LAUSR

Right-sided colorectal cancers typically present with unexplained weight loss and anaemia. In the advanced stages, a perforated caecal cancer can rarely present as necrotizing fasciitis (NF). Anterior abdominal wall NF due to perforated colorectal cancer has only been reported twice in the literature. This report describes the surgical management of a perforated caecal carcinoma, presenting as anterior abdominal wall NF. A 61-year-old female presented to the emergency department with a 2-day history of abdominal pain and confusion. She was morbidly obese but otherwise her medical history was unremarkable. Physical examination revealed cellulitis of the lower abdomen and pannus, with a necrotic area (Fig. 1). She was hypothermic (34.5 C), tachycardic (115 bpm), hypotensive (95/60 mmHg) and tachypnoeic (32 breaths/min). Laboratory findings showed anaemia (haemoglobin 106 g/L), leucocytosis (36.6 × 10/L) and metabolic acidosis on venous blood gas (pH 7.31H, pCO2 35 mmHg, pO2 32 mmHg and bicarbonate 17 mmol/L). Resuscitation and empiric broad-spectrum antibiotics (vancomycin, clindamycin and meropenem) were initiated. Computed tomography (CT) demonstrated a perforated mass arising from the caecum, eroding through the inferior anterior abdominal wall with fluid and gas tracking into the subcutaneous fat. The patient was immediately taken to the operating theatre. A midline laparotomy was performed and a fungating caecal mass was identified, with adhered small bowel loops and an abscess cavity communicating through to the abdominal wall (Fig. 2). An ileocolic resection and two en bloc resections of adherent small bowel loops were performed. Due to high inotropic requirements (25 μg/min of noradrenalin and 0.02 units/h of vasopressin), anastomosis was not performed. Contaminated intra-abdominal tissues and abscess cavity were debrided. The abdominal wall was debrided via a separate transverse lower abdominal approach. Negative pressure foam dressings were applied to both wounds and the patient was transferred to the intensive care unit. Forty-eight hours later, noradrenalin requirements had reduced to 5 μg/min. A re-look laparotomy and oncological resection were performed. This was achieved with a formal right hemicolectomy and high ligation of the ileocolic and middle colic vessels. Intestinal continuity was achieved with two small bowel anastomoses and the patient was not defunctioned. The intra-abdominal abscess cavity was further debrided and closed internally, and the abdominal wall was further debrided. The midline laparotomy was primarily closed and a negative pressure dressing was re-applied to the lower transverse abdominal wound. Forty-eight hours later, the transverse abdominal wound was further debrided and primarily closed with fascia and muscle to the inguinal ligament and closure of skin over two penrose drains. Six weeks later, a negative pressure dressing was applied to a small area of superficial wound dehiscence (Fig. 3).