Necrotizing Fasciitis of the Perineum and the Abdominal Wall-Surgical Approach

Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

The Value of Fournier's Gangrene Scoring Systems on Admission to Predict Mortality: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review and meta-analyze the predictive value of the Fournier gangrene severity index (FGSI), the simplified FGSI (SFGSI), and the Uludag FGSI (UFGSI) on mortality in patients affected by Fournier's Gangrene (FG).

METHODS

A search was performed in PubMed, Web of Science, Embase, and the Cochrane Library, from January 2000 to May 2023, to identify original cohorts comparing data between surviving and non-surviving FG patients. The statistical analysis consisted of two parts. First, the mean and standard deviation (SD) of the FGSI, SFGSI, and UFGSI at admission were extrapolated from each study, and the pooled mean difference (MD) with 95% confidence interval (95% CI) was obtained using the Der Simonian-Laird random-effect model. Second, to evaluate the accuracy of the FGSI, SFGSI, and UFSGI in predicting mortality, true positive (TP), false positive (FP), true negative (TN), and false negative (FN) values were extracted where possible and reported in 2 × 2 contingency tables. The sensitivity, specificity, and AUC values were pooled, and summary receiver operating characteristic (SROC) curves were constructed.

RESULTS

Overall, forty studies comprising 2257 patients were included. The pooled analysis revealed that the FGSI, SFGSI, and UFGSI values at admission were higher in non-survivors than survivors (MD: 5.53 (95% CI: 4.68-6.37); MD: 2.41 (95% CI: 1.06-3.77); and MD: 5.47 (95% CI: 3.68-7.26), respectively). Moreover, the AUC values of the FGSI, SFGSI, and UFGSI were 0.90 (95% CI: 0.87-0.92), 0.84 (95% CI: 0.80-0.87), and 0.94 (95% CI: 0.92-0.96), respectively.

CONCLUSIONS

The higher scores of the FGSI, SFGSI, and UFGSI on admission were associated with mortality. Moreover, when comparing accuracy rates, the UFGSI exhibited the highest AUC value.

Risk factors for mortality in fournier's gangrene in a general hospital: use of simplified founier gangrene severe index score (SFGSI)

Objective

To evaluate risk factors for mortality in patients with Fournier's gangrene (FG), with emphasis in the Simplified Fournier Gangrene Severe Index Score (SFGSI).

Materials and Methods

This was a cross-sectional study that was carried out from January 2010 to December 2014, with 124 patients treated for FG in a General Hospital. Several clinical and laboratory variables, including SFGSI, were evaluated and correlated with mortality through univariate analysis and logistic regression.

Results

Of the 124 patients, 99 were men (79.8%), the mean age was 50.8±19.5 years and the main comorbidity was diabetes mellitus (51.6%). The mortality rate was 25.8%. Variables that presented independent correlation with mortality were the extension of the lesion to the abdomen (OR=4.0, CI=1.10-14.68, p=0.03), hematocrit (OR=0.81, CI=0.73-0.90, p<0.0001), potassium (OR=2.41, CI=1.13-5.10, p=0.02) and creatinine (OR=2.15, CI= 1.04-4.41, p=0.03). When hematocrit, potassium and creatinine were tested together, as part of the SFGSI, a >2 result was the largest of the independent predictors of mortality (OR=50.2; CI=13.18-191.47; p<0.0001).

Conclusion

The SFGSI >2 presented a higher correlation with mortality than any variable tested alone. It seems to be a promising alternative to evaluate predictors of mortality in Fournier's gangrene. The main advantage is easy applicability because it contains only three parameters and can be used immediately after patient's admission.

Fournier's gangrene (necrotising fasciitis) complicated by renal and respiratory insufficiency: a case report

A case report of a 68-year-old male obese diabetic patient with an abscess of left femoral region, and diffuse inflammation of abdominal wall and genital region developing sepsis, respiratory and renal failure. At admission in the regional hospital a diagnosis of polymicrobial necrotising fasciitis with suspected sepsis was declared. The patient was transferred to the special intensive care unit (SICU) of Burns and reconstructive surgery at the Kosice-Saca. The patient was treated surgically, with hyperbaric oxygen and pharmacologically to control his diabetes. The main aetiological agent of the condition was identified as Stenotrophomonas maltophilia. In addition to respiratory and metabolic acidosis and gastric bleeding occurred. Due to acute renal failure (day 38) the patient was transferred to clinic of anaesthesiology and the intensive care medicine at the University Hospital in Kosice. The patient was treated by continuous veno-venous haemodialysis, mechanical ventilation and nasogastric nutritional support. On day 48 the conscious sub-febrile patient with healed wounds was transferred back to the regional hospital with ventilation support and continuous renal replacement therapy. His diabetes was uncontrolled, and only kidney parameters remained pathological. The survival of this patient with an extremely poor prognosis was achieved through prompt transfer to a specialised centre, early identification of the aetiological agent and immediate appropriate antibiotic treatment as a result of good cooperation between surgeons and laboratory specialists.

Fournier’s gangrene: outcome analysis of 62 consecutive cases

Objectives:

The objective of this article is to study the outcome of management of 62 consecutive cases of Fournier’s gangrene (FG).

Patients and methods:

We conducted an observational study of all cases of FG admitted to the Urology and General Surgery departments of Farwaniya Hospital, Kuwait, between 2004 and 2013. We recorded the laboratory and clinical findings on admission. Operative and postoperative data were also recorded.

Results:

Our study included 62 cases of FG. Patients were divided into two groups: Group A (survival) consisted of 55 cases and Group B (mortality) of seven cases. The mean duration of symptoms before admission was significantly longer in the mortality group (3.86 days versus 1.96 days in survival group) ( p < 0.05). The mean duration of symptoms until time of first debridement was also significantly longer in the mortality group (4.39 days versus 2.35 days in survival group) ( p < 0.05). There was also a statistically significant difference between the two groups regarding the percentage of the affected area in relation to total body surface area (4.6% in Group A versus 8% in Group B) ( p < 0.05). The Fournier Gangrene Severity Index score (FGSI) was significantly higher in Group B (10.26) in comparison to Group A (6) ( p < 0.01). The mean duration of hospital stay was significantly higher in the survival group (22.24 days versus 14.28 days) ( p < 0.01). Diabetes and renal failure were significantly higher in the mortality group (100% and 57.1% in Group B versus 54.5% and 9.1% in Group A, respectively) ( p < 0.05). The number of patients presenting with severe sepsis was higher in the mortality group (71.4% in Group B versus 12.7% in Group A) ( p < 0.05).

Conclusion:

We concluded that FG is a serious, potentially fatal disease. Higher mortality is related to severe sepsis on admission, renal failure, diabetes, extensive disease involving extra-genital areas and late presentation. A multidisciplinary approach in diagnosis and management of the disease can achieve good outcome with low mortality rate.

Comparison of Diverting Colostomy and Bowel Management Catheter Applications in Fournier Gangrene Cases Requiring Fecal Diversion

In some patients of Fournier gangrene originated from perianal region, it is important to prevent fecal contamination in order to provide healing without wound infection. For this purposes, diverting colostomy or bowel management catheter methods were performed. In this study, it is aimed to carry out a comparison of prognosis and cost efficiency between diverting colostomy and bowel management catheter methods applied for preventing fecal contamination in Fournier's gangrene patients. Fourty-eight patients with diagnosis of Fournier's gangrene, serious perianal infections, and preserved sphincters and without rectum injury after debridement were included in the study. The cases were divided into two groups as patients who were subjected to colostomy for fecal diversion and who were subjected to bowel management catheter without colostomy. Then, the groups were compared in terms of age, predisposing factors, duration of hospital stay, mortality, additional surgery requirements, and cost. Fourty-eight patients were included the study. Sixteen patients were treated without colostomy. Decreased duration of total hospital stay, additional surgery requirements, and hospital expense in bowel management catheter group has determined. It is thought that preferring bowel management catheter method instead of colostomy in patients without rectum injury, who require diverting colostomy and have undamaged anal sphincters, can relieve patients, patients' relatives, healthcare organizations, and the national economy of a serious burden. In addition, although patients' satisfaction and workforce loss factors are not taken into consideration in this study, the bowel management catheter method is thought to have positive effects also on these parameters.

Fournier's gangrene: etiology and outcome analysis of 41 patients

INTRODUCTION

Fournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area with high mortality.

MATERIALS AND METHODS

A retrospective review included 41 patients diagnosed with FG in our hospitals from 1995 to 2010, divided into survivors and nonsurvivors. We analyzed anamnestic, clinical and laboratory data.

RESULTS

The mortality rate was 36.6% (15/41 patients). Elevated heart and respiratory rates, high serum creatinine, low serum bicarbonate, pre-existing kidney disease, and higher median extent of affected body surface were associated with higher mortality. Severe sepsis on admission and hypotension below 90 mm Hg were also predictive for higher mortality. The median FG severity index (FGSI) score was higher in nonsurvivors (11 compared to 6, p < 0.0001). No cases of testicular necrosis were noted.

CONCLUSION

Besides standard clinical and laboratory parameters included in the FGSI calculation, higher extent of affected body surface area and presence of hypotension on admission were also positively associated with mortality.

Fournier's gangrene: analysis of prognostic variables in 34 patients

INTRODUCTION

Fournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area. The objective of this study was to assess risk factors for mortality.

MATERIALS AND METHODS

We conducted an analytic and retrospective study of the patients with FG treated at our institution between 1998 and 2008. Statistical analysis was performed with the Statistical Package for Social Science for Windows, version 15.0, using the Mann-Whitney test for quantitative variables, and the chi-square and Fisher exact tests for qualitative variables, in univariate analyses.

RESULTS

Of the 34 patients treated, 25 survived (74%) and 9 died (26%) with a median timing of 29 days (13, 60). Statistically significant differences were not found in age, sex and predisposing factors, except heart disease (p = 0.034). Admission laboratory parameters and severity criteria showed significant differences in serum urea (p = 0.007), potassium (p = 0.008), alkaline phosphatase (p = 0.014) and Fournier's gangrene severity index score (FGSIS) (p = 0.008). Others factors such as duration of symptoms before hospital admission, extent of body surface area, number of surgical debridements, additional surgical manoeuvers (supra-pubic catheterization or colostomy), microbiological cultures and ICU stay did not show significant differences.

CONCLUSIONS

FG is a life-threatening necrotizing fasciitis with a high mortality rate. In our study, prognostic variables were heart disease, admission serum urea, potassium, alkaline phosphatase, and FGSIS. More studies are needed to validate these findings.