ARTICLE IN PRESS doi:10.1510/icvts.2009.222323 Editorial
www.icvts.org
Case report - Thoracic non-oncologic
David J. Birnbaum, Xavier Benoit D’Journo, Dominique Casanova, Pascal A. Thomas*
Received 18 September 2009; received in revised form 16 November 2009; accepted 20 November 2009
1. Introduction
Historical Pages Brief Case Report Communication
NF is a rare infection, seen most frequently in the immuno-compromized patients and associated with a high mor-
Nomenclature
䊚 2010 Published by European Association for Cardio-Thoracic Surgery
3. Discussion
Best Evidence Topic
*Corresponding author. De ´partement de Chirurgie Thoracique et des Maladies de l’œsophage, Hˆ opital Sainte Marguerite, CHU Sud, 270 Bd Ste Marguerite, 13274 Marseille Cedex 9, France. Tel.: q33 491 744 680; fax: q33 491 744 590. E-mail address:
[email protected] (P.A. Thomas).
State-of-the-art
A 39-year-old lady, without comorbidity, was admitted to the intensive care unit for an acute respiratory failure and severe sepsis requiring mechanical ventilation. An antibiotic treatment was begun based on tazocilline and gentamycine. Clinical examination found a thickening of the left axillary region without subcutaneous emphysema and a left pleural effusion. A computed tomography scan confirmed the pleural effusion with a pneumonia of the left lower lobe. After a few hours, the patient developed a NF of the left axillary area. Emergency surgical debridement was
Follow-up Paper
2. Case report
Negative Results
Necrotizing fasciitis (NF) is a bacterial derma-hypodermitis affecting the soft tissue and muscular fascia. It is an uncommon and severe infection caused by microorganisms called ‘flesh eating bacteria’, mainly represented by group A beta-haemolytic streptococcus. NF remains a life-threatening condition associated with a high mortality rate w1– 3x. Its location to the chest wall is extremely rare. The few reported cases are subsequent to thoracic drainage, lung surgery or esophageal resection w1, 3x. Here, we report the case of a NF of the chest wall complicating an empyema. We describe the surgical management over several weeks based on a three-step procedure: 1) appropriate antibiotics and surgical debridement, 2) negative pressure wound therapy wvacuum-assisted closure (VAC䊛 )x and 3) delayed surgical reconstruction.
required. A wide section was performed on the medioaxillary line with subcutaneous and muscular debridement. After abundant irrigation, large drainage was positioned in the subcutaneous tissue. Culture demonstrated group A beta-haemolytic streptococcus leading to a targeted biantibiotic treatment (tazocilline and rifadine). Within a few days, the patient felt well and was extubated. On postoperative day 15, all drains were removed and the patient was referred to a medical department with a negative pressure wound therapy (VAC䊛, KCI Inc, San Antonio, TX). After two weeks, despite general improvement, surgical debridement resulted in full-thickness axillary defect with a multiloculated pleural effusion (Figs. 1 and 2a). A pleural decortication and a reconstructive surgery were decided in collaboration with plastic surgeons. The patient was operated on 35 days after her admission, when she was hemodynamically stable and apyretic without signs of infection. An active granulation tissue was achieved in the wound (Fig. 2a). With the patient in left lateral decubitus, an extensive debridement of all non-viable tissues of the antero-lateral thoracoabdominal wall (serratus anterior) was performed. The pleural cavity was opened for decortication and large chest tube drainage were inserted. A left latissimus dorsi free flap for filling and covering the defect (Figs. 2b and c) was raised. The coverage was completed with a transplant of non-pediculized skin taken from the right thigh. The postoperative outcome was uneventful and the patient was discharged home at day 50. Twenty-three months after the reconstruction the patient had no complaint and she had no recurrence of the disease (Fig. 2d).
Proposal for Bailout Procedure
Keywords: Necrotizing fasciitis; Chest wall; Group A beta-haemolytic streptococcus; Vacuum-assisted closure
ESCVS Article
Necrotizing fasciitis (NF) is an uncommon infection caused by microorganisms called ‘flesh eating bacteria’. It remains a life-threatening condition associated with high mortality rate. Its location to the chest wall is exceptional. Herein, we report the case of a 39-year-old female, without comorbidity, presenting a NF of the chest wall complicating an empyema. We describe the surgical management with a three-step procedure: antibiotherapy-debridement, vacuum-assisted closure and delayed surgical reconstruction. 䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Institutional Report
Abstract
Protocol
Department of Thoracic Surgery, Sainte-Marguerite Hospital, University of the Mediterranean and Assistance-Publique Ho ˆ pitaux de Marseille, Marseille, France
Work in Progress Report
Necrotizing fasciitis of the chest wall
New Ideas
Interactive CardioVascular and Thoracic Surgery 10 (2010) 483–485
ARTICLE IN PRESS 484
D.J. Birnbaum et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 483–485
Fig. 1. Chest CT-scan at 30 days.
tality rate w1x. The infection mostly occurs along the lowest part of the body and much more rarely to the chest wall w1, 2x. The thoracic location is most frequently reported after chest drainage or after thoracic surgery. However, contagions from empyema have been reported w1–3x. Group A beta-haemolytic Streptococcus and Clostridium perfringens are the most common pathogens found in this pathology. However, multi-microbial associations are reported w1x. Early diagnosis and treatment are the two main factors responsible for the prognosis w1x. The antibiotic treatment must be started immediately, even before the results of the microbiological analyses. Antibiotics are usually adjuvant to the surgical treatment because the local vascular thrombosis results in poor antibiotic tissue diffusion. The objective of the antibiotic treatment is to limit the progression of the infection. The recommended antibiotic treatment consists in the association of b-lactamine, imidazole"aminoside. There is no cure without complete excision of the nonviable tissues. The additional use of a negative pressure wound therapy (VAC䊛) for management of NF of the chest wall has been recently reported with success w4x. Its use allows drainage of secretions, improves microcirculation development and favours tissue granulation. Delayed parietal reconstruction is justified when full-thickness defect is present. The use of latissimus dorsi free flap seems to be the reconstructive technique of choice with good esthetical and functional results w5x. To summarize, aggressive surgery and antibiotics form the basis for the treatment of NF of the chest wall. Adjuvant
Fig. 2. (a) Granulation of soft tissues after two weeks of VAC䊛 therapy. (b) Extensive debridement of all nonviable tissues (serratus anterior). Left latissimus dorsi free flap for filling and covering the defect. (c) Coverage with a transplant of non-pediculized skin. (d) Results after 23 months of the reconstruction.
use of negative pressure wound therapy seems to be a promising option in order to improve tissue quality before reconstructive surgery. References w1x Safran DB, Sullivan WG. Necrotizing fasciitis of the chest wall. Ann Thorac Surg 2001;72:1362–1364. w2x Urschel JD, Takita H, Antkowiak JG. Necrotizing soft tissue infections of the chest wall. Ann Thorac Surg 1997;64:276–279. w3x Kalkat MS, Rajesh PB, Hendrickse C. Necrotizing fasciitis of chest wall complicating empyema thoracis. Interact CardioVasc Thorac Surg 2003; 2:358–360. w4x Konstantinov IE, Saxena P, Shehatha J, Mitchell A, Cherian S. Novel aeration technique for necrotizing fasciitis of the chest wall. Ann Thorac Surg 2008;86:1973–1974. w5x Barbosa RF, Pinho CJ, Costa-Ferreira A, Cardoso A, Reis JC, Amarante JM. Microsurgical reconstruction of chest wall defect after necrotizing fasciitis. Microsurgery 2006;26:519–523.
eComment: The reconstructive ladder in necrotizing fasciitis of the chest wall Authors: Karsten Knobloch, Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany; Joern Redeker, Peter M. Vogt doi:10.1510/icvts.2009.222323A We read with great interest the recent report by Dr. Birnbaum and colleagues and we would like to congratulate them for the successful clinical outcome w1x. Chest wall involvement is a rare manifestation of necrotizing
ARTICLE IN PRESS D.J. Birnbaum et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 483–485
Institutional Report ESCVS Article Proposal for Bailout Procedure Negative Results Follow-up Paper State-of-the-art
Authors: Nikolaos G. Baikoussis, Department of Cardiac Surgery, University Hospital of Ioannina, Greece; Stavros N. Siminelakis, Petros Tzimas, Georgios S. Papadopoulos
w1x Birnbaum DJ, D’Journo XB, Casanova D, Thomas PA. Necrotizing fasciitis of the chest wall. Interact CardioVasc Thorac Surg 2010;10:483–485. w2x Akman C, Kantarci F, Cetinkaya S. Imaging in mediastinitis: a systematic review based on aetiology. Clin Radiol 2004;59:573–585. w3x Cirino LM, Elias FM, Almeida JL. Descending mediastinitis: a review. Sao Paulo Med J 2006;124:285–290. w4x Mihos P, Potaris K, Gakidis I, Papadakis D, Rallis G. Management of descending necrotizing mediastinitis. J Oral Maxillofac Surg 2004;62: 966–972. w5x Kalkat MS, Rajesh PB, Hendrickse C. Necrotizing fasciitis of chest wall complicating empyema thoracis. Interact CardioVasc Thorac Surg 2003; 2:358–360.
Protocol
eComment: Maltreated dental abscess complicated with chest wall necrotizing fasciitis, empyema thorax and cardiac tamponade
References
Work in Progress Report
w1x Birnbaum DJ, D’Journo XB, Casanova D, Thomas PA. Necrotizing fasciitis of the chest wall. Interact CardioVasc Thorac Surg 2010;10:483–485. w2x Mathes S, Nahai F. Clinical application for muscle and musculocutaneous flaps. St. Louis: Mosby, 1982:3. w3x Heitmann C, Pelzer M, Bickert B, Menke H, Germann G. Surgical concepts and results of necrotizing fasciitis. Chirurg 2001;72:168–173. w4x Barbosa RF, Pinho CJ, Costa-Ferreira A, Cardoso A, Reis JC, Amarante JM. Microsurgical reconstruction of chest wall defect after necrotizing fasciitis. Microsurgery 2006;26:519–523. w5x Yuen JC, Feng Z. Salvage of limb and function in necrotizing fasciitis of the hand: role of hyperbaric oxygen treatment and free muscle flap coverage. South Med J 2002;95:255–257.
New Ideas
References
doi:10.1510/icvts.2009.222323B We read with great interest the recent paper about necrotizing fasciitis of the chest wall and we would like to congratulate the authors for the successful clinical outcome and for the important scientific data which their article provided w1x. We have successfully treated a 31-year-old man with a recent history of a maltreated dental abscess suffering necrotizing fasciitis limited on his cervical region and upper anterior chest wall complicated with bilateral empyema, diffuse descending mediastinitis and cardiac tamponade. We started intravenous broad spectrum antibiotic administration and we led him to the operating room for an emergent sub-xiphoid pericardial window, aggressive radical debridement of the necrotic tissues and bilateral thoracotomy for decortication of both lungs due to empyema. The reconstruction of his chest wall was obtained with primary closure of the wound without the need for any skin flap. After three weeks of intensive care unit management he was discharged from the hospital alive. Acute mediastinitis and necrotizing fasciitis are both life-threatening conditions which must be diagnosed early and treated adequately. It is characterized by acute polymicrobial infection with extensive fascial necrosis that may spread toward the skin and underlying muscles w2x. Piperacillin-tazobactam and vancomycin are a good choice for empirical initial treatment. Another good choice is clindamycin plus ceftriaxone or ceftazidime. Administration of carbapenem and metronidazole is also suggested. When the clinical course appears to be resistant to treatment, mycotic infection may be considered w3x. One peculiarity of this type of infection is its capacity to affect several anatomical zones, thereby provoking muscle and fascia necrosis, abscess formation and systemic toxicity induction leading to septic condition w4x. According to the international literature w2, 5x, early diagnosis, aggressive and emergent surgical intervention are required for the survival of these patients.
Editorial
fasciitis with often fatal outcome. We have just lost a 64-year-old male suffering necrotizing fasciitis of his right arm, right shoulder and upper chest albeit aggressive serial radical debridements due to a candida albicans sepsis after fourteen days of broad spectrum antibiotic treatment. In 1982, Mathes and Nahai introduced the reconstructive ladder in plastic reconstructive surgery to address tissue defects w2x. The reconstructive ladder starts with primary and secondary closure of wounds followed by autologous skin grafting. Regional and local pedicled flaps, tissue expansion and free tissue transfer are further steps. Usually, autologous skin grafting as a second step on the reconstructive ladder is applied subsequent to debridement for defect coverage in necrotizing faciitis w3x. In contrast, free flaps at the top of the reconstructive ladder are quite rare as a defect closure. In 2006, a latissimus dorsi free flap was used for pleural reconstruction and chest wall stabilization in a patient suffering necrotizing fasciitis following a perforating thoracic wound w4x. A rectus muscle free flap was used in 2002 to cover a hand defect following necrotizing fasciitis in combination with hyperbaric oxygenation therapy w5x. Thus, the aforementioned case study by Dr. Birnbaum is unique for both, the location and the type of coverage, e.g. a latissimus dorsi free flap.
485
Best Evidence Topic Nomenclature Historical Pages Brief Case Report Communication
