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Avoidance of total abdominal wall loss despite torso soft tissue clostridial myonecrosis: a case report
© Ball et al; licensee BioMed Central Ltd. 2013
Received: 13 August 2012
Accepted: 7 November 2012
Published: 8 January 2013
Clostridial necrotizing soft tissue infections are often fatal. Myonecrosis of the torso is a particularly lethal combination given the classic need for radical debridement of the abdominal and thoracic walls, and therefore total exposure of the intraperitoneal and intrathoracic viscera. This case is unusual do to our ability to preserve anatomical separation between the viscera and the atmosphere.
We present a 42-year-old Caucasian man with obesity and diabetes who developed clostridial myonecrosis of his right torso following a mesenteric lymph node biopsy. This required an aggressive debridement (sparing subcutaneous flaps and internal oblique aponeurosis) followed by reconstruction of his right hemi-torso with a biologic prosthesis to prevent subsequent hernia formation.
Although basic principles associated with radical debridement were maintained, a full thickness torso wall resection was avoided. This provided reconstruction advantages that included endogenous subcutaneous flap coverage, separation of the peritoneal cavity by the internal oblique aponeurosis, and prevention of a subsequent hernia below the arcuate line. This technique would be of interest to any surgeon or clinician who treats patients with life-threatening torso soft tissue infections.
Necrotizing soft tissue infections comprise a broad spectrum of infectious processes that include, but are not limited to, necrotizing cellulitis, necrotizing fasciitis, and myonecrosis. The classification of these entities is based on the extent of soft tissue involvement as well as the depth of infection. Although the bacteria that cause infections often differ, the general approach to treatment is similar and includes: aggressive resuscitation, broad-spectrum antimicrobial therapy, physiologic support, and immediate radical surgical debridement. The extent of surgical debridement is dictated by the need to achieve margins with normal appearing tissue and vigorous bleeding. This is particularly problematic in cases of trunk myonecrosis because of the requirement for complete abdominal and/or thoracic wall resection, and subsequent exposed intraperitoneal and intrathoracic organs.
Although up to 80% of necrotizing soft tissue infections are polymicrobial, Clostridium species are still associated with the classic presentation of gas gangrene myonecrosis. Typically the presence of soft tissue gas, as observed in this patient, offers a grave prognosis. In addition, gas gangrene of the torso carries an even worse outcome given the typical requirement for radical full thickness debridement that often results in open abdominal and thoracic cavities with exposed viscera. Because of the tremendous risks associated with soft tissue coverage and eventual reconstruction, our patient underwent an alternative strategy. By maintaining two large, well-vascularized subcutaneous flaps as potential coverage, in addition to the internal oblique aponeurosis as a barrier to the peritoneal cavity, we were able to maintain significant reconstructive options. Given the risk inherent in this initial approach, the patient was returned to the operating room for a second tissue evaluation only eight hours after the initial debridement. As a consequence of his radical improvement in physiology and tissue quality, we persisted with this methodology.
In a significant number of patients (40%), a source of the necrotizing soft tissue infections is not readily identifiable. In our patient, the initial lymph node biopsy was clearly the index insult; however, the specific source of the Clostridium is unknown. The gastrointestinal tract was not injured and this species is atypical for our hospital. We postulate that the preoperative skin preparation was insufficient to remove all the patient’s topical bacteria given his employment as a sewer plumber. This is particularly plausible given the known ability of C. perfringens to remain quiescent in tissues and then initiate a clinical infection when minor trauma (lymph node biopsy) provides an opportunity for growth (diabetes mellitus). We also believe the lack of skin changes and crepitus in the initial phases were a result of the patient’s general obesity. Furthermore, it is clear that the immunosuppression associated with his diabetes mellitus represented a significant co-factor in the rapid progression of this disease[2, 6]. In addition, his final confirmed diagnosis of follicular lymphoma may also have negatively impacted his immune status.
Although our avoidance of a complete resection of all layers of the patient’s abdominal wall represents a significant departure from traditional dogma, the principles requiring a normal-appearing margin of tissue were maintained. Although the use of biologic materials represents a significant advancement in the field of surgery, this risk-adjusted technique of partial debridement has been echoed by previous authors in the context of clostridial myonecrosis[8, 9]. Despite this technique, the risk of a subsequent massive ipsilateral abdominal wall hernia was substantial. As a result, we felt reconstruction of the abdominal wall with a prosthesis was essential. Given the reported improvements in function and durability of biologic materials in infected fields, two large pieces were inserted. There is no current evidence on which to base the performance of biologics in the setting of C. perfringens. At a 12-month follow-up however, the patient’s abdominal wall remains well healed, with no drainage and no torso asymmetry. This is particularly important inferior to the arcuate line given the naturally thin posterior rectus sheath and aponeurosis components.
The management of this patient represents a significant departure from the classic concepts surrounding clostridial myonecrosis. Although basic principles associated with radical debridement were maintained, a full thickness torso wall resection was avoided. This provided reconstruction advantages that included endogenous subcutaneous flap coverage, separation of the peritoneal cavity by the internal oblique aponeurosis, and prevention of a subsequent hernia below the arcuate line. These principles must be individualized to any specific patient.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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