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Abdominal Wall Infected Ischemic Necrosis Mimicking Necrotizing Fasciitis
Abdominal Wall Infected Ischemic Necrosis Mimicking Necrotizing Fasciitis Paul David Ainsworth, and Linda de Cossart, Chester, United Kingdom
Emergency surgery to revascularize an ischemic leg in the presence of an aortic aneurysm presents a series of difficult management decisions in both the operative and postoperative phases. We present a case of infected ischemic necrosis that developed in a discrete tissue plane from a transverse incision mimicking necrotizing fasciitis. A 57-year-old man presented with an ischemic leg associated with a 5-cm abdominal aortic aneurysm. The sudden appearance of gangrenous tissue in the inferior flap of the transverse abdominal incision prompted urgent surgical debridement. This case report describes the management of a potentially misleading clinical condition. The key points to remember are to maintain a high index of suspicion for potentially life-threatening soft tissue infections, to be vigilant about regular wound inspection, and to act decisively when urgent wound debridement is indicated.
Emergency surgery to revascularize an ischemic leg in the presence of an aortic aneurysm presents a series of difficult management decisions in both the operative and postoperative phases. We present a case report of a unique postoperative complication affecting the abdominal wound. Infected ischemic necrosis developed in a discrete tissue plane from a transverse incision that mimicked necrotizing fasciitis.
CASE REPORT An unkempt, blind 57-year-old man who lived alone with no relatives or carers presented as an emergency with an acutely ischemic left leg. Computed tomography-arteriography demonstrated a 5-cm abdominal aortic aneurysm with propagated thrombus occluding the left common iliac artery. After left groin exploration and thrombectomy, the abdomen was opened via a supraumbilical curved transverse incision. An aortobifemoral Dacron graft was used to exclude the aneurysm and revascularize the ischemic leg. Further thrombus was removed from the Countess of Chester Hospital, Chester, UK. Correspondence to: Paul David Ainsworth, Countess of Chester Hospital, Countess of Chester Health Park, Liverpool Road, Chester CH2 1UL, UK. Ann Vasc Surg 2010; 24: 553.e7-553.e8 DOI: 10.1016/j.avsg.2009.09.015 Ó Annals of Vascular Surgery Inc. Published online: January 25, 2010
right leg via a below knee popliteal approach. The postoperative course was complicated by a myocardial infarction on day 1. Echocardiogram demonstrated a large mural thrombus and the patient was therefore anticoagulated with a therapeutic dose of low-molecular-weight heparin. Over the next 5 days the patient became increasingly confused with a rising white cell count. Serial wound inspection suggested a developing problem with the abdominal wall below the level of the transverse incision. This started as mild patchy erythema and epidermal sloughing. Abdominal ultrasound scan did not demonstrate any subcutaneous collection. By the seventh postoperative day, the inferior abdominal area was diffusely inflamed. Methicillin-resistant Staphylococcus aureus was cultured from the abdominal wound. By the 11th 553.e7
553.e8 Case reports
postoperative day, areas of patchy gangrene suddenly appeared over the lower abdominal wound. The primary concern was necrotizing fasciitis. He was taken to the operating room for urgent debridement and was found to have infected ischemic necrosis of the lower abdominal area below the level of the transverse incision; this tissue was radically excised. All of the tissue above the initial incision line was well perfused and viable. There was virtually no bleeding from the lower abdominal subcutaneous tissue.
DISCUSSION This case report highlights the importance of serial wound inspection. Whether earlier intervention would have positively influenced the outcome is difficult to assess. We maintain that it was reasonable to treat cellulitis with antibiotics but the sudden appearance of necrotic tissue prompted immediate and appropriate action.1 The presence of wound
Annals of Vascular Surgery
infection in patients with peripheral vascular disease is common and can be life threatening. This is the first case report to describe infected ischemic necrosis in a defined surgical zone that mimicked necrotizing fasciitis. It is particularly interesting to observe how the infection was confined to such a discrete zone. We postulate that the capillary beds of the subcutaneous tissue in the lower flap were compromised by both the surgical incision and systemic hypoperfusion secondary to severe postoperative myocardial infarction. The authors still advocate a transverse incision for aortic surgery due to the well-documented evidence of reduced respiratory complications.2 This case report describes the management of a potentially misleading clinical condition. The key points to remember are to maintain a high index of suspicion for potentially life-threatening soft tissue infections, to be vigilant about regular wound inspection, and to act decisively when urgent wound debridement is indicated. Other case reports in the literature describe the devastating effects of massive abdominal wall necrotizing fasciitis3 but no report describes this unique presentation of infected ischemic necrosis. REFERENCES 1. Lacy PD, Burke PE, O’Regan M, et al. The comparison of type of incision for transperitoneal abdominal aortic surgery based on postoperative respiratory complications and morbidity. Eur J Vasc Surg 1994;1:52e55. 2. Huljev D. Necrotizing fasciitis of the abdominal wall with lethal outcome: a case report. Hernia 2007;11:271e278. 3. Miller G, MacLean AA, Hiotis K. Surgical images: Soft tissue: necrotizing fasciitis of the abdominal wall. Can J Surg 2008;51:56.
Emergency surgery to revascularize an ischemic leg in the presence of an aortic aneurysm presents a series of difficult management decisions in both the operative and postoperative phases. We present a case of infected ischemic necrosis that developed in a discrete tissue plane from a transverse incision mimicking necrotizing fasciitis. A 57-year-old man presented with an ischemic leg associated with a 5-cm abdominal aortic aneurysm. The sudden appearance of gangrenous tissue in the inferior flap of the transverse abdominal incision prompted urgent surgical debridement. This case report describes the management of a potentially misleading clinical condition. The key points to remember are to maintain a high index of suspicion for potentially life-threatening soft tissue infections, to be vigilant about regular wound inspection, and to act decisively when urgent wound debridement is indicated.
Emergency surgery to revascularize an ischemic leg in the presence of an aortic aneurysm presents a series of difficult management decisions in both the operative and postoperative phases. We present a case report of a unique postoperative complication affecting the abdominal wound. Infected ischemic necrosis developed in a discrete tissue plane from a transverse incision that mimicked necrotizing fasciitis.
CASE REPORT An unkempt, blind 57-year-old man who lived alone with no relatives or carers presented as an emergency with an acutely ischemic left leg. Computed tomography-arteriography demonstrated a 5-cm abdominal aortic aneurysm with propagated thrombus occluding the left common iliac artery. After left groin exploration and thrombectomy, the abdomen was opened via a supraumbilical curved transverse incision. An aortobifemoral Dacron graft was used to exclude the aneurysm and revascularize the ischemic leg. Further thrombus was removed from the Countess of Chester Hospital, Chester, UK. Correspondence to: Paul David Ainsworth, Countess of Chester Hospital, Countess of Chester Health Park, Liverpool Road, Chester CH2 1UL, UK. Ann Vasc Surg 2010; 24: 553.e7-553.e8 DOI: 10.1016/j.avsg.2009.09.015 Ó Annals of Vascular Surgery Inc. Published online: January 25, 2010
right leg via a below knee popliteal approach. The postoperative course was complicated by a myocardial infarction on day 1. Echocardiogram demonstrated a large mural thrombus and the patient was therefore anticoagulated with a therapeutic dose of low-molecular-weight heparin. Over the next 5 days the patient became increasingly confused with a rising white cell count. Serial wound inspection suggested a developing problem with the abdominal wall below the level of the transverse incision. This started as mild patchy erythema and epidermal sloughing. Abdominal ultrasound scan did not demonstrate any subcutaneous collection. By the seventh postoperative day, the inferior abdominal area was diffusely inflamed. Methicillin-resistant Staphylococcus aureus was cultured from the abdominal wound. By the 11th 553.e7
553.e8 Case reports
postoperative day, areas of patchy gangrene suddenly appeared over the lower abdominal wound. The primary concern was necrotizing fasciitis. He was taken to the operating room for urgent debridement and was found to have infected ischemic necrosis of the lower abdominal area below the level of the transverse incision; this tissue was radically excised. All of the tissue above the initial incision line was well perfused and viable. There was virtually no bleeding from the lower abdominal subcutaneous tissue.
DISCUSSION This case report highlights the importance of serial wound inspection. Whether earlier intervention would have positively influenced the outcome is difficult to assess. We maintain that it was reasonable to treat cellulitis with antibiotics but the sudden appearance of necrotic tissue prompted immediate and appropriate action.1 The presence of wound
Annals of Vascular Surgery
infection in patients with peripheral vascular disease is common and can be life threatening. This is the first case report to describe infected ischemic necrosis in a defined surgical zone that mimicked necrotizing fasciitis. It is particularly interesting to observe how the infection was confined to such a discrete zone. We postulate that the capillary beds of the subcutaneous tissue in the lower flap were compromised by both the surgical incision and systemic hypoperfusion secondary to severe postoperative myocardial infarction. The authors still advocate a transverse incision for aortic surgery due to the well-documented evidence of reduced respiratory complications.2 This case report describes the management of a potentially misleading clinical condition. The key points to remember are to maintain a high index of suspicion for potentially life-threatening soft tissue infections, to be vigilant about regular wound inspection, and to act decisively when urgent wound debridement is indicated. Other case reports in the literature describe the devastating effects of massive abdominal wall necrotizing fasciitis3 but no report describes this unique presentation of infected ischemic necrosis. REFERENCES 1. Lacy PD, Burke PE, O’Regan M, et al. The comparison of type of incision for transperitoneal abdominal aortic surgery based on postoperative respiratory complications and morbidity. Eur J Vasc Surg 1994;1:52e55. 2. Huljev D. Necrotizing fasciitis of the abdominal wall with lethal outcome: a case report. Hernia 2007;11:271e278. 3. Miller G, MacLean AA, Hiotis K. Surgical images: Soft tissue: necrotizing fasciitis of the abdominal wall. Can J Surg 2008;51:56.