Advertisement

A Rare Case of Lower Limb Gangrene Following Anterior Exenteration in a Previously Irradiated Pelvis

  • Narendra HulikalEmail author
  • Bhavya Bayana
  • Manilal Banoth
  • Abha Chandra
  • Andal Venkataraman
Case Report
  • 7 Downloads

Abstract

Purpose

Limb-threatening ischemia following arterial thrombosis in a patient with no known history of arterial disease or vascular injury following surgery is difficult to explain. This case report illustrates a rare complication of arterial thrombosis leading to limb gangrene in a patient with recurrent carcinoma cervix who underwent anterior exenteration.

Case Report

A 43-year-old woman irradiated 10 years back for FIGO stage IIA carcinoma cervix presented with recurrence. Since the workup revealed localized disease, surgery was planned. Under general anesthesia with an epidural catheter in situ, patient was placed in lithotomy position and abdomen opened through a lower vertical midline incision. As the lesion was adherent to urinary bladder, a decision was made to do anterior exenteration with uretero-colostomy. The surgery lasted for 7 h, and patient was placed in head-low position for more than 3 h to assist small-bowel packing. Postoperatively, patient developed ischemia of right lower leg with documented thrombosis of right common femoral artery. As the arterial embolectomy failed and gangrene had set in, the limb was amputated on the fourth postoperative day.

Results

At the time of this write up, the patient has completed 5 years of disease-free status. She is rehabilitated with the below-knee prosthesis and is mobile.

Conclusion

Prolonged lithotomy positioning in the presence of a prior history of radiation may be associated with arterial thrombosis which can threaten limb perfusion, which if not diagnosed and treated early can result in limb gangrene.

Keywords

Uterine cervical neoplasms Patient positioning Pelvic exenteration Compartment syndromes Thrombosis Gangrene 

Notes

Acknowledgements

We acknowledge the contribution of Ms. Pusuluri Vijayalakshmi, Intern, SVIMS-SPMC (W), Tirupati, AP, India, for the line diagrams in Figures 1a and 1b.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Authors here by assure that all ethical standards have been followed in publishing this article.

References

  1. 1.
    Neel HB, Ketcham AS, Hammond WG, Joseph WL. Vascular complications following cancer surgery of the pelvis and groin. Cancer. 1970;26:669–79.CrossRefGoogle Scholar
  2. 2.
    Sanorama A, Varo B, Castillo M, Domingo S, Mico J, Pellice A. Arterial thrombosis after surgery of pelvic side wall recurrence of a villoglandular adenocarcinoma of the cervix. J Gynecol Surg. 2012;28:227–9.CrossRefGoogle Scholar
  3. 3.
    Butler MJ, Lane RH, Webster JH. Irradiation injury to large arteries. Br J Surg. 1980;67:341–3.CrossRefGoogle Scholar
  4. 4.
    Modrall JG, Sadjadi J. Early and late presentations of radiation arteritis. Semin Vasc Surg. 2003;16:209–14.CrossRefGoogle Scholar
  5. 5.
    Won KB, Kim BK, Ko YG, Hong MK, Choi D, Jang Y. Arterial occlusive disease complicating radiation therapy of cervical cancer. Yonsei Med J. 2012;53(6):1220.CrossRefGoogle Scholar
  6. 6.
    Levenback C, Burke TW, Rubin SC, Curtin JP, Wharton JT. Arterial occlusion complicating treatment of gynecologic cancer: a case series. Gynecol Oncol. 1996;63:40–6.CrossRefGoogle Scholar
  7. 7.
    Matsen FA. A practical approach to compartmental syndromes. Part I. Definition, theory, and pathogenesis. Instr Course Lect. 1983;32:88.PubMedGoogle Scholar
  8. 8.
    Jones WG, Perry MO, Bush HL Jr. Changes in tibial venous blood flow in the evolving compartment syndrome. Arch Surg. 1989;124:801.CrossRefGoogle Scholar
  9. 9.
    Mumtaz FH, Chew H, Gelister JS. Lower limb compartment syndrome associated with the lithotomy position: concepts and perspectives for the urologist. BJU Int. 2002;90:792.CrossRefGoogle Scholar
  10. 10.
    Pfeffer SD, Halliwill JR, Warner MA. Effects of lithotomy position and external compression on lower leg muscle compartment pressure. Anesthesiology. 2001;95:632.CrossRefGoogle Scholar

Copyright information

© Association of Gynecologic Oncologists of India 2019

Authors and Affiliations

  1. 1.Department of Surgical OncologySri Venkateswara Institute of Medical SciencesTirupatiIndia
  2. 2.Department of Cardiothoracic SurgerySri Venkateswara Institute of Medical SciencesTirupatiIndia
  3. 3.Department of Anaesthesia and Critical CareSri Venkateswara Institute of Medical SciencesTirupatiIndia

Personalised recommendations