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Severe Fournier’s gangrene in a patient with rectal cancer: case report and literature review
Yoshino et al. World Journal of Surgical Oncology
Severe Fournier's gangrene in a patient with rectal cancer: case report and literature review
Yu Yoshino 0 1
Kimihiko Funahashi 0 1
Rei Okada 0 1
Yasuyuki Miura 0 1
Takayuki Suzuki 0 1
Takamaru Koda 0 1
Kimihiko Yoshida 0 1
Junichi Koike 0 1
Hiroyuki Shiokawa 0 1
Mitsunori Ushigome 0 1
Tomoaki Kaneko 0 1
Yasuo Nagashima 0 1
Mayu Goto 0 1
Akiharu Kurihara 0 1
Hironori Kaneko 0 1
0 Department of General and Gastroenterological Surgery, Toho University Omori Medical Center , 6-11-1 Omorinishi Ota-Ku, Tokyo 143-8541 , Japan
1 Abbreviations: FG , Fournier's gangrene; CT, Computed tomography; TPE, Total pelvic exenteration
Background: Fournier's gangrene in the setting of rectal cancer is rare. Treatment for Fournier's gangrene associated with rectal cancer is more complex than other cases of Fournier's gangrene. We report on a patient with severe Fournier's gangrene in the setting of locally advanced rectal cancer who was treated with a combined modality therapy. Case presentation: A 65-year-old man presented with general fatigue and anal pain. The medical and surgical histories were unremarkable. A black spot on the perineal skin surrounded by erythema was found on physical examination, suspicious for Fournier's gangrene. Computed tomography scan showed a rectal tumor invading into the bladder (clinically T4bN2M0) and abscess formation with emphysema around the rectum. He was thus diagnosed with locally advanced rectal cancer and Fournier's gangrene with a severity index score of 12 points. We created a diverting loop colostomy of the transverse colon and performed extensive debridement of the perineum and perianal area. Fifty days later, the patient underwent radical total pelvic exenteration with sacrectomy. In addition, reconstruction of the soft tissue defect was performed using the rectus muscle, the gluteus maximus muscle, and the femoral muscle. Histopathological findings of the specimen were as follows: the tumor was a moderately adenocarcinoma with invasion to the bladder and the prostate (T4b), metastases to four resected lymph nodes (N2), and lymphovascular invasion. There were no major postoperative complications, and the patient was discharged 108 days postoperatively. Conclusions: We report a rare case of locally invasive rectal cancer associated with Fournier's gangrene. This case highlights a usual cause of Fournier's gangrene. Physicians should be cognizant not only of the more common condition but also of the rare presentations including those associated with rectal cancer.
Fournier's gangrene; Rectal cancer; Surgical treatment; Reconstructive surgery
Background
Fournier’s gangrene (FG) is necrotizing fasciitis and
commonly begins without trauma or urinary tract
disease. FG in the setting of rectal cancer is rare. A specific
risk factor is rectal cancer perforation. Treatment
includes extensive debridement of the areas of necrosis
and the administration of broad-spectrum intravenous
antibiotics. In the setting of rectal cancer, the causative
rectal tumor should be removed, but the timing of this
is a complex clinical decision.
We report on a patient with severe FG in the setting
of locally advanced rectal cancer who was treated with a
combined modality therapy.
Case presentation
A 65-year-old man was brought to our outpatient
hospital in an ambulance complaining of general fatigue
and anal pain. The medical and surgical histories were
unremarkable. His initial body temperature was 95.7 °F,
blood pressure was 125/58 mmHg, heart rate was 92
beats/min, and oxygen saturation was 98 % on room air.
On physical examination, a black spot on the perineal
skin surrounded by erythema was found. Due to a
clinical suspicion for FG, a computed tomography (CT) scan
and blood tests were obtained urgently (Fig. 1). CT scan
showed abscess formation with emphysema around the
rectum, as well as a tumor invading the bladder (cT4b)
with some lymph node metastases in the mesorectum
(cN2); there was no evidence of distant metastasis (M0)
(Fig. 2). Blood tests were remarkable for a hemoglobin
of 3.2 g/dl and a leukocytosis of 63,200/μl. The patient
was thus diagnosed with locally advanced rectal cancer
and FG with a severity index score of 12 points [
1
]. Urgent
diverting colostomy of the transverse colon and extensive
debridement of the perineal area were performed (Fig. 3).
Biopsies taken previously revealed a moderately
differentiated adenocarcinoma.
The patient received nutritional support after surgery.
Follow-up CT scan after the surgery showed no new
lesions, so we performed a radical total pelvic
exenteration (TPE) with sacrectomy 50 days after the initial
surgery. For the urinary diversion, Bricker’s operation
was performed (Fig. 4). In addition, reconstruction of
the soft tissue defect was performed using the rectus
muscle, the gluteus maximus muscle, and the femoral
muscle (Fig. 5). Histopathological findings of the specimen
were as follows: t (...truncated)