Erosion of bowel by catheter of peritoneal access device during intraperitoneal chemotherapy: A case report and PRISMA-driven systematic review

Several randomized trials have proved that intraperitoneal chemotherapy can confer better overall survival in the treatment of epithelial ovarian cancer. Also, intraperitoneal chemotherapy has been proved to be an effective alternative treatment for colorectal peritoneal carcinomatosis in non-randomized trials. However, complications induced by intraperitoneal chemotherapy deserve attention because of potential mortality in severe relevant cases. Commonly seen complications include infection, obstruction to infusion, retraction, leakage of infusion solution, and bowel erosion by catheter of peritoneal access device. Among these complications, bowel erosion is a relatively uncommon complication with reported rate between 1.2-4.2%. Nonetheless, most cases are occurred during implantation stage of access device due to blind insertion of catheters into the peritoneal cavity. Of note, bowel erosion during the cycle of intraperitoneal chemotherapy or even after completion of intraperitoneal chemotherapy is very rare. Currently, there exist very few published reports of such cases. Here we report a case diagnosed with stage III epithelial ovarian cancer, who underwent intraperitoneal chemotherapy following primary cytoreductive chemotherapy. This patient had an uneventful life during the first four cycles of intraperitoneal chemotherapy. However, during the fifth cycle of chemotherapy, this patient presented symptoms of watery diarrhea upon infusion of chemotherapy solution. Bowel erosion by catheter was suspected. Infusion of contrast medium into the catheter confirmed that contrast medium flowed into the small bowel. We also conducted a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-driven reviews for published cases. Introduction In addition to standard intravenous chemotherapy in the treatment of epithelial ovarian cancer, intraperitoneal (IP) chemotherapy provides a pharmacokinetically advantage of delivering high drug into the peritoneal cavity, a major site for tumor spread. Thus far, three large randomized clinical trials have demonstrated a survival benefit in patients diagnosed with epithelial ovarian cancer who received firstline IP chemotherapy after optimal cytoreductive surgery compared with conventional systemic chemotherapy [1-3]. Furthermore, in long-term follow-up study, IP chemotherapy even shows overall survival benefits that extend beyond 10 years. The longterm survival advantages may encourage more gynecologic oncologist to adopt IP chemotherapy in their communities [4]. Nonetheless, according to a recent report, the adoption of IP chemotherapy is an underused strategy for eligible patients in general, and the integration of IP chemotherapy into clinical practice varies significantly among institutions [5]. Thus, the implementation of IP chemotherapy merits further education and encouragement of gynecologic oncologists. Although IP chemotherapy confers better survival than conventional systemic chemotherapy. However, toxicities of IP chemotherapy still demand attention. The toxicities of IP therapy are generally related to procedures for administration and/or are drugrelated, as in the case of postoperative therapy [6]. Administration of IP therapeutic agents requires the setup of access devices (e.g., Tenckhoff catheters or Port-A-Cath), the placement, malfunction and adverse effects of which may cause significant suffering to patients, and may introduce delay, prevent the completion of IP chemotherapy [7]. Erosion into adjacent viscus by peritoneal access device during IP chemotherapy is an unusual complication. The presenting symptoms span from minor abdominal pain, watery diarrhea upon IP fluid administration, and even fever and peritonitis. In this article, we report on a case diagnosed with advanced stage ovarian cancer who received IP chemotherapy. During the cycle of IP therapy, patient presented with abdominal pain and watery diarrhea upon IP fluid administration. Treatment and outcome were reported. Also, a systematic review was conducted to identify published relevant reports.