Enterocutaneous Fistula: A Challenging Complication in Cervical Cancer Management

A 42-year-old woman with a history of cervical cancer previously treated with radical hysterectomy, lymphadenectomy, and bilateral salpingectomy presented with severe right lower extremity pain, initially attributed to routine chemotherapy-related side effects. Despite symptomatic management, her pain intensified, accompanied by abdominal distention, constipation, and reduced ambulation. Subsequent clinical evaluation revealed a significant abscess extending from the pelvis into the gluteal musculature and thigh. Imaging confirmed that the abscess communicated with a loop of the small bowel, evolving into an enterocutaneous fistula, which manifested as feculent drainage through her thigh incision. Surgical intervention with incision, drainage, and excision of nonviable muscle tissue provided temporary relief but could not entirely resolve the fistula. Microbiological cultures yielded intestinal flora, including Escherichia coli, Enterococcus faecium, and Bacteroides ovatus, confirming bowel origin. A thorough review of the patient's clinical history identified bevacizumab therapy as a significant risk factor, consistent with current evidence linking bevacizumab use to increased fistula formation, especially following prior pelvic surgery or radiation therapy. Bevacizumab, an anti-angiogenic monoclonal antibody that inhibits vascular endothelial growth factor, disrupts essential physiological processes of angiogenesis and tissue repair, thereby facilitating fistula development in susceptible tissues. Management employed conservative measures, including nutritional support, infection control, and wound management using an external ostomy appliance, ultimately achieving medical stabilization. Bevacizumab therapy carries a significant risk of severe complications, including fistula formation, particularly in patients with prior pelvic surgery or radiation therapy. Early clinical suspicion, prompt imaging studies, and a coordinated multidisciplinary approach are essential for timely diagnosis and effective management of these complications. Patients receiving bevacizumab should undergo careful monitoring, especially if they have undergone previous pelvic treatments, to allow for prompt detection and intervention of potential fistula formation.