A 50-year-old woman presented with a one-year history of postmenopause bleeding and was diagnosed by curettage of well-differentiated velloglandular adenocarcinoma with extensive scaly differentiation and epidermoid carcinoma.
She underwent hysterectomy and double adnexectomy, pelvic lymphadenectomy and peritoneal lavage.
In the surgical specimen, all myometrial thicknesses were observed, as well as uterine serosa, cervical epithelium and stroma, mucosa of the right Fallopian tube and lymphatic vessels of the uterine body.
It was decided to treat with concurrent radiochemotherapy.
A total of 46 Gy classic consolidation was administered (5 x 200 cGy) along with five cycles of Cisplatin (40 mg/week).
After finishing both treatment, the patient received endocytic radiotherapy by placing a Chassagne mold with three radioactive sources of low dose rate Cesio-137.
She also received oral treatment with Tegafur.
Three months after receiving conservative treatment, the patient was admitted for intestinal subocclusion.
He had several similar episodes later and lost approximately 30 kg of weight.
The patient was assessed by the Clinical Nutrition Unit, which recommended a low-fat diet, waste and oral hypercaloric supplements, with no response.
He was admitted for intestinal rehabilitation with a weight of 26 kg and a height of 148 cm. BMI: 11.9 kg/m2.
A study performed during admission ruled out tumor recurrence in the upper digestive tract marked dilatation of the duodenum and proximal portion of the jejunum that reaches a maximum diameter of 10 cm in the proximal and proximal ileum.
Very prolonged intestinal transit takes about 48 hours since the contrast was administered until it reached the cecum and ascending colon.
Abdominal ultrasound showed massive small bowel loop dilation occupying the entire abdomen.
Discrete thickening of the wing walls.
A lactose hydrogen hydride test was performed which showed maladjustment.
Colitis performed at that time showed distal signs that histologically corresponded to chronic colitis consistent with post-therapy changes.
A nasogastric tube was placed for continuous enteral nutrition with inability to progress above 30 ml/hour of a normocaloric polymeric formula without response to the addition of prokinetics.
For this reason a tunneled central venous catheter was placed and included in the HPN program of our center.
The initial PN consisted of 1,250 mL volume and 1,440 kcal infused over 10 hours, 7 days a week.
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The initial evolution was good with progressive weight recovery and good tolerance to HPN.
However, two months after discharge, the patient was first admitted for catheter-related bacteremia.
In the 14 months, the patient was admitted twice due to episodes of Gram negative affectation, with involvement of the renal function (prerenal renal insufficiency) secondary to increased losses due to vomiting and reinfection due to several infections.
In all admissions, we reviewed the management guidelines of central venous catheter and HPN without being able to verify that the protocol had been broken.
In view of the poor clinical course and complete remission of the tumor disease, it was decided to propose an alternative surgical solution.
A new digestive tract was performed with similar findings to those performed two years before and an opaque enema in which a decrease in caliber was found in the most distal portion of the sigmoid stenosis, although it allows the passage of papilla without any difficulty.
A large dilation of the duodenum and small intestine was found in the supra and infraumbilical midline laparotomy until reaching a group of loops and jejunal loops adhered to each other and to the pelvis with a normal colon.
The affected loops were released and resected 20 cm including the pathological segment, with an laterolateral anastomosis.
The pathology report of the piece: "intestino with partial bladder fibrosis and subserosa with adhesions, characteristic of post-therapy changes".
The patient had an excellent recovery, with food tolerance and normal intestinal transit.
Six months after surgery the patient has a normal life, is able to tolerate a varied diet with lactose restriction and had regained weight prior to radiotherapy treatment.
