Radiation enteritis is a significant complication of external beam radiotherapy (EBRT) to the pelvis, particularly in patients having high dose radiotherapy (>80 Gy) and in those with a low pelvic peritoneal reflection allowing loops of small bowel to enter the radiation field. Laparoscopic insertion and subsequent removal of a pelvic tissue expander before and after external beam radiotherapy is a relatively convenient, safe and effective method for displacing loops of bowel out of the pelvis. We report on a patient with prostate cancer who ordinarily would not have been a candidate for EBRT due to loops of bowel low in the pelvis. With laparoscopic insertion and subsequent removal of a tissue expander, he was able to have radiotherapy to the prostate without developing radiation enteritis. Introduction midline laparotomy for gastric lymphoma, and open Prostate cancer is the second most common cancer in appendicectomy for perforated appendicitis, and a men. With the increasing use of primary radiotherapy laparoscopic cholecystectomy. Radiation planning CT for prostate cancer and improved survival, chronic demonstrated a low pelvic peritoneal reflection with radiation enteritis is an increasing problem occurring in loops of bowel in the pelvis within the planned radiation over 20%ofpatients.The very high dosesof80Gy field of the prostate (Figure 1). radiotherapy required for prostate cancer, which is dou- These loops of bowel would not move out of the ble that given for most other pelvic malignancies, puts planned radiation field despite several manoeuvrers those patients with a low peritoneal reflection and low- including extreme prone and Trendelenburg positioning, lying loops of small bowel in the pelvis, at particular bladder filling, and use of an open table-top device risk of radiation enteritis. (belly board). Laparoscopic insertion of a tissue expan- Laparoscopic insertion and subsequent removal of a der into the pelvis to displace loops of bowel was his tissue expander before and after radiotherapy is a rela- only option. No bowel prep was required. A 12 mm tively convenient and minimally invasive procedure that infra-umbilical incision was made and an open Hasson may be an option for displacing loops of bowel from the technique used to achieve pneumoperitoneum, with the radiation field. placement of a 12 mm port at the umbilicus and 5 mm ports in both iliac fossa (Figure 2). Adherent loops of Case Presentation bowel from previous surgery were divided by scissored dissection. The patient was a 75 year old man with prostate cancer, confirmed by FNA to investigate a raised PSA. He had In lithotomy and steep Trendelenburg positioning, the stage 2 disease with a Gleason score of 3+4, and suprapubic incision was dilated up to 20 mm with the required primary radiotherapy. He was relatively fit and aid of a medium Alexis wound retractor (Figure 3). healthy, with a BMI of 29. He had a previous upper A TRD 500 ml Nagor tissue expander made of sili- cone with attached silicone tubing (Figure 4) was then * Correspondence: email@example.com rolled tight, lubricated with water soluble hydroxyethyl- Department of Colorectal Surgery, Bankstown Hospital, Eldridge Rd, ® cellulose and glycerine based (K-Y Jelly ) lubricant and Bankstown, NSW, Australia inserted via the 20 mm suprapubic port and placed Full list of author information is available at the end of the article © 2011 McKay et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. McKay et al. Radiation Oncology 2011, 6:47 Page 2 of 6 http://www.ro-journal.com/content/6/1/47 Figure 3 Insertion of tissue-expander through medium Alexis ring retractor in the 20 mm supra-pubic incision: this was facilitated by prior lubrication with water-soluble K-Y Jelly . laparoscopically in the pelvis, leaving the normal-saline inflation port attached externally. Figure 1 Planning sagittal CT in 75 year old man with prostate A running dissolvable 3/0 polydiaxanone (PDA) purse- cancer. Opaque planning fiducial marker visible in prostate with string stitch was then sutured to the peritoneum of the adjacent loops of small bowel within the planned radiation field. sacral promontory, and anterior and side walls of the pel- vis below the level of the common iliacs, and tied snug to keep the expander in the pelvis. With a Huber needle inserted into the inflation port, the tissue expander was then filled with 350 ml of normal saline until the expan- der began to bulge against the retaining stitch (Figure 5). The abdomen was then deflated of gas and the fascia of both the Pfannenstiel and umbilical port closed. The port of the expander was then placed in a small subcu- taneous pocket and sutured to the fascia of the anterior Figure 2 Four incisions used for laparoscopic insertion of a Figure 4 A 500 ml TRD Nagor siliconetissueexpanderwith tissue expander in the pelvis: 12 mm umbilical, 20 mm attached inflation port: this allows for filling with normal pfannenstiel, and 5 mm iliac fossa incisions. saline. McKay et al. Radiation Oncology 2011, 6:47 Page 3 of 6 http://www.ro-journal.com/content/6/1/47 weeks later he went on to have external beam radiother- apy to his prostate (80 Gy in 39 fractions over 8 weeks), achieving a good response without any side effects or symptoms. Repeat CT prior to removal of the expander showed a well placed expander within the pelvis, with no evidence of radiation injury to small bowel or the prosthesis. The tissue expander was removed laparoscopically 6 weeks after completing radiotherapy using the same initial incisions, with a good cosmetic result. There were no adhesions to the silicone implant, and the PDA retaining string was intact, but easily broke with a gentle Figure 5 Tissue expander secured in pelvis with dissolvable tug. These two factors facilitated its easy laparoscopic running 3/0 polydiaxanone (PDA) purse string stitched to removal. peritoneum of sacral promontory, anterior and pelvic side walls: the expander was subsequently filled with normal saline Discussion until it began to bulge against the retaining stitch. Radiation enteritis causes considerable disability, and in many cases can be avoided. Any patient having external abdomen. Skin incisions were closed in the usual man- beam pelvic radiotherapy should have a planning CT, ner. Subsequent CT confirmed adequate placement of with particular attention given to those patients with a the expander device in the pelvis with loops of bowel low peritoneal reflection, and loops of bowel within the now well out of the pelvis and the planned radiation planned radiation field. Methods of reducing injury to field (Figure 6). small bowel include multi-field conformal therapy with His recovery was uneventful being discharged home prior three dimensional planning where the profile of without complication after opening his bowels. Two the radiation beam is shaped to fit the target. The deliv- ery of intensity-modulated radiotherapy can also be adjusted and improves the ability of treatment volumes to conform to the shape of the tumour. Despite these techniques, loops of bowel still occasionally get injured from being in the radiation field. If available, brachyther- apy or cryotherapy may be reasonable alternatives to external beam radiotherapy. Where external beam radio- therapy is the preferred or only option, various methods for removing small bowel from the radiation field exist. Conventional non-operative manoeuvres to remove small bowel from the pelvis at the time of giving radio- therapy include extreme prone or Trendelenburg posi- tioning, bladder distension, abdominal wall compression or the use of an open table-top device (belly board). The response of such manoeuvres is not always repro- ducible. More extreme measures described only in case reports include the surgical insertion of a peritoneal dia- lysis catheter and creation of a temporary artificial pneumoperitoneum or ascites with the installation of gas or normal saline into the abdominal cavity. These are time consuming, painful, and need to be repeated, and do not reliable remove bowel from the radiation field. Early surgical procedures to keep small bowel out of the pelvis were aimed at abdomino-pelvic partitioning, either with the use of native tissue or prosthetic mate- rial. Native tissue partitioning frequently involves the Figure 6 CT following tissue expander insertion. The loops of use of the peritoneum, bladder, uterine broad ligaments bowel are now well out of the pelvis and planned radiation field. and omentum. In 1979, Freund described suturing the McKay et al. Radiation Oncology 2011, 6:47 Page 4 of 6 http://www.ro-journal.com/content/6/1/47 anterolateral peritoneum to the bladder and to the ante- fistula formation. Therefore, there has been a trend rior rectum. In women, the uterus and broad liga- away from the use of mesh, with fixation of the expan- ments may be used in addition to the posterior tissue. der to the peritoneum with a suture the commonest and In 1985, DeLuca and Ragins described the omental safest method. Some expanders have suture tabs for this envelope technique (also called an abomino-pelvic purpose. Since Sugarbaker’s first description, there have omentopexy), where omentum is draped over the been over 160 reported cases of tissue expanders used in the pelvis or the abdomen to prevent radiation injury small bowel as an apron, and the lower edge sutured to to small bowel (Table 1). All of these were inserted at the sacral promontory. The lateral borders are sutured open laparotomy. Lasser first described its use prior to to the ascending and descending colon. In 1995, Choi and Lee described the omental pedicle hammock techni- radiotherapy for rectal cancer . Many reported cases que where a pedicle of omentum based on the left involved the use of large tissue expanders for patients gastroepiploics is sutured circumferentially to the perito- requiring post-operative adjuvant radiotherapy for large neum at the level of the sacral promontory and umbili- retroperitoneal sarcomas or gynaecological malignancies. cus. This creates a sling, or hammock, which keeps For all of these types of malignancies the radiation dose small bowel out of the pelvis. Partitioning with prosthe- received was usually less than 50 Gy (Table 1). tic material has also been described, and includes the Early experience with tissue expanders found that use of absorbable mesh slings. complications were more common when large expan- There are many difficulties with partitioning techni- ders where left in the pelvis long term, with the poten- ques. Firstly, native tissue is frequently not sufficiently tial for bladder, ureteric and iliac vessel compression. adequate or strong enough to achieve partitioning, and Heaviness is a common complaint of very large expan- prosthetic materials run the risk of infection or adher- ders. Deep vein thrombosis with pulmonary embo- ence to loops of bowel or the creation of a fistula. Parti- lism and constipation due to obstructive defecation have tioning of the pelvis from the abdomen may also create been reported[11,12]. More recent reports using smaller an empty pelvic space. Loops of bowel may get caught implants show them to be associated with fewer compli- beneath the partition resulting in an internal hernia and cations[13-17]. Infection, with abscess formation and fis- obstruction. The cavity beneath the partition may also tulisation, have been reported to occur in up to 7% of fill with fluid, and this has the potential to become cases. Wound infections associated with large lapar- infected resulting in a chronic pelvis abscess. otomy incisions are not uncommon, particularly when the incision extends into the radiation field. The Pelvic-space occupying techniques avoid some of the other disadvantage of tissue expanders, is that they do problems inherent to partitioning techniques. In 1984, Russ described using an omental pedicle flap based on very little to prevent radiation injury to the bladder or the left gastroepiploic vessels, which is placed along the rectum, with radiation cystitis and proctitis still left para-colic gutter with the distal tip packed into the common complications. pelvis. This is particularly suitable during open color- Ours is the first report in the literature of a totally ectal surgery where mobilisation of the omentum off the laparoscopic insertion and removal of a tissue expander colon is required. But this procedure is difficult to per- prior to and following primary prostatic radiotherapy. In form laparoscopically, and in the thin patient, the omen- this case, a much higher dose of 80 Gy radiotherapy was tum is usually frequently not sufficient to fill or reach given. Previous major surgery was not a contraindication the pelvis. to this procedure. In our case, a conventional 500 ml Normal saline filled silicone tissue expanders are easy normal-saline-filled siliconetissueexpanderwithout to insert and remove and have the benefit of being non- suture tabs, was used, and it was kept in the pelvis by adherent to both peritoneum and small bowel, as well means of a polydiaxanone (PDA) purse string suture. as radioresistant to degradation, and when filled with This monofilament has a tensile-strength half life of 5 normal saline, are similar in density to human tissues, weeks, with significant degradation of the suture at 10- therefore do not alter the isodose distribution of radio- 12 weeks. Therefore removal of the expander was per- therapy. In 1983, Sugarbaker first described the open formed easily by gentle traction alone. However there is insertion of a normal-saline-filled silicone breast implant a risk with dissolvable sutures of tissue expander migra- into the pelvis to exclude small bowel from the pelvis to tion, therefore a non-dissolvable suture may also be prevent injury from post-operative radiotherapy. appropriate. The choice of a conventional sized expan- der and the avoidance of overfilling were because of lit- Sugarbaker described covering the implant with a mesh erature reports of the risks of ureteric and iliac vessel which was sutured to the peritoneum of the pelvic brim compression. to prevent migration or extrusion of the expander. How- ever, over the years, mesh was found to be associated The ease, simplicity, reversibility, and minimally inva- with an increased risk of small bowel adhesions and sive nature of laparoscopic tissue expander insertion are McKay et al. Radiation Oncology 2011, 6:47 Page 5 of 6 http://www.ro-journal.com/content/6/1/47 Table 1 Cases to date of intra-abdominal or pelvic insertion of a normal saline-filled silicone implant prior to external beam radiotherapy Author Year Origin Number Indication Radiotherapy Site Insertion & Expander fixation Radiation complications due to removal size dose prosthesis Sugarbaker 1983 Washington 1 unspecified adjuvant pelvis open up to prosthetic mesh to 65 Gy no  DC, USA 1000 ml pelvic brim Lasser et al 1986 Paris, France 9 rectal cancer adjuvant pelvis open ? ? no  Armstrong 1990 New York, 2 fibrosarcoma adjuvant renal bed open 400-500 none 30 Gy no et al USA ml Cuttat et al 1991 Lausanne, 4 rectal cancer adjuvant pelvis open 500 ml ? ? no  Switzerland Delaloye 1994 Vandois, 18 cervical cancer adjuvant pelvis open 350-400 absorbable suture 56-60.8 Gy hydronephrosis (n = 1) et al Switzerland ml constipation 9 (n = 1) Hoffman 1998 Philadelphia, 58 sarcomas & adjuvant (n = 57) pelvis & lower open 550-1,500 absorbable suture 40-50 Gy abscess (n = 4) et al USA endometrial, vaginal, primary (n = 1) abdomen ml fistula (n = 4), extrusion rectal, colon & anal (n = 1) cancer Sezeur et al 1999 Paris, France 22 retroperitoneal sarcoma adjuvant pelvis & open ? ? 30-65 Gy heaviness (n = 1)  and pelvic cancer. abdomen flank pain (n = 1) Burnett et al 2000 Los Angeles, 7 cervical cancer adjuvant pelvis open 750-1,500 absorbable suture 50.4 Gy adhesions of bowel to  USA ml implant (n = 1) pulmonary embolism (n = 1) Abhyankar 2005 Wales, UK 1 rhabdomyosarcoma adjuvant right upper open 250 ml mesh 45 Gy no et al abdomen Hølmebakk 2006 Oslo, Norway 1 Retroperitoneal adjuvant pelvic open 500 ml sutured & omental 50 Gy no et al recurrence of colorectal sling cancer White et al 2007 Calgary, 33 sarcomas & neo-adjuvant (n = 25) pelvis & open 700 ml Dexon mesh 45-50 Gy Cystitis (n = 1)  Canada endometrial, vaginal, adjuvant (n = 1) abdomen Ileus (n = 1) rectal & colon cancer primary (n = 11) Hong et al 2008 Sydney, 2 retroperitoneal sarcoma adjuvant lower open 1000 ml ? 50 Gy no  Australia & abdominal wall abdomen sarcoma Angster 2010 Baltimore, 2 cervical cancer & adjuvant pelvis & open 400 ml & none ? no et al USA retroperitoneal sarcoma abdomen 500 ml McKay et al 2011 Sydney, 1 prostate cancer primary pelvis laparoscopic 500 ml absorbable suture 80 Gy No Australia McKay et al. Radiation Oncology 2011, 6:47 Page 6 of 6 http://www.ro-journal.com/content/6/1/47 13. Abhyankar A, Jenney M, Huddart SN, Tilsley DW, Cox R, Saad M: Use of a its main appeal. It should be considered as an option for tissue expander and a polyglactic acid (Vicryl) mesh to reduce radiation excluding small bowel from the pelvis prior to radio- enteritis: Case report and literature review. Pediatr Surg Int 2005, therapy of the prostate. 21:755-757. 14. Armstrong JG, Harrison LB, Dattoli M, Concepcion R, Minsky BD, Fortner J: The use of a prosthetic tissue expander to displace bowel from a Consent brachytherapy implant site. Int J Radiat Oncol Biol Phys 1990, 19:1521-1523. Written informed consent was obtained from the patient 15. Cuttat JF, Coucke P, Mirimanoff R: Radiation protection of the small intestine in the lesser pelvis using an inflatable silicon prosthesis. for publication of this case report and accompanying Schweiz Med Wochenschr 1991, 121:1055-1061. images. A copy of the written consent is available for 16. Hølmebakk T, Wiig JN, Wanderås EH, Harbitz TB: Protective silicone review by the Editor-in-Chief of this journal. prosthesis prior to radiotherapy of recurrent colonic cancer. Tidsskr Nor Laegeforen 2006, 126:447-449. 17. Angster K, Shridharani SM, Rad AN, Ahuja N, Rosson GD, Angster : Intraabdominal tissue expanders to prevent radiation enteritis: Author details preliminary report. Plastic and Recon Surg 2010, 25:177e-79e. Department of Colorectal Surgery, Bankstown Hospital, Eldridge Rd, 18. Hoffman JP, Sigurdson ER, Eisenberg BL: Use of saline-filled tissue Bankstown, NSW, Australia. Department of Radiation Oncology, Liverpool expanders to protect the small bowel from radiation. Oncology 1998, Hospital, Goulburn St, Liverpool, NSW, Australia. 12:51-54, discussion 54, 60, 62. 19. Hong A, Stevens G, Stephen M: Protection of the small bowel during Authors’ contributions abdominal radiation therapy with a tissue expander prosthesis. Aust N Z GM wrote the manuscript, KW did literature review and organised planning J Surg 2000, 70:690-692. CT and radiotherapy; DK inserted and removed the tissue expander and 20. White JS, Biberdorf D, DiFrancesco LM, Kurien E, Temple W: Use of tissue supervised writing of manuscript. All authors read and approved the final expanders and pre-operative external beam radiotherapy in the manuscript. treatment of retroperitoneal sarcoma. Ann Surg Oncol 2007, 14:583-590. Competing interests doi:10.1186/1748-717X-6-47 The authors declare that they have no competing interests. Cite this article as: McKay et al.: Laparoscopic insertion of pelvic tissue expander to prevent radiation enteritis prior to radiotherapy for Received: 15 February 2011 Accepted: 14 May 2011 prostate cancer. Radiation Oncology 2011 6:47. Published: 14 May 2011 References 1. Theis VS, Sripadam R, Ramani V, Lal S: Chronic radiation enteritis. Clinical Oncology 2010, 22:70-83. 2. 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Radiation Oncology – Springer Journals
Published: May 14, 2011
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