What is the treatment for retroperitoneal fasciitis?

Treatment of Retroperitoneal Fasciitis

Retroperitoneal fasciitis requires immediate surgical debridement combined with broad-spectrum antibiotic therapy as the cornerstone of treatment to reduce mortality and morbidity. 1, 2, 3

Diagnosis and Initial Assessment

• CT imaging is essential for diagnosis, showing:

  • Fascial thickening and enhancement
  • Muscular edema and fat stranding
  • Fluid collections and abscess formation
  • Gas tracking along fascial planes (hallmark finding but not present in all cases)
  • Asymmetric involvement of retroperitoneal fascial planes 3

• Laboratory evaluation:

  • Complete blood count
  • Inflammatory markers (C-reactive protein, procalcitonin)
  • Serum glucose (to check for undiagnosed diabetes) 4

Treatment Algorithm

1. Immediate Surgical Management

• Aggressive surgical debridement is the primary and most urgent intervention 4, 5

  • Remove all necrotic tissue
  • Explore the full extent of infection
  • Drain any collections
  • Consider sequential laparotomies to track and control extensive necrosis 1
  • Most patients require return to the operating room within 24-36 hours for re-evaluation and possible additional debridement (average 1.9 operations per patient) 4

• Do not delay surgery for imaging studies when clinical suspicion is high 4

2. Antimicrobial Therapy

• Initiate empiric broad-spectrum antibiotics immediately covering:

  • Gram-positive organisms
  • Gram-negative organisms
  • Anaerobes 4

• Recommended regimens:

  • Combination of ampicillin-sulbactam plus clindamycin plus ciprofloxacin, OR
  • Vancomycin/linezolid/daptomycin plus piperacillin-tazobactam or a carbapenem 4

• Adjust antibiotics based on culture results from surgical specimens 4

3. Supportive Care

• Aggressive fluid resuscitation to address dehydration and hypotension 4
• Nutritional support to ensure adequate intake 4
• Pain management with multimodal analgesia (acetaminophen, NSAIDs, opiates if needed) 4

4. Special Considerations

• Fecal diversion should be considered in cases with extensive perineal involvement to protect wounds from contamination 4
• For retroperitoneal sarcomas with fasciitis:
  • Surgical resection with negative margins is the cornerstone of treatment
  • Extended surgical approach may be needed for liposarcomas 6
  • Postoperative radiotherapy is of limited value and associated with significant toxicities 6

Duration of Treatment

• Continue antibiotics until:
  • No further debridement is needed
  • Patient has improved clinically
  • Patient has been afebrile for 48-72 hours 4

Follow-up Care

• Regular wound assessment and appropriate wound care
• Follow-up imaging to ensure resolution of infection
• Consider underlying causes (e.g., perforated diverticulitis, appendicitis, colorectal malignancy) 1, 2

Prognosis and Complications

• Retroperitoneal fasciitis carries a high mortality rate, especially when diagnosis or treatment is delayed 7, 5
• Complications include sepsis, multi-organ failure, and extensive tissue loss requiring complex reconstruction 2

Pitfalls to Avoid

1. Delaying surgical intervention while waiting for imaging or laboratory results
2. Inadequate debridement of necrotic tissue
3. Narrow-spectrum antibiotic coverage
4. Failure to identify and address the underlying cause
5. Inadequate fluid resuscitation

Early recognition, prompt and aggressive surgical debridement, appropriate antibiotic therapy, and meticulous supportive care are essential for improving outcomes in patients with retroperitoneal fasciitis.