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Perforated Giant Marginal Ulcer While on Chemotherapy: a case report

Connal Robertsn-More, MD, Christopher de Gara, MBBS, Aliyah Kanji, MD, Daniel W Birch, MD, MSc, Shazeer Karmali, MD, MPH. University of Alberta

Introduction: Obesity is a common problem worldwide with numerous associated comorbidities and is associated with an increased risk of developing some cancers. Despite bariatric surgery being associated with a risk reduction for cancer development, some will develop cancer after surgery and little is known about complications which might arise during multimodality cancer treatment.

Here we report the case of a 55 year-old female who developed an unusual giant marginal ulcer (MU) post Laparoscopic Roux-en-Y-Gastric Bypass (LRYGB) while receiving systemic chemotherapy for an early stage breast cancer.

Case Report: In summary, a 55 year-old female with a preoperative BMI of 40kg/m2 had an uncomplicated LRYGB one year prior to her presentation. She was a non-smoker, was abstinent of alcohol and did not use NSAIDs, steroids or other ulcerogenic medications. Eight months post procedure with a BMI of 29.1kg/m2 she was diagnosed and treated with BCS plus SLNB for a pT2N0M0 ER/PR +ve HER2 –ve breast cancer. One week following her third cycle of docetaxel and cyclophosphamide, she presented with two days of melena, small volume hematemesis and abdominal discomfort. The patient was resuscitated with PRBC, started on a PPI infusion and had free air ruled out on a CXR. Upper endoscopy was complete showing a giant MU at the gastrojejunal anastomosis, biopsies ruled out malignancy and H.pylori. Subsequent CT abdomen/pelvis identified contrast extravasation from the anastomosis confirming a free perforation. Broad spectrum antibiotics were started and a diagnostic laparoscopy complete. A graham patch repair utilizing omentum and abdominal washout were complete with placement of surgical drains. The patient was supported with parenteral nutrition while NPO. Diet was advanced after an upper GI series on post operative day 7 showed no ongoing leak. The patient was discharged on post operative day 13, recovered and although further chemotherapy was discontinued she completed whole breast radiotherapy.

Conclusion: To our knowledge this is the first reported case of a perforated giant MU after LRYGB for severe obesity in a patient on systemic chemotherapy with no other risk factors for MU development. Spontaneous small bowel perforation has been documented in patients on chemotherapy without prior abdominal surgery. What is unknown is whether after LRYGB patients are at increased risk of anastomotic or other complications while on chemotherapy and we encourage others to report cases to develop a body of literature on the subject.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 87995

Program Number: P593

Presentation Session: iPoster Session (Non CME)

Presentation Type: Poster

145

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