Use of Saline-Filled Tissue Expanders to Protect the Small Bowel from Radiation
Dr. Hoffman and colleagues have persisted in their efforts to provide a safe, reliable pelvic prosthesis to protect the small bowel during high-dose radiation therapy. I started using this type of plastic device in the early 1980s as part of the management of advanced primary and recurrent rectal cancer.[1,2] Similar to data reported by Drs. Hoffman, Sigurdson, and Eisenberg in this issue, my colleagues and I at the National Cancer Institute also noted a learning curve that accompanied our experience. We reported our experience with two iliac artery fistulas that occurred after extensive radiation therapy, possibly due to the prosthesis.[3] Sepsis within the irradiated field and surrounding the prosthesis led to a prosthesis-related death in one patient. A second patient who had multiple postoperative complications died of a pulmonary embolus.
Dr. Hoffman and colleagues have persisted in their efforts to provide a safe, reliable pelvic prosthesis to protect the small bowel during high-dose radiation therapy. I started using this type of plastic device in the early 1980s as part of the management of advanced primary and recurrent rectal cancer.[1,2] Similar to data reported by Drs. Hoffman, Sigurdson, and Eisenberg in this issue, my colleagues and I at the National Cancer Institute also noted a learning curve that accompanied our experience. We reported our experience with two iliac artery fistulas that occurred after extensive radiation therapy, possibly due to the prosthesis.[3] Sepsis within the irradiated field and surrounding the prosthesis led to a prosthesis-related death in one patient. A second patient who had multiple postoperative complications died of a pulmonary embolus.
Our initial experience with the prosthesis in nine patients was documented in the colorectal cancer literature.[4] A design patent to record the development of this device at the Surgery Branch of the National Institutes of Health was sought and obtained.[5] A preliminary report that documented our experience with afterloading catheters in the pelvis combined with an inflatable displacement prosthesis was published.[6] After all of this effort to develop a pelvic prosthesis, one would anticipate a steady increase in use. However, in contrast to our expectations, extensive use of the saline-filled pelvic displacement prosthesis has not occurred, and the few reports from other groups indicate restricted use of saline-filled pelvic displacement prostheses.
Why Arent We Using the Device?
Why this device has not been incorporated into more general usage is unclear. Saline-filled breast prostheses are readily available to, and used by, general surgeons, and the need to protect the small bowel from radiation damage when treating pelvic malignancy remains.
Two problems related to the use of a pelvic prosthesis come to mind. First, radiation therapy, even at the doses allowed by small bowel exclusion, may not be able to control the pelvic malignancy. In 18 patients treated at the Surgery Branch, National Institutes of Health, who had radical radiation in an attempt to control recurrent rectal cancer, only one attained long-term disease-free survival.
A review of our own data indicates that patients with advanced primary rectal tumors benefited, but those with recurrent rectal cancers developed locally recurrent disease despite our aggressive treatment strategy. Drs. Hoffman, Sigurdson, and Eisenberg do not describe how effective the local control has been in their 57 patients nor do they mention whether any of their patients achieved long-term survival as a result of the use of the pelvic displacement device. As I look back on my own patients, I am not sure that any of them really owed their life to the prosthesis.
Potential for Complications
A second impediment to more general use of the tissue expanders in the pelvis relates to morbidity and mortality. The use of a foreign body in the pelvis after an extensive dissection and bowel transection seems to invite complications. In this series, there were 8 complications in 57 patients (14%). Four of these complications could be considered life-endangering. Given the current medicolegal concerns, the use of an inflatable device within the pelvis seems brave.
After reading the report by Drs. Hoffman, Sigurdson, and Eisenberg, I was determined to rely on their expertise and refer to them my next patient who has insufficient greater omentum or rectum abdominus muscle to exclude small bowel from the pelvis. Their experience, their ready access to a proven prosthesis, and their resulting relative protection from medicolegal risk makes such a referral desirable, in my opinion.
References:
1. Sugarbaker PH: Intrapelvic prosthesis to prevent injury of the small intestine with high dosage pelvic irradiation. Surg Gynecol Obstet 157:269-271, 1983.
2. Sugarbaker PH, Gunderson LL, Wittes RE: Colorectal cancer, in DeVita VT Jr, Hellman S, Rosenberg SA (eds): Cancer: Principles and Practice of Oncology, vol 1, 2nd ed, p 843. Philadelphia, JB Lippincott, 1985.
3. Vetto JT, Culp SC, Smythe TB, et al: Iliac arterial-enteric fistulas occurring after pelvic irradiation. Surgery, 101:643-647, 1987.
4. Sugarbaker PH: The abdomino-pelvic partition and pelvic tissue transplantation: Useful techniques in the surgical management of advanced pelvic malignancy. Perspect Colon Rectal Surg 1:82-88, 1988.
5. Sugarbaker PH, Hancock J: Pelvic displacement prosthesis for the prevention of damage to the small bowel with postoperative radiation therapy. Patent # Des 291,248, Aug. 4, 1987.
6. Edington HD, Hancock S, Coe FL, et al: Preliminary report of a new treatment strategy for advanced pelvic malignancy: Surgical resection and radiation therapy using afterloading catheters plus an inflatable displacement prosthesis in the treatment of advanced primary and recurrent rectal cancer. Surgery 100:494, 1986
