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Laparoscopic-Assisted Reconstructive Management of Perineal Defect due to Ecthyma Gangrenosum
Ruijie Zhou, Zhen Zhang, Qi Li
Department of General Surgery, Capital Center for Children's Health, Capital Medical University, Beijing, China
Introduction
Ecthyma gangrenosum is a rapidly spreading and potentially lethal condition. It usually occurs in patients who are severely immunocompromised. We reported a case of ecthyma gangrenosum in an immunocompromised patient involving perineal lesions, which leaded to severe deformity of perineum.
Case Report
A 6-year-old girl with very severe aplastic anemia was admitted to our hospital with continuous high fever for 2 weeks and anal pain for 1 week. Physical examination showed necrotic lesions and deep ulcerations in the perineal body and perianal area. There was rapidly deterioration in patient’s general condition and her perineal area. The lesions progressed to that a floating free-standing anus was noted concomitant with the beginning of necrotic changes in the anal mucosa. An emergency ileostomy and debridement were performed.
After her progressive perianal healing, perineal area was disrupted with scars of the perineal body, loss of the anal sphincters and anal atresia. So laparoscopic-assisted perineal reconstruction wad performed one year later. Laparoscopic mobilization was carried out at the beginning of surgery. Then carefully remove the undesirable scar tissue and assess the loss of the distal rectovaginal septum during the perineal dissection. The posterior vaginal wall was dissected out as needed until enough pliable and redundant tissue is exposed to allow for interrupted suturing. Under direct visualization, the distal rectum is retrieved.
The patient obtained uneventful postoperative recovery, with an acceptable perineal appearance. However, due to severe damage of anal sphincter, the new anus was difficult to control bowel movements, and the ileostomy was not closed.
Discussion
Perianal sepsis with ecthyma gangrenosum is a severe and potentially mutilating complication in immunocompromised children. Diverting colostomy should be performed when an untractable perianal and endoanal ecthyma gangrenosum is present. Although laparoscopic-assisted reconstructive management can get an acceptable perineal appearance, the anal function is difficult to restore.