LETTER
Hippokratia 2012, 16, 4: 386
Theodoropoulos GE1, Michalopoulos NV1, Linardoutsos D1, Tsamis D1, Kafiri G2, Zografos GC1
1First Propaedeutic Surgical Dept, Athens Medical School, 2Department of Pathology, “Hippocratio” General Hospital, Athens, Greece
Keywords: rectal cancer, abdominal wall recurrence, drain site
Correspoding author: Nikolaos V. Michalopoulos, MD, MSc, PhD, 9 Alexandroupoleos Street, 11527 Athens, Greece, tel.: +306938393500, fax: +302107792819, e-mail: nmichal@med.uoa.gr
Dear Editor,
A 62-year old man presented with a large erythematous abdominal wall mass, occupying almost the whole surface of the left infra-umbilical area. The patient described a continuous, non-radiating, progressively deteriorating pain and stated that the abdominal process had gradually evolved over a few weeks prior to his presentation at the hospital. Eighteen months earlier, the patient had undergone an ultra-low anterior resection for a moderately differentiated T2N0M0 low-lying rectal cancer. A pelvic drain had been placed and a protective loop ileostomy had been constructed at that time, which was reversed 2 months later.
On admission, the patient was febrile (38.5oC) and tachycardic (110/min), with a blood pressure of 100/50 mmHg, an hemoglobin of 11 g/dl and a white blood cell count of 18,000/mm3. Physical examination revealed a tender, hard, craggy, fixed and immobile indurated lump, with cellulitic changes but no apparent superficial areas of flunctuance, measuring at least 10 cm at maximum diameter. The palpable lesion seemed to involve all layers of the abdominal wall and corresponded to the site of the previously placed abdominal drain. CT revealed large edematous thickening of the left lower abdominal wall accompanied by a deeply located intramuscular, supra-peritoneal fluid collection and a small intestinal loop adhered to the inflammatory mass.
Surgical exploration via the previous incision with intent to excise the mass in toto was decided. After a midline laparotomy and adhesiolysis, a generous, at macroscopically healthy margins, right lower abdominal wall excision was performed, avoiding any entrance into the lesion, which could herald dissemination of inflammatory or potentially malignant cells. The firmly adhered intestinal loop was carefully mobilized and a stapled side-to-side enteroanastomosis was performed to restore intestinal continuity. The full thickness 10×10 cm abdominal wall defect was covered by approximation of right and left rectus, as well as left internal and external oblique muscle fascial leaves. At histopathology, the specimen was macroscopically measured 11×10.5cm and consisted of a subacute inflammatory process with intense granulation tissue and abscess formation. No evidence of malignant cells was microscopically apparent.
The history of an intra abdominal visceral malignancy automatically raises the suspicion for recurrence, either isolated on the abdominal wall or being the “iceberg” of a more disseminated disease, which justifies an aggressive surgical strategy. There is scarce data in the literature with regard to late presentation of abdominal wall abscess. A formation of an abdominal wall abscess after 11 years of an appendectomy and 2 cases of late onset fistula following a buttock abscess in patients with an initial ileo-anal j-pouch for ulcerative colitis have been reported1,2. Moreover, an enormous abscess has been formed 3 years after laparoscopic TEP herniorrhaphy3. Our case appears to be the first report of a late abscess formation at the abdominal wall following an initial operation for rectal cancer.
In conclusion, the late appearance of an inflammatory mass on the abdominal wall after surgery may pose significant diagnostic and therapeutic problems and may raise concerns about the true pathogenesis of such an entity.
Conflict of interest statement
The authors declare they have no conflict of interest.
References
1. Matsuda K, Masaki T, Toyoshima O, Ono M, Muto T. The occurrence of an abdominal wall abscess 11 years after appendectomy: report of a case. Surg Today. 1999; 29: 931-934.
2. Banerjee S, Farquharson M, Cecil TD, Gold D, Moran BJ. Late-onset fistula presenting as buttock abscess in two patients with ileo-anal J- pouches for ulcerative colitis. Tech Coloproctol. 2004; 8: 37-39.
3. Ozlem N. Enormous abscess growth at abdominal wall three years after laparoscopic herniorrhaphy. Eur Surg. 2009; 41: 51-54.