Fournier's gangrene: changing face of the disease

A neglected case of strangulated right groin hernia presenting with perforated ileum, vanished right testis and necrotizing fasciitis of the right groin: A case report

INTRODUCTION AND IMPORTANCE

Hernias are one of the commonest procedures performed by general surgeons. Irreducibility, intestinal obstruction, and strangulation are common outcomes of a groin hernia when there is disregard and a delay in elective surgery. Studies have shown a considerable incidence of these hernia complications, along with the associated morbidity and death, because of delayed presentation. Testicular gangrene following incarcerated hernias is a rare entity in the adult population.

CASE PRESENTATION

Here we present a case of a 30-year-old male presented with gangrenous vanished testis, perforated ileum and necrotizing fasciitis of the right groin after a neglected strangulated right inguinal hernia.

CLINICAL DISCUSSION

Testicular infarction/gangrene is most commonly secondary to testicular torsion, an emergency that teenagers frequently experience. When it complicates inguinal hernia, it typically results in ischemia, infarction, and gangrene due to compression and impairment of the vascular supply within the inguinal canal. In cases like our where there is a necrotizing process in the groin, we feel it's appropriate to approach from the abdomen and do the resection first and proceed with the radical debridement after that.

CONCLUSION

Early diagnosis and intervention with emergency surgery are crucial for strangulated inguinal hernia and prevents unnecessary escalation of the problem with progressive infectious and necrotic destruction of adjacent tissues.

Temperature-Neutrophils-Multiple Organ Failure Grading as a Prognostic Indicator in Fournier Gangrene

Background: Severity scoring systems are used widely to predict prognosis in managing various diseases and to tailor the treatment of patients in a personalized way, not in a general concept, by making a risk assessment. This study examines the importance of the Temperature-Neutrophils-Multiple Organ Failure (TNM) scoring system, a new scoring system, in evaluating the prognosis in patients with Fournier gangrene (FG). Patients and Methods: Patients who were operated on with the diagnosis of FG in our clinic between 2012 and 2022 were analyzed with a single-center cross-sectional retrospective study design. Demographic data (age, gender), pre-operative evaluation, body temperature, neutrophil ratio, presence of multiple organ failure, TNM score, and post-operative survival data were recorded. The patients were grouped as those with post-operative hospital mortality (group 1) and without (group 2). Results: The study included 167 patients. Twenty-two (13.2%) of the patients were in group 1 and 145 (86.8%) were in group 2. According to the TNM score, the frequency of stage 3-4 was higher in group 1 than in group 2 (p < 0.001). Patients ≥65 years of age had a 4.80 (95% confidence interval [CI], 1.87-12.29) times greater mortality risk than patients <65. Patients with comorbid disease had a 4.56 (95% CI, 1.47-14.14) times greater risk of mortality than patients without. Patients with TNM scores 3-4 had a 9.38 (95% CI, 3.01-29.28) times greater risk of exit than patients with scores 1-2. Conclusions: The TNM system is a new scoring system that is created quickly using simple laboratory and clinical data in patients with FG and is useful in predicting mortality. Therefore, its clinical use will benefit FG and other deep soft tissue infections.

Conceptos para la identificación y abordaje de la gangrena de Fournier

Introducción. La gangrena de Fournier es una fasciitis necrosante fulminante y progresiva, de origen infeccioso sinérgico polimicrobiano, que afecta las regiones perianal, perineal, genital y abdominal. Su incidencia es mayor en hombres, la edad promedio de presentación reportada está en los 54,7 ± 15,6 años, su mortalidad es del 3-67 %, aunque hay estudios que informan una mortalidad en hombres del 7,5 % y en las mujeres del 12,8 %. Métodos. Se hizo una revisión de la literatura en las bases de datos y fuentes de información PubMed, Scielo y Google Scholar, publicados entre 1950 y 2018, utilizando términos como "fournier gangrene", "fasciitis, necrotizing”, “wound infection”, "therapy"[subheading] y “GRADE approach". Se realizó una segunda revisión para artículos latinoamericanos en español hasta 2020 usando las mismas fuentes y palabras claves. Resultados. Se seleccionaron artículos que reportaron definiciones, datos históricos, actualizaciones en diagnóstico y terapéutica para hacer una revisión actualizada. Para el uso de las imágenes se solicitó consentimiento informado. Conclusión. La gangrena de Fournier continúa siendo una emergencia quirúrgica potencialmente letal. Gracias a las investigaciones realizadas se ha avanzado en su tratamiento, mejorando los resultados. Es importante analizar los factores de riesgo en cada paciente y su etiología para establecer el tratamiento más adecuado.

[Necrotizing myositis of the thigh : Cause or result of a systemic capillary leak syndrome?]

Infektionen des muskuloskeletalen Systems sind in der Unfallchirurgie mitunter die Krankheitsbilder, die Patienten am gravierendsten beeinträchtigen, Ärzte fachlich sowie Kliniken und das Gesundheitssystem ökonomisch herausfordern. Das systemische „Capillary-leak“-Syndrom (SCLS) ist ein seltenes idiopathisches Syndrom, welches auch bei harmlosen Infektionen fulminante lebensbedrohliche Verläufe provozieren kann. Neben einer übersichtlichen Darstellung des SCLS wird über einen betroffenen Patienten, der infolge einer instabilen Narbe eine nekrotisierende Myositis des Oberschenkels entwickelte, berichtet.

Fournier Gangrene as a Complication of a Perinephric Abscess After Kidney Transplant: A Case Report

Fournier gangrene is a progressive necrotizing infection of the external genitalia or perineum that constitutes a urologic emergency. Incidence of Fournier gangrene is rising because of population aging, increasing comorbidities, and widespread use of immunosuppressive therapy, including immunosuppressive regimens used in kidney transplants. This is a rapidly progressive and potentially lethal disease without treatment, and early recognition of the disease, proper management of the predisposing factors, and aggressive surgical debridement are the most essential interventions. We report a rare case of Fournier gangrene in the early postoperative period of a kidney transplant due to a perinephric abscess.

Abdominoperineal Resection with Absorbable Mesh Repair of Perineal Defect for Fournier's Gangrene: A Case Report

Background

Fournier’s gangrene (FG) is a rare but deadly form of necrotizing fasciitis involving the genital, perineal, and anorectal region. Risk factors include diabetes mellitus, immunosuppression, and alcohol misuse. Because multisystem organ failure can rapidly develop, early diagnosis is critical. Treatment includes fluid resuscitation, broad-spectrum antibiotics, and surgical debridement. Uncommonly, extension of perineal infection into adjacent organs can necessitate multivisceral resection, which can make reconstruction a challenge. Even with swift diagnosis and optimal treatment, morbidity and mortality are high.

Case Presentation

A 66-year-old male with a history of diabetes mellitus presented to the emergency department with progressive scrotal pain, swelling, and perineal skin changes. Examination revealed necrosis of the scrotal soft tissues with involvement of the anal canal and rectum. The patient was initiated on intravenous fluids and broad-spectrum antibiotics, then brought immediately to the operating room where surgical care was provided by a urologist, colorectal surgeon, and general surgeon with expertise in complex mesh repair. Extension of necrotic changes travelling proximally through the full thickness of the rectum was noted. The patient underwent extensive scrotal and perineal debridement, laparotomy, abdominoperineal resection (APR), end colostomy, and polyglactin mesh repair of the resultant pelvic floor defect. The patient had appropriate return of bowel function and satisfactory healing of the perineum postoperatively but ultimately died after a ventricular fibrillation-related cardiac arrest precipitated by a flare of idiopathic pulmonary fibrosis.

Conclusion

Early diagnosis and referral to the appropriate specialists are essential elements of managing FG. Here we present a case with extension of necrotizing soft tissue infection into the rectum, requiring pelvic dissection and APR as well as absorbable mesh use to aid in perineal closure. Despite expedient treatment, poor outcomes with this condition are unfortunately common.

Outcomes of patients with Fournier's Gangrene: 12-year experience from a tertiary care referral center

OBJECTIVE

To highlight changing trends of the clinical spectrum, and compare the management options and predictors of Fournier's gangrene (FG) outcomes in a tertiary care referral center.

MATERIAL AND METHODS

This study included patients with FG between August 2005 and July 2017. Patients were classified as "responders" and "nonresponders." We compared the baseline characteristics, clinical spectrum, biochemical data, management modalities, outcomes, and FG severity index (FGSI) and age-adjusted Charlson Comorbidity Index (ACCI) between responders and nonresponders.

RESULTS

We studied 72 patients and further divided them to responders (60 patients) and non-responders (12 patients). All were males; the mean age was 56.27+19.27 years (range, 47-85 years). The most common complaints were perineal discomfort (n=62; 86.1%) and fever (n=48; 66.7%). FG originated from the penoscrotal region in 64 patients (88.8%) and perineal region in 8 patients. Diabetes mellitus was the most common comorbidity (36%). The mean duration of the presentation was 10.19 days (range, 7-30 days). Sixteen patients underwent split skin grafting. The mortality rate was 8.3%. Nonresponders had distinct findings relative to responders: advanced age (71.5±7.17 vs. 53.23±19.85 years; p=0.00); high blood sugar (245.83±116.26 vs. 139.06±35.64 mg/dL; p<0.01); leukocytosis (27166.67±10295.75 vs. 10558.4±3130.64 cumm; p<0.01); elevated serum creatinine (3.78±1.43 vs. 1.38±1.00; p<0.01); hyponatremia (127.33±11.84 vs. 137.33±3.42 meq/l; p<0.01), elevated international normalized ratios (1.66±0.28 vs. 1.32±0.07; p<0.01); and high FGSI (9.83±1.11 vs. 6.46±1.68;p<0.01) and ACCI scores (6.33±0.49 vs. 5±0.82; p<0.01). On univariate and multivariate regression analysis, raised blood sugar and deranged international normalized ratios at presentation were significantly associated with decreased response to treatment (p<0.05).

CONCLUSION

An advanced age, diabetes mellitus, renal impairment, leukocytosis, altered sensorium, shock at presentation, deranged international normalized ratios, and high FGSI and ACCI scores can be used as predictors for poor response. FG risk scores adequately characterize the severity and prognosis of FG, but clinician's judgement is vital. The management comprises of a multidisciplinary approach, including parenteral antibiotics, urgent surgical debridement, and comorbidities optimization.

Necrotizing pelvic infection after rectal resection. A rare indication of endoscopic vacuum-assisted closure therapy. A case report

INTRODUCTION

Anastomotic leak after colorectal surgery is a major problem associated with higher morbidity and mortality. In most cases of contained leaks, treatment recommendations are clear and effective. However, in rare cases like necrotizing pelvic infection, there is no clear treatment of choice, despite the mortality rate almost 21%. We present successful management with endoscopic vacuum-assisted closure therapy.

THE PRESENTATION OF A CASE

A 68-year-old female patient with BMI 26, hypothyroidism and high blood pressure was indicated to low anterior rectal resection because of high-risk neoplasia of lateral spreading tumor type of the upper rectum. Four days after the primary operation, sepsis (SOFA 12) with diffuse peritonitis and unconfirmed leak according to CT led to surgical revision with loop ileostomy. On postoperative days 6-10, swelling, inflammation and subsequent necrosis of the right groin and femoral region communicating with the leak cavity developed. The endoscopy confirmed a leak of 30% of the anastomotic circumference with the indication of debridement and endoscopic vacuum-assisted closure therapy. EVAC sessions with 3-4 day intervals healed the leak cavity. Secondary healing of the skin defects required 4 months.

CONCLUSION

Necrotizing pelvic infection after a leak of the colorectal anastomosis is a very rare complication with high morbidity and mortality. Endoscopic vacuum-assisted closure therapy should be implemented in the multimodal therapeutic strategy in case of major leaks, affecting up to 270° of the anastomotic circumference.

Outcomes in patients with Fournier's gangrene originating from the anorectal region with a particular focus on those without perineal involvement

Background and aim

Fournier’s gangrene (FG) is a fulminant infection in the external genital region and perineum. The present study explored the clinical features of FG originating from the anorectal region, from primary conditions such as anal fistulas and abscesses.

Methods

A retrospective analysis was performed in order to identify the factors associated with clinical outcomes in FG patients derived from two hospitals—the Sixth Affiliated Hospital of Sun Yat-sen University and People’s Hospital Affiliated to Fujian University of Traditional Chinese—over the period from May 2013 to April 2017.

Results

Sixty FG patients were included in this study. The common causative microorganisms cultured were Escherichia coli species. Genital and perirectal regional involvement was evident in 52 and 59 cases, respectively, although the perineum was unaffected in 7 cases (12%), as confirmed by imaging examination and surgical exploration. Management with early radical debridement and broad-spectrum antibiotic therapy is effective with an acceptably sepsis mortality (1.7%). Ten patients underwent protective colostomy. No patient underwent an orchidectomy and required urinary diversion.

Conclusions

FG originating from the anorectal region can be rapidly progressive and life-threatening. Infection can spread superiorly to the genital region without the involvement in perineal tissue. An aggressive surgical debridement of non-viable tissue is essential for satisfactory outcomes and a protective colostomy is not mandatory.

Negative pressure wound therapy and split thickness skin graft aided in the healing of extensive perineum necrotizing fasciitis without faecal diversion: a case report

Background

Perineum necrotizing fasciitis, also known as Fournier gangrene (FG), is a rare but highly mortal infectious necrotizing fasciitis with or without involvement of the underlying muscle. Evidence exists that negative pressure wound therapy (NPWT) combined with a split thickness skin graft (STSG) can help to heal wounds with FG. However, when the wound spreads to the anal area, it can easily be contaminated by faeces, causing a more extensive wounds; thus, faecal diversion is considered. Here, we report a case of extensive perineum necrotizing fasciitis that spread to near the anus; NPWT combined with STSGs was used to help heal the wound without faecal diversion.

Case presentation

A 47-year-old male patient was admitted with extensive perineum fascia necrosis caused by Pseudomonas aeruginosa that rapidly spread to near the anus. After comprehensive therapy completed wound bed preparation, STSGs from the scalp were grafted to the wound, and NPWT was applied to improve STSGs survival and seal the anus without faecal diversion.

After treatment, graft take was 95%, and the exposed testicular and residual wounds were repaired with a local skin flap. At discharge, the wound had decreased to two pea-sized areas. The patient received conventional moist gauze therapy to close the residual wound at the local hospital. A follow-up by telephone 1 month later showed that both wounds had healed and that the patient was satisfied with the outcome.

Conclusion

NPWT use combined with STSGs to cover the whole wound and the anus without faecal diversion is a safe and effective method to help with wound healing and avoid contamination with excrement.

Case report: treatment of Fournier's gangrene of the shoulder girdle

Fournier's gangrene is a rare, high-mortality infection that affects the subcutaneous tissue with rapidly progressive necrosis. The objective is to report a case of Fournier's gangrene involving the region of the shoulder girdle after closed fracture of the clavicle, and to discuss this unusual evolution. The patient underwent a series of surgical procedures and was followed up on an outpatient basis for 12 months, at which point she was discharged. Fournier's gangrene is an aggressive lesion and requires early diagnosis (clinical-laboratory correlation) with the appropriate adequate surgical approach and clinical stabilization.

Fournier's Gangrene: A Review and Outcome Comparison from 2009 to 2016

Objective: The outcome of Fournier's gangrene (FG) may be affected by comorbidities, demographics, and choice of treatment modality. We sought to evaluate our institution's management protocol of FG measured by mortality rate (MR) and length of hospital stay (LHS) in a retrospective cohort study. Approach: A database of 20 FG cases at our institution throughout the 2009-2016 study period was assembled by a retrospective review of medical records. A Fournier's Gangrene Severity Index Score (FGSIS) was calculated for each case. Data were analyzed for statistical significance using logistic regression. Results: The most common presentation of FG at our institution was a hyperglycemic diabetic male in his fifth decade of life with a second risk factor such as recent surgery or active malignancy. The average FGSIS was 9 overall and 14 for the mortalities. An increased FGSIS was predictive of having an increased MR or hospital stay above the median (>25 days) (p = 0.0194). The average LHS was 32 days overall, 22 days for patients treated with hyperbaric oxygen therapy and 40 days for patients treated with tangential hydrosurgery. Overall MR was 15%. Innovation: This is the second known study to characterize usage of tangential hydrosurgery in the management of FG. Conclusion: Treatment outcomes at our institution are comparable to those reported in recent literature, a significant decline from the historical MR of 50-60%.

Case series of Fournier's gangrene: Affected body surface area - The underestimated prognostic factor

Objectives

Identifying the factors affecting the outcome of patients with Fournier's Gangrene and assaying the accuracy of the Fournier Gangrene Severity Index (FGIS), the Uludag score (UdS), affected Body Surface Area (BSA) and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) model as prognostic tools.

Materials and methods

Retrospective study involving all patients with Fournier's gangrene treated in our Hospital between January 2008 and December 2015. The epidemiological, clinical, biochemical and management data of these patients was obtained and analyzed.

Results

The series includes 19 patients, 14 male and 5 female, with a median age of 70 (62; 78,5) years. The mortality rate was 21%. From the data analyzed, only the affected BSA (BSA>3.25%) was associated with mortality (p = 0.016). None of the established scores (FGSI; UdS; LRINEC) proved to be a useful tool for predicting mortality. The combination of affected BSA and FSGI (FGSI≥9 or BSA>3.25%), (p = 0.004) and the combination of the affected BSA and the LRINEC model (LRICEC≥8 and BSA>3.25%), (p = 0.004) led to a major improvement in these scores.

Conclusions

Affected BSA is a useful prognostic factor in Fournier's gangrene. The existing prognostic scores can be improved with the introduction of this factor.

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Fournier's gangrene is a devastating disease that challenges the modern medicine.

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Predicting the outcome may be a crucial step in his management.

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Current scores are not always effective.

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Affected body surface area is a key factor in patients outcome.

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Current scores may be improved with the inclusion of affected body surface area.

Uncommon Locations of Gas Gangrene Treated Successfully With Surgical Debridement and the Vacuum-Assisted Closure Device

Gas gangrene is a life-threatening condition implying necrosis of dermis and hypodermis, along with necrosis of the superficial muscular aponeurosis. Fournier s gangrene is a subtype of the disease affecting the perineal and genital area. The aim of this study is to analyze the clinical presentation, diagnosis, medical, and surgical treatment of three cases of gas gangrene affecting uncommon locations in the human body, treated with extensive surgical debridement followed by the vacuum assisted closure method in two of these cases. Three cases of gas gangrene affecting uncommon locations treated surgically in our Department are presented. In one case the perineal and scrotal region was infected with invasion of the lateral abdominal wall and the peritoneal cavity. In the second case the axillary regions were infected bilaterally and in the third case the left axillary and subscapular regions were infected after a left arm disarticulation. All cases were treated successfully with successive surgical debridement and/or the vacuum-assisted closure method. Gas gangrene is a curable disease if diagnosed early and treated effectively with successive surgical wound cleaning and debridement. The vacuum assisted closure method can be helpful in promoting wound healing.

Long-term follow-up of Fournier's Gangrene in a tertiary care center

BACKGROUND

After surgical debridement, the use of fecal diversion systems (such as an endo-rectal tube or surgical colostomy) in Fournier's Gangrene (FG) to assist with wound healing remains controversial.

METHODS

A 6-y retrospective review of a tertiary medical center emergency surgery database was conducted. Variables abstracted from the database include patient demographics, laboratory and physiological profiles, hospital length-of-stay, intensive care unit length-of-stay, operative data, time to healing, morbidity, and mortality.

RESULTS

Thirty-five patients were treated. Seventy-seven percent (n = 27) required some form of fecal diversion (21 patients using an endo-rectal tube and six patients undergoing construction of a surgical colostomy). One patient had a pre-existing colostomy before the development of FG. The remaining seven patients underwent conservative wound care with multiple daily dressing changes (no diversion system). Twenty-eight of the 35 patients (80.0%) had long-term follow-up with 100% having completely healed surgical wounds at the final clinic visit. Average time to complete wound healing was 4.8 ± 1.0 mo (range, 1.0-31.0). Of the six patients who underwent colostomy formation, two had their colostomies reversed, two were unacceptable surgical risk and did not undergo reversal (due to uncontrolled diabetes and cardiovascular disease), and two were lost to follow-up. Of the two patients who had their colostomies reversed both had complications from their reversal (leak and urinary retention).

CONCLUSIONS

Surgical colostomy may not be mandatory (and might be associated with a high additional morbidity) in FG. With appropriate patient selection, it may be possible to avoid colostomy formation using a less-invasive diversion technology without compromising patient outcomes.

Fournier's gangrene: Causes, presentation and survival of sixty-five patients

Objective:

To report our experience with Fournier’s Gangrene (FG) over the past eight years and evaluate the predisposing factors which affect the mortality.

Methods:

Sixty-five patients who were admitted to emergency surgical unit of our institution presenting with FG between January 2006 and August 2014 were included. The anatomical site of infective gangrene, predisposing factors, etiological factors, and outcomes were retrospectively reviewed.

Results:

Our cases included 8 women and 57 men. The average age of men was 51±13.9 (range 19-75) and the average age of women was 63±10.5 (range 52-76). Average hospitalization time was 9.2±6.6 days (range 5-25) days. The most frequent comorbid disease was diabetes mellitus and the most frequent etiology was perianal abscess. Colostomy was performed in 11 patients, orchidectomy in two patients, cystostomy in two patients. Notably, all of the 8 (12.3%) patients who died from FG had diabetes and low socioeconomic status. A total of six patients who died required more than one surgical debridement.

Conclusions:

Fournier’s gangrene is a severe surgical emergency, with a high mortality rate. Low socioeconomic status, diabetes and more than one debridement play a major role in mortality and morbidity.

Fournier's Gangrene: Epidemiology and Outcomes in the General US Population

PURPOSE

Case series reported 20-40% mortality rates for patients with Fournier's gangrene with some series as high as 88%. This literature comes almost exclusively from referral centers.

MATERIALS AND METHODS

We identified and analyzed inpatients with Fournier's gangrene who had a surgical debridement or died in the US State Inpatient Databases.

RESULTS

One thousand six hundred and forty one males and 39 females with Fournier's gangrene represented <0.02% of hospital admissions. Overall, the incidence was 1.6 cases per 100,000 males and case fatality was 7.5%. Sixty six percent of hospitals cared for no cases per year, 17% cared for 1 case per year, 10% cared for 2 cases per year, 4% cared for 3 cases per year, 1% cared for 4 cases per year, and only 1% cared for ≥5 cases per year. Teaching hospitals had higher mortality (adjusted OR 1.9) due primarily to more acutely ill patients. Hospitals treating more than 1 Fournier's gangrene case per year had an adjusted 42-84% lower mortality (p < 0.0001).

CONCLUSIONS

Most hospitals rarely care for Fournier's gangrene patients. The population-based mortality rate (7.5%) was substantially lower than the case series from tertiary care centers. Hospitals that treated more number of Fournier's gangrene patients had lower mortality rates, thereby supporting the rationale that regionalized care worked well for patients with this rare disease.

Locally advanced adenocarcinoma of the rectum presenting with necrotising fasciitis of the perineum: successful management with early aggressive surgery and multimodal therapy

Colorectal cancer is a common malignant neoplasm and its treatment usually involves surgery associated, in some cases, depending on the staging, with chemoradiotherapy. Necrotising fasciitis of the perineum is a highly lethal infection of the perineum, perirectal tissues and genitals, requiring emergency surgical debridement, broad-spectrum antibiotics and control of sepsis. We present the case of a 59-year-old man with necrotising fasciitis of the perineum as the first clinical manifestation of locally advanced adenocarcinoma of the rectum, in which successful management consisted of early and aggressive surgical debridement, followed by multimodal therapy with curative intent. 2 years and 6 months after surgery the patient is well, with no evidence of local or systemic relapse.

Fournier gangrene in pregnancy

BACKGROUND

Fournier gangrene is a rare and rapidly progressive necrosis of the perineal and genitourinary region. Although predominantly affecting men, we describe an unusual presentation in pregnancy.

CASE

A 30-year old primigravid woman in the third trimester of pregnancy presented with a history of low back pain. Subsequently, a diagnosis of perianal sepsis and associated Fournier gangrene was established. The patient underwent an emergency cesarean delivery followed by radical surgical debridement and colostomy.

CONCLUSION

Expedited delivery, timely diagnosis of gangrene, urgent, extensive debridement, and broad-spectrum antibiotic coverage contributed largely to effective management of this rare presentation in pregnancy.

Negative pressure wound therapy applied before and after split-thickness skin graft helps healing of Fournier gangrene: a case report (CARE-Compliant)

Fournier gangrene is a rare but highly infectious disease characterized by fulminant necrotizing fasciitis involving the genital and perineal regions. Negative pressure wound therapy (NPWT; KCI USA Inc, San Antonio, TX) is a widely adopted technique in many clinical settings. Nevertheless, its application and effect in the treatment of Fournier gangrene are unclear. A 47-year-old male patient was admitted with an anal abscess followed by a spread of the infection to the scrotum, which was caused by Pseudomonas aeruginosa. NPWT was applied on the surface of the scrotal area and continued for 10 days. A split-thickness skin graft from the scalp was then grafted to the wound, after which, NPWT utilizing gauze sealed with an occlusive dressing and connected to a wall suction was employed for 7 days to secure the skin graft. At discharge, the percentage of the grafted skin alive on the scrotum was 98%. The wound beside the anus had decreased to 4 × 0.5 cm with a depth of 1 cm. Follow-up at the clinic 1 month later showed that both wounds had healed. The patient did not complain of any pain or bleeding, and was satisfied with the outcome. NPWT before and after split-thickness skin grafts is safe, well tolerated, and efficacious in the treatment of Fournier gangrene.

Fournier's ganrene in the HIV era

BACKGROUND

Fournier's gangrene is a devastating condition that affects mostly patients whose immunity has been reduced. There is increasing evidence for increasing incidence of the disease in those with HIV disease.

OBJECTIVE

To evaluate the presentation, bacteriology and outcome of Fournier's gangrene in our area in recent times in view of the high prevalence in Nairobi and its environs.

RESULTS

One hundred and forty six patients were treated for Fournier's gangrene during the study period; all were male. They had a mean age of 38.6 years (range 2 months - 86 years). HIV infection was the most common associated underlying illness (16.4 %), followed by diabetes mellitus and alcoholism (11%).

CONCLUSIONS

HIV infection is emerging as leading predisposing factor and has overtaken diabetes in predisposing for Fournier's gangrene in Kenyatta National Hospital.

A clinical case of Fournier's gangrene: imaging ultrasound

Fournier's gangrene is a rapidly progressing necrotizing fasciitis involving the perineal, perianal, or genital regions and constitutes a true surgical emergency with a potentially high mortality rate. Although the diagnosis of Fournier's gangrene is often made clinically, emergency ultrasonography and computed tomography lead to an early diagnosis with accurate assessment of disease extent. The Authors report their experience in ultrasound diagnosis of one case of Fournier's gangrene of testis illustrating the main sonographic signs and imaging diagnostic protocol.

Fournier's Gangrene as a Postoperative Complication of Inguinal Hernia Repair

Fournier's gangrene is the necrotizing fasciitis of perianal, genitourinary, and perineal regions. Herein, we present a case of scrotal Fournier's gangrene as a postoperative complication of inguinal hernia repair. A 51-year-old male with giant indirect hernia is presented. Patient underwent inguinal hernia repair, and after an unproblematic recovery period, he was discharged. He applied to our outpatient clinic on the fifth day with swollen and painful scrotum and it turned out to be Fournier's gangrene. Polypropylene mesh was not infected. Patient recovered and was discharged after repeated debridements. Basic principles in treatment of Fournier's gangrene are comprised of initial resuscitation, broad-spectrum antibiotics therapy, and early aggressive debridement. In the management of presented case, aggressive debridement was made right after diagnosis and broad-spectrum antibiotics were given to the hemodynamically stable patient. In these circumstances, the important question is whether we could prevent occurrence of Fournier's gangrene.

Emergence of antibiotic-resistant bacteria in patients with Fournier gangrene

BACKGROUND

This study was conducted to investigate the bacteriology and associated patterns of antibiotic resistance Fournier gangrene.

METHODS

Patients with Fournier's gangrene from 2008 to 2012 were identified from the computerized database in a medical center in southern Taiwan. The medical records of all patients with Fournier's gangrene were reviewed retrospectively.

RESULTS

There were 61 microorganisms, including 60 bacteria and one Candida spp, isolated from clinical wound specimens from 32 patients. The most common isolates obtained were Streptococcus spp. (n=12), Peptoniphilus spp. (n=8), Staphylococcus aureus (n=7), Escherichia coli (n=7), and Klebsiella pneumoniae (n=7). Among 21 strains of gram-negative bacilli, five (23.8%) were resistant to fluoroquinolones, and three isolates were resistant to ceftriaxone. Two E. coli strains produced extended-spectrum beta-lactamase. Four of the seven S. aureus isolates were methicillin-resistant. Among 15 anaerobic isolates, nine (60%) were resistant to penicillin, and eight (53.3%) were resistant to clindamycin. Four (26.7%) isolates were resistant to metronidazole. The only independent risk factor associated with mortality was inappropriate initial antibiotic treatment (p=0.021).

CONCLUSION

Antibiotic-resistant bacteria are emerging in the clinical setting of Fournier gangrene. Clinicians should use broad-spectrum antibiotics initially to cover possible antibiotic-resistant bacteria.

Enterostomy can decrease the mortality of patients with Fournier gangrene

AIM: To determine the significance of enterostomy in the emergency management of Fournier gangrene.

METHODS: The clinical data of 51 patients (49 men and 2 women) with Fournier gangrene who were treated at our hospital over the past 12 years were retrospectively analyzed. The patients were divided into two groups according the surgical technique performed: enterostomy combined with debridement (the enterostomy group, n = 28) or debridement alone (the control group, n = 23). Patients in the enterostomy group received thorough debridement during surgery and adequate local drainage after surgery, as well as administration of broad-spectrum antibiotics. The clinical data and outcomes in both groups were analyzed.

RESULTS: The surgical procedures were successful in both patient groups. In the enterostomy group, 10 (35.8%) patients required skin grafting with a total of six debridement procedures. While in the control group, six (26.1%) patients required four debridement procedures. However, this difference was not statistically significant. Following surgery, the time to normal body temperature (6 d vs 8 d, P < 0.05) and average length of hospital stay (14.3 ± 7.8 d vs 20.1 ± 8.9 d, P < 0.05) were shorter in the enterostomy group. The case fatality rate was lower in the enterostomy group than that in the control group (3.6% vs 21.7%, P < 0.05).

CONCLUSION: Enterostomy can decrease the case fatality rate of patients with Fournier gangrene.

Fournier's gangrene in a patient with obesity and B-lymphoma

We present a case of Fournier's gangrene disease in a young obese patient with coexistent B-lymphoma. It remains controversial if obesity constitutes a predisposing factor for an individual to develop necrotizing fasciitis. On the other hand, only few cases of patients with coexistence of B-lymphoma and Fournier's gangrene disease have been reported. A 30-years-old obese man was admitted to emergency department with fever (38.7 °C), pain, erythema and swelling extended from the left scrotum to the left lower abdominal quadrant. He was confused, with low urinary excretion and septic shock's signs. The clinical findings were characteristics of Fournier's gangrene disease. Furthermore during physical examination a massive, painless and motionless mass in the left breast was revealed. The patient required urgent surgical debridement of the affected area and pus drainage. Biopsies of the breast mass were received by excision. Pus and blood cultures yielded Staphylococci coagulase(-), Klebsiella and Proteus sp. Intravenous antibiotic treatment with Meropeneme and Clindamycine started immediately. Repeated debridement was often performed. Pathology examination of the massive tissue revealed a diffuse B-lymphoma of large cells (Germinal center B-cell like- GCB). The patient was discharged from the hospital 35 days later. Afterwards, he was treated with chemotherapeutic agents for malignant lymphoma at the oncological department. The aim of this case's presentation is to mention that young obese patients with Fournier's gangrene disease should be particularly investigated due to the possible occurrence of another not obvious predisposing factor, such as a malignant disease.

Causative pathogens, antibiotic sensitivity, resistance patterns, and severity in a contemporary series of Fournier's gangrene

OBJECTIVE

To identify the causative pathogens and evaluate the antibiotic sensitivity, resistance patterns, and virulence in a contemporary series of patients with Fournier's gangrene.

MATERIALS AND METHODS

The medical records of 41 consecutive cases of Fournier's gangrene were evaluated. The patient demographics, causative pathogens, antibiotic sensitivity, and resistance patterns were assessed. The Fournier's gangrene severity index and length of stay were analyzed statistically to determine any differences by causative pathogen.

RESULTS

A total of 122 pathogens were cultured. The wound cultures were polymicrobial for 34 patients (83%). Most common pathogens cultured were Bacteroides sp (43.9%), Escherichia coli (36.6%), and Prevotella sp (34.1%). E coli was resistant to fluoroquinolones and trimethoprim/sulfamethoxazole in 13.3%, and 40% of isolates respectively. The wound cultures were monomicrobial for 7 patients (17.0%). A monomicrobial isolate of methicillin-resistant Staphylococcus aureus was cultured that was susceptible to clindamycin and trimethoprim/sulfamethoxazole. Resistance to ampicillin-sulbactam was seen in Providencia sp, Klebsiella sp, E coli, and methicillin-resistant S aureus. Resistance to ceftriaxone and gentamicin was seen in methicillin-resistant S aureus and E coli, respectively. No resistance to clindamycin was demonstrated. No statistically significant difference was detected between the Fournier's gangrene severity index or length of stay and the causative pathogens.

CONCLUSION

Fournier's gangrene remains a community-acquired polymicrobial infection, with anaerobic bacteria as the most common causative pathogens. Candida and methicillin-resistant S aureus are emerging causative pathogens, but methicillin-resistant S aureus remains sensitive to clindamycin and trimethoprim/sulfamethoxazole. Although resistance was demonstrated by some causative pathogens, together, the currently recommended broad-spectrum antibiotics adequately covered all pathogens. Coverage with agents such as fluconazole, vancomycin, or piperacillin-tazobactam is indicated in patients at risk of fungal or hospital-acquired organisms.

Scrotal and perineal reconstruction

The scrotal and perineal area serves a special function. It is the pelvic outlet for the gastrointestinal tract, urinary system, and sexual function. In the male, the scrotum allows testicular mobility to reduce trauma and allow optimal thermal regulation for spermatogenesis. Trauma, infection, and cancer resection create defects that require reconstruction. The reconstructive goal here is to obtain durable coverage, function, and lastly aesthetic outcome. Pedicled local and regional flaps are the mainstay for this area. Due to the special function and appearance of the scrotum, reconstructive options for total scrotal defect always fall far short of the native scrotum. On the other hand, perineal reconstruction is overall satisfactory.

A case of Fournier's gangrene after liver transplantation: treated by hyperbaric oxygen therapy

Fournier's gangrene (FG) is known as a rapidly progressing necrotizing fasciitis arising from genitourinary and colorectal infections. Misdiagnoses have occurred often because the initial presentation varies and is unclear. We report a case of FG in a 59-year-old man who had undergone a living donor liver transplant. He was in the maintenance phase of immunosuppressant treatment. FG occurred rapidly without symptoms and required prompt and aggressive debridement. Computed tomography demonstrated a small air density in his left testis. Treatment with hyperbaric oxygen therapy followed by intra- operative Gram's staining navigated debridement was additionally performed with general systematic anti-biological therapy and successfully cured the patient. Extra caution should be paid to patients who are maintained on immunosuppressants. Earlier detection and intervention will reduce the rate of mortality to a minimum.

Fournier's gangrene developing secondary to infected hydrocele: A unique clinical scenario

We report the first case of Fournier's gangrene (FG) developing secondary to an infected hydrocele worldwide. We present a case report with a brief overview of the literature relating to FG and its aetiology, diagnosis and management. A 70 year-old male was referred by his General Practitioner with a 2 week history of worsening symptoms of scrotal discomfort and swelling. Following clinical examination, an initial diagnosis of an infected right-sided hydrocele was made and treatment, consisting of antibiotics, was initiated. Despite showing good clinical improvement, several days later, necrotic areas were observed over the right hemiscrotum with spreading cellulitis. A diagnosis of FG was made. The patient was started on triple-therapy antibiotics and taken to the operating room for urgent surgical debridement. Necrotic skin and subcutaneous tissue extending over the perineum and lower anterior abdomen was debrided down to healthy tissue. A further debridement took place 2 days later. The patient continued to improve and was eventually discharged under the care of Plastic Surgeons for reconstruction of the soft tissue defect. FG is a type of necrotising fasciitis predominantly affecting the male perineal, perianal, genital and anterior abdominal wall regions. It has a significant mortality rate, and the key to survival is early detection and treatment consisting of antibiotics and surgical debridement of the affected area. To the best of our knowledge, this is the first reported case of FG developing secondary to an existing hydrocele without any prior urological intervention. The case highlights the important clinical diagnostic and therapeutic interventions required to prevent complications associated with this, potentially fatal, condition.

What are the indications for a stoma in Fournier's gangrene?

AIM

This study examined the indications for a stoma in patients with Fournier's gangrene and its impact on outcome.

METHOD

Patients with Fournier's gangrene were retrospectively reviewed for indications for a stoma. Patients with and without a stoma were compared, based on demographics, disease severity, surgical therapy, length of hospital stay, clinical outcome and cost.

RESULTS

Forty-four patients (median age 57 years, range 28-77 years) were evaluated. Eighteen had a temporary stoma and 26 did not. A stoma was 5 times more likely in males. Patients with Fournier's gangrene originating from an anorectal disorder received a stoma more often than patients with disease originating from an urogenital disorder. Clinical outcomes were similar for patients with or without a stoma. Stoma closure was associated with an extra cost of about $6650 per patient.

CONCLUSION

Stoma creation in the management of Fournier's gangrene was needed for selected patients. Having a stoma did not appear to affect outcomes and resulted in a significant increase in cost of care.

Manejo da gangrena de Fournier: experiência de um hospital universitário de Curitiba

OBJETIVO: Analisar os resultados obtidos no Serviço de Cirurgia Geral do Hospital Universitário Cajuru - PUCPR, com o tratamento da gangrena de Fournier. MÉTODOS: Foram revisados os prontuários de 40 pacientes com diagnóstico de Gangrena de Fournier internados no hospital universitário Cajuru de Novembro de 1999 a Abril de 2006, analisando-se as variáveis: sexo, idade, fatores predisponentes, etiologia, localização da lesão, exames laboratoriais, procedimentos cirúrgicos realizados, antibioticoterapia e utilização de câmara hiperbárica. RESULTADOS: A etiologia mais comum foi de origem anorretal. O agente etiológico mais prevalente foi a E. coli. O fator predisponente predominantes foi a diabetes mellitus, A maioria dos pacientes eram do sexo masculino. A localização e extensão da lesão mais freqüente foi a perineal. Todos foram submetidos à desbridamento cirúrgico, 17 à colostomia e dois à cistostomia. Todos os pacientes utilizaram antibiótico, sendo os mais usados: metronidazol e gentamicina. Vinte e seis pacientes submeteram-se à terapia hiperbárica. A mortalidade global foi de 20%. CONCLUSÃO: A Síndrome de Fournier, apesar de todos os avanços terapêuticos atuais, continua apresentando altos índices de mortalidade. O reconhecimento precoce da infecção associado a tratamento agressivo e invasivo são medidas essenciais para se tentar diminuir esses índices prognósticos.

Diagnosis and treatment of perianal necrotizing fasciitis

Perianal necrotizing fasciitis (PNF) is a serious infectious disease that results from a synergistic action of multiple bacteria and has a high mortality rate. In the early stage of PNF, symptoms are highly variable. Early diagnosis and adequate treatment are important for the prognosis of PNF. Therapeutic measures for PNF include surgical removal of necrotic tissue, drainage, debridement and full dose of broad-spectrum antibiotics. In this article, we will review the recent advances in the diagnosis and treatment of PNF.

Fournier's gangrene: an analysis of 80 patients and a novel scoring system

BACKGROUND

To create a better scoring system for outcome prediction for patients with Fournier's gangrene in order to design more appropriate and feasible management strategies.

METHODS

Using logistic regression, the medical records of 80 patients who underwent surgery for Fournier's gangrene in the last 10 years were reviewed using a prospectively maintained database, and a novel scoring system was adopted combining this data with the Fournier's gangrene severity index (FGSI). The new system consists of a physiological score, an age score, and an extent of gangrene score.

RESULTS

The mortality rate of the 80 patients was 21%. Using the new scoring system (UFGSI), at a threshold value of 9, there was a 94% probability of death with a score greater than 9 and an 81% probability of survival with a score of 9 or less (P < 0.001). The receiver operating characteristics (ROC) analysis concluded that the new scoring system was more powerful than the FGSI (P = 0.002).

CONCLUSIONS

The power of the novel scoring system introduced in this study proves that in patients with Fournier's gangrene, the extent of the gangrene as well as the patient's age and physiological status have a significant effect on the outcome.

Fournier's gangrene: management and mortality predictors in a population based study

PURPOSE

The Fournier's gangrene literature comes almost exclusively from tertiary referral centers. We used a population based database to evaluate variations in management and outcomes.

MATERIALS AND METHODS

Inpatients with Fournier's gangrene who underwent surgical débridement or died were identified from select states in the State Inpatient Databases. Multivariate logistic regression analysis was done to evaluate patient and hospital related predictors of mortality.

RESULTS

We identified 1,641 males with Fournier's gangrene treated at a total of 593 hospitals. At teaching hospitals more Fournier's gangrene cases were treated per year, and more surgical procedures, débridements and supportive care were reported. Patients treated at teaching hospitals had longer length of stay, greater hospital charges and a higher case fatality rate. Patient related predictors of mortality were increasing age (adjusted OR 4.0 to 15.0), Charlson comorbidity index (adjusted OR 1.20 per additional comorbidity), preexisting conditions, ie congestive heart failure (adjusted OR 2.1), renal failure (adjusted OR 3.2) and coagulopathy (adjusted OR 3.4), and hospital admission via transfer (adjusted OR 1.9), after adjusting for hospital factors and Fournier's gangrene experience. Teaching hospitals had higher mortality due primarily to more acutely ill patients (adjusted OR 1.9). Hospitals where more than 1 Fournier's gangrene case per year were treated had 42% to 84% lower mortality after adjusting for patient age, race, Charlson comorbidity index and admission via transfer (p <0.0001).

CONCLUSIONS

Teaching and nonteaching hospitals differ substantially in the populations, case definitions, and severity and management of Fournier's gangrene. Hospitals where more patients with Fournier's gangrene were treated had lower mortality rates, supporting the rationale for regionalized care for this rare disease.

The clinical characteristics of female patients with Fournier's gangrene

INTRODUCTION AND HYPOTHESIS

Our aim was to review our experience with Fournier's gangrene in female patients.

METHODS

A retrospective review of ten consecutive female patients with Fournier's gangrene was performed. Etiological and predisposing factors, causative microbiological organisms, and clinical outcome were investigated.

RESULTS

Mean age of the patients was 52.7 years, and the mean duration of hospitalization was 17.6 days. The etiologic origin of the gangrene was anorectal, dermatological, and urogenital infection in 50%, 20%, and 10% of patients, respectively. All patients underwent aggressive surgical debridement and a diverting colostomy. Nine patients survived, and one patient died for an overall mortality rate of 10%.

CONCLUSIONS

Fournier's gangrene occurred in females with a pattern similar to that in males. We believe that a colostomy is an integral part of management for patients requiring extensive debridement, especially if the infection arises in the anorectal region.

New insights into the epidemiology and etiology of Fournier's gangrene: a review of 33 patients

BACKGROUND

Fournier's gangrene is a necrotizing fasciitis involving the perineal and genital regions. Even today, this often polymicrobial infection still carries a high mortality rate and continues to be a major challenge to the medical community. The purpose of this study was to report our experience with this condition and to compare it with those reported in published studies. We also introduce our approach to treatment.

METHODS

We analyzed data from 33 patients with Fournier's gangrene who were managed in our hospital from 1996 to 2007, focusing on patient gender, age, etiology, predisposing conditions, comorbidities, bacteriology, sepsis, blood results, mortality, and spread of gangrene.

RESULTS

18 (54.5%) of the 33 patients had been referred to our department by smaller district hospitals. The patient cohort consisted of 23 men and ten women with a median age of 59 years (range 40-79 years). The median time between the onset of symptoms and progression to gangrene was 6 days (range 2-28 days). An underlying cause was identified in 27 patients (81.8%). The commonest etiological events were perianal and perirectal abscesses (n = 13; 39.4%). Predisposing factors included diabetes mellitus in 12 cases (36.4%), chronic alcoholism in ten cases (30.3%), immunosuppression in six cases (18.2%), and prolonged immobilization in five cases (15.2%). 17 patients (51.5%) had a body mass index (BMI) of 25 or higher, and 13 patients (39.4%) had a BMI of 30 or higher. Positive cultures were obtained in 30 cases (90.9%). In 26 cases (78.8%), multiple microorganisms were recovered, including nine cases (27.3%) with both aerobes and anaerobes. Sepsis was present in 26 patients (78.8%). The mortality rate was 18.2%.

CONCLUSION

Fournier's gangrene remains a major challenge with a high mortality. Our results suggest that women are more commonly affected than has generally been assumed. Contrary to published reports, we found that anorectal sources appear to account for more cases of Fournier's gangrene than urological sources.

Fournier's Gangrene after Open Hemorrhoidectomy without a Predisposing Factor: Report of a Case and Review of the Literature

Fournier's gangrene (FG) is a fatal synergistic infectious disease with necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and vulva in women. An unpredictable case of FG two weeks after open hemorrhoidectomy in a previously healthy 55-year-old male is described. Full-thickness patchy skin necrosis of the perianal, perineal and scrotal region associated with rectal perforation was detected on admission. Prompt radical debridement together with aggressive fluid resuscitation and broad-spectrum antibiotic administration was initiated. Because of rectal involvement, diverting sigmoid colostomy was fashioned. The patient survived after two additional local debridements. Nevertheless, loss of sphincter function due to massive muscle destruction led to permanent colostomy. Our case together with others reported in the literature illustrates that, although rare, FG after open hemorrhoidectomy represents a life-threatening complication to otherwise healthy patients. The development of fever and urinary retention should draw the attention of the surgeon, even if the presentation is delayed. The current literature only briefly mentions the potential risk of FG after such a common surgical procedure. However, devastating complications occur more often than anticipated. This disastrous complication without predisposing factor is discussed along with a literature review.

Fournier's gangrene: vacuum-assisted closure versus conventional dressings

BACKGROUND

Fournier's gangrene is a fulminant and destructive inflammation of the scrotum, penis, and perineum. The objective of this study was to compare 2 different approaches to wound management after aggressive surgical debridement.

METHODS

Data from 35 patients with Fournier's gangrene were prospectively collected (1996-2007). Once the patients were stabilized following surgery, they were treated with either daily antiseptic (polyhexanide) dressings (group I, n = 16) or vacuum-assisted closure (VAC) therapy (group II, n = 19).

RESULTS

The mean age of the patients was 58.2 years in group I and 57.2 years in group II. In both groups, the most common predisposing conditions were diabetes mellitus, chronic alcoholism, and obesity. Escherichia coli, streptococcal species, Pseudomonas aeruginosa, and Staphylococcus aureus were the most frequently isolated organisms. Length of hospital stay was 27.8 days +/- 27.6 days (mortality: 37.5%) in group I and 96.8 days +/- 77.2 days (mortality: 5.3%) in group II. Enterostomies were performed in 43.8% of group I patients and in 89.5% of group II patients.

CONCLUSIONS

VAC was associated with significantly longer hospitalization and lower mortality. A partial explanation is that some patients with severe sepsis died within the first 3 days after admission and thus could not undergo vacuum therapy. Since our clinical experience has shown that vacuum dressings are particularly effective in the management of large wounds, we use VAC primarily for this indication despite the considerable material requirements involved.

Fournier's gangrene: is it scrotal gangrene?

INTRODUCTION

Fournier's gangrene was originally described as scrotal gangrene in young males. Today, it is generally accepted as synergistic necrotizing fasciitis of perineal, genital, or perianal regions, and the epidemiologic data have changed. However, there are still limited data about females due to the lack of female patients, even in large case series.

METHODS

A retrospective review of the medical records of all patients who received surgery for emergency conditions over the past 22 years was performed to identify patients with Fournier's gangrene. Data from these patients were then reviewed to determine the age, gender, etiology, causative bacteria, predisposing factors, treatment modalities, length of hospital stay, and morbidity and mortality rates associated with Fournier's gangrene. Data were evaluated using multivariate analyses.

RESULTS

Sixty-five patients (20 female) were identified with the diagnosis of Fournier's gangrene. The mean age was 50.8 years. The most common etiology was hemorrhoidectomy in male and perianal abscess in female patients. The most commonly isolated microorganism in both male and female patients was Escherichia coli. Twenty-nine patients had diabetes mellitus, which was the most common predisposing factor. Mean hospitalization time was 24.4 days and the overall mortality was 27.70%.

CONCLUSION

Fournier's gangrene is still an important disease with high mortality rates in spite of the developments in intensive care units and new-generation antibiotics. It seems that there are no major differences between male and female patients in the characteristics of the condition.