Descending Chest Wall Necrotizing Fasciitis and Development of Acute Respiratory Distress Syndrome - A Case Report and Review of Current Management Strategies

胸壁壞死性筋膜炎的重建與後續的急性呼吸窘迫症候群－病例報告與文獻回顧

洪紹育(Shao-Yu Hung) ； Charles Y. Y. Loh ； 林志鴻(Chih-Hung Lin)

《臺灣整形外科醫學會雜誌》 26卷2期 (2017/06) Pp. 213-221

摘要

Background: The management of descending necrotizing fasciitis secondary to post-head and neck cancer radiotherapy treatment has not been reported in the literature before. Necrotizing fasciitis of the chest wall is relatively uncommon and when coupled with a comorbid patient, sepsis control and management of timing of reconstruction can be difficult. The management of Acute Respiratory Distress Syndrome (ARDS) is also relatively unclear in this group of patients. Aim and Objectives: We present a review of the management strategies of this group of patients and highlight our experience with a clinical report. Material and Methods: A thorough Medline search of the literature was conducted in evaluating the current management options of ARDS as well as the management of necrotizing fasciitis in the chest wall. The case highlighted here was obtained from our hospital. Results: A rationalized review of the management strategies of ARDS as well as chest wall necrotizing fasciitis are provided in the article. We have attached clinical photographs taken during the course of the patient's treatment. Discussion: Pearls learned from the case as well as a summary of the evidence in the literature are provided. Timing as to when ARDS should be managed by extracorporeal membrane oxygenation (ECMO) are also presented in the article. We address a possible change in strategy of the timing of reconstruction post debridement of necrotizing fasciitis. We feel that in keeping with the 'multiple-hit' theory and keeping traumatic insults to the body to a minimum, systemic inflammation can be managed and hence decreasing the risk of ARDS.

關鍵字

ARDS ； necrotizing fasciitis

並列摘要

背景：頭頸癌病人術後頸部感染引發的壞死性筋膜炎(NF)在文獻上比較少被提及。頸部壞死性筋膜炎漫延到胸部在臨床上更是棘手。在這個族群的病人之中，若是併發急性呼吸窘迫症候群(ARDS)，治療上的困難度更是大符度提高。目的及目標：我們在此分享我們的臨床經驗，並藉由文獻回顧，希望能歸納出胸部壞死性筋膜炎病人併發急性呼窘迫症候群的危險因子，並提供治療的方向。材料及方法：一位61歲男性在頭頸癌術後兩年併發頸部及胸部的壞死性筋膜炎。經過多次清創後，用闊背肌根蒂皮瓣覆蓋傷口，卻在術後併發急性呼吸窘迫症候群。結果：關於胸部壞死性筋膜炎及急性呼呼窘迫症的處理，利用文獻回顧整理出治療的策略。我們亦推測壞死性筋膜炎造成的胸廓組織壞死，以及之後的多次手術清創會影響胸部的擴張，而全身性發炎反應更會提高併發急性呼吸窘迫症候群的機率。結論：雖然並不常見，但頭頸癌病人術後併發頸部及胸部壞死性筋膜炎在臨床上是十分棘手的。在這些病人身上我們必須更密切觀察及避免併發症的發生，特別是像急性呼吸窘迫症候群這些高死亡率的疾病。