RU2786751C1 - Method for correcting chronic post-radiation proctopathy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely, to coloproctology. 1 to 2 sessions of hyperbaric oxygenation are conducted in the 1.3 to 1.5 at mode with an exposure time of 40 min. In the subsequent sessions, the pressure regime is increased to 2 at with an exposure time of 90 min, wherein the course of treatment lasts from 15 to 30 sessions.

EFFECT: shorter terms of treatment, improved results treatment, safety of the method in use.

1 cl, 3 ex

Description

The invention relates to medicine, namely to coloproctology, and can be used to correct chronic post-radiation proctopathy.

A known method for correcting post-radiation proctopathy by oral administration of drugs of the 5-aminosalicylic acid group, glucocorticosteroids, rectal administration of enemas with sucralfate, short-chain fatty acids, vitamins E and C. [1 - Kochhar R., Patel F., Dhar A. et al. Radiation-induced proctosigmoiditis. Prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate. Dig Dis Sci 1991;36(1): 103-7]. This method is accepted as analog

A known method of endoscopic correction of post-radiation proctopathy by argon plasma coagulation (APC) by exposure to an inert argon gas on the rectal mucosa. To achieve a lasting effect of therapy in this way, several courses of APC are required with intervals between sessions from 4 to 8 weeks [2 - Grishina E.A., Shishin K.V., Nedoluzhko I.Yu. and other Endoscopic methods of treatment of chronic radiation proctitis. Pelvic Surgery and Oncology 2020;10(3-4):65-72.]. This method is taken as a prototype. However, the prototype method is not efficient enough.

The goal is to improve the efficiency of the method by reducing the duration of treatment. The technical result consists in the fact that additionally 1-2 sessions of hyperbaric oxygenation are carried out in the mode of 1.3-1.5 ATA with an exposure time of 40 minutes, in subsequent sessions the pressure mode is increased to 2 ATA with an exposure time of 90 minutes, while the course of treatment is from 15 to 30 sessions

The method is carried out as follows. Chronic post-radiation proctopathy (CPP) is one of the most common complications of radiation therapy in the treatment of oncological diseases of the pelvic organs; it develops in 5-20% of cases, depending on the type and dose of radiation. The disease is based on direct radiation damage to the mucous membrane of the rectum and sigmoid colon with minimal inflammatory changes.

The pathogenesis of HPP is still not fully understood. It begins with radiation damage to the mucous membrane, which leads to additional growth of the endothelium and remodeling of the connective tissue, resulting in ischemic tissue changes. The radiation causes breaks in the DNA chain, which leads to the death of tumor cells, but this effect also extends to the stem cells of intestinal crypts. There is a massive death of cells of the mucous and submucosal layers of the rectal wall. Subsequently, the cytokine system is activated, leading to chronic mucosal ischemia, progressive atrophy of the epithelium, fibrosis, and the development of obliterating endarteritis. All changes in the wall of the rectum, the anal canal lead to the development of recurrent bleeding from the newly formed choroid plexuses, rectal stricture, the formation of deep ulcers and rectovaginal fistulas.

Radiation damage to the rectum is divided into acute and chronic forms. Acute may occur during radiation therapy in the first 6 weeks. after its completion. Depending on the severity of clinical manifestations, these complications may cause a temporary interruption of the course of treatment. Chronic forms appear in the first 2-3 years after the course of radiation therapy, may have a refractory period and have a relapsing course.

Clinical manifestations of CLP are pains in the lower abdomen of varying intensity, which are aggravated by the act of defecation, diarrhea, tenesmus and imperative urge to defecate. However, the most significant clinical manifestation of the disease is rectal bleeding. Rectal bleeding is the most common symptom, occurring in more than 80% of patients with late rectal radiation injury. Rectal bleeding is severe and refractory, often not amenable to conservative therapy, and can lead to severe anemia.

With a detailed clinical picture of the disease, daily activity is significantly limited and the quality of life of patients decreases. The mechanism of bleeding is due to leakage of blood through a loose ischemic mucosa or ruptures of telangiectasias. Bleeding can be quite massive and cause anemia.

An indispensable condition for conducting HBO sessions should be strict observance of safety regulations by all employees of the department.

Only standard equipment with individual grounding is placed in the barosal room; antistatic linoleum or other permitted materials are used as flooring. Electrical switches must be moved outside the baro-hall. Supply and exhaust ventilation, air conditioning systems, water supply, heating, power supply and grounding, lighting used to ensure the operation of the barozal should fully take into account the features of the equipment used. Among the most important measures to ensure the safety of any hazardous facility include the availability of operating instructions that require their mandatory implementation.

For conducting treatment sessions, medical pressure devices approved for use in medical organizations of the Russian Federation are used; in particular, the BLKS-ZOZMK and BLKS-307 "Khrunichev" pressure devices, which have proven themselves well for many years of trouble-free operation. Pressure chambers are convenient for patient placement, providing maximum patient accessibility for visual control. Relative humidity of at least 65% is maintained in the pressure chamber. Flammable objects, fat-containing substances, volatile compounds should not be allowed to enter the pressure chamber and any surfaces in contact with 02. In case of oil and other similar compounds, it is necessary to carry out degreasing and cleaning. During the operation of the pressure chamber, its periodic weekly degreasing is carried out. The gas supplied to the pressure apparatus must comply with the requirements of GOST 5583-78 (medical 02).

When prescribing HBO therapy, the following contraindications should be considered:

1. History of epilepsy

2. The presence of undrained cavities (caverns, abscesses) in the lungs

3. Claustrophobia

4. Severe forms of hypertension (medicated uncorrected hypertension)

5. Violation of the patency of the Eustachian tubes and canals connecting the paranasal sinuses with the external environment (polyps and inflammatory changes in the nasopharynx, middle ear, paranasal sinuses, developmental anomalies)

6. Confluent bilateral pneumonia

7. Tension pneumothorax

Before the HBO session, patients are dressed in special cotton, clean underwear, the hair on the head is covered with a moistened cap or scarf. Without fail, ointment bandages are removed, cosmetics are removed. There should be a special stainless steel plate in the office to remove static electricity from the patient. In addition, before being placed in the pressure chamber, a bracelet with individual grounding is applied to the patient. It is necessary to carefully check the reliability of fixation of all catheters, probes and drains, their connections and plugs. Drainage tubes and probes must be open and hermetically connected with plastic bags-collectors. All connections and the patient must be visually inspected.

Treatment is carried out in stationary pressure chambers in the mode of 1.3 -1.5 ATA (absolute atmospheres), exposure time 40 minutes

1-2 sessions are recommended to be carried out in the mode of 1.3-1.5 ata for 40 minutes. when monitoring respiratory rate, blood pressure, heart rate, Sp02. In subsequent sessions, the pressure regime increased to 2 ATA and the exposure time was 90 minutes. The course of treatment is from 15 to 30 sessions, taking into account the condition of the patients.

During the session, a constant monitoring of the patient and the dynamics of his clinical and physiological parameters is carried out. The absence of motor restlessness, slowing of the pulse and respiration, the natural color of the skin and mucous membranes, and the normalization of the ECG indicate the beneficial effect of hyperbaria. The negative effect of the whole complex of factors acting on the patient in the pressure chamber is evidenced by an increase in heart rate and respiration, an increase in blood pressure, and if pain in the ears occurs during compression, the compression rate must be reduced in patients.

The method is confirmed by the following examples Example 1

Patient A., aged 50, applied to the Moscow Scientific Center named after A.S. Loginov with complaints of bloody discharge from the rectum during defecation and pain in the lower abdomen. From the anamnesis it is known that in June 2019 the patient was diagnosed with stage I cervical cancer. In this connection, on August 12, 2019, laparoscopic extirpation of the uterus with appendages was performed. According to the histological examination of the surgical material, the tumor was represented by an invasive moderately differentiated squamous cell carcinoma with invasion into the thickness of no more than 5 mm. The postoperative period proceeded smoothly. On the 6th day after the operation, the patient was discharged from the hospital in a satisfactory condition.

At a multidisciplinary oncological consultation, it was recommended that the next stage of treatment be carried out - radiation therapy. From September 6 to October 24, 2019, 11 sessions of radiation therapy were performed according to the radical program, remotely in the statistical mode with two open opposing fields of a curly shape with a lower border in the middle of the womb and contact on the Microselectron device. The total dose of radiation therapy was 46 Gy for the regional lymphatic outflow and 67 Gy for the vaginal stump. During radiotherapy, no clinically significant radiation reactions were detected in the patient.

The patient was under the supervision of an oncologist at the place of residence. 6 months after the end of the combined treatment, the patient noted the release of dark blood from the rectum during defecation up to 4-5 times a day. About what was examined on an outpatient basis. Data for recurrence and progression of cervical cancer were not identified. However, colonoscopy in the rectum revealed multiple submucosal telangiectasias with eroded mucosa and contact bleeding. The patient was consulted by a coloproctologist. Based on the examination, a clinical diagnosis was established: chronic post-radiation proctopathy. Within one month, the patient received conservative therapy: Mesalazine 3 grams per day per os, budenofalk 2 milligrams rectally. Despite the treatment, the excretion of blood from the rectum progressively increased. The patient daily had multiple stools up to 5-6 times with blood clots. The patient was twice hospitalized in emergency hospitals with rectal bleeding complicated by severe post-hemorrhagic anemia (hemoglobin 56 g/l) against the background of chronic post-radiation proctopathy. The patient underwent hemostatic therapy and transfusion of blood components with a temporary effect, in the form of a decrease in the release of blood from the rectum. Due to the ineffectiveness of conservative therapy, she turned to the Loginov Medical Scientific Center. When endovideorectoskopiya on the anterior semicircle of the rectum were determined by multiple confluent telangiectasia about 1 cm in size. Severe bleeding of the rectal mucosa was noted. This endoscopic picture of changes in the rectal mucosa was regarded as grade 3 chronic post-radiation proctopathy according to the endoscopic density scale of rectal telangiectasias. To exclude inflammatory bowel diseases, the patient underwent a biopsy of the rectal mucosa, according to which morphological changes corresponded to chronic post-radiation proctopathy. In the mucosa, the surface epithelium was partially absent, sclerosis of the lamina propria with a pronounced proliferation of collagen fibers was noted. Also noted lymphovenous infiltration and expansion of capillary vessels.

The patient urgently underwent argon plasma coagulation of the altered areas of the rectal mucosa in the Precise mode with effect 4. The postoperative period was uneventful. After the operation, the patient noted a positive trend in the form of a significant decrease in the release of blood from the rectum. The chair was up to 2-3 times a day, periodically with a slight admixture of blood. At control rectoscopy 30 days after the operation, positive dynamics was noted in the form of a decrease in the number of telangiectasias of the rectal mucosa. However, on the 43rd day after the operation, the patient noted an abundant discharge of blood from the rectum. In this connection, the patient was urgently performed rectoscopy, according to which there was swelling and infiltration of the rectal mucosa, severe bleeding of tissues.

Given the ineffectiveness of conservative therapy and endoscopic methods of treatment, it was decided to refer the patient to hyperbaric oxygen therapy. At the Research Institute of Sp. N.V. Sklifosovsky, the patient underwent 1 session at a pressure of 1.3 ATA for 40 minutes, the second session at a pressure of 1.5 ATA, for 40 minutes. The course of treatment is 15 sessions under the condition of pressure of 2 ATA for 90 minutes. Against the background of hyperbaric oxygenation, the patient noted an improvement in well-being, mood, reduced fatigue, better exercise tolerance. The patient tolerated the baroseans well, noted a pronounced positive trend in the form of a complete cessation of blood from the rectum during defecation, a decrease in the frequency of defecation to 1 time per day. Control rectoscopy after 30 sessions of hyperbaric oxygenation showed complete absence of edema and infiltration of the rectal mucosa, a significant decrease in the size and number of telangiectasias. The patient was under dynamic observation for three months after the end of hyperbaric oxygen therapy. There are no clinical and endoscopic data for the recurrence of radiation proctitis.

Example 2

Patient K., 80 years old, applied to GBUZ MKNTs named after A.I. A.S. Loginov DZM with complaints of pain in the rectum, the release of blood and mucus from the rectum during defecation, false urge to defecate.

The above complaints have been bothering the patient for the last year and a half. From the anamnesis it is known that in 2018 the patient underwent combined radiation therapy according to a radical program for a total of up to 55 Gy due to stage II cervical cancer. She was constantly monitored by an oncologist at the Center for Outpatient Cancer Care. Data for recurrence and progression of cervical cancer were not identified.

Objectively: the condition is relatively satisfactory. The skin is pale in color. BP 130/70 mmHg Heart rate 82 min. RR 17 per min. Heart sounds are muffled, the rhythm is correct. In the lungs, vesicular breathing, no wheezing. The tongue is moist and clean. The abdomen is not swollen, soft, painless on palpation in all departments. There are no peritoneal symptoms. Stool 3-4 times a day with an admixture of blood. Periodically notes the release of blood clots. He urinates on his own, there are no dysuric phenomena, urine is yellow. Per rectum: the perianal area was not changed, the sphincter tone was preserved, no organic pathology was detected at the height of the finger, there were traces of feces mixed with dark blood on the glove. The study is painless.

Survey results:

Colonoscopy - the endoscope is freely passed into the rectum. At a distance of about 1 cm from the dentate line, a slit-like ulcerative defect of irregular shape, 4 mm in size, covered with fibrin, is determined. The mucosa around with an inflammatory shaft, as well as with multiple confluent telangiectasias. The rectal mucosa is pale, smooth, without inflammation.

Histological examination of endobiopsy of a rectal ulcer - a fragment of the colon mucosa from the ulcer is represented by fibrin-leukocyte masses and necrosis. There is mucosal edema and subepithelial hemorrhages, dense lymphocytic-plasmacytic infiltration. There are no signs of tumor growth. Treatment:

The patient urgently underwent argon plasma coagulation of the altered areas of the rectal mucosa in the Precise mode with effect 4. The postoperative period was uneventful. After the operation, the patient noted a positive trend in the form of a significant decrease in the release of blood from the rectum. The chair was up to 4-5 times a day with an admixture of blood. Control rectoscopy 30 days after the operation showed a slight positive trend in the form of a decrease in the number of telangiectasias of the rectal mucosa. However, on the 38th day after the operation, the patient noted an abundant discharge of blood from the rectum. In this connection, the patient was urgently performed rectoscopy, according to which there was swelling and infiltration of the rectal mucosa, severe bleeding of tissues.

Correction of chronic post-radiation proctopathy was carried out: 1 session of hyperbaric oxygenation is performed in the mode of 1.4 ATA with an exposure time of 40 minutes, in subsequent sessions, the pressure mode is 2 ATA with an exposure time of 90 minutes, while the course of treatment is 30 HBO sessions. Barotherapy was satisfactory. There were no complications.

During the treatment, she noted a positive clinical trend - pain in the rectal area disappeared, no bleeding from the rectum was noted, the stool settled up to 1-2 times a day. The patient noted an increase in exercise tolerance.

During rectoscopy after treatment, a positive endoscopic picture was noted - a slit-like scar about 4 mm in size is determined at a distance of about 1 cm from the dentate line. There is no mucosal edema. The ulcer healed. The rectal mucosa is pale, smooth, without inflammation.

Example 3

Patient E., aged 58, applied to the Moscow Scientific Center named after A.S. Loginova in February 2022 with complaints of bleeding from the rectum during defecation, mushy stools up to 3-4 times a day. From the anamnesis of the disease, it is known that in 2021 the patient underwent CRT under a radical program for cervical cancer, the radiation exposure of SOD was 50 Gy. 6 months after the end of radiation therapy noted the appearance of the above complaints. She was treated conservatively by a coloproctologist in a polyclinic without a significant clinical effect. Objectively: the condition is satisfactory. The skin is pale pink in color. BP 130/75 mmHg Heart rate 68 min. RR 17 per min. The heart sounds are clear, the rhythm is correct. In the lungs, vesicular breathing, no wheezing. The tongue is moist and clean. The abdomen is not swollen, soft, painless on palpation in all departments. There are no peritoneal symptoms. Stool 3-4 times a day, mushy with an admixture of blood. He urinates on his own, there are no dysuric phenomena, urine is yellow.

Per rectum: the perianal region is not changed, the sphincter tone is preserved, at 3, 7 and 11 hours of the conventional dial, internal, not enlarged, and corresponding external hemorrhoids are determined without signs of inflammatory thrombosis. At the height of the finger (6 cm), organic pathology is not determined, traces of feces on the glove are of physiological color. Survey results:

Colonoscopy: The endoscope was freely passed into the rectum, its mucosa is hyperemic, at a distance of 3 cm from the anus, along the left wall, a flat ulcer defect is determined, about 1.5 cm in size. The mucosa around it is sharply hyperemic, with granulation phenomena. Multiple telangiectasias are determined along all walls.

Histological examination of the endobioptate - transmural focal pronounced lymphohistiocytic and neutrophilic infiltration, focal areas of violation of the architectonics of the crypts with areas of destruction, the formation of ulcers. Treatment:

The patient urgently underwent argon plasma coagulation of the altered areas of the rectal mucosa in the Precise mode with effect 4. The postoperative period was uneventful. After the operation, the patient noted a positive trend in the form of a significant decrease in the release of blood from the rectum. The chair was up to 3-5 times a day with an admixture of blood. At control rectoscopy 30 days after the operation, positive dynamics was noted in the form of a decrease in the number of telangiectasias of the rectal mucosa. However, on the 40th day after the operation, the patient noted an abundant discharge of blood from the rectum. In this connection, the patient was urgently performed rectoscopy, according to which there was swelling and infiltration of the rectal mucosa, severe bleeding of tissues.

Correction of chronic post-radiation proctopathy is carried out with 2 sessions of hyperbaric oxygenation in the mode of 1.4 ATA with an exposure time of 40 minutes, in subsequent sessions, the pressure mode is 2 ATA with an exposure time of 90 minutes, while the course of treatment is from 20 HBO sessions. Barotherapy was satisfactory. There were no complications.

On the background of treatment, she noted a positive clinical trend - the discharge of blood from the rectum was gone, the stool settled up to 1 time per day. The patient also noted an increase in exercise tolerance.

During rectoscopy after treatment, a positive endoscopic picture was noted - the rectal ulcer healed, the number and size of telangiectasias decreased. Edema and erosive changes in the rectal mucosa are absent.

Using this method, HBO is presented in 36 patients with CLP. All patients had stopped bleeding and stopped pain. The goal is achieved by reducing the duration of treatment and improving its results.

Sources of information

1. Kochhar R., Patel F., Dhar A. et al. Radiation-induced proctosigmoiditis. Prospective, randomized, double-blind controlled trial of oral sulfasalazine plus rectal steroids versus rectal sucralfate. Dig Dis Sci 1991;36(1): 103-7

2 - Grishina E.A., Shishin K.V., Nedoluzhko I.Yu. and other Endoscopic methods of treatment of chronic radiation proctitis. Pelvic surgery and oncology 2020;10(3-4):65-72.

Claims (1)

A method for correcting chronic post-radiation proctopathy by argon plasma coagulation during endoscopic examination, characterized in that 1-2 sessions of hyperbaric oxygenation are additionally performed in the mode of 1.3-1.5 atm at an exposure time of 40 minutes, in subsequent sessions, the pressure mode is 2 atm at an exposure time 90 minutes, while the course of treatment is from 15 to 30 sessions.