Ann Thorac Surg 2008;86:1973-1974. doi:10.1016/j.athoracsur.2008.05.004
© 2008 The Society of Thoracic Surgeons
Case Reports
Novel Aeration Technique for Necrotizing Fasciitis of the Chest Wall
Igor E. Konstantinov, MD, PhD*,
Pankaj Saxena, MCh, DNB,
Jaffar Shehatha, FRACS,
Andrew Mitchell, FRACS,
Sam Cherian, MBBS
Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, University of Western Australia, Perth, Australia
Accepted for publication May 5, 2008.
* Address correspondence to Dr Konstantinov, University of Western Australia, Nedlands, WA 6009, Australia (Email: konstantinov.igor{at}alumni.mayo.edu).
 |
Abstract
|
|---|
Necrotizing fasciitis of the chest wall is rare and associated with high mortality. Herein we present a patient with necrotizing fasciitis who was managed successfully with aggressive surgical debridement combined with an aeration system that provided effective aeration and drainage of the infected tissues.
|
Introduction
|
|---|
Necrotizing fasciitis (NF) of the chest wall is a rare, but highly lethal condition. It is associated with 59% to 89% mortality, despite aggressive surgical debridement [1–5]. We present a patient with NF who was managed successfully using a novel aeration technique.
A 43-year-old man, who is an intravenous amphetamine abuser, presented to the emergency department with a 2-day history of fever, chills, and rapidly enlarging painful swelling in the left pectoral area. He was hepatitis C positive. There was extensive soft tissue crepitus over the left pectoral area and sternum.
Chest x-ray demonstrated two 2-cm long needles in the chest wall. Computed tomographic (CT) scan demonstrated air in the subcutaneous tissues, spreading below the fascia of both pectoralis major muscles, a needle in the left pectoralis major muscle, and a second needle underneath the fascia of the sixth intercostal muscle. White blood cell count was 16.2 x 109/L. The pus was drained in the emergency department through two small incisions, one placed over the sternum, and the other adjacent to the left nipple. Culture demonstrated abundant growth of mixed anaerobic bacteria and Streptococcus constellatus (formerly Streptococcus milleri group). Intravenous ciprofloxacin, flucloxacillin, fluconazole, and metronidazole were commenced. An attempt to remove the needles failed, and the patient was referred to the cardiothoracic surgeon.
Emergency surgery was performed through a bilateral subpectoral incision (Fig 1A). Necrotic subcutaneous tissues including the lower half of the left pectoralis major muscle were excised and both needles were removed. The necrotic portion of the sixth external intercostal muscle and its fascia were resected. The wound was irrigated with normal saline and hydrogen peroxide. An aeration system designed by one of us (IEK) was placed. It consisted of five 36-French tubes with multiple holes. Two tubes were placed below the pectoralis major muscles and passed through the skin and crossed above the manubrium sterni, and the other two were placed above the pectoralis major muscles. All tubes were connected to -10 kPa of suction. The fifth tube was placed across the chest underneath the subcutaneous tissues. This provided good drainage and aeration of the wound. In addition, two smaller caliber drains were placed underneath the pectoralis minor muscles bilaterally. The subcutaneous tissues were loosely approximated (Fig 1). The patient was ventilated, and the wound was re-explored the following day. A part of the left pectoralis major muscle was found to be necrotic and was debrided further. The ends of four tubes were shortened to allow skin closure above them. The fifth tube was removed from the subcutaneous tissues. A small incision adjacent to the left nipple was left open and packed loosely to permit some aeration of the area. The patient was extubated on postoperative day 2. On postoperative day 7, all drains were removed and the patient was discharged home with a vacuum-assisted closure system (KCI Inc, San Antonio, TX) that was placed in the remaining 4-cm long wound adjacent to the left nipple. The patient is asymptomatic at 1 month after surgery, and the wound healed well.
View larger version (42K):
[in this window]
[in a new window]
|
Fig 1. (A) Intraoperative photograph demonstrating extent of the incision and aeration system. (B) Schematic drawing illustrating tube placement for aeration and drainage.
|
|
|
Comment
|
|---|
Although NF of the chest wall is rare, it is associated with high mortality [1–5]. Mortality of NF of the chest was 89% in a series of 9 patients [2], 77% in a slightly larger series of 13 patients [3], and 59% in the most recent cumulative review of 17 patients [4]. Early diagnosis and surgery with extensive debridement is a key to successful outcome [3–5]. Despite aggressive surgical management, the outcome is often frustrating due to a rampant spread of anaerobic infection. Proper aeration of infected tissues is of critical importance in NF. Hyperbaric oxygen therapy reduces mortality and the need for debridement [5]. However, management of a ventilated patient in a hyperbaric chamber is difficult, and hyperbaric oxygenation is not available in many institutions [1, 5].
Hydrolytic enzymes, such as deoxyribonuclease and chondroitin sulfatase, present in Streptococcus constellatus were most likely responsible for rapid spread of anaerobic infection in our patient and extensive soft tissue necrosis.
A simple aeration system described herein provided thorough drainage and aeration of the infected tissues in our patient. The administration of hyperbaric oxygen, along with an aggressive surgical debridement and the use of broad spectrum antibiotics is quite effective in patients with NF. The described technique of aeration and drainage may be useful in critically ill patients in institutions where the hyperbaric oxygen chamber is not available.
|
References
|
|---|
- Losanoff JE, Jones JW, Richman BW. Necrotising soft tissue infection of the chest wall Ann Thorac Surg 2002;73:304-306.[Abstract/Free Full Text]
- Urschel JD, Takita H, Antkowiak JG. Necrotizing soft tissue infections of the chest wall Ann Thorac Surg 1997;64:276-279.[Abstract/Free Full Text]
- Safran DB, Sullivan WG. Necrotizing fasciitis of the chest wall Ann Thorac Surg 2001;72:1362-1364.[Abstract/Free Full Text]
- Praba-Egge AD, Lanning D, Broderick TJ, Yelon JA. Necrotizing fasciitis of the chest and abdominal wall arising from an empyema J Trauma 2004;56:1356-1361.[Medline]
- Riseman JF, Zamboni WA, Curtis A, et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements Surgery 1990;108:847-850.[Medline]
This article has been cited by other articles:
|
|
|
|
 
D. J. Birnbaum, X. B. D'Journo, D. Casanova, and P. A. Thomas
Necrotizing fasciitis of the chest wall
Interact CardioVasc Thorac Surg,
March 1, 2010;
10(3):
483 - 484.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
