Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy

Table 1 Demographics and characteristics

Variable	Diverting colostomy, n = 14	Conservative treatment, n = 25	Colostomy vs conservative, P value	ITT group, n = 50	ITT group vs colostomy, P value
Age, mean ± SD	61 ± 10.9	60.2 ± 2.4	0.89	59.3 ± 8.7	0.767
Sex, female/male	13/1	23/2	1.01	49/1	1.01
Primary cancer			0.405		0.879
Cervical cancer	12	21		45
Endometrial cancer	0	2		2
Rectal cancer	2	1		2
Prostate cancer	0	1		1
Radiation dosage, Gy	82 ± 15.9	83.6 ± 20.5	0.825	83.4 ± 18.5	0.553
Duration of bleeding in mo	13 ± 4.3	8.0 ± 1.8	0.042	11.3 ± 4.0	0.263
Pre-Op transfusion, yes/no	12/2	6/19	< 0.001	-	-
Pre-Op Hb, g/L (lowest level)	63 ± 17.8	88.2 ± 19.3	< 0.001	80 ± 27.8	0.051
Bleeding remission rate
Post-Op 3 mo	12/14 (86%)	1/25 (4%)	< 0.001	-	-
Post-Op 6 mo	12/14 (86%)	3/25 (12%)	< 0.001	-	-
Post-Op 9 mo	13/14 (93%)	5/25 (20%)	< 0.001	-	-
Post-Op 1 yr	14/14 (100%)	6/25 (24%)	< 0.001	-	-
Post-Op 2 yr	14/14 (100%)	5/25 (20%)	< 0.001	-	-
Bleeding score at initial diagnosis	2.7 ± 0.5	2.0 ± 0.5	< 0.001	-	-
Bleeding score after 1 yr of treatment	0.8 ± 0.5	1.7 ± 0.9	0.008	2.4 ± 0.5	0.033

¹Fisher's exact test. ITT: Intention-to-treat; Pre-Op: Pre-operative; Post-Op: Post-operative; Hb: Hemoglobin.

Table 2 Clinical details and outcomes of 14 colostomy patients

Characteristic	Case														Median(range or %)
	1	2	3	4	5	6	7	8	9	10	11	12	13	14
Age	70	83	49	48	59	72	58	73	56	47	63	68	46	59	61 (47-83)
Sex	F	F	F	F	F	F	M	F	F	F	F	F	F	F	13 (F, 93%)
Primary cancer	Cervix	Cervix	Cervix	Cervix	Cervix	Cervix	Rectum	Cervix	Cervix	Anus	Cervix	Cervix	Cervix	Cervix	12 (Cervix, 86%)
Radiation dosage, Gy	98	80	96	60	80	78	50	80	80	84	86	74	120	80	82 (50-120)
Duration of bleeding in mo	19	15	14	21	15	18	8	7	15	10	10	8	11	10	13 (7-21)
Pre-Op transfusion (U)	5	8	4	2	4	8	4	-	4	2	2	2	2	-	12 (Yes, 86%)
Duration of stoma in mo	48		34	18	10	34	9	26	15	12	53	10	15	14	16 (9-53)
Indication(s) for colostomy	Severe anemia	Severe anemia	Severe anemia	Severe anemia	Severe anemia	Severe anemia	Severe anemia	Moderate anemia + perianal pain	Severe anemia	Severe anemia + perianal pain	Severe anemia	Severe anemia	Severe anemia	Severe anemia+ sigmoid colon sclerosis	-
Hb, g/L
Pre-Op Hb	44	36	76	63	36	35	71	87	52	78	72	78	76	78	63 (35-87)
Post-Op 3 mo	85	-	85	-	-	45	87	-	-	-	-	-	-	-	75 (45-87)
Post-Op 6 m	-	-	-	-	94	-	-	77	-	-	108	118	-	-	99 (77-118)
Post-Op 9 mo	-	-	-	102	-	75	120	-	-	-	-	117	122	-	107 (75-120)
Post-Op 1 yr	-	-	-	100	113	-	-	123	114	114	-	-	-	105	111 (100-123)
Post-Op 2 yr	-	-	118	102	-	111	135	130	114	-	110	-	117	-	117 (102-135)
Post-Op transfusion	No	Yes	No	No	No	yes	No	yes	No	No	No	No	No	No
Stoma closure	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	13 (Yes, 93%)
Stoma complications	Hernia	-	-	-	-	-	Prolapse	-	Obstruction	-	-	-	-	-	3 (Yes, 21%)
Pre-Op bleeding score	3	3	3	3	3	3	3	2	2	3	2	3	3	3	3 (2-3)1
Bleeding score at stoma reversal	-	-	1	1	1	1	-	1	0	0	-	0	1	1	1 (0-1)1
Treatment after stoma	-	-	-	-	-	APC 1	Formalin 1	APC 1	-	-	APC 1	-	-	-

¹Median value. Pre-Op: Pre-operative; Post-Op: Post-operative; Hb: Hemoglobin; RTD: Rectal telangiectasia density; APC: Argon plasma coagulation.

Table 3 Magnetic resonance imaging findings at post-colostomy and at reversal compared in 5 patients with chronic radiation proctopathy

Variable, mm	Pre-colostomy, mean ± SD	At reversal, mean ± SD	P value, paired t-test
Thickness of rectal wall	10.76 ± 4.29	8.91 ± 1.61	0.047
Width of presacral space	15.57 ± 8.86	15.84 ± 4.11	0.328
Thickness of left levator ani	2.81 ± 1.07	3.18 ± 1.39	0.341
Thickness of right levator ani	3.42 ± 1.26	3.45 ± 1.66	0.944
Thickness of left gluteus maximus muscle	31.36 ± 3.80	32.21 ± 9.0	0.769
Thickness of right gluteus maximus muscle	29.89 ± 4.19	32.15 ± 11.95	0.693
Thickness of left obturator internus	15.16 ± 1.97	17.89 ± 1.77	0.160
Thickness of right obturator internus	13.79 ± 4.90	14.36 ± 5.50	0.060
Thickness of distal part of sigmoid colon	4.50 ± 0.73	5.08 ± 1.17	0.503

Table 4 Rectal manometry assessment of anorectal functions before stoma reversals

Patient	Tensity of anorectal ring	Function of contraction	Diagnosis	Sensitivity of rectal mucosa	Rectal volume	Repression of anorectum reflex	Anal relaxation when simulating defecation
1	Increase	Good	Internal sphincter spasm	Increase	Normal	Normal	Good
4	Increase	Good	-	Normal	Decrease	Normal	Good
6	Decrease	Decrease	Decreased sphincter function	Increase	Decrease	Normal	Good
9	Normal	Decrease	Decreased sphincter function	Increase	Decrease	Abnormal	Good
12	Normal	Decrease	-	Increase	Decrease		Good
14	Normal	Good	-	Increase	Decrease	Abnormal	Good

Table 5 Quality of life in the colostomy group and conservative group of chronic radiation proctopathy patients based on the EORTC QLQ-C30 scale

QLQ-C30 scale	Reference: Normal German population	Colostomy group, n = 14, mean ± SD				Conservative group, n = 25, mean ± SD
		Pretreat-ment	Follow-up	Δ(FU)-Pre2	Signifi-cance1	Pretreat-ment	Follow-up	Δ(FU)-Pre	Signifi-cance1
Global health	63.2	23.1 ± 15.1	63.1 ± 18.3	40	< 0.001	47.1 ± 21.5	62.3 ± 25.0	15.2	0.033
Physical function	82.6	50.7 ± 17.8	87.1 ± 13.7	36.4	< 0.001	78.0 ± 22.7	78.6 ± 26.1	0.6	0.856
Role function	75	34.3 ± 23.9	89.3 ± 20.5	55	< 0.001	77.5 ± 24.9	77.5 ± 29.1	0	0.775
Emotional function	62.2	46.3 ± 27.4	85.7 ± 14.9	39.4	< 0.001	75.7 ± 17.6	80.8 ± 23.8	5.1	0.384
Cognition function	81.3	92.6 ± 12.7	95.2 ± 9.8	2.6	1.0	94.2 ± 15.6	95.7 ± 9.0	1.5	0.798
Social function	78.4	43.5 ± 28.9	79.8 ± 18.0	36.3	< 0.001	91.3 ± 20.6	89.1 ± 21.1	-2.2	0.916
Fatigue	34.1	72.8 ± 12.9	10.3 ± 18.5	-62.5	< 0.001	26.6 ± 24.1	23.2 ± 27.2	-3.4	0.695
Nausea/ vomiting	5.7	4.6 ± 15.5	0 ± 0	-4.6	-	5.1 ± 15.4	6.5 ± 16.5	1.4	0.655
Pain	33.1	44.4 ± 28.3	9.5 ± 15.1	-34.9	< 0.001	14.5 ± 21.5	11.6 ± 18.4	-2.9	0.481
Dyspnea	18.8	42.6 ± 31.0	4.8 ± 11.7	-37.8	< 0.001	14.5 ± 19.7	8.7 ± 18.0	-5.8	0.210
Insomnia	38.5	48.1 ± 35.5	11.9 ± 20.3	-36.2	< 0.001	21.7 ± 21.6	26.1 ± 31.7	4.4	0.287
Appetite loss	9.4	22.2 ± 27.2	0 ± 0	-22.2	-	10.1 ± 25.5	8.7 ± 18.0	-1.4	0.785
Constipation	9.1	9.3 ± 14.9	9.5 ± 15.1	-0.2	1.0	8.7 ± 20.6	7.2 ± 22.4	-1.5	0.414
Diarrhea	9.2	33.3 ± 33.3	9.5 ± 26.5	-23.8	< 0.001	11.6 ± 23.8	2.9 ± 9.6	-8.7	0.078
Financial difficulties	17.1	59.3 ± 26.2	23.8 ± 31.9	-35.5	< 0.001	26.1 ± 31.7	24.6 ± 30.5	-1.5	0.595

¹Wilcoxon rank-sum test.

²Point (follow-up) – point (pretreatment). Δ(FU): Change in follow-up; SD: Standard deviation.