Abdominal Wall and limb necrotizing fasciitis: an extremely rare post -operative complication

Abdominal Wall and limb necrotizing fasciitis: an extremely rare post -operative complication | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Abdominal Wall and limb necrotizing fasciitis: an extremely rare post -operative complication Saida Sakhri, Ons Krimi, Nayssem Khessairi, Fethia Abidi, Maher Slimane, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3767300/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Introduction: Infectious affections are the most frequent post-operative complications, the rates have been reducing due to the administration of perioperative antibiotics and they are rarely serious. They are usually associated to pelvic collections, fistulas, urinary tract stenosis and, exceptionally, necrotizing fasciitis (FN) and pelvic organ necrosis [1].There is no well-codified therapeutic consensus,. An urgent care of pelvic necrosis requires surgical debridement of necrotic tissues with a broad-spectrum antibiotic. Case presentation: A 42-year-old female patient, was referred to our department for a stage IIIC2 adenocarcinoma of the uterine cervix. She underwent chemo-radiation followed by a colpo-hysterectomy . Two months after surgery, the patient presented with recto-vaginal fistula associated with a pelvic collection. Abdominal CT scan revealed a recto-vaginal fistula fed by a 5cm pelvic collection originating from the uterine cavity. The patient was treated with antibiotics and then underwent a surgical evacuation of the collection and a bypass colostomy. The post-operative period was marked by the occurrence of an extensive necrosis to pelvic organs, namely the bladder and the anterior wall of the rectum which extended to the anterior and medial left leg’s thigh compartments muscles. She also presented a thrombosis of the left external iliac vein and artery, with necrosis of their vascular walls. Given the septic conditions, a revascularization procedure was not feasible. A bilateral ureterostomy was required, as well as ligature of the left external iliac vessels. The patient underwent post-surgical palliative treatment, and she died one month after surgery of multivisceral failure due to sepsis. Conclusion: Necrotizing fasciitis is a rare, but extremely serious condition, with a mortality rate of up to 30%. The prognosis can be improved with rapid management and appropriate medical and surgical treatment including large excisions of necrotic tissue, and antibiotic therapy adapted to the suspected germs, essentially anaerobic ones. Cervical cancer Radiotherapy complications Surgery Necrotizing fasciitis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION Infectious affections are the most frequent post-operative complications, the rates have been reducing due to the administration of perioperative antibiotics and they are rarely serious. They are usually associated to pelvic collections, fistulas, urinary tract stenosis and, exceptionally, necrotizing fasciitis (NF) and pelvic organ necrosis [ 1 ]. The term necrotizing fasciitis units’ different syndromes of progressive gangrenous infection of the skin and subcutaneous tissue and fascia. it is a rare and rapidly progressive infection that can be associated to thrombosis due to necrosis, muscles’ destruction, and liquefaction of fats [ 2 ][ 3 ]. There is no well-codified therapeutic consensus, Treatment must be individualized according to the patient’s morbidities and particularities of each case. An urgent care of pelvic necrosis requires surgical debridement of necrotic tissues with a broad-spectrum antibiotic. Case presentation We report the case of 42-year-old woman with no personal or familial history ,and no medical comorbidities, who was referred to our department for a stage IIIC2 adenocarcinoma of the uterine cervix. She underwent four courses of chemotherapy based on cisplatine combined with pelvic radiotherapy at a dose of 45 Gy, complicated by post radiation rectitis and cystitis. She did not receive brachytherapy for being beyond the deadline. Evaluating pelvic MRI showed a good therapeutic response associating tumor size regression (32mm VS 40mm), disappearance of parametrial involvement and lymph node invasion. The patient underwent colpo-hysterectomy. The immediate postoperative course was uneventful, and the patient returns home four days after surgery. Final histological examination concluded to a 10mm remnant of a cervical HPV positive adenocarcinoma. Surgical limits and parameters were free of tumor. The multidisciplinary committee of our institute did not indicate any adjuvant therapy. Two months after surgery, the patient presented to the emergency department with fever (39°), pelvic pain, and painful mobilization of the left lower limb. The patient did not have any primary or acquired immunodeficiency. An abdominal CT scan revealed a recto-vaginal fistula fed by a 5 cm pelvic collection originating from the uterine cavity. She was admitted and treated with antibiotics and then underwent surgical evacuation of the collection and a bypass colostomy. The initial progression was favorable, but within two weeks, the patient presented a rise of temperature with swelling and recurrence of pain on mobilization of the left lower limb. Clinical examination finded a swollen, edema, hot skin and “crackling snow crepitus” among the left lower limb. No bullae or other skin signs predicting necrosis were appreciable. An urgent CT scan of the chest, abdomen, and pelvis showed a 10 cm pelvic collection lateralized to the left and fistulated into the bladder and rectum. It also showed intramuscular collections, pan-diaphyseal air bubbles of the left femur with a myositis-like appearance of the gluteal muscles, anterior and medial thigh compartments, and left leg muscles, suggestive of an infectious origin. Thrombosis of the left external iliac artery and left femoral vein were additionally noted ( Fig. 1 + 2 + 3) . The patient was then re-operated; the intraoperative exploration found an extensive necrosis to pelvic organs namely the bladder and the anterior wall of the rectum which extended to the anterior and medial thigh compartments muscles of the left leg. We also noted a thrombosis of the left external iliac vein and artery, with necrosis of their vascular walls ( Fig. 4 + 5). Given the septic conditions, a revascularization procedure was not feasible. A bilateral ureterostomy was required, as well as ligature of the left external iliac vessels. Necrotic tissue of the left lower limb was also effectively excised and revived. The evolution was marked by left lower limb loss of functionality, despite the development of collateral circulation. The patient underwent post-surgical palliative treatment, and she died one month after surgery of multivisceral failure due to sepsis. DISCUSSION The term of Necrotizing fasciitis was firstly described by Jones in 1871 and it was firstly defined as hospital gangrene, other authors grouped this clinical entity in a single category of progressive necrotizing infections. It is a rare and rapidly progressive gangrenous infections of the skin and subcutaneous tissue. Usually associated with thrombosis due to the necrosis of skin and soft tissue, and destruction of muscles [ 2 ]. After that in 1952 Wilson used this term, and suspected, etiologic factors like surgical treatment [ 2 ], chemotherapy and radiotherapy which presents the established treatment for locally advanced cervical cancer, and can rarely induce necrosis of pelvic organs. The necrosis can be explained by cellular depletion, epithelial atrophy as well as hypo vascularization causing tissue hypoxia and micro-ulcers that can lead to fistulae development, and makes the area susceptible to infection, pelvic collections, and necrosis few months after radiotherapy [ 4 , 5 , 6 ]. Nakano et al. reported an incidence of late complications of pelvic radiation in the urinary tract as 18% in 1148 patients treated with exclusive pelvic radiotherapy. According to this study, toxicity depends on the radiation dose, treatment volume, tumor extension and tissue health within the target area [ 6 ]. This hypothesis seems to be more acceptable for our case, in fact the patients received neoadjuvant treatment that contributed to rectovaginal, and vesico-vaginal fistulas, as well as post-operative collections and abscesses, and finally necrotizing fasciitis. Classic clinical presentation involving the triad of fever, abdominal or spinal pain and painful limitation of lower limb’s movements is present in only 35% of cases; and necrotizing fasciitis is masked in 85% by abscess or cellulitis, which explains the frequently delayed care [ 7 ]. The skin appeared swollen and decolorated and a sense of crackling snow suggests the presence of subcutaneous gas. The progression is marked by the development of tense edema, necrosis, and crepitus that are major signs of necrosis. However, hemorrhagic bullae and crepitus are sinister signs, with the likelihood of underlying fascia and muscle being compromised [ 8 ]. Without treatment and in some times, despite administration of intravenous antibiotics, the progression of the disease among the tissues continues and severe general symptoms occur like tachycardia, fever, altered mental state, and diabetic ketoacidosis [ 7 ]. CT imaging is a helpful tool in distinguishing NIF from other infections of the soft tissues such as cellulitis, soft tissues abscess and osteomyelitis that require different management [ 8 ]. It demonstrates skin thickening, septation of the subcutaneous fat, and thickening of the underlying superficial fascia. The literature shows evidence that when necrosisis occurs the CT scan shows a lack of the enhancement of the fascia as well as thickening of the skin and underlying superficial fascia. MRI has no place on first intention ,it can be useful to evaluate the exact extension of the infection to the surrounding organs and to distinguish mild fascial or muscle involvement [ 8 ]. In the present case rectal fistula caused intra-abdominal infection which spread from abdominal wall to the limb by contiguity, invading soft tissues (basically along the psoas muscle) or through pelvic orifices (inguinal canal, obturator foramen). The involvement of the limb's deep fascia is rapidly progressive, potentially leading to necrosis of adjacent tissues: necrotizing fasciitis. These complication may require sacrifice of the limb and can be fatal even after adequate management. Treatment usually involves extensive excision of necrotic and inflammatory tissues, combined with broad-spectrum antibiotic therapy, the mortality of untreated cases may reach 100% [ 9 , 10 ]. Iliac vessel thrombosis is a rare complication of FN, it may due to tumor mass effect or to the infection. It has no specific signs. CT scan confirm the diagnosis and assessing the extent of lesions [ 4 ]. The venous and arterial thromboses observed in our patient's case can be explained by venous stasis due to vascular compression by the voluminous collection, endothelial lesions engendered by the inflammatory and septic environment, and post-radiation fibrosis phenomena altering the vascularization of the pelvic organs, leading to necrosis of the vascular walls and bladder. In our case the bladder necrosis can be explicated by radiotherapy which caused fistula and spread to FN. In the literature post-radiation the necrosis of the bladder has been described in few studies. Marnitz et al described a case of uterine necrosis after radiotherapy and chemotherapy for cervical cancer and a case of uterine and bladder necrosis requiring anterior exenteration [ 11 ]. Micha et al described a case of extensive pelvic necrosis in a patient treated for cervical cancer and surgery followed by radio-chemotherapy requiring multiple and repeated surgery over 15 years [ 12 ]. Also, Sanna et al. described a case of extensive pelvic necrosis after chemoradiotherapy for locally advanced cervical cancer [ 13 ]. If FN affects the extremities, amputations are required. However, if it affects intra-abdominal organs an early recognition aggressive surgical debridement of necrotic and non-viable tissue is needed and should be urgently done if the diagnosis of necrosis is strongly suspected on clinical examination and on radiological findings. An optimal timing for the debridement is within six hours after the onset of clinical symptoms, and the treatment delay significantly influences patient’s survival. The nature of the surgery depends on the extension of necrosis [ 8 ]. Initial administration of intravenous broad-spectrum antibiotics coverage should be started before surgery and should cover pyogenes, aureus, and Gram-negative aerobes and anaerobes. Also anticoagulation in case of thrombosis should be maintained for at least three months [ 2 ]. Bladder necrosis was a real therapeutic challenge: only one case of complete recovery from subtotal bladder necrosis has been reported in the literature, requiring repeated cystoscopy to excise the necrotic tissue [ 14 ]. To achieve this, there must be partial necrosis of the bladder mucosa, sparing the detrusor, to allow regeneration of the mucosa. otherwise, bladder reconstruction is the only alternative, which was not feasible for our patient given the septic conditions and fragility of the bladder wall post radiation [ 15 ]. Hyperbaric oxygen has also been used as an adjunct to surgery and antibiotics helping to heal and regenerate tissues after debridement, improve vascularization and reduce bacterial colonization [ 8 ] [ 15 ]. The rapid progression of necrosis explains the poor prognosis of the disease, for that there is a slim chance of complete debridement, mostly surgery is limited by septic shock and organ failure that can rapidly lead to death particularly in untreated patients [ 8 ] Mortality in these cases is between 50% and 80%, Without surgical intervention, mortality approaches 100% depending on the morbidity factors such as renal insufficiency, respiratory distress syndrome and multiorgan failure also on the rapidity of surgical incision. In the literature it was demonstrated that a delay to surgery more than 24 hours was an independent risk factor for mortality. CONCLUSION The diagnosis of FN is clinical and radiological, CT scan is helpful for the diagnosis and for distinguishing FN from non NIF infections. There are predisposing factors such as diabetes, neoadjuvant radiotherapy or chemotherapy. The emergency is to distinguish NIF from non-necrotizing fasciitis and from other musculoskeletal infections and to evaluate the extension of the disease. The standard treatment is based on early recognition, large surgical debridement of necrotic and nonviable tissue when necrosis is strongly suspected on clinical examination and on radiological findings. LIST OF ABREVIATIONS FN : necrotizing fasciitis CT : Computed tomography Declarations Ethics approval and consent to participate The authors declare no conflicts of interest, and that this work was done with all due respect to the code of ethics under the supervision of the medical and ethics committee of the Salah Azaiez Institute. Consent for publication Written informed consent was obtained from the patient’s parents/legal guardian to publish this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of supporting data Data supporting our findings were taken from the patient’s folders. Availability of Data and Materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No source of funding. Authors’ contributions Saida Sakhri: Data acquisition, literature review, conception drafting and preparing the manuscript Maher Slimane : Data acquisition, preparing and editing the manuscript Hanene Bouaziz: Data acquisition, preparing and editing the manuscript Nayssem Khessairi and Ons Krimi : Literature review, drafting and editing the manuscript Fethia Abidi : Data acquisition and preparing figures Tarek Ben Dhiab: Drafting and revising the manuscript critically Acknowledgements Not applicable References Dem A, Kasse AA, Diop M, Fall-Gaye MC, Diop PS, Dotou C, et al. [Complications of colpohysterectomy with lymph node dissection in the cervix carcinoma at the Cancer Institute of Dakar: report of 412 cases]. Dakar Med. 2001;46(1):39–42. Necrotizing Fasciitis of the Abdominal Wall as a Post-Surgical Complication. : A Case Report [Internet]. [cité 3 sept 2023]. Disponible sur: https://www.hmpgloballearningnetwork.com/site/wounds/article/4418 . Li M, Tian Q. Risk factors for postoperative pelvic floor dysfunction in patients with cervical cancer: evidences for management strategies. Transl Cancer Res oct. 2021;10(10):4338–46. Ben Khalifa B, Naouar S, Lahouar R, Sridi C, Gazzeh W, Salem B et al. Unusual presentation of extended iliofemoral deep vein thrombosis caused by giant retroperitoneal abscess: a rare case report. Ann Med Surg. 27 mars. 2023;85(5):1870–3. Ijaz M, Sakam S, Ashraf U, Marquez JG. Unusual Presentation of Recurrent Pyogenic Bilateral Psoas Abscess Causing Bilateral Pulmonary Embolism by Iliac Vein Compression. Am J Case Rep 10 sept. 2015;16:606–10. Nakano T, Ohno T, Ishikawa H, Suzuki Y, Takahashi T. Current Advancement in Radiation Therapy for Uterine Cervical Cancer. J Radiat Res (Tokyo) janv. 2010;51(1):1–8. Carbonetti F, Cremona A, Guidi M, Carusi V. A Case of Postsurgical Necrotizing Fasciitis Invading the Rectus Abdominis Muscle and Review of the Literature. Case Rep Med. 2014;2014:479057. Carbonetti F, Cremona A, Guidi M, Carusi V. A case of postsurgical necrotizing fasciitis invading the rectus abdominis muscle and review of the literature. Case Rep Med. 2014;2014:479057. An image case of necrotising. fasciitis: a severe postoperative complication | BMJ Case Reports [Internet]. [cité 9 août 2023]. Disponible sur: https://casereports.bmj.com/content/2013/bcr-2012-008247 . Necrotizing Fasciitis of the Abdominal Wall as a Post-Surgical Complication. : A Case Report [Internet]. [cité 9 août 2023]. Disponible sur: https://www.hmpgloballearningnetwork.com/site/wounds/article/4418 . Marnitz S, Köhler C, Füller J, Hinkelbein W, Schneider A. Uterus Necrosis after Radiochemotherapy in Two Patients with Advanced Cervical Cancer. Strahlenther Onkol 1 janv. 2006;182(1):45–51. Micha JP, Goldstein BH, Rettenmaier MA, Caillouette JT, Fee MJ, Brown JV. Pelvic radiation necrosis and osteomyelitis following chemoradiation for advanced stage vulvar and cervical carcinoma. Gynecol Oncol 1 mai. 2006;101(2):349–52. Sanna E, Chiappe G, Lavra F, Nemolato S, Oppi S, Macciò A, et al. Diagnostic Framework of Pelvic Massive Necrosis with Peritonitis following Chemoradiation for Locally Advanced Cervical Cancer: When Is the Surgery Not Demandable? A Case Report and Literature Review. Diagnostics févr. 2022;12(2):440. Subtotal vesical necrosis as. a result of infected traumatic bladder hematoma: A rare case with a literature review of bladder necrosis due to hematoma - PMC [Internet]. [cité 9 août 2023]. Disponible sur: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343294/ . Pandey A, Beier J, Dobkowicz L, Wolf S, Keller H. Extensive necrosis of the bladder with hypostatic abscess: a late complication after radiotherapy. Onkologie. 2010;33(3):116–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Jan, 2024 Reviews received at journal 25 Jan, 2024 Reviews received at journal 20 Jan, 2024 Reviews received at journal 13 Jan, 2024 Reviewers agreed at journal 13 Jan, 2024 Reviewers agreed at journal 10 Jan, 2024 Reviewers agreed at journal 10 Jan, 2024 Reviewers invited by journal 10 Jan, 2024 Editor assigned by journal 10 Jan, 2024 Editor invited by journal 30 Dec, 2023 Submission checks completed at journal 30 Dec, 2023 First submitted to journal 17 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3767300","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":264556437,"identity":"4f64b2d3-0c0a-49fb-8ab5-fba8dfd5f1f4","order_by":0,"name":"Saida 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and excretory (b) phase: rupture of the bladder wall (arrow)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3767300/v1/74c3f0db291e83fd5a7afba2.png"},{"id":49137756,"identity":"3923c700-7d2b-44c9-8ecc-563806d03c03","added_by":"auto","created_at":"2024-01-03 17:37:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":167986,"visible":true,"origin":"","legend":"\u003cp\u003eAxial CT section injected in the abdominal and bone window showing thrombosis of the superficial femoral artery seat of air bubble (long arrow) and intramuscular collection seat of air bubble (short arrow)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3767300/v1/d7f4ee1a212f7d6dd8c9682c.png"},{"id":49137755,"identity":"6047fe68-016f-4383-b239-f2091dcd218a","added_by":"auto","created_at":"2024-01-03 17:37:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":437381,"visible":true,"origin":"","legend":"\u003cp\u003eOblique Coronal reconstruction in the bone window (a) and oblique coronal along the femoral artery reconstrccion (b): pan-diaphyseal air bubble of the left femoral diaphysis (long arrow) thrombosis of the artery superficial femoral (short arrow)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3767300/v1/c446a0994d6c3c016a0364b7.png"},{"id":49137754,"identity":"13053deb-88d3-455b-aa4c-2918ceb6907c","added_by":"auto","created_at":"2024-01-03 17:37:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1106703,"visible":true,"origin":"","legend":"\u003cp\u003e(a) operative imaging showing an extensive necrosis to the bladder and the anterior wall of the rectum . (b) extensive necrosis to pelvic organs and the psoas muscle (short arrow). Thrombosis of the left external iliac vein and artery, with necrosis of their vascular walls (long arrow)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3767300/v1/dd1a516e4d9489e4397fd589.png"},{"id":49137753,"identity":"66a3efd6-684c-4dc1-a41d-6c9a6a0dadf4","added_by":"auto","created_at":"2024-01-03 17:37:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":621435,"visible":true,"origin":"","legend":"\u003cp\u003eper-operative imaging showing an extensive necrosis to the anterior and medial thigh compartments muscles of the left leg.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3767300/v1/127a9d0b8f7faeda6ea24322.png"},{"id":49138240,"identity":"68f5bf3c-7a76-4160-a8f9-f8544368a14a","added_by":"auto","created_at":"2024-01-03 17:45:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3005470,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3767300/v1/9f80eedb-9ae0-4311-8ac6-fb9a0839bbed.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Abdominal Wall and limb necrotizing fasciitis: an extremely rare post -operative complication","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eInfectious affections are the most frequent post-operative complications, the rates have been reducing due to the administration of perioperative antibiotics and they are rarely serious. They are usually associated to pelvic collections, fistulas, urinary tract stenosis and, exceptionally, necrotizing fasciitis (NF) and pelvic organ necrosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The term necrotizing fasciitis units\u0026rsquo; different syndromes of progressive gangrenous infection of the skin and subcutaneous tissue and fascia. it is a rare and rapidly progressive infection that can be associated to thrombosis due to necrosis, muscles\u0026rsquo; destruction, and liquefaction of fats [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is no well-codified therapeutic consensus, Treatment must be individualized according to the patient\u0026rsquo;s morbidities and particularities of each case. An urgent care of pelvic necrosis requires surgical debridement of necrotic tissues with a broad-spectrum antibiotic.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eWe report the case of 42-year-old woman with no personal or familial history ,and no medical comorbidities, who was referred to our department for a stage IIIC2 adenocarcinoma of the uterine cervix. She underwent four courses of chemotherapy based on cisplatine combined with pelvic radiotherapy at a dose of 45 Gy, complicated by post radiation rectitis and cystitis. She did not receive brachytherapy for being beyond the deadline. Evaluating pelvic MRI showed a good therapeutic response associating tumor size regression (32mm VS 40mm), disappearance of parametrial involvement and lymph node invasion. The patient underwent colpo-hysterectomy. The immediate postoperative course was uneventful, and the patient returns home four days after surgery. Final histological examination concluded to a 10mm remnant of a cervical HPV positive adenocarcinoma. Surgical limits and parameters were free of tumor. The multidisciplinary committee of our institute did not indicate any adjuvant therapy. Two months after surgery, the patient presented to the emergency department with fever (39\u0026deg;), pelvic pain, and painful mobilization of the left lower limb. The patient did not have any primary or acquired immunodeficiency. An abdominal CT scan revealed a recto-vaginal fistula fed by a 5 cm pelvic collection originating from the uterine cavity. She was admitted and treated with antibiotics and then underwent surgical evacuation of the collection and a bypass colostomy.\u003c/p\u003e \u003cp\u003eThe initial progression was favorable, but within two weeks, the patient presented a rise of temperature with swelling and recurrence of pain on mobilization of the left lower limb. Clinical examination finded a swollen, edema, hot skin and \u0026ldquo;crackling snow crepitus\u0026rdquo; among the left lower limb. No bullae or other skin signs predicting necrosis were appreciable. An urgent CT scan of the chest, abdomen, and pelvis showed a 10 cm pelvic collection lateralized to the left and fistulated into the bladder and rectum. It also showed intramuscular collections, pan-diaphyseal air bubbles of the left femur with a myositis-like appearance of the gluteal muscles, anterior and medial thigh compartments, and left leg muscles, suggestive of an infectious origin. Thrombosis of the left external iliac artery and left femoral vein were additionally noted\u003c/p\u003e \u003cp\u003e \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026thinsp;\u003cb\u003e+\u0026thinsp;2\u0026thinsp;+\u0026thinsp;3)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThe patient was then re-operated; the intraoperative exploration found an extensive necrosis to pelvic organs namely the bladder and the anterior wall of the rectum which extended to the anterior and medial thigh compartments muscles of the left leg. We also noted a thrombosis of the left external iliac vein and artery, with necrosis of their vascular walls \u003cb\u003e(\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u0026thinsp;\u003cb\u003e+\u0026thinsp;5).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eGiven the septic conditions, a revascularization procedure was not feasible. A bilateral ureterostomy was required, as well as ligature of the left external iliac vessels. Necrotic tissue of the left lower limb was also effectively excised and revived. The evolution was marked by left lower limb loss of functionality, despite the development of collateral circulation. The patient underwent post-surgical palliative treatment, and she died one month after surgery of multivisceral failure due to sepsis.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe term of Necrotizing fasciitis was firstly described by Jones in 1871 and it was firstly defined as hospital gangrene, other authors grouped this clinical entity in a single category of progressive necrotizing infections. It is a rare and rapidly progressive gangrenous infections of the skin and subcutaneous tissue. Usually associated with thrombosis due to the necrosis of skin and soft tissue, and destruction of muscles [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAfter that in 1952 Wilson used this term, and suspected, etiologic factors like surgical treatment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], chemotherapy and radiotherapy which presents the established treatment for locally advanced cervical cancer, and can rarely induce necrosis of pelvic organs. The necrosis can be explained by cellular depletion, epithelial atrophy as well as hypo vascularization causing tissue hypoxia and micro-ulcers that can lead to fistulae development, and makes the area susceptible to infection, pelvic collections, and necrosis few months after radiotherapy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNakano et al. reported an incidence of late complications of pelvic radiation in the urinary tract as 18% in 1148 patients treated with exclusive pelvic radiotherapy. According to this study, toxicity depends on the radiation dose, treatment volume, tumor extension and tissue health within the target area [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This hypothesis seems to be more acceptable for our case, in fact the patients received neoadjuvant treatment that contributed to rectovaginal, and vesico-vaginal fistulas, as well as post-operative collections and abscesses, and finally necrotizing fasciitis.\u003c/p\u003e \u003cp\u003eClassic clinical presentation involving the triad of fever, abdominal or spinal pain and painful limitation of lower limb\u0026rsquo;s movements is present in only 35% of cases; and necrotizing fasciitis is masked in 85% by abscess or cellulitis, which explains the frequently delayed care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The skin appeared swollen and decolorated and a sense of crackling snow suggests the presence of subcutaneous gas. The progression is marked by the development of tense edema, necrosis, and crepitus that are major signs of necrosis. However, hemorrhagic bullae and crepitus are sinister signs, with the likelihood of underlying fascia and muscle being compromised [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWithout treatment and in some times, despite administration of intravenous antibiotics, the progression of the disease among the tissues continues and severe general symptoms occur like tachycardia, fever, altered mental state, and diabetic ketoacidosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCT imaging is a helpful tool in distinguishing NIF from other infections of the soft tissues such as cellulitis, soft tissues abscess and osteomyelitis that require different management [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It demonstrates skin thickening, septation of the subcutaneous fat, and thickening of the underlying superficial fascia. The literature shows evidence that when necrosisis occurs the CT scan shows a lack of the enhancement of the fascia as well as thickening of the skin and underlying superficial fascia. MRI has no place on first intention ,it can be useful to evaluate the exact extension of the infection to the surrounding organs and to distinguish mild fascial or muscle involvement [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present case rectal fistula caused intra-abdominal infection which spread from abdominal wall to the limb by contiguity, invading soft tissues (basically along the psoas muscle) or through pelvic orifices (inguinal canal, obturator foramen). The involvement of the limb's deep fascia is rapidly progressive, potentially leading to necrosis of adjacent tissues: necrotizing fasciitis. These complication may require sacrifice of the limb and can be fatal even after adequate management. Treatment usually involves extensive excision of necrotic and inflammatory tissues, combined with broad-spectrum antibiotic therapy, the mortality of untreated cases may reach 100% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIliac vessel thrombosis is a rare complication of FN, it may due to tumor mass effect or to the infection. It has no specific signs. CT scan confirm the diagnosis and assessing the extent of lesions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The venous and arterial thromboses observed in our patient's case can be explained by venous stasis due to vascular compression by the voluminous collection, endothelial lesions engendered by the inflammatory and septic environment, and post-radiation fibrosis phenomena altering the vascularization of the pelvic organs, leading to necrosis of the vascular walls and bladder.\u003c/p\u003e \u003cp\u003eIn our case the bladder necrosis can be explicated by radiotherapy which caused fistula and spread to FN. In the literature post-radiation the necrosis of the bladder has been described in few studies.\u003c/p\u003e \u003cp\u003eMarnitz et al described a case of uterine necrosis after radiotherapy and chemotherapy for cervical cancer and a case of uterine and bladder necrosis requiring anterior exenteration [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Micha et al described a case of extensive pelvic necrosis in a patient treated for cervical cancer and surgery followed by radio-chemotherapy requiring multiple and repeated surgery over 15 years [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Also, Sanna et al. described a case of extensive pelvic necrosis after chemoradiotherapy for locally advanced cervical cancer [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIf FN affects the extremities, amputations are required. However, if it affects intra-abdominal organs an early recognition aggressive surgical debridement of necrotic and non-viable tissue is needed and should be urgently done if the diagnosis of necrosis is strongly suspected on clinical examination and on radiological findings. An optimal timing for the debridement is within six hours after the onset of clinical symptoms, and the treatment delay significantly influences patient\u0026rsquo;s survival. The nature of the surgery depends on the extension of necrosis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Initial administration of intravenous broad-spectrum antibiotics coverage should be started before surgery and should cover pyogenes, aureus, and Gram-negative aerobes and anaerobes. Also anticoagulation in case of thrombosis should be maintained for at least three months [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBladder necrosis was a real therapeutic challenge: only one case of complete recovery from subtotal bladder necrosis has been reported in the literature, requiring repeated cystoscopy to excise the necrotic tissue [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. To achieve this, there must be partial necrosis of the bladder mucosa, sparing the detrusor, to allow regeneration of the mucosa. otherwise, bladder reconstruction is the only alternative, which was not feasible for our patient given the septic conditions and fragility of the bladder wall post radiation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Hyperbaric oxygen has also been used as an adjunct to surgery and antibiotics helping to heal and regenerate tissues after debridement, improve vascularization and reduce bacterial colonization [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rapid progression of necrosis explains the poor prognosis of the disease, for that there is a slim chance of complete debridement, mostly surgery is limited by septic shock and organ failure that can rapidly lead to death particularly in untreated patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eMortality in these cases is between 50% and 80%, Without surgical intervention, mortality approaches 100% depending on the morbidity factors such as renal insufficiency, respiratory distress syndrome and multiorgan failure also on the rapidity of surgical incision. In the literature it was demonstrated that a delay to surgery more than 24 hours was an independent risk factor for mortality.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe diagnosis of FN is clinical and radiological, CT scan is helpful for the diagnosis and for distinguishing FN from non NIF infections. There are predisposing factors such as diabetes, neoadjuvant radiotherapy or chemotherapy. The emergency is to distinguish NIF from non-necrotizing fasciitis and from other musculoskeletal infections and to evaluate the extension of the disease. The standard treatment is based on early recognition, large surgical debridement of necrotic and nonviable tissue when necrosis is strongly suspected on clinical examination and on radiological findings.\u003c/p\u003e"},{"header":"LIST OF ABREVIATIONS","content":"\u003cp\u003e\u003cu\u003eFN\u003c/u\u003e:\u0026nbsp;necrotizing fasciitis\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCT\u003c/u\u003e: Computed tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest, and that this work was done with all due respect to the code of ethics under the supervision of the medical and ethics committee of the Salah Azaiez Institute.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026rsquo;s parents/legal guardian to publish this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of supporting data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting our findings were taken from the patient\u0026rsquo;s folders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo source of funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSaida Sakhri: Data acquisition, literature review, conception drafting and preparing the manuscript\u003c/p\u003e\n\u003cp\u003eMaher Slimane : Data acquisition, preparing and editing the manuscript\u003c/p\u003e\n\u003cp\u003eHanene Bouaziz: Data acquisition, preparing and editing the manuscript\u003c/p\u003e\n\u003cp\u003eNayssem Khessairi and Ons Krimi : Literature review, drafting and editing the manuscript\u003c/p\u003e\n\u003cp\u003eFethia Abidi : Data acquisition and preparing figures\u003c/p\u003e\n\u003cp\u003eTarek Ben Dhiab: Drafting and revising the manuscript critically\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDem A, Kasse AA, Diop M, Fall-Gaye MC, Diop PS, Dotou C, et al. [Complications of colpohysterectomy with lymph node dissection in the cervix carcinoma at the Cancer Institute of Dakar: report of 412 cases]. Dakar Med. 2001;46(1):39\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNecrotizing Fasciitis of the Abdominal Wall as a Post-Surgical Complication. : A Case Report [Internet]. [cit\u0026eacute; 3 sept 2023]. Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.hmpgloballearningnetwork.com/site/wounds/article/4418\u003c/span\u003e\u003cspan address=\"https://www.hmpgloballearningnetwork.com/site/wounds/article/4418\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi M, Tian Q. Risk factors for postoperative pelvic floor dysfunction in patients with cervical cancer: evidences for management strategies. Transl Cancer Res oct. 2021;10(10):4338\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBen Khalifa B, Naouar S, Lahouar R, Sridi C, Gazzeh W, Salem B et al. Unusual presentation of extended iliofemoral deep vein thrombosis caused by giant retroperitoneal abscess: a rare case report. Ann Med Surg. 27 mars. 2023;85(5):1870\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIjaz M, Sakam S, Ashraf U, Marquez JG. Unusual Presentation of Recurrent Pyogenic Bilateral Psoas Abscess Causing Bilateral Pulmonary Embolism by Iliac Vein Compression. Am J Case Rep 10 sept. 2015;16:606\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakano T, Ohno T, Ishikawa H, Suzuki Y, Takahashi T. Current Advancement in Radiation Therapy for Uterine Cervical Cancer. J Radiat Res (Tokyo) janv. 2010;51(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarbonetti F, Cremona A, Guidi M, Carusi V. A Case of Postsurgical Necrotizing Fasciitis Invading the Rectus Abdominis Muscle and Review of the Literature. Case Rep Med. 2014;2014:479057.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarbonetti F, Cremona A, Guidi M, Carusi V. A case of postsurgical necrotizing fasciitis invading the rectus abdominis muscle and review of the literature. Case Rep Med. 2014;2014:479057.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAn image case of necrotising. fasciitis: a severe postoperative complication | BMJ Case Reports [Internet]. [cit\u0026eacute; 9 ao\u0026ucirc;t 2023]. Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://casereports.bmj.com/content/2013/bcr-2012-008247\u003c/span\u003e\u003cspan address=\"https://casereports.bmj.com/content/2013/bcr-2012-008247\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNecrotizing Fasciitis of the Abdominal Wall as a Post-Surgical Complication. : A Case Report [Internet]. [cit\u0026eacute; 9 ao\u0026ucirc;t 2023]. Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.hmpgloballearningnetwork.com/site/wounds/article/4418\u003c/span\u003e\u003cspan address=\"https://www.hmpgloballearningnetwork.com/site/wounds/article/4418\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarnitz S, K\u0026ouml;hler C, F\u0026uuml;ller J, Hinkelbein W, Schneider A. Uterus Necrosis after Radiochemotherapy in Two Patients with Advanced Cervical Cancer. Strahlenther Onkol 1 janv. 2006;182(1):45\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMicha JP, Goldstein BH, Rettenmaier MA, Caillouette JT, Fee MJ, Brown JV. Pelvic radiation necrosis and osteomyelitis following chemoradiation for advanced stage vulvar and cervical carcinoma. Gynecol Oncol 1 mai. 2006;101(2):349\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanna E, Chiappe G, Lavra F, Nemolato S, Oppi S, Macci\u0026ograve; A, et al. Diagnostic Framework of Pelvic Massive Necrosis with Peritonitis following Chemoradiation for Locally Advanced Cervical Cancer: When Is the Surgery Not Demandable? A Case Report and Literature Review. Diagnostics f\u0026eacute;vr. 2022;12(2):440.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubtotal vesical necrosis as. a result of infected traumatic bladder hematoma: A rare case with a literature review of bladder necrosis due to hematoma - PMC [Internet]. [cit\u0026eacute; 9 ao\u0026ucirc;t 2023]. Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343294/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343294/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePandey A, Beier J, Dobkowicz L, Wolf S, Keller H. Extensive necrosis of the bladder with hypostatic abscess: a late complication after radiotherapy. Onkologie. 2010;33(3):116\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cervical cancer ,Radiotherapy,complications , Surgery , Necrotizing fasciitis","lastPublishedDoi":"10.21203/rs.3.rs-3767300/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3767300/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInfectious affections are the most frequent post-operative complications, the rates have been reducing due to the administration of perioperative antibiotics and they are rarely serious. They are usually associated to pelvic collections, fistulas, urinary tract stenosis and, exceptionally, necrotizing fasciitis (FN) and pelvic organ necrosis [1].There is no well-codified therapeutic consensus,. An urgent care of pelvic necrosis requires surgical debridement of necrotic tissues with a broad-spectrum antibiotic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eA 42-year-old female patient, was referred to our department for a stage IIIC2 adenocarcinoma of the uterine cervix. She underwent chemo-radiation followed by a colpo-hysterectomy . Two months after surgery, the patient presented with recto-vaginal fistula associated with a pelvic collection. Abdominal CT scan revealed a recto-vaginal fistula fed by a 5cm pelvic collection originating from the uterine cavity. The patient was treated with antibiotics and then underwent a surgical evacuation of the collection and a bypass colostomy. The post-operative period was marked by the occurrence of an extensive necrosis to pelvic organs, namely the bladder and the anterior wall of the rectum which extended to the anterior and medial left leg’s thigh compartments muscles. She also presented a thrombosis of the left external iliac vein and artery, with necrosis of their vascular walls. Given the septic conditions, a revascularization procedure was not feasible. A bilateral ureterostomy was required, as well as ligature of the left external iliac vessels. The patient underwent post-surgical palliative treatment, and she died one month after surgery of multivisceral failure due to sepsis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eNecrotizing fasciitis is a rare, but extremely serious condition, with a mortality rate of up to 30%. The prognosis can be improved with rapid management and appropriate medical and surgical treatment including large excisions of necrotic tissue, and antibiotic therapy adapted to the suspected germs, essentially anaerobic ones.\u003c/p\u003e","manuscriptTitle":"Abdominal Wall and limb necrotizing fasciitis: an extremely rare post -operative complication","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 17:37:47","doi":"10.21203/rs.3.rs-3767300/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-01-27T10:20:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-01-25T22:11:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-01-20T13:59:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-01-13T11:03:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1b7b47c8-e995-41e0-9c27-c0d8b452caf5","date":"2024-01-13T09:53:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6ceb21ba-c577-4d04-bb7d-feb3fe4e8fdb","date":"2024-01-10T19:55:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2f7e3d00-5f51-4c53-a9f4-d4c13d35c063","date":"2024-01-10T13:01:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-10T12:09:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-10T12:02:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-12-31T04:24:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-12-31T04:21:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2023-12-17T12:56:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"42fbd4aa-aa70-4d05-b074-0e6319ff5ebb","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-08T06:51:34+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 17:37:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3767300","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3767300","identity":"rs-3767300","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}