The reported mortality rate in trials of adjuvant chemoradiotherapy ranged from 0.3 to 4% [23, 28]. Deaths were due principally to sepsis (40%), intestinal obstruction or perforation (50%) and peritonitis. Completion rate of treatment preview ranged from 65 to 92%.
Major acute gastrointestinal toxicity included severe diarrhoea (7-35%), nausea and vomiting, and stomatitis. Haematological side effects such as leu-copenia and thrombocytopenia occurred in 5-33% of patients [23, 27]. Long-term radiation effects include radiation enteritis, small bowel obstruction (SBO)
and radiation stricture [27,29]. The high incidence of SBO after post-operative RT may be secondary to post-operative adhesions and the prolapse of small bowel loops into the irradiated pelvis and can require surgery. The incidence of SBO increases by 30-40% when the radiation fields extend higher into the abdomen. The extent of this problem seems to be related to the volume of the irradiated small bowel .
Patients receiving post-operative chemoradiation have more bowel movements per day, clustering of bowel movements and nocturnal bowel actions. More of these patients wear a pad and are unable to defer defecation for more than 15 minutes. They also have a higher incidence of faecal incontinence, greater use of anti-diarrhoeal drugs, more perineal skin irritation and more difficulty in differentiating stool from gas.
Improved radiation planning and techniques can be used to minimise treatment-related complications. These techniques include the use of multiple pelvic fields, prone positioning, customised bowel immobilisation moulds (belly boards), bladder distension, visualisation of the small bowel through oral contrast and the incorporation of three-dimensional or comparative treatment planning [32, 33].
At present, the adjuvant approach seems more suitable for patients affected with proximal rectal cancer, where a less accurate pre-operative staging is feasible.
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