Presentation and management of a case of rectal cancer complicated by perforation and necrotizing soft tissue infection

Abstract

A 68-year-old man presented with septic shock and severe perineal pain from a perforated low-rectal cancer causing a perineal necrotizing soft tissue infection. He underwent laparoscopic diverting colostomy and multiple surgical debridements resulting in extensive perineal and left leg wounds. A multidisciplinary rectal cancer team recommended against neoadjuvant chemoradiation or chemotherapy in his current state. He underwent up-front, urgent robotic-assisted abdominoperineal resection with immediate oblique rectus abdominus muscle flap closure. Final pathology demonstrated a T4N1b adenocarcinoma with negative resection margins. The patient subsequently underwent adjuvant chemotherapy. Now at over 18 months, he remains cancer free.

Figure 1

Management of the perineal wound. (A) Perineal wound upon transfer to our hospital following two initial debridements. A small skin bridge is encircled by a Penrose drain and connects the remaining perianal skin and the anus (arrowhead). (B) The perineal wound following complete infectious control and negative pressure wound vac therapy. Additional debridement was required and resulted in a free-floating anus (arrow). (C and D) The perineal wound following oncologic resection and flap reconstruction. Panel C is the anterior view, and Panel D is the posterior view.