Ganesan Sarada
Department of Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia.
Int J Surg Case Rep. 2023 Aug;109:108619. doi: 10.1016/j.ijscr.2023.108619. Epub 2023 Aug 4.
Necrotising fasciitis caused by a perforated colon cancer is a very rare occurrence and can be very life threatening needing urgent intervention involving tissue salvage and oncological treatment. There is not enough evidence in the literature regarding management of the same. This case report highlights one such case along with management principles.
We present a 66 year old male with 3 weeks of a progressive right lower quadrant lump and constitutional symptoms. He had a computed tomography scan demonstrating a complex collection in the right anterior abdominal wall, containing multiple locules of gas and air fluid levels near an abnormally thickened hepatic flexure. He was taken for an urgent debridement followed by laparotomy which demonstrated extensive abdominal wall necrotising fasciitis secondary to a perforated hepatic flexure tumour invading into the duodenum. He was given a diverting ileostomy. He had a relook laparotomy the next day for a right hemicolectomy and part of the duodenum resected with a refashioned end ileostomy. He was subsequently managed on the ward for two weeks and then discharged home. He remains well and has been referred to medical oncology for adjuvant chemotherapy.
A two step surgical approach was key in this case, first step for source control and the second step focused on an oncological resection.
This case explains the importance of excluding malignant causes of necrotising fasciitis. Perforated cancers can manifest as necrotising fasciitis and management should include timely debridement as well as oncological principles.
由穿孔性结肠癌引起的坏死性筋膜炎极为罕见，且极具生命威胁，需要紧急干预，包括组织挽救和肿瘤治疗。文献中关于此类疾病的治疗证据不足。本病例报告着重介绍了这样一个病例及其治疗原则。
我们报告一名66岁男性，右下象限肿块进行性增大3周，并伴有全身症状。计算机断层扫描显示右前腹壁有一复杂积液，在异常增厚的肝曲附近有多个气腔和液气平面。患者接受了紧急清创术，随后进行剖腹手术，结果显示肝曲肿瘤穿孔侵入十二指肠继发广泛的腹壁坏死性筋膜炎。为其实施了转流性回肠造口术。次日再次进行剖腹手术，行右半结肠切除术并切除部分十二指肠，同时重新制作了末端回肠造口术。随后患者在病房接受了两周治疗，然后出院回家。他目前情况良好，已被转介至医学肿瘤科进行辅助化疗。
本病例的关键在于采用两步手术方法，第一步是控制源头，第二步着重于肿瘤切除。
本病例说明了排除坏死性筋膜炎恶性病因的重要性。穿孔性癌症可表现为坏死性筋膜炎，治疗应包括及时清创以及遵循肿瘤治疗原则。
