A fascia lata free flap in pelvic exenteration for Fournier gangrene due to advanced rectal cancer: a case report

Abstract

Background: Fournier gangrene due to advanced rectal cancer is a rapidly progressive gangrene of the perineum and buttocks. Emergency surgical debridement of necrotic tissue is crucial, and secondary surgery to resect tumors is necessary for wound healing. However, pelvic exenteration damages the pelvic floor, increasing the likelihood of herniation of internal organs into the infectious wound. The management of pelvic exenteration for rectal cancer with Fournier gangrene has not yet been established. We herein describe the use of a fascia lata free flap in pelvic exenteration for rectal cancer with Fournier gangrene.

Case presentation: A 66-year-old male who had undergone colostomy for large bowel obstruction due to advanced rectal cancer and continued chemotherapy was referred to our hospital for Fournier gangrene resulting from chemotherapy. Emergency surgical debridement was performed, and the infectious wound around the rectal cancer was treated with intravenous antibiotic agents postoperatively. However, the tumor was exposed by the wound, and exudate persisted. Pelvic exenteration was performed due to tumor infiltration into the bladder and prostate. Tumor resection resulted in a defect in the pelvic floor. A fascia lata free flap (15 × 9 cm) obtained from the left thigh was fixed to the edge of the peritoneum and ileal conduit to close the defect in the pelvic floor and prevent small bowel herniation into the resected space. There was no intraabdominal inflammation or bowel obstruction postoperatively, and outpatient chemotherapy was continued.

Conclusions: Surgical repair with a fascia lata free flap to close the defect in the pelvic floor led to a good clinical outcome for pelvic exenteration in a patient with Fournier gangrene due to advanced rectal cancer.

Keywords: Fascia lata; Fournier gangrene; Pelvic exenteration; Rectal cancer.

Fig. 1

Computed tomography and pictures of the perineum and buttocks region. Computed tomography showed necrotizing soft tissue infection with large amounts of gas throughout the perineum (arrows) (a). The necrotic soft tissue in the perineum and buttocks surrounding rectal cancer was resected (b). The perineum and buttocks region on day 35 after total pelvic exenteration (c). Computed tomography 8 months postoperatively (d)

Fig. 2

Surgical repair of the pelvic floor defect with a fascia lata free flap. A 15-cm incision was made, and a fascia lata flap (15 × 9 cm) was created from the left thigh (a, b). The patch was fixed to the edge of peritoneum and the ileal conduit wall (c)

Fig. 3

Irradiation plan for the pelvic area