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Management of Necrotizing Fasciitis and Fecal Peritonitis following Ostomy Necrosis and Detachment by Using NPT and Flexi-Seal
Abstract
Management of necrotizing fasciitis and severe faecal peritonitis following ostomy in elderly patient with comorbid disease is challenging. We would like to report management of frozen Open Abdomen (OA) with colonic fistula following ostomy necrosis and detachment in an elderly patient with comorbid disease and malignancy. 78-year-old woman with high stage rectum carcinoma was admitted to emergency department and underwent operation for severe peritonitis and sigmoid colonic perforation. Loop sigmoidostomy was performed. At postoperative 15th day, she was transferred to our clinic with necrotizing fasciitis and severe faecal peritonitis due to ostomy necrosis and detachment. Enteric effluent was removed from the OA wound by using the Flexi-Seal Fecal Management System (FMS) (ConvaTec) and pesser tube in deeply located colonic fistula in conjunction with Negative Pressure Therapy (NPT). Maturation of ostomy was facilitated by using second NPT on ostomy side. After source control, delayed abdominal closure was achieved by skin flap approximation.
1. Introduction
More than half of all patients with intestinal stomas have complications. Complications are classified as early or late. Early complications present immediately after surgery (under a month). Ostomy necrosis and mucocutaneous dehiscence are very important early complications; they may cause major morbidity and even mortality. After ostomy, 7–25% mucocutaneous dehiscence and 1–34% necrosis of ostomy are reported [1]. It may be limited to one part of the ostomy or to total. If necrosis extends below the myofascial and peritoneal layers, immediate reoperation is required for stoma resection and reconstruction [1]. Nursing care is essential for keeping the subcutaneous site clean between the stoma and the skin, filling it with absorbent materials, paste, or powder depending on its depth until the new mucocutaneous junction has healed by secondary intention. In more complex cases, assisted vacuum cures have been used [2].
Open Abdomen (OA) management is a life-saving and challenging strategy in severe generalized peritonitis [3, 4]. Mortality rates up to 50% were reported and even higher in the infected OA [5]. Enteric fistulas are one of the most devastating abdominal complications in abdominal surgery [6]. Management of OA with fistula is very challenging.
Flexi-Seal Fecal Management System (FMS) (ConvaTec) is a device which is used for bedridden or immobilized, incontinent patients with liquid or semiliquid stool. It is designed to safely and effectively contain and divert fecal matter, protect patients’ wounds from fecal contamination, and reduce both the risk of skin breakdown and the spread of infection [7].
We would like to report treatment of necrotizing fasciitis and fecal peritonitis following ostomy necrosis and detachment by OA management with NPT. We would like also to emphasize, in this case, converting fistula to ostomy by the help of Flexi-Seal FMS and second NPT.
2. Presentation of Case
78-year-old woman with high stage rectum carcinoma was planned to take neoadjuvant chemoradiotherapy for down staging. During this period, she was admitted to emergency department with complaint of abdominal pain, distention, constipation, and vomiting. For last 3 days, the severity of complaints has increased. Her consciousness and orientation were also worsened. In her past history, she had hypertension, diabetes mellitus (DM), and hyperlipidemia. In physical examination, vital parameters were as follows: blood pressure (BP): 120/65 mmHg, heart rate (HR): 86, respiratory rate (RR): 24, fever (F): 38°C, and body mass index (BMI): 18. On her abdominal examination there was distention on abdomen and hyperactive bowel sounds were present. Rebound and rigidity were positive at all quadrants of abdomen. Air/fluid level was seen on abdominal X-ray film. She underwent emergent operation. At first operation, severe peritonitis and perforation of dilated sigmoid colon were seen at exploration. Curative oncological resection could not be applied, operation had to be deliberately abbreviated due to hemodynamic instability and physiologic derangement of patient, and so septic abdomen was irrigated, and loop sigmoidostomy was performed. At postoperative 7th day, there was infective fluid coming from midline incision. After drainage and debridement, local NPT was applied to incision.
At postoperative 15th day, ostomy necrosis was identified and the patient was consulted to our clinic. Her general condition, consciousness, and orientation were not well. She was mechanically ventilated. Her vital parameters were BP: 85/50 mmHg, HR: 120, RR: 28, F: 38°C, and intra-abdominal pressure (IAP): 14 mmHg. She was in septic shock and mild acidosis (Table 1). SOFA score of the patient was 12 and estimated mortality was 50% accordingly. She underwent emergent reoperation. Necrosis all around the ostomy and complete collapse with mucocutaneous detachment of ostomy were seen. Connection was present between the ostomy opening and midline incision with severe fasciitis and fecal peritonitis. Detached proximal and distal sigmoidostomy openings were seen in abdomen deeply (Figure 1). According to new modified Björck classification OA score of the patient was 4 [8]. All intra-abdominal content was irrigated with saline. Since bowel was very edematous and fragile with severe adhesion and short mesentery, these openings of ostomies could not be mobilized. New proximal end transvers colostomy was opened on right side hardly. To redirect colonic effluent to outside, Flexi-Seal was inserted into proximal opening of detached sigmoidostomy and pesser tube was inserted into distal opening. Glycerin-impregnated gauze was used around detached ostomy opening; pesser drainage tube and Flexi-Seal were also used to support segmentation of ostomy side from OA wound (Figure 2). Abdominal NPT was applied to OA. Low dose enteral nutrition was started at postoperative 1st day and increased day by day.