Eriksen Mh, Bulut O
Department of Surgical Gastroenterology, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark.
Int Med Case Rep J. 2014 Jan 23;7:11-3. doi: 10.2147/IMCRJ.S54192. eCollection 2014.
This is the first reported case of an enterocutaneous fistula as a late complication to reconstruction of the pelvic floor with a Permacol™ mesh after a perineal hernia. A 70-year-old man had a reconstruction of the pelvic floor with a biological mesh because of a perineal hernia after laparoscopic abdominoperineal resection. Nine months after the perineal hernia operation, the patient had multiple metastases in both lungs and liver. The patient underwent chemotherapy, including bevacizumab, irinotecan, calcium folinate, and fluorouracil. Six weeks into chemotherapy, the patient developed signs of sepsis and complained of pain from the right buttock. Ultrasound examination revealed an abscess, which was drained, guided by ultrasound. A computed tomography scan showed a subcutaneous abscess cavity located in the right buttock with communication to the small bowel. Operative findings confirmed a perineal fistula from the distal ileum to perineum. A resection of the small bowel with primary anastomosis was performed. The postoperative course was complicated by fluid and electrolyte disturbances, but the patient was stabilized and finally discharged to a hospice for terminal care after 28 days of hospital stay. It seems that hernia repairs with biological meshes have lower erosion and infection rates compared with synthetic meshes, and so far, evidence suggests that biological grafts are safe and effective in the treatment of pelvic floor reconstruction. There have been no reports of enteric fistulas after pelvic reconstruction with biological meshes. However, the development of intestinal fistulas after chemotherapy with bevacizumab has been described in the literature. Our case report supports this association between bevacizumab and fistula formation among rectal cancer patients, as symptoms of a fistula started only 6 weeks into bevacizumab treatment but approximately 12 months after the perineal hernia operation, even after pelvic reconstruction using a biological mesh and without local recurrence.
这是首例报道的经会阴疝修补术后使用Permacol™补片重建盆底出现肠皮肤瘘这一晚期并发症的病例。一名70岁男性因腹腔镜腹会阴联合切除术后发生会阴疝，使用生物补片进行了盆底重建。会阴疝手术后9个月，患者出现双肺和肝脏多发转移。患者接受了化疗，包括贝伐单抗、伊立替康、亚叶酸钙和氟尿嘧啶。化疗六周后，患者出现败血症迹象，并主诉右臀部疼痛。超声检查发现一个脓肿，在超声引导下进行了引流。计算机断层扫描显示右臀部有一个皮下脓肿腔与小肠相通。手术结果证实存在从回肠末端至会阴的会阴瘘。进行了小肠切除并一期吻合。术后病程出现了液体和电解质紊乱等并发症，但患者病情稳定，住院28天后最终出院前往临终关怀机构。与合成补片相比，使用生物补片进行疝修补的侵蚀和感染率似乎更低，到目前为止，有证据表明生物移植物在盆底重建治疗中是安全有效的。此前尚无使用生物补片进行盆腔重建后发生肠瘘的报道。然而，文献中已描述了使用贝伐单抗化疗后发生肠瘘的情况。我们的病例报告支持了直肠癌患者中贝伐单抗与瘘管形成之间的这种关联，因为瘘管症状在贝伐单抗治疗仅6周后出现，但在会阴疝手术后约12个月出现，即使是在使用生物补片进行盆腔重建且无局部复发的情况下。
