Colonic stenosis caused by infection of an intraperitoneal access port system: a rare complication of intraperitoneal chemotherapy for gastric cancer with peritoneal metastasis
- Jun Kinoshita1Email author,
- Sachio Fushida1,
- Tomoya Tsukada1,
- Katsunobu Oyama1,
- Toshifumi Watanabe1,
- Koichi Okamoto1,
- Isamu Makino1,
- Keishi Nakamura1,
- Hironori Hayashi1,
- Hisatoshi Nakagawara1,
- Tomoharu Miyashita1,
- Hidehiro Tajima1,
- Hiroyuki Takamura1,
- Itasu Ninomiya1,
- Hirohisa Kitagawa1,
- Takashi Fujimura1 and
- Tetsuo Ohta1
© Kinoshita et al.; licensee BioMed Central Ltd. 2014
Received: 28 February 2014
Accepted: 16 May 2014
Published: 4 June 2014
Intraperitoneal (IP) chemotherapy is garnering attention as an effective treatment for gastric cancer with peritoneal metastasis. We report the case of a patient who developed colonic stenosis caused by infection of an IP access port system during IP chemotherapy. It was difficult to differentiate whether the extrinsic colonic stenosis arose from a catheter infection or peritoneal metastasis of the gastric cancer.
A 66-year-old Japanese man underwent total gastrectomy for gastric cancer. Because the intraoperative findings revealed peritoneal metastasis, a port system was implanted for subsequent IP chemotherapy. Two months after initiation of chemotherapy, he complained of vomiting and abdominal pain. A computed tomography scan revealed marked thickening of the sigmoid colon wall adjacent to the catheter of the IP access port system. A barium enema demonstrated extrinsic irregular stenosis of the sigmoid colon. Although it was difficult to distinguish whether infection or peritoneal metastasis had caused the colonic stenosis, we removed the port system to obtain a therapeutic diagnosis. Coagulase-negative staphylococci were detected by catheter culture. The wall thickening and stenosis of the sigmoid colon completely resolved after removal of the port system.
We report the case of a rare complication in association with an IP access port system. Infection of the port system should be considered as a differential diagnosis when colonic stenosis adjacent to the catheter is observed during IP chemotherapy.
KeywordsIntraperitoneal chemotherapy Gastric cancer Peritoneal metastasis Port complication
Gastric cancer is a major cause of cancer death worldwide. Recent advances in systemic chemotherapy regimens have shown encouraging tumor response rates and increased survival in patients with unresectable or metastatic gastric cancer . However, treatment outcomes for patients with peritoneal metastasis, which is the most frequent metastatic pattern of recurrence, have not improved sufficiently .
Intraperitoneal (IP) chemotherapy is garnering attention as an effective treatment for peritoneal metastasis because of the theoretical advantage of higher local concentrations, prolonged tumor exposure, and reduced systemic toxicity [3, 4]. IP chemotherapy was shown to prolong survival in a phase III study of ovarian cancer with peritoneal metastasis and has been approved as a recommended regimen by the National Cancer Institute in the United States . IP chemotherapy has also been shown to be a promising treatment option for gastric cancer [6–9]. A multicenter randomized clinical trial is now ongoing to generate evidence regarding the effects of IP chemotherapy on gastric cancer with peritoneal metastasis.
A subcutaneous port and catheter system has been developed and is now the most common route through which chemotherapeutic agents are administered into the peritoneal cavity. The main advantages of subcutaneous systems are the low rate of port-related infections and the ease of drug administration into the peritoneal cavity . However, complications associated with subcutaneous port systems have been reported in patients with ovarian cancer and gastric cancer [10–19].
We herein describe a patient who developed colonic stenosis caused by the infection of an IP access port system during IP chemotherapy for gastric cancer with peritoneal metastasis. It was difficult to differentiate whether the extrinsic colonic stenosis arose from a catheter infection or the peritoneal metastasis.
The postoperative course was uneventful. On postoperative day 14 the patient began chemotherapy with S-1 (TS-1®; Taiho Pharmaceutical Company, Tokyo, Japan) at 80 mg/m2/day (2 weeks on, 2 weeks off) and docetaxel administered intraperitoneally at 45 mg/m2 (days 1 and 15). He was discharged on postoperative day 29 and underwent outpatient chemotherapy.
Outpatient chemotherapy with S-1 and intravenous docetaxel was performed. A re-laparoscopy was subsequently performed to evaluate the patient’s response to chemotherapy. There were abnormal findings such as fibrosis, scar formation, or macroscopic progression of peritoneal metastasis in the sigmoid colon and its mesentery.
An IP access port system was re-implanted four months after removal. The patient remains alive without progression of peritoneal metastasis six months after surgery.
A well-established principle of IP chemotherapy is the regional pharmacologic advantage achieved by direct instillation of drugs into the peritoneal cavity. A recent phase II study of intravenous and IP paclitaxel combined with S-1 showed a 1-year overall survival rate of 78% and a median survival time of 22.5 months for patients with peritoneal metastasis from gastric cancer . Other clinical trials involving IP chemotherapy with taxane agents have also shown favorable prognoses, with a median survival time of 16.2 to 24.6 months [7–9]. A multicenter randomized clinical trial is now ongoing to generate evidence regarding the effects of IP chemotherapy on gastric cancer with peritoneal metastasis.
Complications associated with intraperitoneal access port systems in previous reports *n: number of patient
Type of cancer
Small bowel obstruction
Pfeifle et al.
Piccart et al.
Braly et al.
Davidson et al.
Malmastorm et al.
Topuz et al.
Makhija et al.
Walker et al.
Emoto et al.
Previous studies have reported that gut-associated complications included fistula formation and perforation (0.0 to 3.5%). Braly et al. also reported one case of small bowel obstruction due to an IP catheter . Fibrous sheath formation around the catheter was thought to pose a risk of small bowel obstruction .
To the best of our knowledge this is the first case of colonic stenosis as a complication of an IP port. We could not clarify the mechanism of the stenosis of the sigmoid colon in this case. We speculate that inflammation secondary to the catheter infection was the main contributor to the wall thickening and subsequent stenosis of the sigmoid colon because we did not observe numerous fibrous sheaths attached to the catheter at the time of removal. An important point of our case is that the extrinsic stenosis was remarkably similar in appearance to peritoneal metastasis. In general, peritoneal metastasis from gastric cancer frequently involves stenosis of the colorectum. In this case, the gut stenosis was not histologically confirmed by colonofiberscopy because it extended from the serosal side of the colonic wall. The findings obtained by barium enema were characteristic of the metastatic carcinoma that extended from the serosal side of the colonic wall.
Our patient had no fever and no severe acute inflammatory changes were found upon blood examination during the infectious episode. Therefore, it was difficult to distinguish whether infection or peritoneal metastasis caused the colonic stenosis. Such a diagnosis should be cautiously obtained because it substantially influences the subsequent treatment plan.
The occurrence of port complications in gastric cancer has been investigated in only one other report  according to our review of the literature, and has not been fully eliminated as is the case in ovarian cancer. Because peritoneal metastasis of gastric cancer more frequently involves enterostenosis than peritoneal metastasis of ovarian cancer, our case is thought to be significant in terms of the management of IP chemotherapy-induced complications, especially in patients with gastric cancer.
In summary, we report the case of a rare complication in association with an IP access port system. Infection of the port system should be considered as a differential diagnosis when colonic stenosis adjacent to the catheter is observed during IP chemotherapy.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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