Hormone receptor-positive, HER2-positive breast cancer treatment interrupted by vaginal cuff dehiscence and bowel evisceration

What happened, in summary

This 81-year-old woman was receiving active treatment for hormone receptor-positive, HER2-positive breast cancer when she developed a rare surgical emergency. She had been taking letrozole for 5 months and trastuzumab emtansine, also called T-DM1, for 3 months. Five months before the emergency, she had been diagnosed with recurrent vaginal vault prolapse, but treatment had been deferred while breast cancer therapy continued. She came to the emergency department with sudden severe lower-abdominal pain and a vaginal bulge that had started 3 hours earlier. Examination showed complete vaginal cuff dehiscence, meaning the prior surgical closure at the top of the vagina had opened, with edematous but viable small bowel protruding through it. She underwent emergency laparotomy. Surgeons carefully returned the bowel to the abdomen, closed the vaginal cuff, took biopsies, and performed sacrocolpopexy to strengthen apical support and reduce prolapse recurrence risk. The bowel was viable, so no bowel resection was needed. She received cefuroxime and metronidazole, prophylactic anticoagulation, bowel-regulating measures, and low-dose aspirin. On postoperative day 7, her abdominal wound separated completely, requiring urgent re-laparotomy and retention sutures. Antibiotics were later escalated to vancomycin plus metronidazole because of rising inflammatory markers and wound drainage. She also received 2 red blood cell transfusions for anemia. She was discharged on postoperative day 28. Letrozole continued, and T-DM1 was resumed 7 weeks after discharge. At 21 months after surgery, she was symptom-free with POP-Q stage 0. Her cancer treatment was resumed after recovery, while the emergency surgery addressed a separate but serious complication that could have become life-threatening without rapid intervention.