Necrotizing fasciitis secondary to enterocutaneous fistula: Three case reports

Clinical parameters and outcomes of necrotizing soft tissue infections secondary to gastrointestinal fistulas

Background

Necrotizing soft tissue infections (NSTIs) is severe surgical infections which can occur following trauma or abdominal surgery. NSTIs secondary to gastrointestinal (GI) fistula is a rare but severe complication.

Methods

A retrospective cohort study was performed on all subjects presenting with GI fistulas associated NSTIs were included. Clinical characteristics, microbiological profile, operations performed, and outcomes of patients were analyzed.

Results

Between 2014 and 2017, 39 patients were finally enrolled. The mean age were 46.9 years and male were the dominant. For the etiology of fistula, 25 (64.1%) of the patients was due to trauma. Overall, in-hospital death occurred in 15 (38.5%) patients. Microbiologic findings were obtained from 31 patients and Klebsiella pneumoniae was the most common species (41.0%). Eight patients were treated with an open abdomen; negative pressure wound therapy was used in 33 patients and only 2 patients received hyperbaric oxygen therapy. Younger age and delayed abdominal wall reconstruction repair were more common in trauma than in non-trauma. Non-survivors had higher APACHE II score, less source control< 48 h and lower platelet count on admission than survivors. Multiple organ dysfunction syndrome, multidrug-resistant organisms and source control failure were the main cause of in-hospital mortality.

Conclusions

Trauma is the main cause of GI fistulas associated NSTIs. Sepsis continues to be the most important factor related to mortality. Our data may assist providing enlightenment for quality improvement in these special populations.

Enterocutaneous fistulas: a primer for radiologists with emphasis on CT and MRI

Abstract

Enterocutaneous fistulas (ECFs) represent abnormal communications between the gastrointestinal tract and the skin. Nowadays, the majority (~80%) of ECFs develops secondary to abdominal surgeries; alternative, less common causes include chronic inflammatory bowel diseases (IBD) such as Crohn’s disease, tumours, and radiation enteritis in descending order of frequency. These rare disorders require thorough patient assessment and multidisciplinary management to limit the associated morbidity and mortality. This pictorial review includes an overview of causes, clinical manifestations, complications and management of ECFs. Afterwards, the imaging appearances, differential diagnoses, and therapeutic options of post-surgical, IBD-related, and malignant ECFs are presented with case examples. Most of the emphasis is placed on the current pivotal role of CT and MRI, which comprehensively depict ECFs providing cross-sectional information on the underlying postsurgical, neoplastic, infectious, or inflammatory conditions. Radiographic fistulography remains a valid technique, which rapidly depicts the ECF anatomy and confirms communication with the bowel. The aim of this paper is to increase radiologists’ familiarity with ECF imaging, thus allowing an appropriate choice between medical, interventional, or surgical treatment, ultimately resulting in higher likelihood of therapeutic success.

Teaching Points

• Enterocutaneous fistulas may complicate abdominal surgery, sometimes Crohn’s disease and tumours.

• The high associated morbidity and mortality result from sepsis, malnutrition and metabolic imbalance.

• The multidisciplinary management of ECFs requires thorough imaging for correct therapeutic choice.

• Radiographic fistulography rapidly depicts fistulas and communicating bowel loops in real-time.

• Multidetector CT and MRI provide cross-sectional information on fistulas and underlying diseases.

Thoracoabdominal necrotising soft tissue infection secondary to enterocutaneous fistulae: a case report

OBJECTIVE

Necrotising soft tissue infection is a rare surgical emergency, which requires immediate and aggressive surgical debridement. Following control of the infection, patients are often left with large defects, with wound reconstruction and closure creating significant challenges. Here we describe a case of extensive thoracoabdominal necrotising soft tissue infection and provide a discussion on the standard of care and treatment based on a current literature review.

METHOD

A 53-year-old female presented with bilious and feculent discharge from her surgical incision two weeks after a total abdominal hysterectomy. She was found to have two enterocutaneous fistulae and an extensive abdominal wall necrotising soft tissue infection extending to the lower thorax. Wide excision and debridement were performed, leaving a large triangular defect. Following serial washouts and debridements, a biologic mesh with openings for the enterocutaneous fistulae was used to cover the fascial defect Results: Postoperatively, the patient was discharged to a nursing facility where she remained on total parenteral nutrition due to high fistula output. She subsequently underwent fistulectomy nine months later followed by skin grafting. To date, she has not had any recurrent fistulae or infection.

CONCLUSION

Necrotising soft tissue infection resulting in a large abdominal wall defect secondary to enterocutaneous fistulae poses a significant challenge for source control and abdominal wall reconstruction. After serial debridements, use of biologic mesh for temporary closure followed by staged resection of the bowel with abdominal wall reconstruction can be performed.

DECLARATION OF INTEREST

The authors have no personal financial or institutional interest in any of the drugs, materials, or devices used.

Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Fournier’s gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.