Hyperbaric Oxygen as Prophylaxis for Radiation Injury
Posted on November 13, 2017
A growing body of literature supports the use of HBO2 in the prevention of radiation injury, usually in the setting of surgery within an irradiated field where the likelihood of complications is very high.
Hyperbaric Oxygen as Prophylaxis for Radiation Injury: Most of the literature cited reports the results of application of HBO2 to already expressed radiation injury. A growing body of literature supports the use of HBO2 in the prevention of radiation injury, usually in the setting of surgery within an irradiated field where the likelihood of complications is very high. The first published clinical report investigating prophylactic HBO2 is that by Marx(30) where hyperbaric oxygen has been shown to decrease the incidence of mandibular osteoradionecrosis from 29.9% to 5.4% when a course of 20 daily HBO2 treatments was delivered prior to dental extractions from heavily irradiated mandibles. In this protocol, an additional 10 treatments are delivered after extractions to support tissue metabolic demands after surgical wounding. Marx(6) has also reported the benefit of hyperbaric oxygen in the enhancement of osseointegration of dental implants in irradiated bone. Most oral surgeons are reluctant to attempt dental implants in irradiated jaws due to the very high rate of failure and the risk of precipitating osteoradionecrosis. Both Marx(6) and Grandstrom(94) have reported the benefit in supporting dental implants in radiated tissues with significant improvement in osseous integration of the dental implant in patients receiving hyperbaric oxygen. Using the same protocol as for osteoradionecrosis prophylaxis (20 preoperative and 10 postoperative HBO2 treatments), Marx6 has achieved an 81% osseointegration success rate with prevention of osteoradionecrosis in 100% of the patients so treated. Nineteen percent failed to osseointegrate as compared to 6% in non-irradiated patients undergoing dental implants. Ueda and colleagues(95) have reported a success rate of 92.3% (in a total of 21 implants) using a similar regimen of HBO2 in conjunction with dental implants (98).
As already cited above, Feldmeier et al(4-8) have reported the utility of hyperbaric oxygen in preventing serious wound complications in patients with recurrent head and neck cancer who had salvage procedures including radical resection within irradiated fields. In that report, 87.5% of
Hyperbaric Oxygen Therapy Indications: Delayed Radiation Injuries (Soft Tissue and Bony Necrosis)
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patients had prompt wound healing without complication whereas previous publications report up to a 60% incidence of serious complications in this setting without prophylactic HBO2. Pomeroy and his associates(96) have reported their results in applying preoperative hyperbaric oxygen as an adjunct to surgery for soft tissue injuries of the pelvis. All 5 patients in this report had an uneventful postoperative course, although 2 of 5 required a second surgical procedure to resolve the radiation injury. In an animal model, Feldmeier and associates have shown the effectiveness of hyperbaric oxygen in the prevention of radiation injury to small bowel even when there is no surgical trauma.(60,61)
A promising area for clinical application will be the further definition of prophylactic hyperbaric oxygen in the prevention of radiation injury. The development of reliable biochemical predictors of radiation injury would permit the identification of the population at risk for development of radiation injury. At the present time, a reasonable approach is to provide adjunctive HBO2 when surgery is planned to occur in a heavily irradiated bed. The medical literature is consistent in demonstrating a high rate of serious complications and even death when radical surgical procedures are required in irradiated tissues without prophylactic HBO2.(37-39,48-50) Third party insurance carriers must be convinced that such prophylactic intervention is not only valuable for humanistic reasons but also for financial reasons. It is hoped that the literature cited above will provide the individual practitioner with the needed documentation to make a case for the prophylactic application of HBO2. Hyperbaric oxygen in a preventative setting is likely to be more cost effective than a prolonged course of rehabilitation and reconstructive surgeries in a corrective fashion.
In summary, the use of hyperbaric oxygen prior to surgery in an irradiated field may prevent or decrease the incidence of catastrophic events such as wound breakdown with bony or hardware exposure, vascular rupture, infection, fistula formation, and/or flap loss and prevent further surgical intervention in an already compromised patient.
Tyler Sexton MD,CHWS,CHT, DMT