Patient Liu Moumou, an elderly male, was admitted to the hospital because of recurrent episodes of abdominal pain, abdominal distension, vomiting, and cessation of defecation after radical rectal cancer and postoperative radiotherapy for more than one year. The patient underwent radical rectal cancer surgery (combined transabdominal perineal rectal cancer resection and sigmoid colonic abdominal wall stoma) under general anesthesia in February 2012, and the postoperative pathological diagnosis was “moderately differentiated adenocarcinoma, stage T3N1M0”. “In July 2012, he started to have abdominal pain, abdominal distension and vomiting, which gradually worsened and became more frequent and longer in duration, and stopped passing gas and bowels, and lost weight significantly. He was admitted to our hospital on January 10, 2014. After admission, he underwent preoperative nutritional status assessment, imaging examination (to clarify the site and extent of the lesion and to exclude intestinal obstruction due to extensive tumor metastasis), colon imaging examination (to exclude stenosis due to radiation damage to the rectum), and nutritional support for 1 week. Then on January 17, 2014, “dissection, intestinal adhesion release, resection of small intestine and ileocecal injury, and ileo-ascending colon anastomosis” was performed under general anesthesia. Intraoperative investigation: no tumor metastasis was found, and extensive dense adhesions were formed in the abdominal cavity, especially in the lower abdomen and pelvic cavity, with dense adhesions between the intestinal canal of the terminal ileum and the ileocecal region and the pelvic floor, forming a “frozen pelvic cavity”. “There was no anatomical gap between the intestinal canal, between the intestinal canal and other tissues and organs and the pelvic wall, and there were also adhesions between the small intestine on the proximal side without radiation damage, and the intestinal canal was highly dilated with a large amount of gas and fluid accumulation inside. After a difficult and meticulous “frozen pelvis” organ freezing surgery, the pelvic organs were completely separated, and it was seen that the last 100 cm of ileum was heavily damaged by radiation, and the intestinal tube lost elasticity and plasma membrane was pale, which was a typical manifestation of chronic radioactive intestinal injury and could not be used, while the 320 cm of small intestine on the near side was less damaged by radiation. According to the results of preoperative discussion and the surgical principles of chronic radiation intestinal injury, we decided to perform resection of radiation damaged intestine, ileal resection, and anastomosis of the proximal healthy 320 cm small intestine with the ascending colon. The anastomosis was placed in the subhepatic right paracolic sulcus, and the anastomosis was closed laterally with a linear cutting closure device, and the anastomosis was closed with a bioprotein sealant, and a double abdominal cannula was placed next to the anastomosis. The surgery was very difficult and challenging. After the operation, the patient recovered smoothly and resumed normal defecation, bowel movement and normal diet, and the patient was discharged without discomfort. The postoperative pathology showed that the resected intestine was consistent with the pathological changes of chronic radiation enteritis. The small intestine in the pelvic cavity was thoroughly separated, and it was seen that the last 100 cm of ileum was heavily damaged by radiation, and the intestine had lost elasticity and pale plasma membrane, which were typical manifestations of chronic radiation intestinal injury; the proximal small intestine was highly dilated, and there was a large amount of gas and fluid in it. The pale intestinal segment with radiation damage was separated from the pelvic cavity, and the cavity with fibrosis and small amount of blood leakage remained in the pelvic cavity. Review by Prof. Li Yuanxin: For rectal cancer, especially if the local tumor invasion is more serious or the pathology has lymph node metastasis, simultaneous radiotherapy and systemic chemotherapy after surgery can significantly improve the survival time. Some studies have shown that synchronized radiotherapy after surgery can increase the survival rate by 10%-15%, which means that the survival rate of comprehensive treatment for rectal cancer is about 70%-75%, in which radiotherapy plays an important role. Although the application of “intensity-modulated radiation therapy” and “conformal radiation therapy” techniques can prevent normal organs from being overly irradiated or oversized, as the number of people receiving radiation therapy increases, radiation therapy-related intestinal damage, especially serious long-term complications –bowel obstruction have also increased considerably. In most cases, although the patient is free from the survival threat of the tumor, prolonged and progressive intestinal obstruction is often painful and seriously affects the patient’s quality of life. Chronic radiation enterocolitis usually develops months or years after the end of radiotherapy, and its characteristic pathological changes are occlusive small artery endocarditis and intestinal wall fibrosis. The incidence of chronic radiation enteritis has been estimated in the United States: of the approximately 100,000 patients treated with radiotherapy for abdominal or pelvic tumors in the United States each year, 5-15% (50,000-150,000 people) develop chronic radiation enteritis, and approximately 50% of these 50,000-150,000 patients with severe symptoms require surgery. The clinical symptoms of chronic radiation enteritis usually include: intestinal obstruction (including obstruction due to narrowing and adhesions in the small intestine and/or rectum), intestinal fistula (including complex internal fistulae formed between the intestine and the bladder and vagina), diarrhea (including excessive bacterial proliferation in the small intestine, malabsorption of bile salts, and loss of intestinal absorption), intestinal bleeding, etc. Among the long-term complications that require surgery, intestinal obstruction accounts for the majority, about 75-80%. 80%. In the literature, the onset of chronic radiation enteritis is usually 6 to 24 months after radiotherapy, and some cases may occur after 20 years. The first onset of obstruction is about 1 year and 6 months after the end of radiotherapy, and the first visit of patients with obstruction is about 2 years and 6 months after the end of radiotherapy, and most patients have a brief history of diarrhea during radiotherapy. The radiologically damaged bowel segment causing intestinal obstruction is usually in the terminal ileum, accounting for more than 70% of the cases in the literature, and the majority of our cases (including this patient) are in the terminal ileum. This is mainly because different parts of the intestine have different degrees of tolerance to radiation damage. Although the rectum receives a large radiation dose, its degree of tolerance to radiation damage is much better than that of the small intestine; secondly, during radical surgery for rectal cancer, whether it is minimally invasive laparoscopic surgery or traditional open surgery, a large surgical wound will be formed in the pelvic cavity due to lymphatic tissue removal, so that the adjacent terminal ileum will be fixed in the pelvic radiation field and continuously suffer from radiation damage. The injury is continuous. The characteristic pathological changes of chronic radiation enteritis are interstitial fibrosis of the intestinal wall, edema and fragility of the radiation-injured intestinal wall, pallor of the plasma membrane surface, and poor tissue healing ability. We compare the radiation-injured intestine to a “dead tree”, although the shape of the “tree” is still there, it is difficult to grow branches and leaves again, lacking “vitality”. Radiation injury can cause severe adhesions to the abdominal organs, which can form “pie fusion” and “frozen pelvis” by scar healing between intestinal loops. In this case, a “frozen pelvis” was formed, and a “pancake fusion” was formed by scar healing between intestinal loops and between the intestinal canal and other pelvic organs. The progressive course of chronic radiation enteritis and the poor healing ability of radiation-damaged intestinal wall tissues make treatment extremely difficult, and the combination of severe malnutrition in most patients with long-term chronic disease increases the risk of postoperative complications. Most surgeons are either less exposed to chronic radiation enteritis in their careers or do not have a good understanding of the pathophysiology, development and regression of this disease, on the one hand, some surgeons diagnose this disease preoperatively as “adhesive intestinal obstruction” and find intraoperative fibrosis of the intestinal wall, “pancake fusion” and “fusion of abdominal organs”. On the one hand, some surgeons feel helpless to start the operation because of the preoperative diagnosis of “adhesive intestinal obstruction”, intraoperative finding of intestinal wall fibrosis, “pancake fusion” and “frozen pelvis”, which leads to serious complications such as hemorrhage or intestinal fistula, or they still apply the conventional techniques for On the other hand, surgeons who have experience with difficult surgery and disastrous consequences of chronic radiation enteritis are “afraid of surgery for chronic radiation enteritis”, and they adopt “non-surgical conservative treatment” for patients with chronic radiation enteritis who have indications for surgery. The “non-surgical conservative treatment” has affected the healing and quality of life of patients. In fact, studies of large numbers of cases at home and abroad have shown that successful patients with chronic radiation enteritis surgery can achieve long-term survival and a better quality of life. The ideal surgery for intestinal obstruction in chronic radiation enteritis is resection of the radiation-damaged bowel segment along with GI reconstruction. The anastomotic strategy and technique of GI reconstruction is very important, such as selection of the anastomotic bowel segment (at least one side of the anastomosis is less radiation-damaged), anastomotic placement (unradiated area), and anastomotic technique (lateral anastomosis with anastomosis). Even so, anastomotic fistulas occur in a small number of patients, so intraoperative placement of a double intraperitoneal trocar, close postoperative observation and timely management, and nutritional support are particularly important to allow the anastomotic fistula to heal on its own with satisfactory results even if it occurs (see a typical case on our website). In this case, according to the principles of surgery for chronic radiation enteritis, the small intestine was reconstructed with the hepatic flexure of the colon, the anastomosis was placed in the subhepatic right paracolic sulcus, the anastomosis was closed laterally with a linear cutting closure device, the anastomosis was closed with a bioprotein sealant, and a double abdominal cannula was placed next to the anastomosis. The pathological characteristics of fibrosis and extensive dense adhesions in the radiologically injured intestinal segment and the chronic progressive natural course of the disease determine that the surgical treatment of chronic radiation enteritis is extremely challenging, and special surgical strategies, surgical techniques, perioperative nutritional support and timely management of postoperative complications are the keys to successful treatment. Studies have investigated independent risk factors for surgical complications in chronic radiation enteritis, suggesting that the first surgery for chronic radiation enteritis has an important impact on prognosis and that specialized surgical centers and experienced surgeons play an important role in reducing serious surgical complications in patients. Currently, we have standardized the “treatment pathway” and “surgical procedure” for chronic radiation enteritis intestinal obstruction, and our team is rapidly becoming an experienced and specialized surgical treatment center due to the relative concentration of cases. As the leader of the discipline, I was introduced to 309 Hospital from Nanjing General Hospital of Nanjing Military Region in 2011. Before that, I studied and worked in the Institute of General Surgery of Nanjing General Hospital of Nanjing Military Region under the leadership of Academician Li for nearly 20 years, and had the honor to study under Academician Li Jieshou, the leading surgeon in China, and treated a large number of complicated gastrointestinal surgery patients from all over the country under the guidance of Academician Li. In 2006, he had the honor to learn from Professor Abu-Elmagd of the United States, the world’s most famous expert in small bowel transplantation and abdominal multi-organ cluster transplantation and president of the International Society for Small Bowel Transplantation. He became the doctor with the highest number of small intestine transplantation cases and the best quality of surgery in China. The long-term accumulation of study and work at the Southern General Hospital Institute of General Surgery has made the unique technique of separating severe abdominal adhesions, the technique of drainage of abdominal infection of intestinal fistula and reconstruction of digestive tract, the technique of minimally invasive laparoscopic surgery, the technique of difficult surgery of small intestine transplantation and the technique of surgical nutritional support become our distinctive and important technical means capable of solving difficult and complex clinical problems, and has made our complex post-radiotherapy radioenteritis caused by chronic The treatment of complex intestinal obstruction and extra-intestinal fistula caused by chronic post-radiotherapy radiation enteritis has gained a certain reputation in the industry. In the past 2 years since we came to Beijing, we have successfully treated dozens of cases of intestinal obstruction due to chronic radiation enteritis from all over China, most of them are patients after radiotherapy for cervical cancer, and radiotherapy for rectal cancer is the second largest group of such patients.