Necrotizing pelvic infection after rectal resection. A rare indication of endoscopic vacuum-assisted closure therapy. A case report

• Published in: International journal of surgery case reports Vol. 61; pp. 44 - 47
• Main Authors: Řezáč, Tomáš, Stašek, Martin, Zbořil, Pavel, Vomáčková, Katherine, Bébarová, Linda, Hanuliak, Jan, Neoral, Čestmír
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Ltd 01-01-2019; Elsevier
• Subjects: Anastomotic leak in colorectal surgery; Case report; Endoscopic vacuum-assisted closure (EVAC); Low anterior rectal resection; Necrotizing pelvic infection; CRP; NPI; Low anterior rectal resection; Anastomotic leak in colorectal surgery; Necrotizing pelvic infection; CT; Case report; EVAC; ASA score; ECOG performance status; Endoscopic vacuum-assisted closure (EVAC); ICU; CR POSSUM; BMI
• ISSN: 2210-2612; 2210-2612
• DOI: 10.1016/j.ijscr.2019.06.054

•Necrotizing pelvic infection after rectal resection is a rare complication.•There are no clear recommendations for the treatment of choice.•Multimodality therapy requires intensive care, antibiotics and usually repeated surgeries.•Endoscopic vacuum-assisted closure therapy may decrease the disease burden in properly indicated cases.
Anastomotic leak after colorectal surgery is a major problem associated with higher morbidity and mortality. In most cases of contained leaks, treatment recommendations are clear and effective. However, in rare cases like necrotizing pelvic infection, there is no clear treatment of choice, despite the mortality rate almost 21%. We present successful management with endoscopic vacuum-assisted closure therapy.
A 68-year-old female patient with BMI 26, hypothyroidism and high blood pressure was indicated to low anterior rectal resection because of high-risk neoplasia of lateral spreading tumor type of the upper rectum. Four days after the primary operation, sepsis (SOFA 12) with diffuse peritonitis and unconfirmed leak according to CT led to surgical revision with loop ileostomy. On postoperative days 6–10, swelling, inflammation and subsequent necrosis of the right groin and femoral region communicating with the leak cavity developed. The endoscopy confirmed a leak of 30% of the anastomotic circumference with the indication of debridement and endoscopic vacuum-assisted closure therapy. EVAC sessions with 3–4 day intervals healed the leak cavity. Secondary healing of the skin defects required 4 months.
Necrotizing pelvic infection after a leak of the colorectal anastomosis is a very rare complication with high morbidity and mortality. Endoscopic vacuum-assisted closure therapy should be implemented in the multimodal therapeutic strategy in case of major leaks, affecting up to 270° of the anastomotic circumference.