Necrotising fasciitis of the thigh secondary to colonic perforation: the femoral canal as a route for infective spread

A 57 year-old man with a history of corticosteroid use presented with abdominal pain and diarrhoea. He was initially treated for presumed Clostridium difficile colitis, but later developed a left inguinal mass with spreading erythema. A CT scan showed gas within the retroperitoneal tissues, with surgical emphysema of the left groin. Necrotising fasciitis was diagnosed, and the patient underwent extensive debridement of the left thigh and inguinal region. The femoral vein was covered in infected fascia in the femoral canal, and a laparotomy revealed a posterior perforation of the sigmoid colon. Necrotising fasciitis of the thigh is a rare complication of colonic perforation. Our case highlights the femoral canal as a potential channel for the spread of intra-abdominal infection into the thigh.

Short- and long-term outcome of laparostomy following intra-abdominal sepsis

AIM

This study reports the short- and long-term outcomes of laparostomy for intra-abdominal sepsis.

METHOD

Twenty-nine sequential patients with intra-abdominal sepsis treated with a laparostomy over 6 years were included.

RESULTS

The median age of the patients was 51 years, postoperative intensive care unit stay was 8 days, postoperative length of hospital stay was 87 days and follow up was 2 years. The expected mortality of 25% was insignificantly different from the observed mortality of 33% (P = 0.35). Seven per cent of patients required percutaneous drainage of intra-abdominal collections. An enterocutaneous fistula developed in 31% of all patients and in 15% of those treated with vacuum dressings. Component-separation fascial reconstruction was successful and uncomplicated in 83% of recipients compared with 25% of mesh repairs.

CONCLUSION

Laparostomy does not significantly reduce mortality from the expected rate and commits the patient to a prolonged recovery with a high risk of enterocutaneous fistulation. Component-separation fascial reconstruction has a better outcome than mesh repair.

Randomized clinical trial of metronidazole ointment versus placebo in perianal Crohn's disease

BACKGROUND

The potential for metronidazole 10 per cent ointment to exert therapeutic benefit in perianal Crohn's disease, while minimizing the adverse effects found with oral metronidazole, was evaluated in a randomized placebo-controlled study.

METHODS

Subjects with perianal Crohn's disease were randomized to metronidazole 10 per cent ointment, 0.7 g applied perianally three times daily, or placebo ointment. The Perianal Crohn's Disease Activity Index (PCDAI) was scored at baseline and after 4 weeks of treatment. Perianal pain was assessed on a visual analogue scale.

RESULTS

Seventy-four subjects (33 metronidazole, 41 placebo) were evaluated. The mean(s.e.m.) reduction in PCDAI score at 4 weeks was 2.4(0.5) in the metronidazole group and 2.2(0.4) in the placebo group (P = 0.660). More subjects in the metronidazole group than the placebo group showed a reduction in PCDAI score of at least 5 points (10 of 27 versus 4 of 34; P = 0.031). Perianal discharge was reduced significantly in metronidazole-treated subjects (P = 0.012). A greater reduction in perianal pain was seen in the metronidazole group, which approached statistical significance (P = 0.059). No serious adverse events were reported.

CONCLUSION

Metronidazole 10 per cent ointment was not effective in the reduction of PDCAI score, but some secondary outcomes showed improvement suggestive of a treatment effect. It is well tolerated, with minimal adverse effects, and has potential as treatment for pain and discharge associated with perianal Crohn's disease.

REGISTRATION NUMBER

NCT00509639 (http://www.clinicaltrials.gov).

Use of myocutaneous flaps for perineal closure following abdominoperineal excision of the rectum for adenocarcinoma

INTRODUCTION

Abdominoperineal excision (APE) following radiotherapy is associated with a high rate of perineal wound complications. The use of myocutaneous flaps may improve wound healing. We present our experience using myocutaneous flaps for immediate reconstruction.

METHOD

Prospective data were collected on patients undergoing APE from October 2003 to December 2008. Patient demographics, operating time, wound complications and length of stay were recorded.

RESULTS

Fifty-one patients underwent APE for rectal adenocarcinoma, 21 had primary closure and 30 had myocutaneous flap closure (24 VRAM, 6 gracilis). The proportion of patients undergoing preoperative radiotherapy in each group were 62% and 93% respectively (P = 0.011). There were no major complications following primary closure of the unirradiated perineum. Major perineal wound complications requiring reoperation or debridement were seen in three (14%) patients following primary closure and five (17%) patients with flap closure. After radiotherapy, closure with a flap reduced the length of stay from 20 to 15 days, but this difference was not statistically significant (P = 0.36).

CONCLUSION

The use of flap closure in irradiated patients is associated with fewer perineal complications and a shorter hospital stay.

Use of a double rhomboid transposition flap in the treatment of extensive complex pilonidal sinus disease

OBJECTIVE

Rhomboid transposition flaps are safe and successful in treating recurrent, complex pilonidal disease. There are little data on treatment of very large (> 12 cm) pilonidal sinuses. We describe a new technique using two simultaneous rhomboid flaps to achieve primary closure following extensive wide-excision.

METHOD

With antibiotic prophylaxis, the sinus is excised en-bloc as a parallelogram (two adjacent rhomboids). Two rhomboid fasciocutaneous flaps are transposed to close this defect over suction-drains. Sutures are removed after 14 days.

RESULTS

Eight patients (seven males) were treated with this technique (median age 26 years; range 22-35 years). All had very extensive and recurrent disease, having had multiple previous procedures. Median drain-duration was 2 days (range 1-5 days) and postoperative stay was 2 days (range 0-5 days). One complication arose: a wound infection with partial dehiscence which healed with conservative treatment. No recurrence or further complication arose in a 33-month follow-up (range 8-41 months).

CONCLUSION

This is the first description of the use of two simultaneous rhomboid flaps for very large recurrent pilonidal disease. It is a relatively simple and safe alternative to major plastic reconstruction which is often resorted to in such large-scale disease.

Outcome of patients on renal replacement therapy after colorectal surgery

PURPOSE

Patients on renal replacement therapy are reported to have a high complication rate after abdominal surgery, the result of uremia and immunosuppression. A review of this group of patients undergoing colorectal surgery was undertaken.

METHODS

Seventy-three separate colorectal operations were performed for 44 patients. Thirty-eight patients were on dialysis and 35 had a renal transplant. Data (coexisting disease, preoperative blood results, operative details, complications, and colorectal POSSUM score) were completed for each surgical event.

RESULTS

Forty-two elective and 31 emergency procedures were performed. Infective complications were common (overall 60 percent). There were two anastomotic leaks in the elective group, but five leaks from seven emergency anastomoses. Stomas were frequently raised. Ninety percent of patients who survived and had a defunctioning stoma underwent a successful reversal. The overall major complication rate after elective and emergency surgery was 19 and 81 percent, respectively, and mortality was 5 and 26 percent, respectively.

CONCLUSIONS

Renal patients have a high rate of complications after colorectal surgery, and emergency surgery has a significant risk of anastomotic leak. Primary anastomosis should be avoided in all patients undergoing emergency intestinal resections. Subsequent surgery to restore intestinal continuity is possible in 90 percent of patients with far fewer complications.

Prospective comparison of faecal incontinence grading systems

BACKGROUND

Existing scales for assessing faecal incontinence have not been validated against clinical assessment, or with regard to reproducibility. They also fail to take into account faecal urgency, and the use of antidiarrhoeal medications.

AIMS

To establish the validity, and sensitivity to change, of existing scales and a newly designed incontinence scale.

METHODS

(1) Twenty three patients (21 females, median age 57 years) were prospectively evaluated by two independent clinical observers, using three established scales (Pescatori, Wexner, American Medical Systems), a newly devised scale which also includes details about urgency and antidiarrhoeal drugs, and by a 28 day diary. (2) A further 10 female patients were assessed by the same scales before and after surgery for faecal incontinence.

RESULTS

(1) Assessments by two independent clinicians correlated well. All four scales and a diary card correlated highly and significantly with the clinical impression, with the new scale reaching the highest correlation (r=0.79, p<0.001). (2) All except one score changed significantly in response to surgical treatment; the new scale showed the greatest change, at the highest level of significance (p=0.004), and correlated best with the clinicians' assessment of change (r=0.94, p<0.001).

CONCLUSIONS

Existing scales for the assessment of faecal incontinence correlate well with careful clinical impression of severity, and serve as useful and reproducible measures for comparison of patients and treatments. A newly devised scale has shown high clinical validity and utility.