Negative Pressure Wound Therapy for a Giant Wound Secondary to Malignancy-induced Necrotizing Fasciitis: Case Report and Review of the Literature

Background. Necrotizing fasciitis (NF) is a life-threatening condition in which rapid diagnosis, debridement of nonviable tissue, and broad-spectrum antibiotics are critical to effective treatment. The debridement required can be extensive, resulting in large wounds that can sometimes be covered with split-thickness skin grafts (STSGs) with the help of negative pressure wound therapy (NPWT), or vacuum-assisted closure, to decrease the wound size. Case Report. The authors report a rare case of NF due to malignancy-associated bowel perforation with a giant lower extremity wound secondary to debridement that involved 20% of the total body surface area (TBSA) in a 64-year-old, previously healthy, nonsmoking man. The wound was surgically debrided twice and packed before NPWT was applied. Based on the authors’ literature search, this case is 1 of the single largest wounds successfully managed with a STSG and NPWT. Conclusions. Rapid diagnosis of NF is critical to guide surgical management and administration of antibiotics. It is important to be mindful of the origin of certain necrotizing infections, and clinicians should have a greater index of suspicion for NF when assessing skin infections in unwell patients with concomitant bowel perforation secondary to gastrointestinal malignancy. 

Necrotizing fasciitis (NF) is a life-threatening condition in which rapid diagnosis, debridement of nonviable tissue, and broad-spectrum antibiotics are critical to effective treatment. The debridement required can be extensive, resulting in large wounds that can sometimes be covered with a split-thickness skin graft (STSG). In the circumstance of a massive wound, there can be great benefit in initially treating the wound with negative pressure wound therapy (NPWT) to decrease the size.¹ Reported herein is a rare case of NF due to malignancy-associated bowel perforation with a giant lower extremity wound secondary to debridement that involved 20% of the total body surface area (TBSA). Based on the authors’ literature search, this case report is 1 of the single largest wounds successfully managed with a STSG and NPWT.

A 64-year-old, previously healthy, nonsmoking man, with an untreated right colon tumor diagnosed 2 weeks prior, presented to the emergency department (ED) in septic shock. The tumor was staged T4N2 radiologically (7.1 cm x 7.5 cm x 9.7 cm) and was locally advanced with invasion of the retroperitoneum. Since the initial diagnosis, he had radicular pain in the right lower extremity. In the ED, an exquisitely tender, violaceous, and erythematous rash covering the right side of his back (just inferior to the scapula), right flank, groin, and lateral thigh distally to the foot was noted. Crepitus was palpitated in the right inguinal region in keeping with subcutaneous emphysema on x-ray. He was febrile and hypotensive despite fluid resuscitation. His white blood cell count and lactate were elevated at 20 x 10⁹/L and 7.9 mmol/L, respectively. 

A presumptive diagnosis of NF was made, and this patient underwent immediate and extensive debridement with irrigation in the operating room (OR). The etiology was a cecal perforation secondary to the colon tumor. He received intravenous piperacillin-tazobactam, clindamycin, and vancomycin, concurrently. Debridement involved affected skin, subcutaneous fat, and fascia overlying the right latissimus dorsi, paraspinal, external oblique, and lower extremity muscles. A small communication to the peritoneal cavity was appreciated in the right lower quadrant. Escherichia coli was isolated as the predominant pathogen in this polymicrobial NF; other organisms included coagulase-negative staphylococci, Corynebacterium, and Candida parapsilosis. 

In a subsequent operation that took place within 1 week of initial presentation to the ED, the patient underwent drainage of a retrocecal abscess and placement of a loop ileostomy. The wound bed was explored and surgically debrided once within 24 hours from initial debridement. ACTICOAT (Smith & Nephew, London, UK), burn gauze, and Kling dressing were applied to the wound after each debridement until NPWT was initiated on post-admission day (PAD) 3. Following final debridement, the wound measured 0.465 m², or approximately 20% TBSA in size, and resulted in anterior and posterior skin and subcutaneous flaps over the flank and thigh that were not adherent to the underlying muscle. These undermined the subcutaneous tissues 10 cm anteriorly and 10 cm posteriorly (Figure 1A). 

The NPWT dressing was applied for a total of 30 days at a continuous pressure of -125 mm Hg (V.A.C. Therapy; KCI, San Antonio, TX). During this time period, the NPWT dressing was changed every 10 days in the operating room under general anesthesia (total of 3 dressing applications). Dressing changes required the staff surgeon and 1 or 2 other physicians and/or nurses; for each change, the NPWT sponges were contoured to fit the wound bed and secured by transparent films to obtain an air-tight seal. This allowed for the size of the wound to decrease, the anterior and posterior skin and subcutaneous flaps to heal onto the underlying muscle, and the formation of granulation tissue throughout the wound base (Figure 1B). 

On PAD 33, following the completion of NPWT and as judged on clinical appearance, the wound base was lightly debrided to create punctate bleeding. Subsequently, a STSG was applied for wound coverage in the main OR. The STSG was harvested from the contralateral lower extremity using dermatome (Zimmer Air; Zimmer Biomet, Warsaw, IN) with a thickness of 0.3048 mm. The grafts were meshed with a ratio of 1.5:1 and secured by staples to completely contour and resurface the defect. The skin grafts were bolstered with BACTIGRAS (Smith & Nephew, London, UK) and covered with Polysporin (Johnson & Johnson, New Brunswick, NJ), burn gauze, and Kling dressing.

The bolster dressing was removed 7 days later (PAD 40) to reveal excellent graft take of 95%, and dressings were changed every 3 days with the antiseptic bolster dressing and the topical antibiotic ointment. For small areas where the skin graft did not take, antimicrobial silver dressing and IntraSite gel (Smith & Nephew) were applied every 3 days during dressing changes. At 10 days post-STSG, the grafted area showed 95% take (Figure 1C). Thirty days after STSG application, the wound was completely healed and no longer required formal dressings (Figure 1D). 

Literature search. A title and abstract search up to May 2016 was conducted for the literature review component of this case report using MEDLINE and EMBASE databases, with the following search strategy: (“massive” OR “complex” OR “large”) AND (“wound” OR “trauma” OR “burn” OR “necrotizing fasciitis” OR “wound”) AND (“negative pressure wound therapy” OR “NPWT” OR “vacuum” OR “VAC” OR “hyperbaric oxygen therapy” OR “split thickness skin graft” OR “STSG”). 

Necrotizing fasciitis is a rare, life-threatening condition with a global prevalence of 0.4 cases per 100 000.² The male-to-female ratio is 3:1, mainly due to the higher incidence of Fournier’s gangrene in males.² Most affected patients are more than 50 years of age.² Despite trauma being the most common etiology, NF can arise in cancer patients, especially those who are immunocompromised secondary to chemotherapy and/or radiation, including patients with gastrointestinal (GI) carcinoma.^3,4

The etiology of NF in the case presented herein is quite rare and only 10 cases have been reported to have the same etiology: bowel perforation of an untreated primary GI tumor.^5-14 In this series of patients, the age range was 52 to 79 years and 7 patients were male. Gram-negative bacteria was commonly isolated from these wounds, which is consistent with the case herein. Affected body regions included the perineum (Fournier’s gangrene), abdomen, and lower extremities.

Thorough and immediate debridement remains the cornerstone treatment for NF, and the resulting defects can be massive. The authors’ literature search showed the presented case had 1 of the largest single wounds upon initial presentation successfully managed by NPWT, which was first commercialized in 1995 to aid in complex wound treatment.¹⁵ The use of NPWT in NF therapy started in 1999 and, along with STSG, has been very effective for the management of massive wounds caused by NF.^1,16 Complex wounds of other etiologies also have been successfully treated with NPWT, such as burns, open fractures, fasciotomies, diabetic foot wounds, pressure ulcers, purpura fulminans (PF), and many others.^16,17 

Negative pressure wound therapy is a powerful bolster known to improve STSG take in burn populations. Kamolz et al¹⁸ reported a graft take rate > 95% and eventual complete wound closure in 36 of 37 burn patients with TBSA > 25% treated by NPWT and STSG.^18,19 Furthermore, Fischer et al²⁰ proposed that NPWT provides a more accurate estimate of fluid loss to facilitate resuscitation in their study of 12 burn patients (TBSA, 15%–60%; mean, 29.6%) with a graft take rate ranging from 85% to 100% (mean, 97.1%). However, there is not enough evidence to support the use of NPWT in the treatment of partial-thickness burns according to a Cochrane review.²¹ A prospective study²² of 35 patients with Fournier’s gangrene showed that NPWT was associated with significantly reduced mortality as compared with conventional dressings. Negative pressure wound therapy has a significant impact on limb salvage in the treatment of complex diabetic foot wounds and is helpful for optimizing patients requiring reconstructive surgery due to severe open lower extremity fractures.^23,24 A 2010 meta-analysis of 10 randomized controlled trials by Suissa et al²⁵ demonstrated NPWT can also significantly reduce healing time and wound size compared with standard wound care, primarily in populations with diabetic foot ulcers and pressure ulcers.

Mechanistically, NPWT improves graft take by eliminating extravascular edema and improving microcirculatory blood supply.¹⁶ In addition, the negative pressure creates tension that stimulates granulation tissue formation as well as reduces wound size and bacterial load.^16,19,23 Additional mechanisms that facilitate wound healing include secure wound coverage and stimulation of angiogenesis.^26,27 However, in such extensive wounds, NPWT foam has been reported to be left in patients, causing persistent infections.²⁸ Other drawbacks of the device include high material cost, inconvenience for ambulation, labor-intensive dressing changes, difficulty maintaining an air-tight seal, and pain and discomfort caused by suction.^29-31 Still, the total cost of NPWT as compared with traditional wound care for postoperative patients in long-term acute care facilities can be almost threefold less per unit of defect volume that is contracted.³²

Negative pressure wound therapy with instillation (NPWTi) is a variation of NPWT first used in 1999 and features retrograde introduction of a cleansing solution such as acetic acid or polyhexanide into the sealed wound bed, which is allowed to soak (eg, for 20 minutes) before suction removal.¹⁶ The NPWTi technique has not been found to be superior to conventional NPWT for treatment of contaminated wounds; however, it can be successfully used as an adjunct, such as with treating a perianal NF complication secondary to complex pressure ulcers.^16,33 

Hyperbaric oxygen therapy (HBOT) has been proposed to improve wound healing and survival in patients with NF by possibly increasing oxygen tension at the ischemic wound bed, facilitating the action of cytotoxic leukocytes, and improving antibiotic delivery via hyperoxygenation.^34,35 A recent Cochrane review³⁶ failed to demonstrate any definitive evidence to support the effectiveness of HBOT for adjunct management of NF. Given the conflicting study results, and the fact that HBOT is not an entirely benign intervention, this treatment modality is not part of routine patient care at the authors’ center.

Acellular dermal matrix (ADM) is an alternative to autografting techniques (such as full-thickness skin grafts and flaps) in wound reconstruction and is typically used as a foundation for STSG secured by NPWT.³⁷ This alternative increases skin pliability, reduces hypertrophic scarring, and decreases donor site morbidity and pain.^38,39 Utilization of ADM is popularized with breast and abdominal wall reconstruction and repairing tendon-exposed wounds and smaller traumatic tissue defects (eg, 5 cm x 5 cm).^40-42 However, the use of ADM for massive wounds caused by NF is comparatively rare; it has been used in pediatric patients with NF and PF, a NF case report featuring a leg wound of 768 cm² with multiple exposed tendons, and a torso wound of 1400 cm² caused by NF.^38,43,44 This paucity of ADM use may be due to the high cost anticipated to cover such large wound defects following NF debridement. Although it certainly varies by center and region, the cost of ADM for each 1% TBSA of coverage can reach $5500 to $6700, which is calculated using an average adult human body surface area of 1.79 m².^45,46 This cost may be perceived as impractical from a systems perspective for the management of massive wounds, particularly in single-payer health care systems such as Canada.⁴⁷ In addition, to the best of the authors’ knowledge, there are no high-quality studies suggesting that ADM improves outcomes compared to autologous reconstruction in patients with NF.  Therefore, the use of ADM in massive wound management secondary to NF must be considered on a case-by-case basis from a cost-benefit perspective until higher-quality evidence becomes available.

Rapid diagnosis of NF is critical to guide surgical management and administration of antibiotics. Physicians should be aware of other causes of NF besides trauma. In particular, it is important to be mindful that the origin of certain necrotizing infections, especially those on the trunk, perineum, buttock, or thigh, may be an unrecognized GI malignancy. Clinicians should have a greater index of suspicion for NF when assessing skin infections in unwell patients with concomitant bowel perforation secondary to GI malignancy. Given the rarity of the situation, it is not necessary to routinely inform patients with GI malignancy of the risk of NF. Postdebridement, large wound defects (20% TBSA) can be reconstructed with STSG with the aid of a NPWT system. This not only decreases the size of the wound, lessening the area to be grafted, but also helps stabilize skin flaps that have lifted from the underlying fascia.  A foam sponge must be completely removed during dressing change to prevent possible chronic infections.

Affiliations: Division of Plastic & Reconstructive Surgery, McMaster University, Hamilton, Ontario, Canada; and Faculty of Medicine, Michael G. DeGroote School of Medicine, McMaster University

Correspondence:
Jiayi Hu, MD
Division of Plastic & Reconstructive Surgery
McMaster University
1280 Main Street West
Hamilton, Ontario, Canada
ON L8S 4L8
Jiayi.hu@medportal.ca

Disclosure: The authors disclose no financial or other conflicts of interest.