Necrotizing Fasciitis management

NECROTIZING FASCIITIS MANAGEMENT

Dr Mohamad Al-Gailani FRCSالكيالني. محمد د

العامة الجراحة استشاريالرياضالسعودية العربية المملكة

Consultant SurgeonAl Hammadi Hospital, Suwaidi

RiyadhKSA

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Case Presentation:

• A 45 year old male patient presented with a few days history of perineal pain and irritation while on holiday.• Treated with a course of flucloxacillin antibiotics.• Otherwise healthy, not diabetic and on any regular

medication.• On Exam: unwell, temp 39 degree centigrade • Perineal exam showed features of Necrotising Fasciitis.

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Management

• Emergency Surgery following stabilization• Preoperative management: 1. CBC, U&E, LFT, Group & Save 2. iv antibiotics (Clindamicin + Ciprofloxacilin) 3. iv fluids 4. CT scan5. Anaesthetic assessment

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Preoperative CT findings Ant. abdominal wall

collection & Gas

DR. MOHAMAD AL-GAILANI FRCS

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

5Operative Findings DR. MOHAMAD AL-GAILANI FRCS

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

6Operative FindingsDR. MOHAMAD AL-GAILANI FRCS

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

7Extensive wide debridement excising All dead tissueDR. MOHAMAD AL-GAILANI FRCS

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Left iliac fossa “trephine” sigmoid loop diverting colostomy

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

9Follow up at 4 weeks

DR. M

OHAM

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NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

10Follow up at 6 weeks

DR. M

OHAM

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NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Follow up at 10 weeks

DR. M

OHAM

AD A

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NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

12Examination Under Anaesthesia & Closure of Colostomy

at 3 months

DR. M

OHAM

AD A

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NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Necrotizing Fasciitis•Localized infection ultimately leading to an obliterative endarteritis.•Cutaneous & subcutaneous vascular necrosis.•Localized ischemia & further bacterial proliferation. •Rates of fascial destruction as high as 2-3 cm/h

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Aetiology• Streptococcal species, Staphylococcal species,

Enterobacteriaceae, Anaerobic organisms and Fungi• Anorectal: Perianal, perirectal, ischiorectal abscesses & anal

fissures• Urogenital: Infection in bulbourethral glands, urethral injury,

iatrogenic injury secondary to urethral stricture manipulation, epididymitis, orchitis & lower urinary tract infection• Skin: Hidradenitis Suppurativa, ulceration due to scrotal

pressure and trauma.

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Clinical PresentationProdromal symptoms: fever and lethargy for 2-7 daysIntense pain & tendernessProgressive oedema of the overlying skin & pruritus Dusky appearance Subcutaneous crepitationPurulent drainage Obvious Gangrene

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Antibiotic Treatment

•Broad-spectrum antibiotic therapy. •Staphylococci, Streptococci, Enterobacteriaceae and Anaerobes.•Ciprofloxacin and Clindamycin. •Clindamycin has gram-positive & anaerobic spectrum of activity.

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Surgical Treatment: Radical Debridement • A Surgical Emergency!• No place for conservative, minimal or key hole surgery!• All necrotic tissue must be excised widely• The skin should be opened widely to expose the full

extent of the underlying fascial and subcutaneous tissue necrosis. • All fascial planes that separate easily with blunt

dissection should be considered involved and therefore excised. • Dissection should be carried out to reach healthy bleeding

tissues

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Prognosis• Mortality rates are as high as 75%• The overall 30-day mortality rate is 10%• The mortality is directly proportional to the age of the patient and the extent of disease burden and systemic toxicity upon admission. • Improved prognosis: 1. Age younger than 60 years2. Localized clinical disease3. Absence of systemic toxicity 4. Aggressive surgical debridement

NECROTIZING FASCIITIS MANAGEMENT 2016 Dr Mohamad Al-Gailani FRCS

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Necrotizing Fasciitis: Conclusion• Necrotizing fasciitis is an uncommon disease that results in gross

morbidity and mortality if not treated in its early stages• At onset it may be difficult to differentiate it from other superficial

skin conditions such as cellulitis• Only early diagnosis and aggressive surgical treatment can reduce

mortality and morbidity• Once diagnosed, urgent and (possibly multiple) wide wound

debridement, excision of nonviable tissue and wide spectrum intravenous antibiotics should be instituted