patients tolerate radiation to the pelvis or abdomen with minimal to moderate side
effects. The bigger the area treated and the higher the dose... the more likely the side
effects. With routine preOp or postOp doses of 4500-5000cGy patients have a
20% to 30% risk of postoperative complications and the risks go up with higher doses (like 6000cGy or up, see safe dose
tables) and the risks are higher if the surgery is more extensive (see
For a discussion of chronic radiation damage to the small bowel go here and to the large bowel go here, For more specifics on pelvic radiation problems in men go here and in women go here, and for risk to pelvic bones go here.
Dose guidelines from RTOG
(anal) and 0438 (liver)
Patients who have had
cancer colon or rectal surgery may have even more problems (see large
German study comparing preOp versus postOp
radiation in rectal cancer) and when the radiation is combined with chemotherapy
(particularly 5FU or Gemzar) the higher the likelihood of side effects (particularly
The lower pelvis area tolerates radiation better than higher up on the abdomen...so the location of the treated area will effect tolerance. The most common side effects are noted below.
|Other studies that discuss complications:|
preoperative combined modality therapy and radical resection of locally
advanced rectal cancer: a 14-year experience from a specialty service.
Chessin DB,J Am Coll Surg. 2005 Jun;200(6):876-82
Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
Preoperative combined modality therapy followed by total mesorectal excision has emerged as the optimal treatment paradigm for locally advanced rectal cancer (T3 to 4, N1, or both). But its impact on postoperative complications has not been adequately evaluated. Our aims were to evaluate our comprehensive experience and identify factors predictive of complications in this patient population. STUDY DESIGN: The study group consisted of 297 consecutive patients with locally advanced rectal adenocarcinoma treated with preoperative combined modality therapy (radiation: 5,040 cGy; chemotherapy: 5-FU-based) and then operation.
Major complications were defined as those requiring medical or surgical treatment. A prospectively collected database was queried to determine the incidence of postoperative complications and associated clinicopathologic factors. RESULTS: Median followup was 43.9 months (range 0.8 to 128.6 months). There were no postoperative mortalities (within 30 days of operation). But there were 145 major complications in 98 patients (33% of study population). The most common complications were small bowel obstruction (n = 32 [11%]) and wound infection (n = 31 [10%]). There were eight anastomotic leaks (4%) and nine pelvic abscesses (4%) in patients treated with low anterior resection (n = 210).
CONCLUSIONS: Although postoperative mortalities are rare, complications requiring treatment can be anticipated in one-third of patients undergoing preoperative combined modality therapy and total mesorectal excision. A policy of selective fecal diversion after preoperative combined modality therapy and total mesorectal excision for locally advanced rectal cancer can achieve low rates of pelvic sepsis, but may lead to an increased incidence of small bowel obstruction.
efficacy of low anterior resection for rectal cancer: 681 consecutive
cases from a specialty service.
RESULTS: The perioperative mortality rate was 0.6% (4/681). Postoperative complications occurred in 22% (153/681). The operative time, estimated blood loss, and rate of pelvic abscess formation without associated leak were higher in the Preop RT group than the No Preop RT group. However, the overall complication rate, rate of wound infection, anastomotic leak, and length of hospital stay were no different between Preop RT and No Preop RT patients. CONCLUSION: The use of preoperative chemoradiation results in increased operative time, blood loss, and pelvic abscess formation but does not increase the rate of anastomotic leaks or the length of hospital stay after low anterior resection for rectal cancer. The 5-year actuarial overall survival rate for patients undergoing curative resection exceeded 80%, with a local recurrence rate of 10%.
Impact of neoadjuvant therapy on
postoperative complications in patients undergoing resection for rectal
no significant difference
between complication rates for APR and SS with 19 per cent and 14 per
cent, respectively. The preoperative therapy had no effect on
complications after APR. However, the SS group showed 21 per cent of the
patients who received radiation had complications compared to 11 per cent
in those who did not (P = 0.087). Complications in the SS
group included leaks, wound infections, abscess, embolism, cardiac
dysrhythmias, and myocardial infarctions. The 30-day mortality was 1.9
per cent for the entire cohort with no clear difference between groups.
There was no significant difference in complication rate between APR and
SS. In the APR group, neoadjuvant therapy had no impact on the incidence
of complications. However, the SS group did show a trend between
preoperative chemotherapy and radiation and complication rate. However,
this may not outweigh the advantages of preoperative therapy in this
Primary perineal wound closure after
preoperative radiotherapy and abdominoperineal resection has a high
incidence of wound failure.
RESULTS: A total of 160 patients underwent abdominoperineal resection with primary closure of the perineal wound (mean age, 63 +/- 12 years); 117 (73 percent) patients received preoperative radiation therapy; 114 received radiation therapy for rectal cancer (radiation therapy + chemotherapy = 107, radiation therapy alone = 7); 3 received radiation therapy for other pelvic malignancies. Median radiation dose was 5,040 (range, 900-5,400) cGY. Overall wound complication rate was 41 percent. Major wound complication rate was 35 percent. Delayed healing was the most common complication (24 percent), followed by infection (10 percent). Radiation therapy increased the risk of any wound complication (47 vs. 23 percent; P = 0.005), risk of a major wound complication (41 vs. 19 percent; P = 0.021), and risk of infection (14 vs. 0 percent; P = 0.015). Risk of wound complications did not correlate with age, gender, disease stage, smoking, or diabetes. CONCLUSIONS: Wound complications are frequent after abdominoperineal resection and primary closure of the perineum. Preoperative radiation therapy doubles the rate of total and major perineal wound complications. Alternatives to primary perineal closure should be considered, particularly after radiation therapy.
Neoadjuvant chemoradiation increases the
risk of pelvic sepsis after radical excision of rectal cancer.
RESULTS: From January 1994 to December 2002, 246 patients (151 males; mean age 68 (range, 36-97) years) underwent curative resection for rectal cancer. Procedures included 186 anterior resections, 52 abdominoperineal resections, and 8 Hartmann's. Of 60 patients (24.4 percent) who had neoadjuvant chemoradiation, 9 (15 percent) developed pelvic sepsis (3 leaks, 6 abscesses) compared with 9 of 186 (4.8 percent) after primary surgery (6 leaks, 3 abscesses; P < 0.01). Ninety-three patients had an anastomosis <or=6 cm from the anal verge. Of these, 9 patients (9.7 percent) developed pelvic sepsis (5 leaks, 4 abscesses): 5 of 28 (17.9 percent) after neoadjuvant chemoradiation vs. 4 of 65 (6.2 percent) after primary surgery (P = 0.22). Only 6 of 93 patients (6.5 percent) with an anastomosis >or=7 cm developed pelvic sepsis (5 leaks and 1 abscess), of whom 1 had preoperative radiation. Pelvic abscess developed in 3 of 24 patients after neoadjuvant chemotherapy and abdominoperineal resection. After primary abdominoperineal resection, none of the remaining 28 patients developed pelvic sepsis. A multivariable logistic regression model was constructed to determine predictors of sepsis. Neoadjuvant chemotherapy was the only variable that was predictive (odds ratio, 3.4; 95 percent confidence interval, 1.3-9). CONCLUSIONS: The addition of neoadjuvant chemoradiation to mesorectal excision significantly increased the rate of pelvic sepsis. This was particularly true for anastomoses in the lower third of the rectum. Fecal diversion should be considered in these patients.