Thigh Abscess Secondary to Intra-Abdominal Pathologic Conditions

Three Cases Progressing to Necrotizing Fasciitis

Arife Simsek, MD

Disclosures

Wounds. 2021;33(9):226-230. 

In This Article

Discussion

Abscess of the groin, gluteus, and thigh may spontaneously arise from surrounding soft tissues, or it may be a sign of intraperitoneal, retroperitoneal, or pelvic pathologic conditions.[3,5–7] The abdominal contents may drain to the groin and down into the thigh directly through the subcutaneous tissues or via the psoas sheath, femoral canal, sacrosciatic notch, pudendal canal, and obturator foramen.[4,6]

Thigh abscesses have a wide range of clinical presentations. Thus, they are subject to misinterpretation, which may cause delays in management, especially when subspecialty consultations are not well directed to the appropriate department. This study demonstrated that delays in surgical and radiologic consultations and incorrect assessment of the clinical urgency contributed to increased mortality in patients with thigh abscesses. The 3 cases reported arose from colorectal perforation to the retroperitoneum, resulting in an infection spreading down to the thigh. All patients had undergone previous colorectal surgery for malignancy, and all 3 presented with a deep, vague pain in the back or hip area that spread down to the buttock and leg. Patients' symptoms were misinterpreted as a nonspecific complaint in case 1, vertebral disk herniation in case 2, and urinary tract infection in case 3, which led to diagnostic delays of 2 or more days. Additionally, inadequate consultation processes led to surgical delays of 2 or more days. Two patients were initially treated with percutaneous drainage based on the surgeon's preference, while 1 patient underwent surgery for thigh abcesses. Failure of percutaneous drainage required surgery in both patients with persistent symptoms. Negative pressure wound therapy is a form of treatment that promotes wound healing via application of subatmospheric pressure through a sealed vacuum system consisting of a suction pump, tubing, and a dressing; it removes excess exudate and increases blood supply.[8] In this case study, NPWT was used as a component of wound management. The reasons for NPWT application included failed surgery and the presence of NF. Application of NPWT was not possible in case 2 due to the rapid death of the patient following surgical debridement of NF.

As noted previously, the mortality rate in patients with thigh abscesses arising from intra-abdominal pathologic conditions is 34% in cases in which both the preceding pathologic condition and the thigh abscess are treated.[4] However, the mortality rate can reach 93% in cases that are managed locally without attention to the underlying causes.[4] In case 1 reported herein, percutaneous drainage was performed to manage abdominal abscess, but it was not as effective as the surgeons had hoped. In case 2, definitive surgery was delayed due to the patient's refusal and misdiagnosis. In case 3, definitive surgery was performed too late to prevent NF.

Although this was a small case series without a comparator, it could be concluded that thigh abscesses arising from intra-abdominal pathologic conditions should not be treated locally. Failed NPWT indicates that the elimination of the underlying pathologic condition was necessary. It might be possible to infer that percutaneous drainage should not be the treatment of choice for a secondary intra-abdominal pathologic condition; instead, definitive surgery should be performed immediately. The underlying pathologic condition may only be defined intraoperatively, as stated previously.[4] Hsieh et al[9] successfully managed a thigh abscess in a patient with ruptured retrocecal appendicitis, with timely surgical intervention for both the thigh abscess and intra-abdominal pathologic condition. They[9] stated that surgery is advantageous over percutaneous drainage in patients with conditions such as perforated appendicitis, diverticulitis, or malignancy. Lal et al[10] also successfully treated a patient with a perforated appendicitis, but surgery for the intra-abdominal pathologic condition was delayed because of diagnostic problems. Although an attempt at definitive therapy was made, Rotstein et al[4] reported mortality in 2 cases. They concluded a delay in diagnosis was responsible for mortality. Mair et al[11] reported a mortality rate of 50% in 4 patients with thigh abscess secondary to colon cancer. Both wide local drainage and fecal diversion were performed in 3 patients, and 1 patient was treated with local drainage.

Prompt diagnosis and immediate surgical intervention are the keys to successful outcomes in a patient with NF; extension of the necrotizing infection beyond the urogenital and/or anorectal triangle has been independently associated with mortality.[12,13] Unfortunately, all 3 patients died of overwhelming sepsis, reflecting poor prognosis in this group of patients, especially when definitive surgery was delayed. This study recommended strategies aimed at improving the education of health care practitioners about NF, especially in patients with thigh abscess originating from an intra-abdominal pathologic condition.

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