A fascia lata free flap in pelvic exenteration for Fournier gangrene due to advanced rectal cancer: a case report

Abstract

BackgroundFournier gangrene due to advanced rectal cancer is a rapidly progressive gangrene of the perineum and buttocks. Emergency surgical debridement of necrotic tissue is crucial, and secondary surgery to resect tumors is necessary for wound healing. However, pelvic exenteration damages the pelvic floor, increasing the likelihood of herniation of internal organs into the infectious wound. The management of pelvic exenteration for rectal cancer with Fournier gangrene has not yet been established. We herein describe the use of a fascia lata free flap in pelvic exenteration for rectal cancer with Fournier gangrene.Case presentationA 66-year-old male who had undergone colostomy for large bowel obstruction due to advanced rectal cancer and continued chemotherapy was referred to our hospital for Fournier gangrene resulting from chemotherapy. Emergency surgical debridement was performed, and the infectious wound around the rectal cancer was treated with intravenous antibiotic agents postoperatively. However, the tumor was exposed by the wound, and exudate persisted. Pelvic exenteration was performed due to tumor infiltration into the bladder and prostate. Tumor resection resulted in a defect in the pelvic floor. A fascia lata free flap (15 × 9 cm) obtained from the left thigh was fixed to the edge of the peritoneum and ileal conduit to close the defect in the pelvic floor and prevent small bowel herniation into the resected space. There was no intraabdominal inflammation or bowel obstruction postoperatively, and outpatient chemotherapy was continued.ConclusionsSurgical repair with a fascia lata free flap to close the defect in the pelvic floor led to a good clinical outcome for pelvic exenteration in a patient with Fournier gangrene due to advanced rectal cancer.

Fournier’s Gangrene in the Setting of Underlying Carcinoma: A Case Report and Review of the Literature

“…Over 83% (5/6) of patients who did undergo DRE demonstrated positive findings, including a palpable mass (4), purulent anal drainage (1), and pain out of proportion (1). This over 80% rate of positive findings on DRE is consistent with a study by the World Journal of Gastroenterology in 2015 which showed that preoperative DRE resulted in positive findings in 75% of FG with underlying rectal cancer and it highlights the importance of including a thorough anorectal examination in all patients with FG [ 1 , 3 , 15 - 17 ].…”

“…It is included in many medical calculator applications and includes the measurement of CRP, hemoglobin, white blood cell count, serum sodium, creatinine, and blood glucose level. Scores of ≥6 raise the suspicion for necrotizing fasciitis/FG and scores of ≥8 are strongly predictive of the disease [5,17]. Initial studies of the LRINEC score showed a 92% positive predictive value in diagnosing FG but subsequent studies have questioned its utility [19].…”

Case Report on Fournier's Gangrene

“…Fournier's Gangrene is a rare 11 condition marked by fluminent polymicrobial necrotising fasciitis [1][2][3][4][5][6][7][8][9][10] , which is generally localised disease of scrotum or penis or both with occasional extention up to the abdominal wall 11 . In literature many terms have been used synonymously to describe the condition which include idiopathic gangrene of the scrotum, periurethralphelgmon, streptococcal scrotal gangrene and cenegesiticnecrotising cellulitis.…”

“…Fournier's Gangrene is a serious surgical emergency condition which involves scrotum or penis or both with occasional extension upto the abdominal wall (3,23) . This clinical condition was first described by GeanAlfered Fournier, A French Dermatologist and Venereologist reported five cases in 1882 3,6 . The hallmark of FG is intense pain and tenderness in the genitalia.…”

“…The hallmark of FG is intense pain and tenderness in the genitalia. Fournier's gangrene occurs at any age even early childhood 6 . Fournier's gangrene occurs in both male and female in a ratio of 10:1 12 .…”