INTRODUCTION: 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. THE PRESENTATION OF A CASE: 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. CONCLUSION: 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.

Department of Surgery 1 Faculty of Medicine and Dentistry Palacky University Olomouc Olomouc 77900 Czech Republic

Department of Surgery 1 University Hospital Olomouc Olomouc 77900 Czech Republic

Zobrazit více v PubMed

Daams Freek, Luyer Misha, Lange Johan F. Colorectal anastomotic leakage. Aspects of prevention, detection and treatment. World J. Gastroenterol. 2013;19(April (15):2293–2297. PubMed PMC

Kang C.Y., Halabi W.J., Chaudhry O.O. Risk factors for anastomotic leakage after anterior resection for rectal cancer. JAMA Surg. 2013;148:65–71. PubMed

Sorensen M.D., Krieger J.N., Rivara F.P., Broghammer J.A., Klein M.B., Mack C.D., Wessells H. Fournier´s gangrene: population based epidemiology and outcomes. J. Urol. 2009;181:2120–2126. PubMed PMC

Agha R.A., Borrelli M.R., Farwana R., Koshy K., Fowler A., Orgill D.P., For the SCARE Group The SCARE 2018 statement: updating consensus Surgical CAse REport (SCARE) guidelines. Int. J. Surg. 2018;60:132–136. PubMed

Bruketa T., Matea Majerovic, Augustin G. Rectal cancer and Fournier´s gangrene – current knowledge and therapeutic options. World J. Gastroenterol. 2015;21(August (30)):9002–9020. PubMed PMC

Yaghan R.J., Al-Jaberi T.M., Bani-hani I. Fournier´s gangrene: changing face of the disease. Dis. Colon Rectum. 2000;43:1300–1308. PubMed

Cameron J.L. 8th ed. Elsevier Mosby; Philadelphia: 2004. Current Surgical Therapy; pp. 1079–1085.

Unalp H.R., Kamer E., Derici H., Atahan K., Balci U., Demirdoven C., Nazli O., Onal M.A. Fournier´s gangrene: evaluation of 68 patients and analysis of prognostic variables. J. Postgrad. Med. 2008;54:102–105. PubMed

Buketa T., Majerovic M., Augustin G. Rectal cancer and Fournier´s gangrene - current knowledge and therapeutic options. World J. Gastroenterol. 2015;21(30):9002–9020. PubMed PMC

Cárdenas-Turanzas M., Ensor J., Wakefield C., Zhang K., Wallace S.K., Price K.J., Nates J.L. Cross-validation of a Sequential Organ Failure Assessment score-based model to predict mortality in patients with cancer admitted to the intensive care unit. J. Crit. Care. 2012;27(December (6)):673–680. Epub 2012 July 2. PubMed

Neeki M.M., Dong F., Au C. Evaluating the laboratory risk Indicator to differentiate cellulitis from necrotizing fasciitis in the emergency department. West. J. Emerg. Med. 2017;18(4):684–689. PubMed PMC

Strangio G., Zullo A., Ferrara E.C., Anderloni A., Carlino A., Jovani M., Ciscato C., Hassan C., Repici A. vol. 47. 2015. pp. 465–469. (Endo Sponge Therapy for Management of Anastomotic Leakages after Colorectal Surgery: a Case Series and Review of Literature: Digestive and Liver Disease). PubMed

Blumetti J., Abcarian H. Management of low colorectal anastomotic leak: preserving the anastomosis. World J. Gastrointest. Surg. 2015;7(December (12)):378–383. PubMed PMC

von Renteln D., Schmidt A., Vassiliou M.C., Rudolph H.U., Caca K. Endoscopic full thickness resection and defect closure in the colon. Gastrointest. Endosc. 2010;71:1267–1273. PubMed

Seebach L., Bauerfeind P., Gubler C. “sparing the surgeon”: clinical experience with over the scope clips for gastrointestinal perforation. Endoscopy. 2010;42:1108–1111. PubMed

Chopra S.S., Mrak K., Hunerbein M. The effect of endoscopic treatment on healing of anastomotic leaks after anterior resection of rectal cancer. Surgery. 2009;145:182–188. PubMed