|Ahead of print
Necrotizing fasciitis of the lower extremity secondary to a perforated rectosigmoid tumor
Suleyman Utku Celik, Rahman Senocak
Department of General Surgery, Gulhane Training and Research Hospital, Ankara, Turkey
|Date of Submission||21-Jun-2020|
|Date of Decision||12-Jul-2020|
|Date of Acceptance||02-Aug-2020|
|Date of Web Publication||14-Sep-2021|
Suleyman Utku Celik,
Department of General Surgery, Gulhane Training and Research Hospital, Ankara
Source of Support: None, Conflict of Interest: None
Necrotizing fasciitis (NF), which is a rare but life-threatening soft tissue infection, can present as a complication of colorectal diseases. The development of NF of the lower extremity secondary to a perforated colorectal tumor has been reported in only a few patients. We present a case of a 68-year-old woman, in which necrotizing soft tissue infection of the left lower extremity was the presenting feature of a perforated rectosigmoid tumor. On examination, there was a tender swelling and edema with palpable crepitus in the left inguinal region and thigh. Computed tomography showed gas within the retroperitoneal tissues, with subcutaneous edema and emphysema extending from the thigh to the ankle. NF was diagnosed, and the patient underwent Hartmann's procedure and fasciotomy with an aggressive debridement of the left thigh and inguinal region. In the case of NF of the lower extremity or abdominal wall without an obvious cutaneous source, an intraabdominal cause should be considered and sought.
Keywords: Colon cancer, intestinal perforation, lower extremity, necrotizing fasciitis
| » Introduction|| |
Necrotizing fasciitis (NF) is a rare, rapidly progressing, and life-threatening bacterial necrotizing soft tissue infection of the fascial planes and surrounding tissues. NF typically follows a blunt trauma, complicated intraabdominal infections, or minor wounds., However, it can also occur in healthy individuals following a surgical procedure., Especially in patients presenting early with mild or nonspecific symptoms, the NF diagnosis may be delayed, and a high index of clinical suspicion is essential for a timely diagnosis. In addition to an early diagnosis of NF, aggressive surgical debridement should occur as quickly as possible and treatment with appropriate antimicrobials are critical in reducing mortality and morbidity.,,
The development of NF of the lower extremity secondary to a perforated colorectal tumor has been reported in only a few cases.,,,,, Here, we present a patient in which necrotizing soft tissue infection of the left thigh was the presenting feature of a perforated rectosigmoid colon tumor.
| » Case Report|| |
A 68-year-old woman receiving chemotherapy with a history of metastatic rectosigmoid cancer to the liver was admitted to emergency department with a fever and progressive swelling and pain in her left thigh for 3 days. On admission, the patient was tachypneic, tachycardic, hypotensive, and hyperthermic at 38.3°C. Localized pain was elicited in the left lower quadrant on the abdominal examination. There was a large tender swelling and edema with palpable crepitus in the left inguinal region and thigh, extending to the inner side of the ankle. Vascular and neurologic examinations of the left lower extremity were normal. Initial laboratory investigations revealed leukocytosis (16.5 × 109/L) and high C-reactive protein level (295 mg/L). Lower extremity venous Doppler ultrasonography revealed no evidence of a deep vein thrombosis (DVT). Abdominopelvic computed tomography (CT) scan showed a metastatic lesion in the liver and malign thickening of the rectosigmoid colon with perforation as well as fascial thickening. In addition, lower extremity CT revealed subcutaneous edema extending into the intermuscular septa and extensive gas in the subcutaneous tissue and deep fascia extending from the thigh to the ankle [Figure 1].
|Figure 1: Axial computed tomography (CT) image demonstrating a thickened wall of the rectosigmoid tumor (arrow), free air (star), and fluid collection. Coronal CT image shows fascial thickening and an impressive amount of gas. This gas extended up the fascial planes from the retroperitoneum into the left thigh (dotted circle), extending through the femoral canal along the femoral vein and artery (arrow) to the ankle|
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After informed consent was obtained, the patient underwent an immediate surgical exploration. After washing out the peritoneal cavity and releasing the rectosigmoid colon, multiple full-thickness perforations on the anterior upper rectum and fecal material tracking from retroperitoneum into the femoral canal were observed and Hartmann's procedure was performed. An exploration of the thigh revealed necrotic infection extending between the muscles of the anterior thigh deep to the inguinal ligament, and a fasciotomy with an aggressive debridement was performed [Figure 2].
|Figure 2: A preoperative image of the patient showing a significantly swollen left leg compared to the right leg (a) and an intraoperative image demonstrating a perforated rectosigmoid tumor (star). The image also shows a severe soft tissue infection of the femoral region of the left groin and a hole (arrow) in the femoral canal along the femoral vein and artery and upper rectum distal to the perforation (arrowhead) (b). Finally, an intraoperative image of the medial thigh demonstrates a necrotizing infection involving the skin, subcutaneous fat, and fascia (c)|
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Histological analysis showed abundant necrosis and mixed inflammatory cell infiltration of the fascia and microbiological examination revealed large numbers of Escherichia More Details coli and anaerobes. After repeated debridements, multiple negative pressure wound therapies for both the abdomen and thigh were performed. The abdomen was then closed primarily, and the thigh defect was closed with a rotational muscle flap. After 45 days in the intensive care unit and an additional 2 weeks of hospitalization, the patient was discharged with an uneventful postoperative course. However, the patient died due to liver metastases and local cancer recurrence 10 months after the surgery.
| » Discussion|| |
NF, which is a severe and uncommon bacterial infection involving subcutaneous tissues, can occur in any part of the body. However, NF of the lower extremity secondary to a perforation of a colon tumor, as in this case, is very rare. The present literature review represents the largest summarized report of NF of the lower extremity secondary to a colorectal malignancy, reporting 18 distinct cases.,,,,,,,,,,,,,,,
Most patients in the literature were men (66.6%), and the average age was about 67 years. Nearly all tumors were in the caecum, sigmoid colon, or rectum. Most NF cases were polymicrobial, and Escherichia coli was the most common organism, isolated in 61.1% of patients. All except six patients died despite therapy, especially in the early period of treatment [Table 1].
|Table 1: Reported case reports of colorectal malignancy presenting with necrotizing fasciitis of the lower extremity|
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As we have learned from the aforementioned studies, several possible routes of spread of fecal material and infection from the intraabdominal space into the thigh have been identified. These routes include those through the obturator foramen, by way of the femoral canal, along the femoral sheath, through the sacrosciatic notch, and along the psoas or piriformis muscle.,,,, In the present case, the possible route into the thigh was through the femoral canal and the infection spread along the fascial planes with the femoral sheath into the proximal leg. We think the reason for the perforation may be rapid tumor regression in the colon by chemotherapy. However, an obstruction might have developed synchronously because there was another perforation site proximal to the tumor.
NF is more commonly found in immunocompromised patients.,, In the literature, NF cases associated with colonic perforation have been reported in patients taking corticosteroids, chemotherapy, or radiotherapy., Clinical signs of a perforation may initially be subtle and masked in these patients, which may delay the diagnosis of intraabdominal infection and lead to lifethreatening conditions. Pain initially occurs in the affected area, but the visual appearance may not change. The tissues then become edematous with erythema, necrosis, and the crepitus is palpated. The suggested treatment for NF due to colorectal cancer is early surgical therapy and intensive care for sepsis. After the initial open drainage, a colostomy can be a reasonable option. As soon as the NF is controlled, the primary tumor should be resected. It was known that a time interval of less than 12 hours from diagnosis to surgery increases survival rates., The current patient was taken to surgery immediately after diagnosis and eventually recovered after a prolonged convalescence following multiple surgical interventions and intensive care support.
This case is interesting due to the unusual clinical presentation of the patient with a colon perforation. Nonspecific abdominal symptoms and a painful swollen leg led us to the preliminary diagnosis of DVT. However, an urgent CT scan revealed a necrotizing infection of the thigh and a perforated rectosigmoid tumor. This case also emphasizes the importance of early clinical suspicion, appropriate antimicrobials, and aggressive surgical debridements in the management of NF, regardless of its cause. Finally, and most importantly, when NF of the lower extremity or abdominal wall is not associated with an obvious cutaneous source, an intraabdominal cause should be considered and sought.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal representative has given consent for patient's images and other clinical information to be reported in the journal. The representative understand that patient name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank Emin Lapsekili, Sahin Kaymak, Oguz Hancerliogullari, and Aytekin Unlu for their contribution in the management of the patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg 2014;1:36.
Chen KJ, Klingel M, McLeod S, Mindra S, Ng VK. Presentation and outcomes of necrotizing soft tissue infections. Int J Gen Med 2017;10:215-20.
Puvanendran R, Huey JC, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009;55:981-7.
Chen JH, Chang PY, Ho CL, Chen YC, Kao WY. Retroperitoneal metastatic adenocarcinoma complicated with necrotizing fasciitis of the thigh in a patient with advanced rectal colon cancer. Case Rep Oncol 2010;3:304-9.
Highton L, Clover J, Critchley P. Necrotising fasciitis of the thigh secondary to a perforated rectal cancer. J Plast Reconstr Aesthet Surg 2009;62:e17-9.
Evans WDG, Winters C, Amin E. Necrotising fasciitis secondary to perforated rectal adenocarcinoma presenting as a thigh swelling. Case Reports 2015;2015:bcr2014208312.
Khalil H, Tsilividis B, Schwarz L, Scotte M. Necrotizing fasciitis of the thigh should raise suspicion of a rectal cancer. J Visc Surg 2010;147:e187-9.
Harada S, Kato T, Okada S, Nakatani K, Matsumoto R, Nishida K, et al
. Necrotizing soft tissue infection of the thigh associated with retroperitoneal abscess in a patient with locally advanced ascending colon cancer: A case report. IDCases 2017;10:112-4.
Sato K, Yamamura H, Sakamoto Y, Morohashi H, Miura T, Yoshikawa T, et al
. Necrotizing fasciitis of the thigh due to penetrated descending colon cancer: A case report. Surg Case Rep 2018;4:136.
Mzabi R, Himal HS, MacLean LD. Gas gangrene of the extremity: The presenting clinical picture in perforating carcinoma of the caecum. Br J Surg 1975;62:373-4.
Bohrer SP, Bodine J. Perforated cecal carcinoma presenting as thigh emphysema. Ann Emerg Med 1983;12:42-4.
Lam TP, Maffulli N, Chen EH, Cheng JC. Carcinomatous perforation of the sigmoid colon presenting as a thigh mass. Bull Hosp Jt Dis 1996;55:83-5.
Liu SYW, Ng SSM, Lee JFY. Multi-limb necrotizing fasciitis in a patient with rectal cancer. World J Gastroenterol 2006;12:5256-8.
Takakura Y, Ikeda S, Yoshimitsu M, Hinoi T, Sumitani D, Takeda H, et al
. Retroperitoneal abscess complicated with necrotizing fasciitis of the thigh in a patient with sigmoid colon cancer. World J Surg Oncol 2009;7:74.
Agalar F, Balas S, Saygun O, Agalar C, Dom S, Daphan C, et al
. Retroperitoneal abscess and necrotizing infection with extension to thigh secondary to right colon carcinoma: Report of two cases. Turk J Colorectal Dis 2011;21:194-7.
Park SH, Choi JR, Song JY, Kang KK, Yoo WS, Han SW, et al
. Necrotizing fasciitis of the thigh secondary to radiation colitis in a rectal cancer patient. J Korean Soc Coloproctol 2012;28:325-9.
Tai HC-H, Yao C-T, Chen W-L, Chen J-H, Shen Y-S. Necrotizing fasciitis as an initial manifestation of perforated rectal cancer in a young man. J Acute Med 2012;2:62-4.
Haemers K, Peters R, Braak S, Wesseling F. Necrotising fasciitis of the thigh. BMJ Case Rep 2013;2013:bcr2013009331.
Pouriki S, Skalistir M, Zoumpouli C, Alexakis N. Necrotising fasciitis of the left leg caused by perforated caecal adenocarcinoma. Ann R Coll Surg Engl 2017;99:e223-4.
Tsukuda K, Ikeda E, Miyake T, Ishihara Y, Watatani H, Nogami T, et al
. Abdominal wall and thigh abscess resulting from the penetration of ascending colon cancer. Acta Med Okayama 2005;59:281-3.
Wiberg A, Carapeti E, Greig A. Necrotising fasciitis of the thigh secondary to colonic perforation: The femoral canal as a route for infective spread. J Plast Reconstr Aesthet Surg 2012;65:1731-3.
[Figure 1], [Figure 2]