Schorge John O
Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA 02111, United States of America.
Gynecol Oncol Rep. 2019 Mar 20;28:84-85. doi: 10.1016/j.gore.2019.03.003. eCollection 2019 May.
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).
A 76-year old woman with stage IIIC disease initiated carboplatin AUC 5 and paclitaxel 175 mg/m 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.
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.
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.
晚期卵巢癌的新辅助化疗与老年患者发病率降低相关（迈耶等人，2018年）。自发性结肠穿孔常导致多系统器官衰竭和死亡（卡特和德费，2007年；罗斯和皮弗，1995年）。
一名76岁患有IIIC期疾病的女性开始接受卡铂AUC 5和紫杉醇175mg/m治疗，但意外出现严重中性粒细胞减少。到第九天时她的临床状况恶化，CT扫描显示有大量游离气体。遂进行急诊手术。
诊断性腹腔镜检查证实腹腔内有粪便和广泛的炎性渗出物（视频）。确定穿孔部位的可能性似乎很小，但盆腔肿瘤包绕高度提示乙状结肠起源。清除了粪便，轻柔地清创了渗出物，并部分游离了回肠末端。进行了大量冲洗并放置引流管，解除了气腹。延长了右下腹壁套管针切口，以便将回肠段引出并成熟。术后第2天她出院接受康复治疗，继续使用两周的广谱抗生素。一个月内恢复单药卡铂治疗。在第五和第六周期之间进行了简单的回肠造口拆除和造口旁疝修补术。患者目前处于缓解期。
老年患者因晚期卵巢癌出现恶病质和治疗引起的全血细胞减少而发生肠穿孔，往往是早期死亡的先兆。部分患者可能受益于经验丰富的妇科肿瘤学家采用的微创方法，而非垂直剖腹术、腹腔冲洗、改道以及开放腹部的潜在后遗症。
