Cascade of Surgical Complications: A Case of Necrotizing Fasciitis

Abstract

A 60 year old female presented with abdominal distension and non-specific abdominal pain and describes herself to have a ‘lazy bowel’, with a complicated surgery history. Patient subsequently underwent an emergency laparotomy for multiple small bowel perforations, requiring small bowel resection. The patient developed necrotizing fasciitis (NF) due to an increased use of inotropes during surgery which causes excessive vasoconstriction, and she had a major portion of the abdominal flab removed. This followed by a 33 day ITU admission (level 3) due to septic shock and poor pulmonary compliance. During the ITU stay, the patient was taken back into theatre 14 times for vac dressing changes to reduce the pressure from 150 mmHg down to 25 mmHg. Back in the surgery ward, the patient developed a fistula due to the vac dressing eroding the small bowel, leading to a proximal jejunostomy in situ which effectively worked as a high output stoma. The patient later suffered from re-feeding syndrome as the feed was primarily through the jejunostomy. Eventually absorbable mesh was added behind the vac dressing to protect the soft tissue underneath and the final stage was referral to plastic surgeons that would a joint reconstruction of the abdominal wall with the general surgeons at St Marks (tertiary centre for intestinal feeding and the combined reconstruction).