Intestinal perforation mimicking postoperative gas gangrene: a differential diagnosis of a rare but feared surgical complication

Gas gangrene (GG) represents a rare but feared complication following abdominal surgery. Immediate diagnosis and emergency surgical de-bridement remains the therapy of choice. Herein we present a case in which clinical and typical computer tomographic (CT) appearance of GG was mimicked by an emphysema resulting from an intestinal perforation following laparoscopic surgery. Radiologic and clinical features are compared with a historic case of GG from our center. In March 2020, a 68-year-old male patient presented with abdominal pain and rising in-flammatory parameters two days following laparoscopic cholecystectomy. A subcutaneous thoracic emphysema was suspected and confirmed by chest-X-ray. Contrast-enhanced CT-scan revealed a rapidly progressing soft tissue emphysema spreading along the thoracic and abdominal wall with dissolvement of the left pectoral muscle. Therefore, clinical and CT features fulfilled the criteria for GG described in the current literature and closely resembled the findings in a historic case of verified GG from our unit, which are presented herein. Consequently, emergency surgery was initiated. The pectoral incision confirmed the presence of emphysema but revealed no signs of necrosis. Instead, a focal intestinal wall defect with a transfascial longitudinal dissemination of bile content to the subcutaneous fat was identified as the underlying cause. As shown by this rare clinical case, seemingly typical CT-morphological and clinical signs can be mimicked by an intestinal perforation following laparoscopic surgery.