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Hou S, Cheng B, Shen K, Gao Z, Liu F, Ye Y. Fournier's gangrene due to rectal cancer: A case report. Mol Clin Oncol 2024; 20:30. [PMID: 38476336 PMCID: PMC10928661 DOI: 10.3892/mco.2024.2728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/04/2024] [Indexed: 03/14/2024] Open
Abstract
Fournier's gangrene (FG) is an extremely rare necrotizing fasciitis that is insidious, rapidly spreading and life-threatening. FGs due to rectal cancer occur rarely and there is a lack of clinical reference. In the present study, a severe FG due to rectal cancer perforation was described and the features of this rare disease were summarized with a literature review. A 57-year-old man was admitted because of rectal cancer-induced FG. The patient was misdiagnosed with extensive perianal abscess until the intraoperative biopsy confirmed that rectal cancer was the culprit. Incision, debridement and drainage were carried out to reduce infectious burdens. After that, the patient was transferred to Peking University People's Hospital for the subsequent therapy. Empirical broad-spectrum antibiotic therapy was used at the initial stage. Diversional transverse loop colostomy was performed to control infection and resume oral feeding. After four rounds of vacuum-assisted closure (VAC) therapy, radical resection and wound closure were accomplished. The scrotal defect was repaired by a skin flap. Pathological results indicated a moderately differentiated adenocarcinoma with perforation. The patient was discharged from the hospital on postoperative day 15 without any post-operative complications. No signs of recurrence were observed during a 22-month follow-up. In the setting of rectal cancer-induced FGs, the liquid resuscitation, broad-spectrum antibiotic therapy, and prompt debridement are the cornerstones of the initial management. Diversional colostomy and VAC therapy were effective in the management of severe infection and large wounds. The present case report also provided a clinical reference for the implementation of staged surgeries and the perioperative multidisciplinary management of FGs.
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Affiliation(s)
- Sen Hou
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, P.R. China
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing 100044, P.R. China
| | - Baosen Cheng
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, P.R. China
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing 100044, P.R. China
| | - Kai Shen
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, P.R. China
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing 100044, P.R. China
| | - Zhidong Gao
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, P.R. China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, P.R. China
| | - Fan Liu
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, P.R. China
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing 100044, P.R. China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, P.R. China
| | - Yingjiang Ye
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, P.R. China
- Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing 100044, P.R. China
- Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, P.R. China
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Ortega Ferrete A, López E, Juez Sáez LD, García-Pérez JC, Ocaña J, Ballestero A, Fernández-Cebrián JM, Die Trill J. Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform? Langenbecks Arch Surg 2023; 408:428. [PMID: 37932463 DOI: 10.1007/s00423-023-03137-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 10/04/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Fournier's gangrene (FG) is a necrotizing fasciitis affecting the perineum and urogenital tissue. The mortality rate is high although early detection and aggressive debridement can reduce mortality by up to 16%. The prevalence of sequelae is very high and a colostomy is often necessary to control the perineal wound. MATERIAL AND METHODS A retrospective study was carried out to recruit all patients operated on by the General Surgery and Urology Departments with a diagnosis of GF at the University Hospital over 22 years. Mortality, the Fournier gangrene severity index (FGSI), and fecal diversion (either surgical (colostomy) or straight (Flexi-seal)) are collected. RESULTS A total of 149 patients met the inclusion criteria. FG's most frequent cause was a perianal abscess (107 patients-72%). Eighteen patients (12%) died of a specific cause of FG. Age (p = 0.014) and patients with an oncological history (p = 0.038) both were the only mortality risk factors for mortality according to logistic regression. Fifty patients required some form of fecal diversion in the postoperative period (32 colostomies and 18 Flexi-seal). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality. CONCLUSIONS One in eight patients died in the immediate postoperative period secondary to FG. Despite improved outcomes, 22% required a colostomy during admission. However, neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality. Non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible.
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Affiliation(s)
- Ana Ortega Ferrete
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Km 9.1, 28034, Madrid, Spain
| | - Enrique López
- Urology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Luz Divina Juez Sáez
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Km 9.1, 28034, Madrid, Spain.
- Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain.
| | - Juan Carlos García-Pérez
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Km 9.1, 28034, Madrid, Spain
- Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
- Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Juan Ocaña
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Km 9.1, 28034, Madrid, Spain
- Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - Araceli Ballestero
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Km 9.1, 28034, Madrid, Spain
- Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - Jose María Fernández-Cebrián
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Km 9.1, 28034, Madrid, Spain
- Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - Javier Die Trill
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Km 9.1, 28034, Madrid, Spain
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Hughes T, Bowen D, Saeed K, Juliebø-Jones P, Somani B. Management of Fournier's gangrene: a practical guide for clinicians. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 37769264 DOI: 10.12968/hmed.2023.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Fournier's gangrene is a localised form of necrotising fasciitis affecting the external genitalia, perineal and perianal regions. Although rare, it is associated with high rates of morbidity and mortality, so clinician awareness is essential for prompt treatment. Risk factors include diabetes mellitus, hypertension, chronic alcoholism and immunosuppression. Perineal pain in patients with sepsis should be treated with a high level of suspicion and early surgical referral is required as prompt debridement can improve outcomes. Repeated surgical intervention and antimicrobial therapy are often needed and recovery can take a long time, with a long-term impact on quality of life. This article discusses the natural history of Fournier's gangrene, aetiology, risk factors, investigations and treatments with an algorithm to support clinical practice.
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Affiliation(s)
- Thomas Hughes
- Department of Urology, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - Daniel Bowen
- Department of Urology, Mid and South Essex NHS Foundation Trust, Chelmsford, UK
| | - Kordo Saeed
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | | | - Bhaskar Somani
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Ghabisha S, Ahmed F, Al-Wageeh S, Badheeb M, Alyhari Q, Altam A, Alsharif A. Prognostic determinants and treatment outcomes of Fournier's Gangrene treatment in a resource-limited setting: A retrospective study. Arch Ital Urol Androl 2023; 95:11450. [PMID: 37491981 DOI: 10.4081/aiua.2023.11450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/08/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Fournier's gangrene (FG) is a destructive necrotizing infection with a generally poor prognosis. This study aims to share our experience in handling FG patients in a resource-limited setting and identify prognostic factors for FG mortality. METHODS A retrospective study of thirty-six patients diagnosed with FG and treated at our teaching hospital between Jun 2010 to Oct 2022 was conducted. Laboratory and nonlaboratory data and patients' outcomes were gathered. A univariate analysis was computed for identifying prognostic factors for FG mortality. RESULT The main age was 68.30 ± 5.61years and most (69.4%) were older than 65 years. The overall survival was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age (p = 0.02), delayed in hospital presentation (p = 0.024), involvement of larger area (p = 0.001), a history of diabetes mellitus (p < 0.006), end-stage renal disease (p = 0.018), heart failure (p = 0.005), cerebrovascular accident (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidities (p = 0.001), septic conditions at admission (p = 0.048), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mortality in patients with FG. CONCLUSIONS Fournier's gangrene is a fulminant condition with a high mortality rate, especially in resource-limited settings. In this study, the mortality rate was 36.1%. Advanced age, delayed in hospital presentation, involvement of larger area, a history of diabetes mellitus, end-stage renal disease, heart failure, cerebrovascular accident, liver cirrhosis, presence of multiple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality.
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Affiliation(s)
- Saif Ghabisha
- Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb.
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb.
| | - Saleh Al-Wageeh
- Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb.
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport.
| | - Qasem Alyhari
- Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb.
| | - Abdulfattah Altam
- Department of General Surgery, School of Medicine, 21 September University, Sana'a.
| | - Afaf Alsharif
- Department of Gynaecology, School of Medicine, Jeblah University for Medical and Health Sciences, Ibb.
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Zhang KF, Shi CX, Chen SY, Wei W. Progress in Multidisciplinary Treatment of Fournier's Gangrene. Infect Drug Resist 2022; 15:6869-6880. [PMID: 36465810 PMCID: PMC9717591 DOI: 10.2147/idr.s390008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/10/2022] [Indexed: 07/27/2023] Open
Abstract
Fournier's gangrene (FG) is a life-threatening and special form of necrotizing fasciitis, characterized by occult onset, rapid progress and high mortality, occurring mainly in men over 50 years of age. Risk factors of FG include diabetes, HIV infection, chronic alcoholism and other immunosuppressive state. FG was previously considered as an idiopathic disease, but in fact, three quarters of the infections originated from the skin, urethra and gastrointestinal tract. Initial symptoms of FG are often inconsistent with severity and can progress promptly to fatal infection. Although the treatment measures of FG have been improved in recent years, the mortality does not seem to have decreased significantly and remains at 20% - 30%. The time to identify FG and the waiting period before surgical debridement are directly related to the prognosis. Therefore, in addition to the combination of intensive fluid resuscitation and broad-spectrum antibiotics, treatment of FG should particularly emphasize the importance of early surgical debridement assisted with fecal diversion and skin reconstruction when necessary. This paper is to briefly summarize the progress in the definition, epidemiology, clinical manifestations, diagnosis, treatment and prognosis of Fournier's gangrene in recent years, more importantly, illustrates the importance of multidisciplinary cooperation in the management of FG.
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Affiliation(s)
- Ke-Fan Zhang
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Chuan-Xin Shi
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Si-Yu Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, People’s Republic of China
| | - Wei Wei
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
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Bowen D, Juliebø-Jones P, Somani BK. Global outcomes and lessons learned in the management of Fournier's gangrene from high-volume centres: findings from a literature review over the last two decades. World J Urol 2022; 40:2399-2410. [PMID: 36059020 DOI: 10.1007/s00345-022-04139-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/15/2022] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION Fournier's Gangrene (FG) carries a high mortality and morbidity with underreported short and long-term outcomes. Our aim was to perform a review of the recent literature to evaluate the short and long-term outcomes in patients with FG in the acute setting from large-scale studies. METHODS A PubMed search was performed between January 2000 and December 2021 for studies reporting on patients with FG. Exclusion criteria included small samples (n < 100), review articles and animal studies. Primary outcomes of interest were mortality, number of operative episodes for surgical debridement and admission to intensive care unit (ICU). Other outcomes assessed included rate of faecal and urinary diversion, orchidectomy rate, penectomy rate and length of hospital stay. RESULTS From a total of 1182 studies, 18 were eligible for inclusion and included in this review. In total, data were analysed from 13,903 FG patients. Mean inpatient mortality rate was 7.3% (range 4.7-40.4%). Mean number of surgical debridement operations performed was 1.8 (range 1.5-4.2). On average, 6.8% (range 3.6-50.5%) and 7% (range 1.2-53.2%) underwent faecal and urinary diversions, respectively. Mean rate of orchidectomy was 5.6%, with rate of penectomy being lower at 0.2%. The mean length of hospital stay was 18.5 days (range 13.0-26.6). On average, 17.5% (range 10.1%-67.5%) required ICU admission for at least a single-system support. CONCLUSION Our review from the past twenty years of literature suggests that the mortality for FG, whilst still high, has fallen compared to previous years. Whilst inpatient metrics are well-covered in the literature there is a lack of large-scale studies detailing long-term patient outcomes.
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Affiliation(s)
- Daniel Bowen
- University Hospital Southampton NHS Trust, Southampton, UK
| | - Patrick Juliebø-Jones
- Department of Urology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - B K Somani
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK.
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