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Vacuum-Assisted Healing of a Devastating Retroperitoneal Colonic Perforation With a Homemade Device

Retroperitoneal colonic perforation is a very rare condition, usually due to the presence of a nondiagnosed diverticular disease. Most frequently it manifests with the presence of abscesses of the abdominal wall that invariably causes severe systemic complications. Toilette and drainage is the therapy of choice together with the confection of a derivative colostomy. However, often abscess healing takes a long time. The introduction of vacuum-assisted device medication has proven to be helpful in keeping patient discomfort at minimal levels and helping the healing process. Commercial vacuum-assisted device medication is however costly and often not available for immediate use. We recently encountered a case of a retroperitoneal sigmoid diverticular perforation that led to a devastating necrosis of the abdominal wall, flank, and buttock extending to the articulation of the hip in an obese and diabetic patient, which was successfully treated by a homemade vacuumassisted device (HVAD). This strategy was adopted because of the unavailability of the commercial device. A 61-year-old female was admitted to our department with a 15-day history of left lateral abdominal pain diffused to the homolateral lower extremity. Past history was significant for obesity (body mass index 40) and type II diabetes. Physical examination revealed the following: body temperature 39.2°C, blood pressure 100/60 mm Hg, pulse rate 110 beats per minute, and respiratory rate 40 breaths/minute. There was severe cognitive deterioration. Patient was intubated and transferred to the intensive care unit with diagnosis of septic shock and multiple organ failure. Presence of a large fluctuating abscess extending from the left hip to the gluteal region was evident. Blood and laboratory test results were as follows: white blood cell count 14 600/mm, hemoglobin 11.4 g/dL, platelet count 563 000/mm, blood urea nitrogen 106 mg/dL (normal 10-23 mg/dL), creatinine 3.4 mg/dL (normal 0.71.2 mg/dL), bilirubin 5.6 mg/dL (normal 0.3-1.2 mg/dL), and GOT 165 IU/L (normal 7-45 IU/L). A computed tomography scan (Figure 1) showed a muscle fascial thickening of the left abdominal wall with multiple gas bubbles between the muscle fibers. An abscess measuring 8 cm in diameter extended up to the left iliac crest and a thickening and an enhancement of the perinefric and paranefric left fascie were present. Wide spectrum antibiotic therapy was administered (teicoplanin, meropenem, metronidazole) and a timely surgical intervention for complete drainage was performed. A huge abscess involving the left abdominal wall was drained and a retroperitoneal sigmoid diverticular perforation was detected. A wide muscolofascial necrosis extended from the iliac wing up to the homolateral hip joint (Figure 2). During this operation, a derivative colostomy on the transverse colon was performed. At intervention the use of vacuum-assisted device was considered useful because of the enormous extension of the tissue necrosis, the presence of concomitant comorbidities such as diabetes, obesity, and septic shock. A HVAD was then assembled in the following manner. Vacuum-Assisted Healing of a Devastating Retroperitoneal Colonic Perforation With a Homemade Device