SURGICAL PALLIATION OF MALIGNANT SMALL BOWEL OBSTRUCTION IN A PATIENT WITH LOCAL RECURRENCE OF MUCINOUS ADENOCARCINOMA ON ACTIVE CHEMOTHERAPY: A CASE REPORT

Rachel Stern, MD; Shadi Arjmand, DO, MS; Feroze Tejani, MD; Staten Island University Hospital

Introduction: Surgical palliation can manage malignant small bowel obstruction with peritoneal metastases, even in patients receiving active chemotherapy, when systemic control is limited. Procedures like decompression or stoma creation relieve symptoms and improve quality of life despite poor prognosis. We present a case where surgical palliation was performed in a complex patient despite local recurrence of malignancy on chemotherapy with a positive outcome

Case: A 67-year-old female with past surgical history of right hemicolectomy for T4N2 mucinous adenocarcinoma two years prior, on chemotherapy with FOLFIRI/cetuximab developed focal thickening at the original anastomosis site and an indeterminate left adnexal mass on CT. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for the adnexal mass and was found to have recurrent colonic mucinous adenocarcinoma with signet ring cells. 

She presented one year later with intermittent abdominal pain, nausea, vomiting, and constipation. CT demonstrated a small bowel obstruction (SBO) at the original anastomotic site with nodular thickening and peritoneal nodules. A nasogastric (NGT) was placed for decompression. After failing non-operative management, the decision was made to take her to the operating room on hospital day (HD) 6 for exploratory laparotomy. Obstruction was found to be due to carcinoma invading the ileocolic anastomosis. The small bowel was decompressed via a controlled enterotomy with drainage outside the bowel to minimize contamination. A side-to-side ileocolic anastomosis to the transverse colon was performed. The skin was partially left open.  

On post-op day (POD) 2, she began experiencing worsening abdominal pain with tachycardia, leukocytosis, and hypotension.

She was taken back to the OR on POD3 for re-exploration, which revealed purulent peritonitis and gangrenous small bowel with enterotomy leak requiring resection. End ileostomy and mucus fistula were created, and the abdomen was partially closed. 

Post-operatively she initially required pressors, meropenem for gram-negative rod sepsis, TPN, and ventilatory support, but gradually improved, was extubated, tolerated diet, and was discharged on POD 15 from her initial surgery.

Discussion: This case demonstrates the role of surgical palliation in managing malignant bowel obstruction from recurrent mucinous adenocarcinoma with peritoneal spread in a patient on active chemotherapy. Despite postoperative complications, surgical intervention successfully relieved the obstruction, allowing the patient to recover and be discharged.

Conclusion: Tailored surgical palliation can effectively address symptoms in advanced recurrent colorectal cancer with obstruction, including in patients on active chemotherapy.

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