GS23 - Necrotizing Fasciitis of Abdominal Wall Secondary to Perforated Sigmoid Colon Malignancy: A Case Report

Primary Presenter(s)

Eloise Rogers, D.O.

Resident Physician, General Surgery
St. John's Episcopal Hospital
St. John's Episcopal Hospital
Long Beach, New York, United States

Author(s)

AC

An Guo Michael Chin, D.O.

Resident Physician, General Surgery
St John's Episcopal Hospital
Arverne, New York, United States
PC

Pedro Cordero, MD, RVT, RPVI, FACS

RJWBarnabas Trinitas Regional Medical Center
Elizabeth, New Jersey, United States

Introduction/Purpose: Extraperitoneal rupture of colonic malignancy is exceedingly rare, with the vast majority of malignant colonic perforations presenting as intra-abdominal sepsis and peritonitis. We present a unique case report of a healthy gentleman with only a few days of vague abdominal pain who came to the hospital for firm, erythematous, edematous skin changes to his left lower abdomen spreading to his flank and back found to be necrotizing fasciitis due to colonic malignancy which eroded the peritoneum and extended into the abdominal wall with perforation. Aggressive surgical debridement and intensive medical care postoperatively led to a fantastic outcome for our patient, who has since had his ostomy reversed and is clinically with no evidence of disease. We will discuss the unique aspects of the presentation, operative decision making, and postoperative care of this patient in hopes of expanding the discussion and recognition of this unique presentation of sigmoid adenocarcinoma.

Methods or Case Description: Our patient is a robust 69 year old male with a past medical history of hypertension who presented to the emergency department with 5 days of abdominal pain and fever. Has also started experiencing nausea over the two days prior to presentation, and states that he is constipated for the past several days. As the pain and fever have been getting worse, he has noticed that the left side of his abdomen has become firm and the skin is very red and warm to touch. Vital signs on presentation were notable only for tachycardia to 124 beats per minute. Labs revealed leukocytosis to 15,600 with a 90.7% shift and lactic acidosis of 3.94. Physical examination was notable for left lower quadrant abdominal tenderness and significant erythema and induration along left lower quadrant spreading to left flank and posterior left chest without open wound. CT scan demonstrated a large collection of edema/fluid and gas tracking throughout the superficial and deep tissues of the left flank and left lateral chest wall, presumably representing necrotizing fasciitis. The involved area measured approximately 30 cm in craniocaudal dimension, 25 cm in anteroposterior dimension, and 4.5 cm in thickness. Left lower quadrant colonic diverticulitis with a small amount of pericolonic edema, fluid, and gas consistent with perforation likely causing the necrotizing infection was noted. The patient was taken emergently to the operating room where he underwent exploratory laparotomy, Sigmoid colon resection, creation ostomy, extensive drainage of abdominal wall necrotizing fasciitis. Intraoperatively, the colon was noted to be completely adherent to the left abdominal wall. Due to location necrotizing fasciitis along the left-sided abdomen and flank, the splenic flexure was mobilized and an end colostomy was brought up in the right upper quadrant and Hartmann’s pouch was created.

Outcomes: Pathology for the resected colon demonstrated adenocarcinoma of the colon with perforation into the serosa and surrounding fat, abdominal wall abscess tissue also contain necrotic tissue consistent with metastatic disease. 0/7 lymph nodes seen in the specimen were positive for malignancy DNA mismatch repair was intact. Once pathology had reported, a CEA level was 1 (within lab normal limits). Preoperative CEA was not drawn as there was no suspicion from malignancy on original imaging or exam. Of note, the patient had not had a colonoscopy or colon cancer screening prior to admission and reported that prior to the few days prior to admission he was in usual good health and had no weight loss, change in stool color or pattern, night sweats, or malaise. The patient underwent serial washouts and debridements with eventual VAC placement and was successfully discharged to subacute rehabilitation. After discharge, the patient was started on FOLFOX and bevacizumab which he completed with a full 6 cycles. He later underwent a screening colonoscopy exam where benign tubular adenomas were noted, and a PET scan which did not demonstrate further active areas of concern. The patient was subsequently admitted electively for reversal of colostomy which he tolerated well and is currently being observed with no evidence of disease.

Conclusion: Abdominal wall necrotizing fasciitis as a result of perforated bowel is exceedingly rare, and reports of the perforation being secondary to malignancy is even more unusual. Only a few scattered case reports exist of such anomalous presentations. As the incidence of colon cancer rises in increasingly young and robust patients, we can expect an increase in presentations such as this. We present this case of sigmoid adenocarcinoma presenting as abdominal wall and flank necrotizing fasciitis to facilitate discussion and raise awareness of rare presentations of malignancy. Further investigation of the causes and risk factors for this phenomenon are needed and will hopefully lead to earlier recognition, allowing surgeons to obtain adequate margins and lymph node dissections at the index surgery.