Small Bowel Complications Patients with previous abdominal surgery are more likely to have pelvic adhesions and thus sustain more radiotherapy complications in the small bowel. The terminal ileum may be particularly susceptible to chronic damage because of its relatively fixed position at the cecum. Patients with small bowel complications have a long history of crampy abdominal pain, intestinal rushes, and distention characteristic of partial small bowel obstruction. Often, low-grade fever and anemia accompany the symptoms. Patients who have no evidence of disease should be treated aggressively with total parenteral nutrition, nasogastric suction, and early surgical intervention after the anemia resolves and good nutritional status is attained. The type of procedure performed depends on individual circumstances (148). Small bowel fistulas that occur after radiotherapy rarely close spontaneously while total parenteral nutrition is maintained. Recurrent cancer should be excluded; aggressive ﬂuid replacement, nasogastric suction, and wound care should be instituted. Fistulography and a barium enema should be performed to exclude a combined large and small bowel fistula. The fistula-containing loop of bowel may be either resected or isolated and left in situ. In the latter case, the fistula will act as its own mucous fistula.
Urinary Tract Chronic urinary tract complications occur in 1% to 5% of patients and depend on the dose of radiation to the base of the bladder. Vesicovaginal fistulas are the most common complication and usually require supravesicular urinary diversion. Occasionally, a small fistula can be repaired with either a bulbocavernosus ﬂap or an omental pedicle. Ureteral strictures are usually a sign of recurrent cancer, and a cytologic sample should be obtained at the site of the obstruction using FNA guided by a CT scan. If the findings are negative, the patient should undergo exploratory surgery to evaluate the presence of recurrent disease. If radiation fibrosis is the cause, ureterolysis may be possible or indwelling ureteral stents may be passed through the open urinary bladder to relieve obstruction.
Neoadjuvant Chemotherapy Randomized trials were initiated by the GOG and other large centers to determine the efficacy of neoadjuvant chemotherapy. In the era of effective chemoradiation therapy, there is no evidence that neoadjuvant chemotherapy offers superior results or a survival advantage over standard therapy.