CASE REPORTS
APPLYING THE NEGATIVE PRESSURE WOUND
THERAPY PRINCIPLES IN NECROTIZING FASCIITIS
FOLLOWING ABDOMINOPLASTY FOR MORBID OBESITY
Mirela Sarandan1, Zorin Crainiceanu2, Mihaela Mastacaneanu2,
Alina-Carmen Cradigati1, Bogdan Tunescu3, Adriana Opris2, Tiberiu Bratu2
REZUMAT
Introducere: Fasceita necrozantă este o complicaţie infecţioasă rară a ţesuturilor moi, cu evoluţie rapid progresivă şi potenţial fatală. Obiective: Articolul
prezintă un caz de fasceită necrozantă după abdominoplastie la o pacientă cu obezitate morbidă. Material şi metode: Se prezintă cazul unei paciente
de 43 de ani suferind de obezitate morbidă, supusă unei abdominoplastii care s-a complicat postoperator cu fasceită necrozantă. S-au practicat debridări
seriate şi tratamentul cu presiune negativă al plăgii sub folie auto-adezivă, însoţite de terapie intensivă prelungită. Rezultate: Pacienta a supravieţuit, cu
refacerea progresivă completă a peretelui abdominal, fiind externată după 110 zile de spitalizare. Concluzii: Succesul terapeutic în acest caz s-a datorat
debridărilor seriate, antibioterapiei cu spectru larg şi aplicării principiilor tratamentului cu presiune negativă al plăgilor.
Cuvinte cheie: Fasceită necrozantă, abdominoplastie, obezitate morbidă, tratament cu presiune negativă al plăgilor
ABSTRACT
Introduction: Necrotizing fasciitis is a rare infectious complication of the soft tissues, with rapid progressive evolution and potentially fatal. Objectives:
To present a case of necrotizing fasciitis following abdominoplasty in a patient suffering of morbid obesity. Material and methods: A 43-years old
patient suffering of morbid obesity underwent an abdominoplasty, which complicated postoperatively with necrotizing fasciitis. Serial surgical debridment
and negative pressure wound therapy (npwt) under self adhesive foil have been performed, associated with prolonged intensive care. Results: The patient
has survived, with a complete progressive recovery of the abdominal wall and discharge after 110 days of hospitalization. Conclusions: The therapeutic
success in this case is due to the serial surgical debridment, to broad spectrum antibiotherapy and the applying of npwt principles.
Key Words: Necrotizing fasciitis, abdominoplasty, morbid obesity, negative pressure wound therapy
INTRODUCTION
The term of necrotizing fasciitis has been used
for the first time in 1952 by Wilson, to describe the
necrotic infection of the subcutaneous tissue and
fascia, with relative sparing of the underlying muscle
but with rapid progression towards septic shock and
death if not promptly recognized and treated.1
Department of Anesthesiology and Intensive Care, 2 Clinic of Plastic and
Reconstructive Microsurgery, 3 Department of Politraumatology, Casa
Austria, Clinical Emergency County Hospital Timisoara
1
Correspondence to:
Mirela Sarandan, Department of Anesthesiology and Intensive Care,
Casa Austria, Clinical Emergency County Hospital, 10, I. Bulbuca Blvd.,
300736 Timisoara, Tel. +40356433603.
Email: mirelasara@yahoo.com
Received for publication: Nov. 27, 2009. Revised: Sep. 25, 2010.
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Initial symptoms are unspecific, with local discreet
signs, edema and inflammation, modification of the
skin color; in cases of late diagnostic there are bullosa
skin necrosis, subcutaneous gas crepitus and a general
clinical aspect of severe sepsis and septic shock.
Diagnosing this condition requires a high rate of
suspicion; therefore Wong and al published a laboratory
score of diagnosis, allowing early recognition and
differential diagnosis with non necrotic infections of
the soft tissues.2
Although necrotic infections are usually caused by
species of Streptococcus and Staphylococcus, a wide
range of bacteria can also be involved: Gram-negative
- E. Coli, Pseudomonas Aeruginosa, species of Proteus or
Serratia, and anaerobic species – Bacteroides, Clostridium
and Peptostreptococcus.3 This complication can affect any
anatomical region (abdomen, perineum, extremities),
its etiology can be multifactorial and many times
without an identifying cause. Most of the patients
that develop necrotizing fasciitis also have preexisting
comorbidities that make them more vulnerable to
infection, such as immunosuppression, diabetes
mellitus, chronic diseases, malnutrition, age>60 years,
obesity, peripheral vascular disease, renal failure, cancer,
steroids administration; common triggering factors are
surgery, trauma, soft tissue infections, administration
of intravenous drugs, burns, child birth.3
Local and systemic bacterial and toxins invasion
determines destruction of skin, fat and muscle, and
a systemic inflammatory response syndrome evolving
towards sepsis, septic shock and multiple organ
dysfunction syndrome. Morbidity and mortality have
significant rates. A study by McHenry and al reports a
33% mortality rate in cases of necrotizing fasciitis of
the extremities, while other authors report mortality
rates up to 80% in cases with comorbidities and
complications (acute renal failure, acute respiratory
distress syndrome, multiple organ dysfunction
syndrome).2,4,5
The management of this genuine emergency
condition consists of extensive surgical debridment
to remove the necrotic infected tissue, along with
systemic antibiotherapy and intensive support of vital
functions.
CASE PRESENTATION
A 43 years old female patient, height 1.67 m,
weight 137 kg, BMI 46 (morbid obesity) addressed
our clinic in March 2009, to undergo the surgical
removal of a gigantic abdominal skin and fat excess.
Associated diagnostics were postoperative abdominal
eventration after an umbilical hernia surgically
treated in 2002, bilateral congenital hip dysplasia.
From the patient’s personal history we record that
she underwent a progressive, accelerated postpartum
weight gain – caesarian section in 1995 at 90 kg weight;
this, associated with the lack of mobility due to the
congenital hip dysplasia, led to a weight of 140 kg in the
next 10 years. In 2005 she was the victim of a domestic
accident with left coxofemural joint dislocation;
orthopedic joint replacement surgery was postponed
due to excessive weight and a particularly large adipose
layer around the articulation. Although she followed a
medically controlled diet and psychological counseling
to improve the alimentary habits, the lack of
mobilization, the depression syndrome and the algic
syndrome only aggravated the patient’s condition; she
reached 160 kg weight in 2008. The same year she was
included in the gastric balloon program and lost 23 kg,
but the abdominal skin and fat excess required surgical
removal. (Fig. 1) The patient was under discontinuous
Ketoprofen administration for episodes of hip pain
and Tianeptine for the depressive syndrome.
Figure 1. Preoperative aspect.
Preoperative evaluation of the patient followed
the protocol of our clinic, including medical history
and biological investigations:
- Complete blood workup and lipidic profile –
within normal range;
- Cardiologic examination - HR 100/min, BP
110/70 mmHg, ECG low voltage, without acute
ischemia signs;
- Chest X-ray – elevation of right hemidiaphragm,
heart and lung aspect age accordingly;
- Sspirometry – no respiratory dysfunction;
- Doppler examination of carotid arteries and
lower limb veins – no morphological or functional
modifications;
- Abdominal ecography – no pathological findings.
All investigations were done with the patient
admitted, because of extreme difficulty in patient
mobilization (pathological standing posture of
extreme anteflexion and support from an orthopedic
frame), and also under prophylactic administration of
single daily dose of Enoxaparine 0.5mg/kgc sc.
The thromboembolic score was appreciated as
high, the ASA score was III and the surgical risk was
medium; informed consent was signed. The surgical
intervention proceeded under general anesthesia:
surgical cure of the eventration with polypropylene
mesh covered by suturing the rectus abdominis
muscles and abdominal dermolipectomy with excision
of a 10 kg flap. The intervention lasted for 4 hours, and
the antibacterial prophylaxis has been done according
to local protocols with Cefuroxime 2g 1 hour before
surgery, repeated after 4 hours.
The postoperative evolution was initially
favorable, but 6 days after intervention the patient
presented local redness at the incision site along
approximately 5 cm, with moderate local pain; after
another 48 hours there were cutaneous pallor and
clinical signs of skin and fat necrosis, which imposed
surgical debridment.
Mirela Sarandan et al 163
Antimicrobial de–escalation was initiated with
Tygecicline. Tissue culture revealed E. Coli and the
Tygecicline treatment has been continued according to
the antibiogram. Local wound care was done twice a
day, but the patient’s condition was getting worse; at day
13 there were clinical and paraclinical signs of sepsis,
with local extended necrosis of the dermal fat flap and
altered general status, digestive intolerance, hypotension
(BP 95/60 mmHg), HR 110/min, rectal temperature
38.5°C, anemia (Hb 8.4 g/dL, Ht 28%), leucocytosis
(11.6 x 106/µL), lymphopenia and monocytopenia,
progressive elevation of protein C levels.
Microbiological monitoring of the wound has
been done every 4-5 days, with the adjustment
of the antibiotic treatment according to germ
sensibilities.
Figure 3. Application of negative pressure wound therapy
Figure 2. Abdominal wall skin and fat defect after serial debridment
The patient was isolated in a room with
intermediate intensive care facilities, under clinical
and biological monitoring; treatment included broad
spectrum antibiotics (Meropenem 3 g/day and
Targocid 2x400 mg/day), fluid and electrolyte control,
continuous deep venous thrombosis prophylaxis,
mixed oral and parenteral nutrition, and serial surgical
debridments. Repeated tissue culture samples showed
E. coli and Proteus; both hemoculture and uroculture
were sterile.
Despite all the measures taken and an improvement
of the general status, the local evolution was towards
extensive flap necrosis, with important skin loss that
required the applying of negative pressure wound
therapy (NPWT) principles. (Fig. 2)
As we do not dispose of VAC® or other
commercially available standard devices, we have
applied gauze wet with saline and Betadine impregnated
sponges, while aspiration was made through a drainage
tube under an IobanTM foil (self-adhesive, impermeable,
transparent, Betadine impregnated, 120/60 cm, from
3MTM) applied as equally as possible on the surface of
the lesion. (Fig. 3) The drainage tube was connected
to the existent wall suction device, using continuous
pressure of -75 -100 mmHg, adjusted on clinical bases
according to the level of exudate. Dressing changes
were spaced at 2-4 days.
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The Doppler examination, in a context of
prolonged immobilization, vicious position of the left
coxofemural articulation and systemic sepsis, revealed
another complication in day 30 – partial thrombosis
of the left femoral vein, with extension into the left
external iliac vein, without any clinical signs of deep
venous thrombosis. Continuous Heparin therapy was
initiated on automatic syringe, maintaining the APTT
value at double of normal range. After 8 days another
ecography revealed the resorbtion of the thrombus;
treatment was continued with Enoxaparine 2x120
mg/day. The patient was monitored with venous
Doppler at 2 weeks distance, switching the therapy to
oral anticoagulants when surgical debridment was no
longer necessary.
All this time the patient has been under intensive
care of fluid, electrolytes and metabolic balance,
received blood transfusions to redress the anemia,
correction of the low albumin levels, oral and parenteral
nutrition, intensive specific nursing. The difficulties in
the medical care and the slow improvement of the
patient’s condition had a major emotional impact which
led to a decompensation of the depressive syndrome
and therefore to an adjustment in the psychotropic
therapy.
RESULTS
The slow favorable progression of the wound
due to the efficient drainage system during 65 days of
negative pressure wound therapy and to the metabolic
support by intensive care measures allowed surgical
approach at 3-4 days distance, obtaining a clean wound
fit for secondary suture in day 95. (Fig. 4)
Figure 4. Final closure of abdominal wall.
The patient was discharged after 110 days of
treatment, with complete restoration of the abdominal
wall (discharge weight: 108 kg) and permanent
counseling regarding the diet and home care, with
independent mobility by help of orthopedic mobile
frame, subsequently addressing to an orthopedics
clinic for left hip joint implant.
DISCUSSIONS
The case presented is one of a subacute necrotizing
fasciitis; the literature also reports a growth in the
number of cases of the subacute model.5 The difficulty
in establishing a clinical diagnosis and in differentiating
it from the postoperative cellulites represented the main
cause of delay of extensive debridment. The aggressive
surgical approach and antibiotic treatment are the basis
of the treatment and the key to patients’ survival.6,7
Extensive debridment leads to a large skin
and subcutaneous tissue defect, which has to be
subsequently closed. Management options in soft
tissue defects of such magnitude have evolved during
the past decade, a widely accepted additional technique
being that of negative pressure wound therapy.7-9 This
method consists of applying subatmospheric pressure
under a special system of sponges and impermeable
foil, which drains the secretions, decreases the
edema and inflammation, promotes circumferential
wound contraction and maintains the surrounding
skin intact.8 The negative pressure determines a high
blood flow in the wound bed, favoring tissue growth
and increased influx of cellular factors (leukocytes,
fibroblasts); the number of microorganisms per gram
of contaminated tissue is inversely proportional with
the blood flow. The effective drainage of secretions
also has direct consequences upon the degree of
bacterial contamination and the absolute decrease in
the number of bacteria per gram of tissue, healing of
the wound being closely correlated to a bacterial load
of under 105/gram of tissue.
The technique of negative wound pressure has been
used since mid-90’s. A report of Morykwas and Argenta
in 1997 presents a retrospective analysis of their clinical
experience in 175 chronic, 94 subacute and 31 acute
wounds, observing the positive effects of vacuumtherapy upon several difficult local conditions (soft
tissue avulsions, contaminated wounds, hematomas).
Another series of studies have demonstrated the
benefits of vacuum therapy in enhancing infected
wounds closure), with superior effectiveness compared
to the traditional wound dressings.9-13
Previous to applying the negative pressure wound
therapy the patient underwent marginal debridments
of the abdominal wall and classical dressings
changed twice per day, with subsequent surgical
stress, maintaining SIRS and high risk of septic
complications,15 while the NPWT system allowed a
few days between the procedures, increasing patient
comfort and diminishing the pressure upon hospital
resources (operating room time, work load, materials).
Average closure time with VAC® technique
reported in literature for similar abdominal defects is
of 60 days; in our case NPWT was applied for 75 days,
followed by secondary suture.6,14
Microbiological surveillance of the wound showed
a significant improvement after initiating the NPWT,
with significant diminishment of contamination level;
clinically, the decrease of the necrosis, but also SIRS
and hipercatabolic syndrome remission were obvious.
Morbid obesity is a serious condition, in itself a
risk factor for complications of surgery.15,16 Abdominal
and systemic sepsis management necessitated close
monitoring of biological and microbiological samples,
effective communication with the central laboratory,
strict isolation and aseptic conditions and priority
to the operating room.17 Losing the integrity of the
abdominal wall escalated patient’s morbid condition;
the local and systemic sepsis and the temporary
immobilization led to thrombotic complications and
increased mortality risk. Also the frequent surgical
procedures, the repeated catheterization maneuvers,
and the difficulties occurred during nursing care had
a substantial neuropsychological impact upon the
patient, with sustained psychological support needed.
Along the entire period of hospitalization the patient
benefited of intensive specific nursing care, permanent
monitoring and a dedicated team formed of surgeon,
anesthesiologist, nursing staff, and kynetotherapist.
CONCLUSIONS
1. Surgical treatment, sustained intensive care and
the implementation of the negative pressure wound
therapy principles in the medical management of this
Mirela Sarandan et al 165
serious complication have contributed to survival and
therapeutic success.
2. Morbid obesity is an independent risk factor
for postoperative infectious complications; early
clinical diagnosis is essential and necessitates the
implementation of risk scores in the laboratory
diagnosis.
3. Doppler monitoring applied to the patient
according to our department protocol and correlated
to the calculated thromboembolic risk made evident
the major thrombotic complication in absence of any
clinical signs, allowing the adequate treatment of this
potentially lethal complication.
4. The price of patient’s survival included high
financial costs (aproximatively 160,000 RON),
significant human resources and work load, and
tremendous organizational effort in the rather tough
hospital environment under the existing sanitary policy.
Up-to-date treatment of this condition with a high
mortality risk imposes granting of adequate resources,
towards an alignment to the international therapeutic
standards and applying of the modern techniques for
high risk surgical wound care.
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