Hip necrotizing fasciitis after transvaginal mesh repair for uterine prolapse: A rare but severe complication

摘要

A 59-year-old woman with hypertension presented to our emergency department with left hip pain and swelling for one week. She had 38.4 ? C fever. Laboratory tests showed leukocytosis (20150/ m L), neutrophil 85%, and C-reactive protein 28.1 mg/dL. Left thigh radiography showed subcutaneous gas formation. Contrast- enhanced pelvic computed tomography demonstrated a peri- rectal abscess and fistula from the lateral rectal wall to the left hip, complicated with necrotizing fasciitis (Fig. 1A and B). She had undergone total vaginal hysterectomy and mesh repair (Avaulta? anterior mesh; C. R. Bard, Inc., Murray Hill, New Jersey) for stage 3 uterine prolapse 4 years ago. She made two out-patient clinic follow-up visits after the mesh repair. She had no specific discomfort. Last year, she was experiencing progressive vaginal bleeding for 6 months, because of which she visited the clinic again; her vaginal examination showed mesh extrusion and was indicative of an infection. Therefore, the mesh was removed. She had no other discomfort such as abdominal pain or fever. No evi- dence of a fistula was noted at that time. Pathology results confirmed ulcers and abscess. As the transvaginal mesh is close to rectum, mesh erosion and migration would lead to rectal fistulas. Most cases of rectal fistulas are at the medial thigh [1]. However, in our case, the fistula was connected to the lateral thigh and complicated with necrotizing fasciitis. Afterward, she had left thigh soreness for 3 months and foul-smell stools for 1 month before she visited our emergency room for left hip pain. Emergency fasciotomy and fasciectomy (Fig. 1C) were performed; she was admitted to the intensive care unit. After admission, a general surgeon was consulted. Proctoscopy showed mesh migration and fistula formation, indicating that the remaining mesh migrated to the rectum and resulted in fistula formation from the rectum to the left hip. Unfortunately, we did not have the image from procto- scopy. The general surgeonfirst performed colostomy to control the infection. Second, he performed laparotomy to debride the peri- rectal abscess and remove the meshoma (i.e., the mesh was folded with surrounding tissue like a tumor. Doctor Amid has used the term “meshoma” in his article [2]). She received 4 weeks broad- spectrum antibiotics for multimicrobial infections (Enterococcus faecium, Klebsiella pneumoniae, Streptococcus anginosus, Bacteroides thetaiotaomicron, and Anaerococcus prevotii). She showed good re- covery 3 months later. Follow-up lower gastrointestinal series and colonoscopy showed no residual fistula. Colostomy was closed 6 months after initial surgery.