Prathusha Yerramilli

Honors (Bachelor's)

Immediate surgical intervention is often required for intestinal perforation to avoid the high morbidity and mortality of peritonitis and the complications associated with sepsis. (1, 2). Surgery is a definitive way to establish source control in the presence of intestinal leakage and is an effective approach in cancer patients to avoid delays in chemotherapy. However, micro perforations and contained perforations can be treated nonoperatively, especially in patients at elevated risk for surgery (2, 3, 4). This can also be considered in cancer patients without delaying planned chemotherapy. We report a case of intestinal microperforation in a 59-year-old female patient with metastatic breast cancer to the bone with malignant ascites and peritoneal carcinomatosis. Due to her hemodynamic stability and the high risk of operative complications in the setting of ascites and carcinomatosis, she was treated with nonoperative management. Throughout her hospital course, her vitals and abdominal examination remained stable, and she was safely managed nonoperatively and discharged home. Post hospitalization she had follow-up with oncology and the planned start date for chemotherapy was not delayed due to any concern for ongoing infection from nonoperative management. Management of intestinal perforation should be tailored to the patient's clinical status and comorbidities. Due to this patient's malignant ascites and carcinomatosis, operative intervention carried significant risk of respiratory compromise, marked shifts in body fluids, anastomotic leak, and wound healing complications (5).

Abdominoperineal resection (APR) is a surgical procedure that involves the complete removal of the anal canal, anal sphincter complex, rectum, and a portion of the sigmoid colon with creation of an end colostomy. This procedure is primarily indicated for patients with low rectal cancers where the anal sphincters cannot be spared and anal cancers refractory to chemoradiation or recurrent anal cancers. It can also be performed in patients with severe perianal Crohn's disease, complex anorectal fistulae, or patients with severe trauma to the anus/rectum where the sphincter complex is significantly affected. This is a complex procedure with a high complication rate, and patients generally undergo extensive perioperative planning and assessment to optimize a positive outcome. In this report, we describe a rare case of emergent APR in a patient who presented with pelvic sepsis secondary to necrotic rectum and colon after a prior emergent Altemeier procedure at another hospital. A thorough literature review has revealed only one prior documented case of emergent APR.