Chemotherapy-induced enterocutaneous fistula after perineal hernia repair using a biological mesh: a case report
A 70-year-old man with a T3V1N0M0 rectal tumor underwent laparoscopic APR followed by adjuvant chemotherapy with oxaliplatin, fluorouracil, and calcium folinate. At 1 year control, radiological work-up and colonoscopy showed no signs of recurrence or distant metastases. Thirteen months after the APR, the patient developed a perineal hernia and had a reconstruction of the pelvic floor with a biological mesh (Permacol™) via a transperineal approach. The postoperative course was uneventful, and the initial follow-up with a pelvic–abdominal computed tomography (CT) scan 4 months after the surgery showed no signs of locoregional recurrence or reherniation. Nine months after the perineal hernia operation, the patient experienced weight loss. A thoracic–abdominal CT scan was performed and showed multiple metastases to the liver and lungs. The patient was treated with chemotherapy: bevacizumab, irinotecan, calcium folinate, and fluorouracil. Twelve months after the perineal hernia operation, but only 6 weeks into chemotherapy, the patient developed signs of sepsis with a high temperature, tachycardia, and hypotension and complained of pain in the right buttock. Physical examination showed signs of infection at the area. Possible differential diagnoses could have been local recurrence of the rectal cancer, intraabdominal abscess, or pelvis sepsis. We could have chosen to examine the patient with a positron emission tomography scan or, for example, an ultrasound (US)-guided biopsy, but we chose an acute US examination. This revealed an abscess, and drainage was established by a US-guided procedure. The patient was moved to an intensive unit and started treatment with intravenous fluids and broad-spectrum antibiotics. The following CT scan with contrast given through the drain showed a subcutaneous abscess cavity located in the perineum, with communication to the small bowel (). The patient underwent a laparotomy, and operative findings confirmed a perineal fistula from the distal ileum (). A resection of the small bowel with primary anastomosis was performed. The postoperative course was complicated by severe fluid and electrolyte disturbances. The patient was in the intensive care unit for a total of 16 days before treatment with pressors, intravenous fluids, and parenteral nutrition stabilized the patient. The perineal wound was treated with vacuum-assisted closure for a total of 20 days. There were no complications in the closure treatment. According to the patient’s request, he was discharged to hospice for terminal care after 28 days of hospital stay.