METASTATIC MELANOMA PRESENTS AS ENTEROCUTANEOUS FISTULA WITH ANTERIOR ABDOMINAL
WALL ABSCESS: AN EXCEEDINGLY RARE CLINICAL SCENARIO
Akram Alashari, MD, Lawrence Lottenberg, MD
Department of Trauma/Acute Care Surgery/Surgical Critical Care; University of Florida Shands Hospital
Background:
Extra-abdominal infections that result from extra-peritoneal perforations of gastrointestinal
structures are exceptionally rare and are only sporadically reported in the literature. There are a number
of reports of necrotizing fasciitis that occurred in the setting of appendiceal rupture, perforated
diverticulitis, as well as perforated colon cancer. We present a case of metastatic melanoma to the small
bowel which eroded through the bowel, into the anterior abdominal wall, and presented as a
subcutaneous abscess with underlying enterocutaneous fistula.
Methods:
This is a case report of a 46-year-old patient with a history of metastatic melanoma, who
presented to the Emergency Department with an anterior abdominal wall abscess. He underwent
incision and drainage of the abscess, and was subsequently discharged home with wound care services.
He returned 4 weeks later with an overnight history of pain extending to the thigh as well as
increased foul-smelling drainage from the incision site. He also reported increasing lethargy. Upon his
second presentation to the Emergency Department, he underwent a CT scan of the abdomen/pelvis. It
showed a massive fluid- and air-filled abscess cavity under the skin with a lesion extending deep into
right pelvis with right hydroureter and possible fistulization into the small bowel.
With these findings, he was taken to the operating room and underwent exploratory
laparotomy with extensive debridement of the necrotizing soft-tissue infection of the anterior
abdominal wall. The wound was left open for a subsequent take-back to the OR for repeated
debridements.
In his second operation, copious amounts of necrotic debris and succus was drained from the
cavity. The lesion was firmly adherent to the abdominal contents in all directions. There was no plane of
dissection that wound not require a massive small bowel resection, and in the setting of widely
metastatic melanoma, it was felt futile to consider such a massive resection. Once more, he was taken
to the OR for another debridement and again copious amounts of succus was drained. There was no
distinct fistulous tract, although there was clear fistula formation within the wound. The wound was left
open and management of the wound was assisted by the wound team.
Objectives:
The objective of presenting this case is to increase surgeon awareness of the fact that
necrotizing soft-tissue infections and abscesses of the anterior abdominal wall can indicate an
underlying bowel perforation with enterocutaneous fisutla. In patients presenting with abscesses
and/or necrotizing infections of the anterior abdominal wall, CT scan of the abdomen and pelvis should
be considered to evaluate for underlying intra-abdominal pathology.
Results:
After clinical stabilization in the intensive care unit, the patient was subsequently transferred to
the floor. Palliative care was consulted. Upon resolution of the acute illness, he was then discharged
from the hospital with palliative care services as well as wound care services for the site of the operative
debridement.