Abstract
Objective
Neoadjuvant chemotherapy for advanced ovarian cancer is associated with reduced morbidity in the elderly (Meyer et al., 2018). Spontaneous colonic perforation often leads to multisystem organ failure and death (Carter and Durfee, 2007; Rose and Piver, 1995).
Methods
A 76-year old woman with stage IIIC disease initiated carboplatin AUC 5 and paclitaxel 175 mg/m2 with unanticipated development of profound neutropenia. She clinically deteriorated by day nine and CT scan revealed a large volume of free air. Emergent surgery was performed.
Results
Diagnostic laparoscopy confirmed the presence of intra-abdominal stool and extensive inflammatory exudate (Video). The likelihood of identifying the site of perforation appeared remote, but pelvic tumor encasement was highly suggestive of a sigmoid origin. The stool was evacuated, the exudate gently debrided and the terminal ileum partially mobilized. Copious irrigation was performed with drain placement and the pneumoperitoneum was decompressed. The right lower abdominal wall trocar incision was extended so that the ileal segment could be brought out and matured. She was discharged to rehab on postoperative day 2 to continue a two week course of broad spectrum antibiotics. Single-agent carboplatin was resumed within a month. Uncomplicated ileostomy takedown with parastomal hernia repair was performed between cycles five and six. The patient is currently in remission.
Conclusion
Bowel perforation in the elderly, presenting with cachexia and treatment-induced pancytopenia for advanced ovarian cancer, is often a harbinger of early death. Selected patients may benefit from a minimally invasive approach by an experienced gynecologic oncologist instead of vertical laparotomy, abdominal washout, diversion and the potential sequelae of an open abdomen.
Keywords: Advanced ovarian cancer, Paclitaxel-induced colon perforation, Minimally invasive surgery, Diverting loop ileostomy
Highlights
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Spontaneous colon perforation during chemotherapy is associated with high mortality
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Vertical laparotomy and washout might not be always required
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Minimally invasive diversion by an expert laparoscopist may reduce morbidity
(Fig. 1)
Fig. 1.
The terminal ileum is laparoscopically mobilized in a background of extensive inflammatory exudate for planned diversion.
The following is the supplementary data related to this article.
The terminal ileum is laparoscopically mobilized for planned diverting loop ileostomy.
Supplementary data to this article can be found online at https://doi.org/10.1016/j.gore.2019.03.003.
Disclosure information
Nothing to disclose.
References
- Carter J., Durfee J. A case of bowel perforation after neoadjuvant chemotherapy for advanced epithelial ovarian cancer. Gynecol. Oncol. 2007;107:586–589. doi: 10.1016/j.ygyno.2007.09.008. [DOI] [PubMed] [Google Scholar]
- Meyer L.A., He W., Sun C.C. Neoadjuvant chemotherapy in elderly women with ovarian cancer: rates of use and effectiveness. Gynecol. Oncol. 2018;150:451–459. doi: 10.1016/j.ygyno.2018.06.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rose P.G., Piver M.S. Intestinal perforation secondary to paclitaxel. Gynecol. Oncol. 1995;57:270–272. doi: 10.1006/gyno.1995.1140. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The terminal ileum is laparoscopically mobilized for planned diverting loop ileostomy.