Rare Complication of Stomas: Peristomal Necrotizing Fasciitis

Introduction. A stoma formation is a frequently performed procedure in patients undergoing colorectal surgery. Although stoma formation is a simple process, it should be performed with caution. The aim of this study was to attract physicians’ attention to this rare disease and also to identify the surgical and medical treatment options for peristomal necrotizing fasciitis as a rare complication. Materials and Methods. Risk factors including age, sex, additional diseases, previous surgical procedures, source of infection, physical findings, and vital signs of 14 patients with peristomal necrotizing fasciitis over a period of 10 years from 2005 to 2015 were retrospectively evaluated. Results. Of the 14 patients, 9 were men and 5 were women. The average age was 63.28 years (range, 45–85 years). Risk factors were also observed: diabetes mellitus, 4 (28.57%); obesity, 3 (21.42%); alcoholism, 1 (7.14%); and malignancy, 10 (71.42%). Prophylactic antibiotic treatment was given to all patients, and they all underwent debridement and stoma replacement. Conclusion. Peristomal necrotizing fasciitis is an urgent and mortal disease. Risk factors, physical findings, and infection sources should be determined, and treatment modalities should be applied immediately. Medical treatment and surgical options should be performed, and vacuum devices should also be considered when treating this complication.

Creating a stoma is a simple surgical procedure, but serious complications can develop early or late postoperatively. Well-known complications include stenosis, retraction, hernia, prolapse, skin excoriation, and less frequent complications consist of leakage, soiling, and odor.¹ Parastomal necrotizing fasciitis is a rare complication; according to the authors’ research, only case reports of this complication exist in the literature.^2-5 The authors have aimed to share their experience with this rare complication in this case series.

The authors obtained Institutional Review Board (IRB) approval for this study, informed all patients, and obtained written informed consent for participation of all patients. Fourteen patients developed parastomal necrotizing fasciitis over a period of 10 years from 2005 to 2015, and these were retrospectively examined. Risk factors such as age, sex, source of infection, physical findings, vital signs, comorbidities, and prior surgeries were examined. All underlying causes of primary surgical procedures were examined. All operation reports were noted. Patients who required interventions for their complication were assessed and managed either conservatively or through active surgical intervention. The authors also documented photographs of the cases to chart the progress of the condition.

Of the 14 patients, 9 were men and 5 were women. The average age was 63.28 years (range, 45–85 years). Etiological factors and primary diseases are shown in Table 1. Patients had the following additional major risk factors: 4 had diabetes mellitus (28.57%), 3 obesity (21.42%), 1 alcoholism (7.14%), and 10 malignancy (71.42%). 

The average entry time for surgery after diagnosis was 14.35 hours (range, 3–72 hours). The patients received 1 g prophylactic cefepime 2x/day for 3 days, and they also received 500 mg daily of metronidazole 3x/day for 3 days. All patients underwent debridement and stoma replacement, and vacuum-assisted closure (VAC) devices were also used at 100 mm Hg continuous suction in all procedures. The VAC sponge was changed every 48 hours. The average number of VAC changes was 9.16 times (range, 4–14 times). Debridement was performed an average of 1.91 times per patient (range, 1–3 times). Escherichia coli and Bacteroides spp were grown and developed in microbiological samples. The patients received 3 daily doses of 4.5 g of piperacillin-tazobactam for 14 days. Treatment doses were adjusted according to renal function. Basic complications included multi-organ failure (MOF) in 5 patients (35.71%), sepsis in 4 (28.57%), and stoma retraction in 3 (21.42%). Nine patients with MOF were treated in the intensive care unit, and 2 patients died. Patients with stoma retraction underwent stoma revision on days 2 and 3. The average duration of hospital stay was 27.41 days (range, 14–45 days). The mortality rate was 14.2% (Table 2). 

Necrotizing soft tissue infection (NSTI) has an incidence of approximately 1000 cases/year in the United States.⁶ The incidence of NSTI increased between 1980 and 2000, although the accurate reasons for this remain speculative.⁷ Possible reasons may include increased microbial virulence or resistance to antibiotics because of the excessive use of antibiotics.

Necrotizing soft tissue infection is related to anatomy, depth of infection, or microbial source of infection (Table 3). Immunodeficiencies or underlying abdominal pathology such as undergoing gastrointestinal malignancy surgery, experiencing trauma or perforating the viscera, and having chronic liver disease were the most common affects in the literature (80%) in type I NSTI. Sources frequently include E coli, Pseudomonas spp, or Bacteroides spp.⁸ Classification systems have not proven useful for affecting diagnosis and treatment, thus they have only been used in research. The depth of the primary infection site can also affect mortality.⁷ 

The most common clinical signs are an extension of erythema and tenderness to other quadrants of the abdomen, blister formation or bullae areas with fluctuation or induration⁹ (Figure 1), fetid skin necrosis progressing to gangrene, and spontaneous outflow of feces to the tissues, which becomes parietal gangrene. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for NSTI consists of C-reactive protein, leukocytosis, hemoglobin, sodium, and creatinine levels would be beneficial in treating NSTI¹⁰ (Table 4). Positive predictive value of 92% and negative predictive value of 96% were the score for 6 of the NSTI, and also it revealed the positive predictive value increases as the score increases; for score 7, the probability of disease was 75% in the LRINEC. Larger and prospective studies are needed.

Imaging methods could be useful for confirming and determining a patient’s NSTI severity, because computerized tomography (CT) could reveal inflammatory changes such as fascial edema and thickening or abscesses, in addition to gas formation.^11,12 In a retrospective study of 20 patients,¹¹ CT with intravenous (IV) contrast had 80% sensitivity in revealing fascial thickening, which means it could be useful for diagnosing NSTI. Another study¹³ has shown CT with IV contrast could reveal thickening and had increased contrast involvement in the affected tissue planes, but less frequent and more specific findings included gas or fluid collections. The sensitivity of magnetic resonance (MR) was from 90%–100%, but specificity was only 50%–85% for detecting NSTI.^14,15

Prophylactic antibiotic treatment of a polymicrobial infection should be based on Gram staining, antibiogram, and the patient’s medical history. Ampicillin or ampicillin–sulbactam combined with metronidazole or clindamycin can be used in the initial treatment.⁹ Anaerobic coverage is quite important for type 1 infection; metronidazole, clindamycin, or carbapenems (imipenem) are effective antimicrobials. Broad gram-negative coverage is necessary for patients with NSTI. In such cases, ampicillin–sulbactam, piperacillin–tazobactam, ticarcillin–clavulanic acid, third- or fourth-generation cephalosporins, or carbapenems have been used. 

Numerous studies^16-20 have shown the most important determinant of mortality is timing and adequacy of initial debridement.Wong et al¹⁷ reported a ninefold increase in mortality if the procedure was delayed > 24 hours from the time of hospital admission. In a retrospective study, Bilton et al¹⁸ compared early and complete debridement with delayed and incomplete debridement and determined the mortality rate increased from 4% to 38%. Two previous studies^19,20 also determined there are dramatic increases in mortality with delayed and inadequate operative intervention. In this case series, the patients underwent surgery within 14.35 hours of presentation (range, 3–72 hours) on average, which is within the recommended timing.

A combination of antibiotics is key for successful adjuvant therapy. Most of the authors’ patients were treated with empiric antimicrobial therapy before the early diagnosis of necrotizing infection. In the authors’ study, E coli and Bacteroides spp growth occurred in all cultures. Upon the recommendation of the Department of Infectious Disease, the patients were treated with 4.5 g of piperacillin-tazobactam 3x/day for 14 days. Doses were adjusted according to renal function.

Today, the preferred and used algorithm for treatment is 1) resuscitation; 2) broad spectrum antibiotics for possible infection sources; 3) early and comprehensive debridement of all dead tissue (Figures 2 and 3) (if necessary, a frozen section for microbiologic analysis is included); 4) repeat debridements every 24–48 hours until the infection is controlled; 5) change antibiotic regimen according to initial culture; and 6) hyperbaric oxygen therapy for stable patients.²⁰ 

Another worldwide-preferred technique has been to use VAC therapy for fast and effective healing of wounds.^9,21 There are several studies such as general surgery, orthopedic, and gynecology clinics that support the use of VAC devices. A VAC device includes a sterile, open-cell foam sponge; a transparent adhesive drape; and a portable vacuum pump. The sponge is placed in the wound, covered with the drape for an airtight environment to create noncollapsible tubing, and evacuation to the sponge is provided under continuous negative pressure. Granulation of microstrains was the method to improve wound healing. Several randomized studies^22,23 have shown adding a full-thickness graft while using VAC devices was significantly more successful than the standard gauze therapy. Vacuum-assisted closure dressings should be changed every 24–72 hours. This therapy has several prominent benefits such as wound area reduction and formation of granulation tissue (Figure 4). 

Necrotizing fasciitis is a surgical urgency with a high mortality rate ranging from 6% to 36%.^23-28 Of the 14 patients, 2 died; the mortality rate was 14.28%, which was within acceptable limits.

In these 14 cases, the authors noticed unusually severe evolution of parastomal parietal suppuration and also a rapidly progressive NSTI. Physicians should be aware of this rare complication and act quickly when signs of peristomal inflammation occur. A NSTI can rapidly progress into a life threatening condition; therefore, prompt and radical surgical debridement is mandatory in the treatment of NSTIs. Vacuum-assisted closure therapy should facilitate wound healing and patient compliance. The use of VAC therapy in wound management has greatly improved the results of postoperative management.

Affiliations: Department of General Surgery, Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey; and Department of General Surgery, Faculty of Medicine, Istanbul University, Istanbul, Turkey

Correspondence:
Burak M. Ilhan, MD 
Department of General Surgery
Faculty of Medicine
Istanbul University
Millet Caddesi
34093 Fatih
Istanbul, Turkey
burakmd@yahoo.com

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