CASE REPORT – OPEN ACCESS

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CASE REPORT – OPEN ACCESS

InternationalJournalofSurgeryCaseReports80(2021)105668

ContentslistsavailableatScienceDirect

International Journal of Surgery Case Reports

j o ur na l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Multidisciplinary approach for large retroperitoneal abscess management: A case report

Fekhaza Alfarissi

^a,∗

, Nandita Melati Putri

^b

, Widi Atmoko

^a

aDepartmentofUrology,FacultyofMedicineUniversitasIndonesia–CiptoMangunkusumoHospital,Indonesia

bPlasticReconstructiveandEstheticDivision,DepartmentofSurgery,FacultyofMedicineUniversitasIndonesia–CiptoMangunkusumoHospital,Indonesia

a rt i c l e i nf o

Articlehistory:

Received12January2021

Receivedinrevisedform15February2021 Accepted15February2021

Availableonline21February2021

Keywords:

Retroperitonealabscess Multidisciplinaryapproach NPWT

Honey-impregnatedgauze Lumbararteryperforatorﬂap Keystoneﬂap

a b s t ra c t

INTRODUCTIONANDIMPORTANCE:Retroperitonealabscessisararediseasethatisoftendifﬁculttodiag- noseandrequiremultidisciplinarymanagement.Wereportacaseoflargeretroperitonealabscessand theusagelumbararteryperforator(LAP)forthedefectclosure.

CASEPRESENTATION:A52-year-old-womenwasadmittedtoouremergencywithachiefcomplaintof leftﬂankpain.Patienthadhistoryofmultiplegenitourinarytractprocedureanddiabetesmellitustype 2.Wefoundabulgingmassontheleftﬂankaccompaniedbypressurepain.AcontrastCTscanrevealeda largeabscessontheretroperitonealregionthatinvolvedtheleftretroperitonealhemiabdomenmuscles.

Weperformedmultistage-treatmentcomprisingofradicalabscessdebridement,followedbyhoney- impregnatedgauzeandnegativepressurewoundtherapyforwoundbedpreparation.Post-debridement, thedefectwasclosedwithLAPandkeystoneﬂap.LAPﬂapwasraisedandtransposedtoclosethedefect onthecaudalarea.One-monthfollowupshowedtheoutcomewassatisfactory.

CLINICALDISCUSSION:Inourcase,thesourceofinfectionwasthoughttooriginfromgenitourinary infection.The historyof multipleurologyproceduresand diabetesmellitus becamethemain risk factors.Multistagemanagementswereneededtoeradicatetheabscess.TheusageofNPWTandhoney- impregnatedgauzewasprovensuccessfulinpreparingthewoundbedpriortodefinitiveclosure.Lastly, theutilizationLAPflapcombinedwithkeystoneflapshowedsatisfactoryoutcomefordefectclosure.

CONCLUSION:Themanagementofpatientwithlargeretroperitonealabscessrequiremultidisciplinary approachincludingextensivedebridementandwell-preparedwoundbed.Inthisreport,LAPﬂapwas provenreliableoptiontoresurfacelargedefectaroundﬂankarea.

1. Introduction

Retroperitonealabscessisararediseaseentity.Withaninsid- ious developmentand lackof speciﬁcclinicalmanifestation, its workupmayoftenleadtomisdiagnosis.Severalcomorbiditiesare associatedwiththedevelopmentofretroperitonealabscesssuchas kidneystone,previousurologicalsurgery,diabetes,andimmuno- suppression[1].Moreover,untreatedretroperitonealabscesscould leadtoseriousconsequencesandisassociatedwithmortalityrate of20%[2].Anadequateabscessdebridementandantibioticadmin- istrationiswarranted.

Moreover,theremovaloflargeabscesscouldcreatesigniﬁcant areaofbodydefectwhichrequirefurtherreconstructivesurgery.

Oneoftheavailableoptionsfortheflaptocloselargedefectislum- bararteryperforator(LAP)flap.PreviousstudybyKatoreported thatLAPflapprovidedadurablesolutiontolumbosacraldefects

∗ Correspondingauthorat:Jl.PangeranDiponegoroNo.71,Kec.Senen,Central Jakarta,DKIJakarta10430,Indonesia.

E-mailaddress:[email protected](F.Alfarissi).

causedbyoncologicalresection,pressuresores,traumaorinfection [3].

Uptothisday,thereisnoavailablestudyregardingtheusageof lumbararteryperforator(LAP)ﬂapinretroperitonealabscessman- agement.Therefore,wereportthecomprehensivemanagementfor patientwithretroperitonealabscesswhichincludethediagnostic approachanddefectclosureusinglumbararteryperforator(LAP) ﬂap.

2. Casepresentation

A52-year-oldwomenpresentedtoouremergencydepartment withchiefcomplaintleftﬂankpainforthepastweekpriortohospi- taladmission.Thepainwasdullandwasnotaffectedbypositional changes.Thepatientalsopresentedwithblisteredskinaroundthe leftﬂankarea.Referralpain,vomitandhistoryoffeverweredenied.

Previoushistoryofurinarytractstonewasalsodenied.Patienthad historyofdiabeticketoacidosisandwastreatedwithtwotypes oforalhypoglycemicmedications.Moreover,patienthadhistory ofstaghornofleftkidneyandunderwentmultiplestoneremoval procedureswhichwereopenpyelolithotomy(2010)andextracor-

https://doi.org/10.1016/j.ijscr.2021.105668

creativecommons.org/licenses/by-nc-nd/4.0/).

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Fig.1.UrographyCT-Scanwithcontrastshowingthepresenceofretroperitonealabscess.

porealshockwavelithotripsy(2015).Itwasstatedthattherewas noresidual stoneobserved afterthesecondintervention. Upon physicalexaminations,wefoundabulgingmassontheleftﬂank accompaniedbypressurepainwitherythematousskin.

Based on contrast CT-Scan, we found a large abscess on retroperitoneal regioninvolvingtheleft hemiabdomenmuscles withposteriorwalldefectextendingtocutisandsubcutisofthe leftflank(Fig.1).Thereisalsopyelonephritiswithkidneystone (diameter0.9cm)onthemajorcalyxofleftkidney.Thelabora- toryfindingsrevealedthatthepatienthadleukocytosisandhigh bloodglucose.Basedonthesefindings,patientwasdiagnosedwith retroperitonealabscess,leftkidneystone,andtype2diabetesmel- lituswithunregulatedbloodglucose.

Thepatient’streatmentprocesswasperformedinseveralstages andinvolvedurologyandplasticreconstructivesurgerydivision.In theﬁrststage,thepatientunderwentabscessincisiondrainageand debridementleftperitonealregion(Fig.2)bytheurologists.Wound drainagewasperformed,and 700mLofpus wasextracted.The defectwasclosedwithsituationalsutureanddrainwasinserted.

Duringpostoperativefollow-up,theskinbecamenecrotic.Wethen decided to proceedwith radicalabscess debridement and pro- ceedwithnegativepressurewoundtherapy(NPWT)forexudate removal.Postoperativedefectwasthenregardedtobetoolarge and direct closurecouldnotbeperformed.Patientthen under- went woundtreatmentusinghoney-impregnated gauze forten days(Fig.3.a)untilwoundbedwasdeemedviable.

Aftertendaysofhoney-impregnatedgauzetreatment,patient underwentre-debridementofleftretroperitonealcavitytoresur- face vital muscles as thewound bed. We continued NPWT for woundbedpreparationpriortodeﬁnitiveclosure(Fig.3.cand.d).

Aftertendays,plasticreconstructivesurgeryperformedthedefect closurewithlumbararteryperforator(LAP)andkeystoneflap.LAP flapwasraisedandtransposedtoclosethedefectonthecaudal areawhile thekeystoneflapwasusedtoclosethecranialarea (Fig.4).

During postoperative follow-up, there were no remarkable issuesregardingoverallpatientconditionandtheﬂapwasdeemed vital(Fig.5.a).One-monthfollowuprevealedtherewasnosigniﬁ- cantcomplaintregardingsurgicaloutocome(Fig.5.b).

3. Discussion

Retroperitonealabscessisacomplicateddiseasewithunclear symptoms due to the lack of retroperitoneal signs thus may leadtomisdiagnosis.StudybyAltermeierWAandAlexanderJW successfully collected 189 patientswith proven abscess in the retroperitonealarea[4].Thestudyfoundthatthemostcommoneti- ologywaspyelonephritiswiththemainsymptombeingabdominal orﬂankpain.FurtherstudyconductedbyManjonC.Cetal.in2003 foundsimilarresults[1].Thepresenceofkidneystoneswasthe mainpredisposingfactorfollowedbyhistoryofpreviousurologi- calsurgeryanddiabetes.Themostcommonchiefcomplaintinthis

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CASE REPORT – OPEN ACCESS

F.Alfarissi,N.M.PutriandW.Atmoko InternationalJournalofSurgeryCaseReports80(2021)105668

Fig.2.PhaseIintervention.a)Clinicalpictureofpatientretroperitonealabscess;b)Pusremovalwithradicaldebridementandsuction;c)Drainplacement.

Fig.3.PhaseIIintervention.a)thedefectafter10-daysofhoney-impregnatedgauzetreatment.b)Adefectwithsizeof9cm×11cmfollowingsecondarydebridement.c) NPWTapplicationforbedwoundpreparation.d)ThedefectafterNPWTtreatment.

cohortwasﬂankpainandmass.Moreover,studybyHuangS.etal.

foundthattheoriginofretroperitonealabscessinfemalepatient waspredominatedbygenitourinarytractinfection[5].Basedon theseﬁndings,webelievethattheinfectionoriginofourpatient’s retroperitonealabscesswasofgenitourinarytract;pyelonephri- tisduetothepresenceofkidneystone.Thepresenceofdiabetes mellitustype2alsocontributesasthemainriskfactorforthedevel- opmentofretroperitonealabscess.

Inordertoestablishthediagnosis,computedtomography(CT) andmagneticresonanceimaging(MRI)haveproventobereliable tools.Previous studiesindicatedthatthesensitivities ofCTand MRIwere88.5%and100%,respectively[5].Thepresenceofopaque shadowsordiminishedpsoaslineisthehallmarkofretroperitoneal abscess.Asanalternative,sonographycouldbeusedintheaidof diagnosticprocess despiteitslow sensitivity(53.8%) [5].In our

case,theusageofCT-Scansuccessfullyestablishedthepresence retroperitonealabscess.

Thetreatmentofchoiceforretroperitonealabscessareantibi- oticcombinedwithpercutaneousdrainageorsurgicaldebridement [1,5,6]despitetheabsenceofadeﬁnedprotocol.Aliteraturereview byWinteretal.statedthatpatientwithabscesssizelargerthan 3cmisrequiredtoreceiveactivetreatmentseitherwithsurgical debridementorpercutaneousdrainage[7].Thestudyfoundthat abscesswiththesizeof3−5cm,failedpreviousantibiotictreat- ment, or patientwith poorgeneralhealth would beneﬁt more frompercutaneous drainage.On the other hand,if theabscess sizeislargerthan5cmwithlowexpectationofkidneyfunction, surgicaldrainageisthetreatmentofchoice[7].In ourcase,the abscesswaslargedespitenormal kidneyfunctiontherefore we decidedtoperformextensivedebridement.Duetotheextensive

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Fig.4. PhaseIIIintervention.a)Preoperativewounddefect.b)Flapmarkinganddonorpreparation.c)LAPandKeystoneﬂapwasappliedtoclosethedefect.

Fig.5.Followup.a)5-dayfollowupafterdefectclosure.b)onemonthafterthedefectclosure.Bothshowedvitalﬂapwithoutanysignofcomplications.

tissuelossfollowingthedebridement,musculocutaneousﬂapwas neededfordefectclosure.Topreparethewoundbed,wecombined honey-impregnatedgauzetreatmentwithNPWT.Therationaleof usinghoneygauzedtreatmentisbasedonitsmethylglyoxaland hydrogenperoxidefeature[8].Anunpublishedevidencebasedcase reportfromourcenterfoundthattheefﬁcacyofhoneyaswound dressingisequivalenttohydrogelfortreatingwoundsintermsof durationofwoundhealing[9].Moreover,honeyisamoreeconomic andaccessibleoptionespeciallyinadevelopingcountrysuchas Indonesia.Theresultfromhoney-impregnatedgauzetreatmentin ourpatientalsoshowedsatisfactoryoutcomes.

Negative pressure therapy aids the wound management throughtwoprocesses:woundcontraction(macro-deformation)

andaccelerationofgranulationtissueformation.Asaresult,itwill minimizethewoundsizeanddecreaseitscomplexity[10].Aproper granulatingbedwouldenhancethewoundbedoutcomeforclosure byeitherflaporgraft.FurtherstudyreportedbyLuglioGetal.also foundtheusageNPWTinenterocutaneousfistulaswithabdominal abscesshadoverallsatisfactoryresult[11].Based onthesefind- ings,NPWTwasusedtopreparethebedwoundinourpatient.As aresult,thedefectsizewasreducedsignificantlyandthewound bedappearedvital(Fig.3.d)

Fordefectclosure,weutilizedlumbararteryperforator(LAP) ﬂapcombinedwithkeystoneﬂap.ArcoGetal.reportedtheusage LAPFlapforclosurelargedefectinpatientunderwentexophytic exulceratedbasalioma[12].Toclosethedefect,theyusedcaudal

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CASE REPORT – OPEN ACCESS

F.Alfarissi,N.M.PutriandW.Atmoko InternationalJournalofSurgeryCaseReports80(2021)105668

lumbararteryperforatorcombinedwithcraniallateralintercostal perforatorwithsatisfactoryoutcome[12].Moreover,recentstudy analysestheusageofpropellerlumbarperforatorﬂapin32cases lumbardefectwithvariousetiologies[13].Theresultshowedthat therewerenocoveragefailureorcomplicationsatthedonorsite.

Similarly,ourpatientshowedavitalflapduringtheinitialpost- operativeassessment.Afteronemonthfollowup,theflapwasin excellentcondition(Fig.5.b)andthepatientissatisfiedwithher condition.

4. Conclusion

Based onourstudy,themanagementof patientwithsevere retroperitonealabscessrequireamultidisciplinaryapproach.Con- trastCT-Scanremainsasthemainoptiontoestablishthediagnosis of retroperitoneal abscess.Moreover,honey-impregnatedgauze followedbyNPWTcouldaidthepreparationofalargedefectto beclosedwithflap.Lastly,lumbararteryperforatorflapcombined withkeystonedesignperforatorislandflapisareliableoptionto resurfacelargedefectaroundtheflankarea.

5. SCAREcriteria

Weconﬁrmedthatourworkhasbeenreportedinlinewiththe SCARE2020criteria[14].

DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest.

Funding

Private funds form the Department of Urology Ciptoman- gunkusumohospital,FacultyMedicineUniversityIndonesia.There arenostudysponsors.

Ethicalapproval

Theauthorsdeclarethatweobtainedpermissionfromethics committeeinourinstitution.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Registrationofresearchstudies NotApplicable.

Guarantor

FekhazaAlfarissiMD.,MRes.

WidiAtmokoMD.

NanditaMelatiPutriMD.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

CRediTauthorshipcontributionstatement

FekhazaAlfarissi:Conceptualization,Methodology,Writing- originaldraft,Writing - review &editing, Visualization, Formal analysis,Investigation.NanditaMelatiPutri:Datacuration,Writ- ing-review&editing,Projectadministration,Conceptualization, Methodology,Resources,Fundingacquisition, Supervision.Widi Atmoko:Datacuration,Writing-review&editing,Methodology, Resources,Supervision.

Acknowledgement

ThecontributorswouldliketothankCiptoMangunkusumoHos- pitalteamforsupportingthisreport.

References

[1]C.C.Manjón,Á.T.Sánchez,J.D.PiedraLara,V.M.Silva,G.C.Betriu,A.R.Sánchez, C.G.Pe ˜nalver,Ó.L.Galvis,Retroperitonealabscesses–analysisofaseriesof66 cases,Scand.J.Urol.Nephrol.37(2003)139–144,http://dx.doi.org/10.1080/

00365590310008884.

[2]J.T.Crepps,J.P.Welch,R.Orlando3rd,Managementandoutcomeof retroperitonealabscesses,Ann.Surg.205(1987)276–281,http://dx.doi.org/

10.1097/00000658-198703000-00010.

[3]H.Kato,M.Hasegawa,T.Takada,S.Torii,Thelumbararteryperforatorbased islandﬂap:anatomicalstudyandcasereports,Br.J.Plast.Surg.52(1999) 541–546,http://dx.doi.org/10.1054/bjps.1999.3120.

[4]W.A.Altemeier,J.W.Alexander,Retroperitonealabscess,Arch.Surg.83(1961) 512–524,http://dx.doi.org/10.1001/archsurg.1961.01300160024004.

[5]S.H.Huang,W.O.Lo,C.M.Lin,T.S.Hsieh,S.F.Wang,S.W.Tsai,K.C.Chen, Retroperitonealabscess:7-yearexperienceof29casesinatertiarycare centerinTaiwan,Urol.Sci.26(2015)218–221,http://dx.doi.org/10.1016/j.

urols.2015.01.009.

[6]R.He,X.Qi,B.Wen,X.Y.Li,L.Guo,Successfultreatmentofarareextended retroperitonealnecrotizingsofttissueinfectioncausedbyextended-spectrum beta-lactamase-producingEscherichiacoli:acasereport,Med.(United States)95(2016)e5576,http://dx.doi.org/10.1097/MD.0000000000005576.

[7]B.M.Winter,M.Gajda,M.O.Grimm,DiagnostikundTherapie

retroperitonealerAbszesse,Urology55(2016)741–747,http://dx.doi.org/10.

1007/s00120-016-0118-1.

[8]M.D.Mandal,S.Mandal,Honey:itsmedicinalpropertyandantibacterial activity,AsianPac.J.Trop.Biomed.1(2011)154–160,http://dx.doi.org/10.

1016/S2221-1691(11)60016-6.

[9]N.M.Putri,P.Kreshanti,N.Tunjung,A.Indania,A.Basuki,C.L.Sukasah, EfﬁcacyofHoneyDressingversusHydrogel,(n.d.).

[10]H.Birke-Sorensen,M.Malmsjo,P.Rome,D.Hudson,E.Krug,L.Berg,A.Bruhin, C.Caravaggi,M.Chariker,M.Depoorter,C.Dowsett,R.Dunn,F.Duteille,F.

Ferreira,J.M.F.Martínez,G.Grudzien,S.Ichioka,R.Ingemansson,S.Jeffery,C.

Lee,S.Vig,N.Runkel,R.Martin,J.Smith,Evidence-basedrecommendations fornegativepressurewoundtherapy:treatmentvariables(pressurelevels, woundﬁllerandcontactlayer)-stepstowardsaninternationalconsensus,J.

Plast.Reconstr.Aesthet.Surg.64(2011),http://dx.doi.org/10.1016/j.bjps.

2011.06.001.

[11]G.Luglio,A.Amendola,G.Pagano,F.P.Tropeano,C.Errico,E.Esposito,G.

Palomba,P.Dinuzzi,G.DeSimone,G.D.DePalma,Combinedsurgicaland negativepressuretherapytotreatmultipleenterocutaneousﬁstulasand abdominalabscesses:acasereport,Ann.Med.Surg.57(2020)123–126, http://dx.doi.org/10.1016/j.amsu.2020.06.037.

[12]G.Arco,R.E.Horch,A.Arkudas,A.Dragu,A.D.Bach,U.Kneser,Double pedicledperforatorﬂaptocloseﬂankdefects:analternativeforclosureofa largelumbardefectafterbasaliomaexcision–acasereportandreviewofthe literature,Ann.Plast.Surg.63(2009)422–424,http://dx.doi.org/10.1097/SAP.

0b013e318195361e.

[13]H.Falinower,C.Herlin,J.Laloze,F.Bodin,N.Kerfant,B.Chaput,Useofthe propellerlumbarperforatorﬂap:aseriesof32cases,Plast.Reconstr.Surg.- Glob.Open.(2020)1–7,http://dx.doi.org/10.1097/GOX.0000000000002522.

[14]R.A.Agha,T.Franchi,C.Sohrabi,G.Mathew,A.Kerwan,TheSCARE2020 Guideline:UpdatingConsensusSurgicalCAseREport(SCARE)Guidelines,Int.

J.Surg.84(2020)226–230,http://dx.doi.org/10.1016/j.ijsu.2020.10.034.

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