Necrotizing Fasciitis of the Thigh as Unusual Colonoscopic Polypectomy Complication: Review of the Literature with Case Presentation

Necrotizing fasciitis (NF) is an infection characterized by necrosis of the superficial muscle fascia and surrounding soft tissues. It usually occurs following skin breaches from penetrating traumas or high-degree burns. Less frequently, it could be related to major abdominal surgery. However, no cases of thigh NF after minor abdominal procedures have ever been reported. A previously healthy 59-year-old male patient underwent a colonoscopic polypectomy. After the procedure, the patient developed an increasing right groin pain. The CT scan showed a gas collection in the right retroperitoneum space and in the right thigh soft tissues. Thus, a right colon perforation was hypothesized, and the patient was moved to the nearest surgery department and underwent a right hemicolectomy procedure. During surgery, the right thigh was also incised and drained, with gas and pus leakage. Nevertheless, the right lower limb continued to swell, and signs of systemic infection appeared. Afterward, clinical conditions continued to worsen despite the drainage of the thigh and antibiotic therapy, and the patient died of septic shock after just two days. This case shows that, although rare, lower limb NF should be considered among the causes of early post-operative local painful symptoms.

Rapidly Spreading Deep Dissecting Hematoma Occurring One Month After A Minor Trauma: A Case Report.

Background: Deep dissecting hematoma (DDH) is a rapidly extending blood collection that splits the hypodermis from muscle fascia, constituting a medical surgical emergency. The natural history of this condition includes trauma (even minor physical injury) shortly before onset of the lesion, occurring in a patient with advanced dermatoporosis. A delay of several weeks between the appearance of a superficial haematoma following a minor trauma and its sudden decompensation into a rapidly spreading DDH has been scarcely mentioned in the medical literature. Case presentation: We report the admission of a 70-year-old woman under anticoagulation to the emergency department of our hospital for the sudden appearance of a rapidly evolving hematoma one month after a negligible trauma to the right leg. A complete skin examination revealed clinical signs (spontaneous superficial skin haematomas, lacerations, wrinkles, stellate pseudo-scars) of advanced dermatoporosis, especially on the forearms. The initial biological testing disclosed an International Normalized Ratio of 3.15. The clinical aspect of the haematoma, its rapid extension and the cutaneous signs of dermatoporosis on the forearms allowed the diagnosis of DDH. Bedside ultrasound examination was used to eliminate differential or additional diagnoses and to assess the main features of the hematoma (dimensions, existence of blood supply). Due the extent of the lesion and the risk of extended skin necrosis, surgical debridement and hematoma drainage were performed. The operative report confirmed the diagnosis of DDH. Wound healing was obtained spontaneously after three months. Conclusion: DDH is the most serious complication of dermatoporosis. Given its rapid horizontal extension and the risk of skin necrosis it induces, DDH is a medical-surgical emergency and must be diagnosed early. This observation emphasises that in patients with severe dermatoporosis, on the occasion of a Vitamin K Antagonist overdose, a limb-threatening DDH can develop suddenly, even several weeks after a minor impact.

Rapidly Evolving Deep Dissecting Hematoma With Sudden Onset, Developed One Month After A Minimal Trauma.

Background: Deep dissecting hematoma is a rapidly extending blood collection that splits the hypodermis from muscle fascia, constituting a medical surgical emergency. The natural history of this condition includes trauma (even minor physical injury) shortly before onset of the lesion, occurring in a patient with advanced dermatoporosis. Case presentation: We report the admission of a 70-year-old woman to the emergency department of our hospital for the onset of a deep dissecting hematoma one month after a negligible trauma in the right leg, complicating secondary iatrogenic dermatoporosis. Bedside ultrasound examination was used to eliminate differential or additional diagnoses and to assess the main features of the hematoma (dimensions, existence of blood supply). Surgical debridement and hematoma drainage were performed due to rapid horizontal extension of the hematoma and unresolved pain, with the operative report confirming the diagnosis. Conclusion: This observation emphasises that in patients with severe dermatoporosis, several weeks can elapse between a minor impact and the sudden development of a limb-threatening deep dissecting hematoma.

Autologous fascial slings remain viable at long-term follow-up: a post cystectomy case report

Background Autologous fascial slings (AFS) have been used for a very long time in the treatment of female stress urinary incontinence, but the introduction of synthetic mesh slings placed either retropubicallyor trans-obturator has decreased the need to harvest the autologous rectus muscle fascia, thus reducing invasiveness and operative time. However AFS are still indicated in complicated cases and re-interventions, and the FDA has underlined safety concerns over the use of surgical meshes for the transvaginal repair of prolapsed pelvic organs. Case presentation A 76-year-old woman with muscle-invasivebladder cancer underwent radical cystectomy 16 years after retropubic positioning of an autologous rectus muscle fascial sling for SUI, with complete symptom resolution. The sling was easily identified and removed en bloc with the bladder and urethra, providing an opportunity to histologicallyevaluate the autologous fascial graft after its long permanence in the new position. Histopathological examination demonstrated increased fibroblastic proliferation and formation of capillaries. A slight separation and an increased waviness of the connective fibers were both evident. An increased vascularity was also apparent, including transverse vessels, with clusters of vessels. A relative inflammatory reaction was present in over 300 cells/10 HPF. All these characteristics indicated viable connective tissue. Conclusions AFS remain a valuable surgical option for both primary and recurrent SUI in women, showing high cure rates and low complications in the long-term. The present case, to the best of our knowledge, presents the longest follow-up period of an autologous rectus muscle fascia placed retropubically and its histological evaluation documents characteristics which support its mechanical strength and viability.