Case Report

A 70-year-old female with a history of right hemicolectomy due to adenocarcinoma of the right colon (cecum) Stage IIIB (pT4N2M0), operated one year ago, presented to the emergency room of Asklepieion General Hospital Surgical Department in septic shock due to extensive anterior and lateral abdominal wall necrotizing fasciitis. (Figure 1) We obtained a CT (computed tomography) scan of abdomen, which revealed deep fascial thickening and enhancement, fluid, and gas in soft-tissue planes, signs of extensive soft tissue necrosis of the right anterior lower and lateral abdomen, and a loop of small intestine attached to the anterior abdominal wall on the right side.

The patient was admitted to our clinic, and we immediately received treatment with broad spectrum antibiotics (meropenem, linezolid and metronidazole) and aggressive fluid resuscitation. She was taken urgently to the operating room, where we found pervasive soft tissue infection of the abdominal wall, extending from the right iliac fossa to the right hypochondrium due to small intestine rupture (terminal ileum) to the anterior abdominal wall, which was located about 10cm cephalad to the previous ileotransverse anastomosis due to recurrence of cancer. The peritoneal cavity was thoroughly checked and washed, although there was no fecal peritonitis. She underwent considerable/ aggressive surgical debridement of the skin, subcutaneous tissue and abdominal wall aponeurosis, culture samples were taken. Resection of the ruptured small bowel that was attached to the wall was performed as well as a side-to-side ileo-transverse anastomosis. Due to septic shock and the inability to achieve abdominal wall closure, the method of open abdomen was decided.  Within the open abdominal cavity, we instated surgical towels covered with sterilized membrane which were perforated multiple times with a 19G needle to cover and protect the abdominal viscera. We placed two 19 French silicone tubes on top of this envelop of surgical towels and another sterile surgical towel to cover the tubes. Another sterile membrane was used to cover the surgical site. The silicone tubes were connected to a Y adapter which was then connected to continuous negative pressure of 100-150 mmHg. The patient remained intubated and was transferred to the Intensive Care Unit (ICU). She underwent another two revisory surgical debridements and change the envelope with surgical towels in the next 5 days (Figure 2-5).

The samples’ cultures revealed Proteus species and E. coli (sensitive to the already administered empirical antibiotic treatment). On the 11^th postoperative day complete closure of the abdominal wall aponeurosis was achieved and a negative pressure device was placed on the patient’s trauma (Vacuum Assisted Closure- VAC) to achieve skin and subcutaneous tissue closure. The patient, while remained intubated in ICU due to respiratory failure, suffered from deep vein thrombosis of her lower right extremity on the 42^nd postoperative day and was immediately diagnosed by Doppler ultrasonography and initiated appropriate treatment with therapeutic doses of Low Molecular Weight Heparin. She ultimately passed away on the 68^th postoperative day due to massive pulmonary embolism.

Figure 1: Initial presentation of our patient in the emergency room.