Necrotizing Fasciitis Following Laparoscopic Left Hemicolectomy for Diverticulitis

Introduction

Necrotizing fasciitis (NF) is a rapidly progressing bacterial infection of the fascia, followed by superinfected necrosis of the subcutaneous layer. Skin traumata, such as insect bites, scratches, or even iatrogenic manipulation such as acupuncture, needle injection, or surgical procedures, are access points for bacteria, the most common group being a beta-hemolytic streptococci. Only a few case reports of NF associated with laparoscopic procedures can be found, mostly after gallbladder removal or appendectomy, rarely following colorectal surgery. The early recognition of NF as a cause for severe patient conditions is mandatory. Diagnosis is often delayed. Immediate aggressive treatment is required, as NF is associated with high mortality rates ranging from 6 to 80%.

Case Report

A 61-year-old female with a body-mass index (BMI) of 24 kg/m² who presented with abdominal pain and obstipation arrived in our emergency department. She had a history of sigmoid diverticulitis, diabetes mellitus type IIa, and a hysterectomy performed in 1996. The patient smoked 15 cigarettes per day. A barium enema showed a sigmoid stenosis caused by acute diverticulitis. She was initially treated conservatively with parenteral feeding, intravenous antibiotics (mezlocillin and metrodinazol), and received bowel preparation.

After initial recoverance, at 2.5 weeks of admission, the patient underwent a laparoscopic left hemicolectomy with low anterior resection, followed by end-to-end anastomosis. A small lesion in close proximity to the indurated region of the diverticulitis mass occurred intraoperatively with a small portion of feces leaking into the abdominal cavity. The leakage was closed safely by suture and the abdomen was rinsed carefully, using NaCl 0.9%. The patient was treated with intravenous (i.v.) antibiotics (mezlocillin and metrodinazol) and recovered well. Postoperative laboratory showed a white blood cell count of 1.8 × 10⁹/L without any clinical findings.

In the morning on postoperative day 1, the patient complained of lower abdominal pain with local tenderness. Laboratory findings were a white blood cell count of 1.6 × 10⁹/L, hemoglobin of 10.5 g/dL, and a CRP of 95.3 mg/L. We decided to perform a diagnostic laparoscopy to exclude an anastomotic leak, but no bleeding or anastomotic leak was found during the operation. The following partial colonoscopy showed a vital anastomosis in the endoluminar and dorsal portion, excluding an anastomosal leakage as the cause for the clinical condition of the patient. The diagnosis of postoperative septic shock was made, and the patient was moved to the Intensive Care Unit where mechanical ventilation was continued after the operation (blood pressure: 100/50 mm Hg; pulse: 120 beats/min; pH: 7.168; pO₂: 79.6 mm Hg; pCO₂: 42.3 mm Hg; base excess −13.8 mmol/L HCO₃: 15.4 mmol/L). Vasopressory therapie (noradrenaline) was needed to control the blood pressure of the patient. Antibiotic treatment was changed to imipenem and clindamycin.

Despite intensive therapy, the patient's condition worsened over time. In the right-lower abdomen, where the CO₂ inflating trocar was placed, a rapidly progressing dark reddish-purple discoloration appeared (Fig. 1). This led to the diagnosis of fast progressive NF. The patient was transferred to the operation theater again. To reassure a sufficient and vital anastomosis, a laparotomy was performed. Again, no leakage could be found, but because of septic condition and the remaining high risk of anastomosal leakage, a Hartmann's situation was created. Then, aggressive debridement of the affected tissue was performed. All perforating vessels in this area were thombosed. The skin, subcutaneous, and fascia layers were found in a “cooked-like” easy-to-dissect condition. Muscle and peritoneum could be spared. Multiple swabs of the wound as well as blood cultures showed the presence of Enterococcus faecalis and Escherichia coli, sensible to imipenem and metronidazole.

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FIG. 1.

Preoperative findings of typical skin discolorations.

Despite aggressive debridement, infection spread further and made reoperations necessary throughout the following 2 days. The patient's condition worsened, with septic shock leading to multiple organ failure, and finally, the patient deceased on the fourth day after the initial operation. The postmortal obduction verified the diagnosis of necrotizing fasciitis in combination with septic shock and multiple organ failure (Fig. 2). Again, no enteral leakage could be detected.

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FIG. 2.

Postmortal view after aggressive skin debridement.

Discussion

In 1764, Baurienne ¹ first described a fulminant gangrenous infection of the scrotum, usually associated with diabetes. Fournier ² redescribed it in 1883 and established the term Fournier's gangrene. Meleney (1924) found the close relationship to group A beta-hemolytic streptococci and called his findings Hemolytic streptococcus gangrene. In 1952, Wilson ³ coined the term necroting fasciitis.

Previously, a monomicrobial infection was thought to be cause of the fulminant fascial necrosis, most closely linked to group A beta-hemolytic streptococcus. In fact, 55–75% cases of NF are the result of type 1 (polymicrobial) infections. Staphylococcus aureus, streptococcus, or klebsiella serotypes are most commonly found. These bacteria provoke only a few of the cases. Most are caused by other bacteria, such as enterococcus, klebsiella, or different streptococcal serotypes. Polymicrobial infections can also occur.^4–6

Conclusions

The key points for successful treatment of NF are early recognition, immediate intensive care treatment with broad-spectrum antibiotics, and stabilization of vital parameters, followed by aggressive debridement of the infected tissue. NF is, nevertheless, a rare complication, and therefore, initial examination of the abdominal cavity for organic complications, such as enteric leakage or peritonitis, remains obligate.