Annals of Coloproctology

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Original Articles

Colorectal cancer

Preventive efficacy of hydrocortisone enema for radiation proctitis in rectal cancer patients undergoing short-course radiotherapy: a phase II randomized placebo-controlled clinical trial: Mohammad Mohammadianpanah, Maryam Tazang, Nam Phong Nguyen, Niloofar Ahmadloo, Shapour Omidvari, Ahmad Mosalaei, Mansour Ansari, Hamid Nasrollahi, Behnam Kadkhodaei, Nezhat Khanjani, Seyed Vahid Hosseini; Ann Coloproctol. 2024;40(5):506-514. Published online October 22, 2024; DOI: https://doi.org/10.3393/ac.2024.00192.0027

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Purpose
This study aimed to investigate the efficacy of hydrocortisone enema in preventing radiation proctitis in patients with rectal cancer undergoing short-course radiotherapy (SCRT).
Methods
This phase II randomized controlled trial enrolled patients with newly diagnosed locally advanced rectal cancer (clinically staged T3–4 and/or N1–2M0). Participants received a median of 4 cycles of neoadjuvant chemotherapy (capecitabine plus oxaliplatin) followed by 3-dimensional conformal SCRT (25 Gy in 5 fractions). Patients were randomly assigned to receive either a hydrocortisone enema (n=50) or a placebo (n=51) once daily for 5 consecutive days during SCRT. The primary endpoint was the incidence and severity of acute proctitis.
Results
Of the 111 eligible patients, 101 were included in the study. Baseline characteristics, including sex, age, performance status, and tumor location, were comparable across the treatment arms. None of the patients experienced grade 4 acute gastrointestinal toxicity or had to discontinue treatment due to treatment-related adverse effects. Patients in the hydrocortisone arm experienced significantly less severe proctitis (P<0.001), diarrhea (P=0.023), and rectal pain (P<0.001) than those in the placebo arm. Additionally, the duration of acute gastrointestinal toxicity following SCRT was significantly shorter in patients receiving hydrocortisone (P<0.001).
Conclusion
Hydrocortisone enema was associated with a significant reduction in the severity of proctitis, diarrhea, and rectal pain compared to placebo. Additionally, patients treated with hydrocortisone experienced shorter durations of gastrointestinal toxicity following SCRT. This study highlights the potential benefits of hydrocortisone enema in managing radiation-induced toxicity in rectal cancer patients undergoing radiotherapy.

Citations

Citations to this article as recorded by

Efficacy of Neoadjuvant Hypofractionated Chemoradiotherapy in Elderly Patients with Locally Advanced Rectal Cancer: A Single-Center Retrospective Analysis
Jae Seung Kim, Jaram Lee, Hyeung-min Park, Soo Young Lee, Chang Hyun Kim, Hyeong Rok Kim
Cancers.2024; 16(24): 4280. CrossRef

Anorectal benign disease

Proctitis distal to colorectal anastomosis: a retrospective cohort study of an underreported complication after sigmoidectomy: Ajmal Khan, Maziar Nikberg, Kenneth Smedh, Abbas Chabok; Ann Coloproctol. 2024;40(5):498-505. Published online October 22, 2024; DOI: https://doi.org/10.3393/ac.2023.00675.0096

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Abstract PDF: Purpose
Proctitis distal to colorectal anastomosis is rare and infrequently reported. We evaluated the incidence, symptoms, treatment, and potential risk factors associated with this condition.
Methods
We conducted a retrospective population-based cohort study in Västmanland County, Sweden. This investigation included all patients who underwent sigmoidectomy with colorectal anastomosis between 2008 and 2020. We excluded patients without an anastomosis and those with inflammatory bowel disease.
Results
Of the 546 patients identified, 233 fulfilled the inclusion criteria, of whom 26 (11.2%) developed proctitis distal to colorectal anastomosis. The most frequent symptoms included urgency (n=16, 61.5%), increased stool frequency (n=12, 46.2%), and anorectal pain (n=12, 46.2%). Endoscopic balloon dilation was performed in 20 cases (76.9%), with 10 requiring only a single therapeutic procedure. The median number of dilations was 3 (range, 1–8). Multivariable analysis revealed that surgery due to malignancy and emergency surgery were associated with elevated risk of proctitis. A subgroup analysis of patients who underwent surgery due to malignancy indicated that smoking (odds ratio, 3.9; 95% confidence interval, 1.1–14.0) and emergency surgery (odds ratio, 6.5; 95% confidence interval, 1.1–37.1) were also associated with increased proctitis risk.
Conclusion
Proctitis distal to colorectal anastomosis is not uncommon following sigmoidectomy. Patients undergoing emergency surgery or surgery due to malignancy and who had a history of smoking displayed an increased risk of developing proctitis. Due to the paucity of symptoms observed, particularly in patients with a diverting stoma, routine endoscopic rectal examination should be performed during follow-up after sigmoidectomy.

Case Reports

Benign bowel disease

Recurrent perianal abscess in a patient with Hermansky-Pudlak syndrome–associated granulomatous colitis: a case report: Ahmet Omak, Tevfik Kıvılcım Uprak, Wafi Attaallah; Ann Coloproctol. 2024;40(Suppl 1):S11-S14. Published online November 19, 2021; DOI: https://doi.org/10.3393/ac.2021.00437.0062

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Abstract PDF: Hermansky-Pudlak syndrome (HPS) is a rare genetic disease consisting of the triad of oculocutaneous albinism, bleeding diathesis, and pigmented reticuloendothelial cells. In HPS patients’ granulomatous colitis could be an additional feature and perianal abscess could be seen in such patients. We report a patient with HPS-associated granulomatous colitis, refractory to medical treatment, and perianal involvement. Patients with HPS-associated granulomatous colitis and perianal involvement may require multiple surgical interventions and there is no consensus yet for treatment in such patients.

A Case of Hydrogen Peroxidese Induced Proctitis..: Lee, Sang Gil , Ko, Young Guk , Whang, Young Woong , Kim, Won Ho; J Korean Soc Coloproctol. 1997;13(3):541-546.

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Abstract: Hydrogen peroxide is commonly used for cleansing superficial wounds, because of its antimicrobial action attributed to oxidizing capacity. The release of oxygen doping oxidation results in effervescence, which promotes a weak mechanical means of removing tissue debris. In the past, hydrogen peroxide was used for the management of meconium ileum and for fecal impaction because liberated oxygen tend to break up impaction and initiate peristaltic reflex. However, the stronger solution has a caustic action. The potential dangers of hydrogen peroxide enema were not so well known until 1950s when Pumphery recognized deleterious effects from such enema. During 1980s, hydrogen peroxide was used for disinfection of endoscope and several authors reported peroxide-induced colitis. We report a case of hydrogen peroxide induced chemical colitis in a 47-year-old man, who complained bloody stools and tenesmus after introducing hydrogen peroxide soaked gauss into the rectum to relieve pruritus am. Colonoscopy demonstrated diffuse erythema, edema and friability of rectal mucosa upto 6-7 cm from anal verge. The proximal margin of the lesion was well demarcated from normal appearing mucosa. Mucosal biopsy revealed histologic findings compatible with ischemic changes. His symptoms improved rapidly with conservative treatment.

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