Radyasyon Maruziyetinin Sebep Olduğu Gastrointestinal Hasarın Cerrahi Yönetimi
Özet
Radyasyon kaynaklı intestinal hasar, tüm vücudu etkileyen akut radyasyon sendromu (ARS) veya kanser tedavisinin bir parçası olan radyoterapiye (RT) bağlı olarak gelişmektedir. RT sonrasında ilk 3 ayda görülen epitelyal inflamasyon akut dönem, aylar veya yıllarca süren iskemi, fibrozis ve nekroz süreci ise kronik dönem olarak sınıflandırılır. Kronik radyasyon enteriti (RE) ve proktiti (RP) olgularının %30-50’sinde obstrüksiyon, striktür, fistül veya şiddetli kanama gibi komplikasyonlar nedeniyle cerrahi müdahale gerekebilir. Cerrahi yönetimde, hastalıklı dokunun rezeksiyonu ve anastomozu intestinal bypasa tercih edilmekle birlikte, yoğun adezyonlar varlığında bypass veya proksimal saptırıcı ostomiler uygulanmaktadır. Sabit konumu nedeniyle pelvik radyasyondan en çok etkilenen organ rektumdur; hemorajik proktit tedavisinde öncelikle argon plazma koagülasyonu gibi endoskopik yöntemler kullanılırken, rektovajinal fistül ve darlıklarda lezyonun yerleşimine göre transabdominal veya perineal cerrahi yaklaşımlar seçilir. RT hasarını önlemek amacıyla primer kanser cerrahisi sırasında ince bağırsakları pelvis dışına iten omental flep veya emilebilir meş askı gibi profilaktik cerrahi prosedürler de mevcuttur. Başarılı bir yönetim süreci, hastalık patofizyolojisini anlamaya ve malnütrisyonun düzeltilmesine dayanan multidisipliner bir yaklaşım gerektirir.
Radiation-induced intestinal injury occurs either due to acute radiation syndrome (ARS) affecting the whole body or as a side effect of radiotherapy (RT) utilized in cancer treatment. Tissue responses within the first 3 months characterized by epithelial inflammation are classified as acute, whereas the subsequent progressive processes involving ischemia, fibrosis, and necrosis spanning months or years constitute the chronic phase. Approximately 30-50% of patients diagnosed with chronic radiation enteritis (RE) and proctitis (RP) require surgical intervention due to severe complications such as obstruction, strictures, fistulas, or intractable bleeding. In surgical management, resection with primary anastomosis is preferred over intestinal bypass, yet bypass procedures or proximal diverting ostomies are implemented in cases presenting with extensive adhesions. Owing to its fixed anatomical position, the rectum is the organ most frequently damaged by pelvic RT; hemorrhagic proctitis is primarily managed via endoscopic interventions like argon plasma coagulation, while rectovaginal fistulas and strictures dictate transabdominal or perineal surgical approaches based on their levator ani anatomical localization. To mitigate radiation injury, prophylactic surgical procedures such as omental flaps or absorbable mesh slings can be performed during primary cancer surgery to displace the small bowel from the pelvic radiation field. Successful management relies on a multidisciplinary approach focused on understanding disease pathophysiology and correcting malnutrition.
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