Case Reports - Necrotizing fasciitis after placement of intraperitoneal catheter

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Highlights

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Necrotizing fasciitis has not previously been reported in association with placement of intrapertioneal port at the time of cytoreductive surgery

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Consensus is lacking regarding the placement of intraperitoneal ports at the time of bowel surgery

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Delayed placement of intraperiteonal ports may be considered in patients undergoing bowel resection

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Introduction

Intraperitoneal (IP) chemotherapy has a proven survival advantage in patients with optimally cytoreduced advanced epithelial ovarian cancer [1]. Placement of IP catheters can be performed at the time of optimal cytoreductive surgery [2-3]. Reported here is the case of a woman with stage IIIC serous adenocarcinoma of primary peritoneal origin who underwent optimal cytoreductive surgery and IP catheter placement, who was readmitted on post-operative day 10 with necrotizing fasciitis of her anterior abdominal wall originating at the IP catheter site.

Case

A 63-year-old nulligravid female with a past medical history significant for moderately controlled type II diabetes (glycosylated hemoglobin 7.5%), hypertension, hyperlipidemia, and morbid obesity (BMI 44 kg/m²) presented to her primary care physician with complaints of two weeks of lower abdominal pain, bloating, early satiety, and nausea. She was treated with antibiotics for presumed diverticulitis for 2 weeks without resolution of symptoms. A CT scan of the abdomen and pelvis revealed inflammatory changes in the pelvis surrounding the bilateral adnexa and sigmoid colon with multiple colonic diverticula present suggestive of uncomplicated diverticulitis, omental nodularity, and soft tissue prominence in the left adnexa. Pelvic ultrasound showed a 5 cm calcified fibroid with submucosal extension, and the ovaries could not be visualized. A serum CA125 level was elevated to 907 U/mL. She was referred to the Gynecologic Oncology clinic for further evaluation and scheduled for surgery. The patient underwent a diagnostic laparoscopy, which revealed omental caking, moderate straw-colored ascites, and bowel adhesions to the anterior abdominal wall. Due to findings concerning for malignancy, the procedure was converted to laparotomy and optimal cytoreduction to < 1 cm residual disease was performed, including total abdominal hysterectomy, bilateral salpingo-oophorectomy, infragastric omentectomy, appendectomy, resection of proximal descending colon with side-to-side re-anastomosis. IP port was placed at the time of surgery. Surgical pathology showed a stage IIIC high-grade serous adenocarcinoma of primary peritoneal origin.

The immediate post-operative course was uncomplicated and she was discharged home on post-operative day 5. On post-operative day 10, the patient presented to clinic with complaints of increased left sided abdominal pain that she described as a constant, pulling sensation centralized around the IP port site.........