(A Case Report) By M. B. WAGLE and R. D. SHETtI

Transcription

1 GAS GANGRENE--CONSERVATIVE MANAGEMENT (A Case Report) By M. B. WAGLE and R. D. SHETtI K.M. School of Postgraduate Medicine and Research, Sheth Vadilal Sarabhai General Hospital and Sheth Chinai Maternity Hospital, Ahmedabad, India THIS case report concerns the management of a case of gas gangrene of the lower extremity using conservative methods, due to the pertinacity of the patient's parents in forbidding an amputation. This type of infection is prone to occur in wounds of the extremities or the buttocks which contain a large amount of devitalised tissue or contaminated muscle. Cases have been recorded, however, of gas gangrene occurring in such diverse situations as the anterior abdominal wall following an abdominal operation (Spann and McGill, I957) and the scalp following an automobile accident (Roberts and Austin, 1957). The incubation period between the injury and the onset of gas gangrene varies between a few hours and four or more days according to the nature of the wound and the type of causative organism. Because of the ubiquity of this group of organisms, the infrequency of clinical infection is far more surprising than the frequency of culturing the specific pathogen from traumatic wounds. In the Korean war only four infections were reported in 4,900 consecutive war wounds, whereas bacteriological examination of I54 of these wounds at the time of primary debridement demonstrated a clostridial contamination in 26 per cent. It is obvious from this study that wound contamination with the pathogen does not per se prognosticate catastrophe. Gas gangrene is a clinical and not a bacteriological entity. Our patient, M. S., a Muslim boy aged 5 years, was admitted to our hospital on 3Ist May I96I with a foul-smelling wound on the lateral aspect of the left leg and severe toxa~mia. Four days before admission the child had been knocked down by a car and had sustained a long contused lacerated wound on the lateral aspect of the left foot. The wound had been sutured without surgical debridement by the local medical officer. No antibiotics were exhibited till three days later when the civil surgeon saw him. On this day his dressing was opened and the condition diagnosed as gas gangrene. The wound was dressed with hydrogen peroxide without opening of the stitches or the wound. Antigas gangrene serum, 6,000 units, was injected intramuscularly, along with Steclin, IOO mg., and the patient transferred to our hospital. Before admission, on consulting two or three prominent surgeons in the city, he had been unanimously advised to have an above-knee amputation of the left lower limb as a life-saving measure for gas gangrene. On admission there was a 4-in. long sutured wound with white necrotic edges on the lateral aspect of the left foot. The wound was producing a foul odour. The left lower limb was markedly ~edematous, the oedema extending to a little above the knee joint. Evidence of gas formation with crepitus was present. There was no clinical evidence of fracture. General examination showed a very sick child with very high temperature (Io5 ~ F.) and all the signs of profound shock and toxa:mia. The diagnosis of the case was confirmed by X-ray evidence of gas in the tissues (Fig. i), profound tox~emia, and the recovery of Clostridium welchii from the wound exudate. 4 G. 391

2 392 BRITISH JOURNAL OF PLASTIC SURGERY As to treatment, we agreed with the other consultants in also advising an above-knee amputation to save the life of the child. This advice was vehemently opposed by the parents, who were prepared to go to any length to preserve the limb even if it meant a functionless limb of skin and bone. FIG. I Gas seen in the sole of the foot and medial aspect of the middle of the leg. FIG. 2 Resulting defect after radical debridement. Note the almost total loss of skin from the sole of tile foot. Under such duress we had no option but to remove the sutures and do a minimal surgical debridement followed by continuous hydrogen peroxide lavage. The debridement was minimal as the patient's condition was very critical. Two days later, when the child's condition improved somewhat, radical surgical debridement of skin, subcutaneous tissues, and muscles was carried out under trilene analgesia, and hydrogen peroxide

3 GAS GANGRENE--CONSERVATIVE MANAGEMENT 393 FIG. 3 FIG. 4 Fig. 3.--The result of grafting procedure. The limb is diminished in girth and the toes are clawed due to loss of muscle and tendon. Fig. 4.--The result of grafting procedure on the sole of the foot. FIG. 5 FIG. 6 Fig. 5.--Walking caliper with patten worn for six weeks. Fig. 6.--Final result.

4 394 BRITISH JOURNAL OF PLASTIC SURGERY lavage continued. Over a period, at successive operations, all visible dead tissues were excised thus leaving a large defect on the medial aspect of the leg, a lesser defect on the lateral aspect of the leg, and an almost complete surface loss from the dorsum and the sole of the foot. The patient received Io,ooo units of anti-gas gangrene serum by intravenous injection every eight hours on the first two days after admission. This had to be discontinued because of severe serum reaction. The patient received in all I litre of blood in four separate transfusions, and intravenous fluids and Periston " N " to combat shock and tox~emia. Antibiotic cover was supplied by giving Tetracycline, 250 rag., intramuscularly twice a day for five days and thereafter IOO mg. three times a day by mouth till the temperature fell. Using local dressings with IO per cent. mercurochrome, xeroform gauze, and padded dressings the granulating areas became clean enough for resurfacing (Fig. 2). The patient's general condition improved markedly. On 27th June I96I, i.e., twenty-seven days after admission, the defects on the medial and lateral aspects of the leg and the dorsum of the foot were resurfaced by freehand knife grafts obtained by " skinning" the circumference of the right thigh. Grafts were secured with a 2-in. bandage impregnated with petrolatum as the granulations were very hyper~emic. There was a 2,5 per cent. graft loss because of infection. Two weeks later the left thigh was used extensively to provide grafts for the entire sole and the patchy losses on the dorsum of the foot. This time the grafts were sutured into place. The take was almost ioo per cent. (Figs. 3 and 4). The patient was discharged from the hospital on 29th July I96I, almost two months after admission, with a walking caliper to prevent weight-bearing on the grafted sole (Fig. 5). The boy has done very well subsequently and has now discarded the ill-fitting caliper ; he can now walk and even run on his own sole (Fig. 6). DISCUSSION The diagnosis of gas gangrene rests primarily on the appraisal of the clinical phenomena, most important of which are pain, cedema, gas formation, and the general condition of the patient. It must be emphasised that other types of infection can cause the formation of gas in the tissues so that its demonstration by X-ray or the presence of crepitation does not specifically incriminate clostridia. Bacteria of the genus Aerobacter or Escherichia may be responsible for gas production. The most effective treatment of an established case of gas gangrene is a fourpronged attack : (I) debridement, (2) polyvalent serotherapy, (3) blood transfusion, and (4) covering antibiotics. Debridement consists of early adequate excision of the infected areas, but if the infection is limited to an extremity, particularly the distal portion, the obvious treatment is amputation--an open or a guillotine amputation at that! A case of gas gangrene managed conservatively is presented. The interest in this case stems from the fact that because of the stubborn refusal of amputation we were able to observe that a case of gas gangrene with minimal muscle involvement can be managed without an amputation. Sparm and McGill (x957) and Roberts and Austin (I957) reported such management in gas gangrene in the abdominal wall and scalp respectively. Poate and Macafee (I962) described one of two cases of gas gangrene following electric burns which responded to radical debridement and subsequent skin grafting. It should go on record that the successful outcome of this case was largely due to the co-operation and teamwork of the house staff, the nursing staff, and the physiotherapy department. The healthy growing tissues of the young patient played their part in the general process of repair. In the final photograph the defects

5 GAS GANGRENE--CONSERVATIVE MANAGEMENT 395 appear smaller than at the time of grafting, due to the shrinkage of the skin grafts. It is debatable whether such a successful outcome in such a short period would have resulted had the patient been much older. A follow-up of the patient a few months ago showed the grafted sole to be bearing up very well despite the fact that the child is running about on his grafts. Earlier on, the possibility of having to replace the grafted sole with a more durable tube pedicle was kept in mind, but the last follow-up has revealed this to be unnecessary. Indeed, the grafts are building up a thin pad of fat under them and are quite supple and mobile--a great tribute to the healing qualities of young tissues. We would like to acknowledge our thanks to Dr M. D. Desai, M.S.,F.R.C.S., M.Ch.Orth., Superintendent, Sheth Vadilal Sarabhai General Hospital and Director, K.M. School of Postgraduate Medicine and Research, Ahmedabad, India, for his kind permission to utilise the hospital records and for his help in compiling this communication. REFERENCES POATE, W. J., and MACAFEE, A. L. (1962). Brit. J. plast. Surg., 15, I7. ROBERTS, B., and AUSTIN, G. M. (I957). Ann. Surg., 145, 123- SVANN, J. L., and McGILL, R. A. (1957). Ann. Surg., I46, 98. Submitted for publication, February i963.