RESUMEN
PURPOSE: Rectal contact X-ray brachytherapy (Papillon radiotherapy) has recently received approval from the National Institute for Health and Care Excellence. In particular, it is suitable for elderly patients who are high-risk for a major operation, but it may also be undertaken for patients who wish to avoid a stoma. It is imperative to be able to identify clinical response or tumor regrowth on surveillance magnetic resonance imaging (MRI) and sigmoidoscopy. This article aims to help clinicians to interpret MRIs and endoscopic appearances following Papillon radiotherapy. MATERIAL AND METHODS: MRI and sigmoidoscopy images are presented from a case series of seven non-consecutive, heterogeneously treated patients with T2 to 3C N0 rectal adenocarcinoma. Treatments included transanal excision, adjuvant or neoadjuvant chemo/radiotherapy, and Papillon radiotherapy. These patients wished to avoid a stoma or were high-risk for a major operation. These cases have been chosen to demonstrate response assessment alone. RESULTS: The "black spider" sign of maturing, low signal fibrosis on MRI was found to be reassuring, as was the presence of a flat scar on endoscopy. Residual tumor mass or intermediate signal suggest equivocal response, which may necessitate transanal excision. Loss of low signal fibrosis, or the development of soft tissue nodularity or mass should prompt biopsy. CONCLUSIONS: MR scans should be used in combination with endoluminal mucosal assessment (and digital rectal examination) to determine response following Papillon radiotherapy. This is the first paper to describe both the endoscopic and imaging findings following Papillon radiotherapy.
RESUMEN
BACKGROUND: Bariatric surgery (including gastric bypass) is associated with long-term deficiencies in vitamins and minerals, which may have deleterious effects on physiology. The American Association of Clinical Endocrinologists' (AACE) guidelines regarding post-operative vitamin supplementation have recently been endorsed by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). Supplements have cost implications. Non-branded multivitamins may have similar compositions to branded multivitamins, but at a lower cost. This study assesses multivitamin supplementation following bariatric gastric bypass in England against AACE guidelines. It also examines the composition and cost of branded and non-branded multivitamins. METHODS: Micronutrient amounts in common multivitamin preparations were obtained from product literature. Costs were collected from a standard retailer. To determine vitamin prescribing patterns, the 37 NHS hospitals performing bariatric gastric bypasses in England were contacted. Practice was assessed against AACE guidelines. RESULTS: All non-branded multivitamins met AACE guidelines for composition. Most had similar compositions to branded multivitamins, and all were cheaper. There was no standard practice regarding post-operative supplementation among the 35 responding hospitals. Only 7/35 (20%) hospitals followed the guidance for two-tablet doses of multivitamins. Immediately post-operatively, 25/35 (71%) hospitals administered calcium carbonate and vitamin D (none recommended calcium citrate, as recommended by AACE to improve absorption), and only 9/35 (26%) hospitals recommended iron to all patients. CONCLUSION: Most non-branded multivitamins are lower cost alternatives to branded multivitamins, with similar compositions. The AACE recommendation for two-tablet doses of multivitamins is not being met by most English centres. Calcium and iron supplementation is also inadequate.
