This is the first reported case of an
enterocutaneous fistula as a late complication to reconstruction of the pelvic floor with a Permacol™ mesh after a perineal
hernia. A 70-year-old man had a reconstruction of the pelvic floor with a
biological mesh because of a perineal
hernia after laparoscopic
abdominoperineal resection. Nine months after the perineal
hernia operation, the patient had multiple
metastases in both lungs and liver. The patient underwent
chemotherapy, including
bevacizumab,
irinotecan,
calcium folinate, and
fluorouracil. Six weeks into
chemotherapy, the patient developed signs of
sepsis and complained of
pain from the right buttock. Ultrasound examination revealed an
abscess, which was drained, guided by ultrasound. A computed tomography scan showed a subcutaneous
abscess cavity located in the right buttock with communication to the small bowel. Operative findings confirmed a perineal
fistula from the distal ileum to perineum. A resection of the small bowel with primary anastomosis was performed. The postoperative course was complicated by fluid and
electrolyte disturbances, but the patient was stabilized and finally discharged to a hospice for
terminal care after 28 days of
hospital stay. It seems that
hernia repairs with
biological meshes have lower erosion and
infection rates compared with synthetic meshes, and so far, evidence suggests that
biological grafts are safe and effective in the treatment of pelvic floor reconstruction. There have been no reports of enteric
fistulas after pelvic reconstruction with
biological meshes. However, the development of intestinal
fistulas after
chemotherapy with
bevacizumab has been described in the literature. Our case report supports this association between
bevacizumab and
fistula formation among
rectal cancer patients, as symptoms of a
fistula started only 6 weeks into
bevacizumab treatment but approximately 12 months after the perineal
hernia operation, even after pelvic reconstruction using a
biological mesh and without local recurrence.