Bowel strangulation caused by massive intraperitoneal adhesion due to effective chemotherapy for multiple peritoneal metastases originating from descending colon cancer

Abstract

We describe a case of bowel strangulation caused by massive peritoneal adhesion as a result of effective chemotherapy. A 71-year-old man, who had obstructive descending colon cancer with massive peritoneal metastases and, therefore, received palliative surgery consisting of diverting colostomy and sampling of peritoneal nodules, developed bowel strangulation on day 4 of the 2nd course of chemotherapy, including irinotecan, l-leucovorin, and 5-fluorouracil. Emergent celiotomy showed a massive intraperitoneal adhesion formed around several intestinal loops, which were not observed at the prior surgery. One loop was strangled, but recovered by adhesiotomy alone. Intestinal loops were formed around aggregates of peritoneal nodules as the centers, several of which were then sampled. We closed the abdomen after all intestinal loops were eradicated by total enterolysis. Fortunately, the patient has been doing well and received chemotherapy without recurrent bowel obstruction 10 months after the present episode. Histological findings of the aggregates causing intestinal loops demonstrated extensive necrosis of cancerous tissue surrounded by fibrosis with abundant lymphocyte infiltration. These findings were not observed in the specimen sampled before chemotherapy, suggesting that intestinal loops were caused by inflammatory adhesion occurring around the peritoneal metastases as a result of effectiveness of chemotherapy.

Keywords: Adhesion; Chemotherapy; Colorectal cancer; Peritoneal dissemination; Strangulated ileus.

Fig. 1

Findings of barium enema, colonoscopy, and abdominal computed tomography. a A severely stenotic lesion (white arrowheads) was observed in the descending colon just proximal to the sigmoid-descending junction. b A large circular type 2 lesion was detected by colonoscopy and caused severe bowel stenosis. c, d Greater omentum was occupied with numerous peritoneal nodules (black arrows) and formed an omental cake. Moderate ascites was identifiable. e Primary lesion was easily detectable as a large mass by computed tomography (large white arrow)

Fig. 2

Findings of abdominal X-ray and computed tomography taken at the onset of bowel strangulation. a Abnormal intestinal gases (black arrows) observed by abdominal X-ray suggested formation of several intestinal loops. b Dilated intestine was observed in the right upper abdomen. c, d Dilatation of the intestine was tapered (white arrow) and disrupted by the severe caliber change (white arrowhead). These findings suggested that bowel strangulation was caused by the torsion of the intestinal loop

Fig. 3

Photograph and schematic image of intraabdominal findings schematic image at the second emergent laparotomy. a Dilated and mildly discolored ileum was found in the right upper abdomen. b Intestinal loops were formed around the aggregates of peritoneal metastatic nodules as the centers (small and large black arrows). Notably, one loop was twisted on the aggregate at the axis (large black arrows) and strangled

Fig. 4

Comparison of histological findings between peritoneal nodules before and after chemotherapy. a–c Loupe image (a original magnification, ×5), low-power (b original magnification, ×40), and high-power maicroscopic findings (c original magnification, ×100) of the specimens sampled at the first semi-emergent surgey, i.e., before receiving chemotherapy, showed that peritoneal nodules were mainly composed of well-differentiated tubular adenocarcinoma and in part mucin-enriched cancerous cells, which leads to the diagnossis of well differentiated mucinous carcinoma. d–f Loupe image (d origincal magnification, ×5), low-power (b, e original magnification, ×40), and high-power maicroscopic findings (f original magnification, ×100) of the specimens sampled at emregent surgery for bowel strangulation, i.e., after two courses of chemotherapy, showed that peritoneal nodules were occupied mainly with abundant mucous lake and a little viable canceraous tissue was observed sparsely in the mucous lake. Each nodule was encapsulated with fresh fibrous tissue, through which mononuclear cell infiltration was diffusely observed. It seems that the fibrous tissue attached surrounding mesothelial membranous structures to peritoneal metastatic nodules