title: Clinical features, outcome and risk factors in cervical cancer patients after surgery for chronic radiation enteropathy.
abstract: BACKGROUND
  Radical hysterectomy and radiotherapy have long been mainstays of cervical cancer treatment. Early stage cervical cancer (FIGO stage IB1-IIA) is traditionally treated using radical surgery combined with radiotherapy, while locally advanced cervical cancer is treated using radiotherapy alone or chemoradiotherapy. In this retrospective study, we describe and analyse the presenting clinical features and outcomes in our cohort and evaluate possible risk factors for postoperative morbidity in women who underwent surgery for chronic radiation enteropathy (CRE).
  
  
  METHODS
  One hundred sixty-six eligible cervical cancer patients who underwent surgery for CRE were retrospectively identified between September 2003 and July 2014 in a prospectively maintained database. Among them, 46 patients received radical radiotherapy (RRT) and 120 received radical surgery plus radiotherapy (RS + RT). Clinical features, postoperative morbidity and mortality, and risk factors for postoperative morbidity were analysed.
  
  
  RESULTS
  RS + RT group patients were more likely to present with RTOG/EORTC grade III late morbidity (76.1 % vs 92.5 %; p = 0.004), while RRT group patients tended to show RTOG/EORTC grade IV late morbidity (23.9 % vs 7.5 %; p = 0.004). One hundred forty patients (84.3 %) were treated with aggressive resection (anastomosis 57.8 % and stoma 26.5 %). Overall and major morbidity, mortality and incidence of reoperation in the RRT and RS + RT groups did not differ significantly (63 % vs 64.2 % [p = 1.000], 21.7 % vs 11.7 % [p = 0.137], 6.5 % vs 0.8 % [p = 0.065] and 6.5 % vs 3.3 % [p = 0.360], respectively). However, incidence of permanent stoma and mortality during follow-up was higher in the RRT group than in the RS + RT group (44.2 % vs 12.6 % [p = 0.000] and 16.3 % vs 3.4 % [p = 0.004], respectively). In multivariate analysis, preoperative anaemia was significantly associated with overall morbidity (p = 0.015), while severe intra-abdominal adhesion (p = 0.017), ASA grades III-V (P = 0.022), and RTOG grade IV morbidity (P = 0.018) were predicators of major morbidity.
  
  
  CONCLUSIONS
  Radiation-induced late morbidity tended to be severe in the RRT group with more patients suffering RTOG/EORTC grade IV morbidity, while there were no significant differences in postoperative morbidity, mortality and reoperation. Aggressive resection was feasible with acceptable postoperative outcomes. Severe intra-abdominal adhesion, ASA grades III-V and RTOG/EORTC grade IV late morbidity contributed significantly to major postoperative morbidity.
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. yang_jianbo@126.com.
authors.forename: Jianbo
authors.initials: J
authors.lastname: Yang
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. dingchaojlh@126.com.
authors.forename: Chao
authors.initials: C
authors.lastname: Ding
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Clinical School of Nanjing, Southern Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. zhangthjlh@126.com.
authors.forename: Tenghui
authors.initials: T
authors.lastname: Zhang
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. zhangljlh@163.com.
authors.forename: Liang
authors.initials: L
authors.lastname: Zhang
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. lvtfjlh@126.com.
authors.forename: Tengfei
authors.initials: T
authors.lastname: Lv
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. gexljlh@126.com.
authors.forename: Xiaolong
authors.initials: X
authors.lastname: Ge
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. gongjfjlh@126.com.|Research Institute of General Surgery, Jinling Hospital, Clinical School of Nanjing, Southern Medical University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. gongjfjlh@126.com.
authors.forename: Jianfeng
authors.initials: J
authors.lastname: Gong
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. zhu_wmjlh@163.com.
authors.forename: Weiming
authors.initials: W
authors.lastname: Zhu
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. liningnjujlh@126.com.
authors.forename: Ning
authors.initials: N
authors.lastname: Li
authors.affiliation: Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. lijsnjujlh@126.com.
authors.forename: Jieshou
authors.initials: J
authors.lastname: Li
mesh_terms: D059248:Chemoradiotherapy / Q000009:adverse effects*; D003125:Colostomy / Q000009:adverse effects / Q000706:statistics & numerical data; D003131:Combined Modality Therapy; D015897:Comorbidity; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007044:Hysterectomy; D007081:Ileostomy / Q000009:adverse effects / Q000706:statistics & numerical data; D007410:Intestinal Diseases / Q000453:epidemiology* / Q000209:etiology / Q000601:surgery; D009102:Multiple Organ Failure / Q000209:etiology / Q000401:mortality; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D010532:Peritoneal Diseases / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D011832:Radiation Injuries / Q000453:epidemiology* / Q000209:etiology / Q000601:surgery; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects*; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D012778:Short Bowel Syndrome / Q000209:etiology; D000267:Tissue Adhesions / Q000453:epidemiology / Q000209:etiology; D002583:Uterine Cervical Neoplasms / Q000532:radiotherapy* / Q000628:therapy