Necrotizing Fasciitis of the Abdominal Wall as a Post-Surgical Complication: A Case Report

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Author(s): 
Dubravko Huljev, MD,1 and Nastja Kucisec-Tepes, MD, DSc2

N ecrotizing lesions of soft tissue are infrequently encountered in routine surgical practice. The term necrotizing fasciitis unites different syndromes of progressive gangrenous infections of the skin and subcutaneous tissue into a single category.1 It is a rare, rapidly progressive infection that affects the fascia and subcutaneous tissue concomitantly with the development of thrombosis of skin microcirculation, resulting in necrosis of skin and soft tissue, destruction of muscles, and liquefaction of fats.1,2
The treatment is complex. The priority lies in an urgent surgical debridement with a targeted application of broad-spectrum antibiotics. Often, the combined surgical-antibiotic treatment is insufficient, prompting the use of auxiliary measures, such as negative pressure wound therapy (NPWT) or hyperbaric oxygenation.3,4 When the extremities are affected, amputations are required with a frequency of up to 25%.2 Mortality in these patients is between 50% and 80%, depending on the comorbid factors in the patient, characteristics of surgical incision, and the development of complications.5–11 Severe complications are acute renal insufficiency with a frequency of 31.6% and mortality of 50%, acute respiratory distress syndrome (ARDS) with a frequency of 29% and mortality of 59%, and multiorgan failure (MOF) with a frequency of 21% and mortality of 77.5%.4

Case Report

Clinical status and course of treatment. A 63-year-old woman was hospitalized initially for prospective surgical treatment of an umbilical hernia. The patient’s status was characterized by elevated blood pressure and diabetes mellitus, which were both controlled with medication. Physical parameters and laboratory values were within normal limits. Hysterectomy with adnexectomy was performed due to carcinoma corporis uteri (Ib/grII) and followed by radiation therapy 3 years prior to presentation. The patient did not consume alcohol or smoke.
In the course of primary hospitalization, the authors performed plastic surgery of the umbilical hernia with partial resection of the omentum magnum. Antimicrobial therapy was not administered. The operation and the postoperative course were normal, and the patient was released to home care on the fourth day. Three days after release, during a control visit, a normal clinical status of the abdomen and postoperative wound was established. On the second control visit, 10 days after the operation, the patient was urgently hospitalized with clinical symptoms of phlegmona and abscess of the abdominal wall.
At the time of hospitalization, the patient was fully conscious, mobile, and febrile at over 39oC with a broad phlegmona of the lower half of the abdominal wall spreading toward the groin with the presence of partial fluctuation. The values of laboratory parameters were as follows: leukocytes 16.9 x 109/L, erythrocytes 3.9 x 1012/L, thrombocytes 273 x 109/L, serum glucose 26.6 mmol/L, urea 22.2 mmol/L, creatinine 104 mmol/L, and C-reactive protein (CRP) > 400 mg/L. Lung radiography revealed infiltrate of unknown etiology of the middle and lower right lung lobe.
The physical examination revealed adiposity (160 cm/96 kg) with a body mass index of 37.5 kg/m2 (normal physiological values are 18–25 kg/m2). Other physiological functions were normal, with the exception of mild incontinence of urine and skin erosions in the perineal region.
Immediately upon hospitalization, the infected abdominal wall was incised and the abscess evacuated. The abscess cavity was cleansed with 3% hydrogen peroxide and physiological solution, and drains were placed in the cavity. Empirical parenteral antimicrobial therapy was administered simultaneously with surgical intervention.

References: 

References

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