Morbidity after intraperitoneal insertion of saline-filled tissue expanders for small bowel exclusion from radiotherapy treatment fields: A prospective four year experience with 34 patients

When prolonged small bowel exclusion (SBE) from external radiotherapy (RT) fields or immediate exclusion of bowel from brachytherapy sources is required for a patient without adequate omentum, there are no simple proven methods available for accomplishing these goals. We report a prospective study of SBE by intraperitoneal, saline-filled tissue expanders (TE). Thirty-four patients had exclusion of small bowel from either external radiotherapy (RT) ports (20), afterloading catheter treatment fields (5), both (5), or from intracavitary implants (4). Twenty-seven TEs were placed in the pelvis and 7 in the iliolumbar fossa. TE volume ranged from 400-1500 cc (median 550 cc). Patients had rectal (n = 15), colon (6), endometrial (4), anal (3), and vaginal (1) cancers and sarcomas (5). Fifteen patients had recurrent neoplasms, 13 of which were in previously irradiated fields. Nine patients had colorectostomies directly behind the TE, and 12 had other bowel (6) or ureteral (3) anastomoses or bladder repairs (3) adjacent to the TE. Results: TEs remained in the patients from 6 to 173 days (median 95). Morbidity included three early TE withdrawals before RT was begun, one for a prolonged ileus, one for a perineal would dehiscence, and one for an unrelated small bowel obstruction. Two patients (5.9%) early in the series had post- withdrawal complications (non-lethal small bowel fistulas requiring reoperation), although in a recent cohort of patients no post-withdrawal complications occurred using a different placement technique (0/17 vs. 2/14, P = 0.2). The patient injury complication rate was 4/34 (11.8%). None of these limited or delayed RT, but RT was limited to less than that planned in one other by TE deflation (total complication rate 14.7%). There were no clinical infections involving the prostheses, even though one patient had an abdominal wound dehiscence, 3 had pelvic abscesses, and 2 had exposure of the TE through the vagina (1 planned, 1 at dehisced vaginal cuff) after TE placement. We noted no acute and one possible late RT complication in these patients (18 months median follow-up, range 3-43 months). Small bowel was displaced from >95 per cent of the RT treatment volume in 70 per cent and from >75 per cent of the treatment volume in 89 per cent of 27 evaluable patients treated with external RT. Conclusions: Intraperitoneal placement of a saline-filled tissue expander is a simple, safe and effective means of small bowel exclusion from RT portals.