Fournier's gangrene: report of six cases

Hyperbaric oxygen therapy decreases mortality due to Fournier's gangrene: a retrospective comparative study

There is no consensus about the role of adjunctive hyperbaric oxygen therapy (HBOT) in the management of Fournier's gangrene. The aim of this study was to compare the evolution of patients with Fournier's gangrene treated with all classical measures with and without adjuvant HBOT. A retrospective comparative study regarding the evolution of patients treated for Fournier's gangrene was conducted in two periods. In period I, from 1990 to 2002, patients received standard treatments for Fournier's gangrene, which consisted of surgical debridement, antibiotic therapy and intensive care. In period II, from 2012 to 2019, adjunctive HBOT was added to the classical management strategy. All patients were assigned into four groups according to the anatomical severity classification and the area affected after the first debridement. This classification ensured that the groups could be comparable. The total number of patients in this study was 197, and these patients were divided into control group (118/59.9%) and HBOT group (79/40.1%). The mean age, comorbidities, and anatomical severity classification were similar between the two groups. In period I, 34 out of 118 (28.8%) patients died, while in the HBOT group, 3 out of 77 (3.7%) patients died (P < 0.001). The use of adjuvant HBOT in combination with classical treatment was associated with reduced mortality. This study was approved by the Institutional Review Board and the Ethics Committee of Ribeirão Preto Medical School, University of São Paulo, Brazil (No. 08/2018) on May 2, 2018.

Fournier's gangrene secondary to an acutely inflamed appendix herniating into the deep inguinal ring

Fournier's gangrene (FG) requires prompt recognition and management. We report the case of a 68-year-old man who presented with extensive pain and purple discolouration from the right iliac fossa to perineum. Computed tomography demonstrated gas within the right hemiscrotum extending into the inguinal canal and right buttock, with a right pelvic fluid and air collection. At debridement necrotic fluid was arising from the superficial inguinal ring so laparotomy was performed, revealing a grossly inflamed appendix herniating into the inguinal canal; a right hemicolectomy was performed. Unfortunately, the patient went into cardiac arrest and passed away on the operating table. Histological analysis demonstrated acute-on-chronic inflammation involving the appendix. The condition where appendicitis is implicated in FG is usually due to retroperitoneal rupture and tracking into the perineal spaces. This is the first case reported of an inflamed appendix herniating into the inguinal canal and thus causing FG.

[Perineal-scrotal gangrene: epidemiological and therapeutic aspects. About 45 cases]

Perineoscrotal gangrene is an acute disease, a rare and severe affection of the perineum, whose evolution is unpredictable and rapidly extensive. The diagnosis is clinical. The paraclinical examinations allow early diagnosis and assessment of anatomical and biological repercussions. We conducted a retrospective study of 45 patients spread over six years, involving a multidisciplinary team consisting of three specialists (urologists, visceral, plastic surgeons). The average age was 52 years. The largely male dominated our series. Fournier gangrene was the most common etiology. We noted five cases of death (11%) in the acute phase, secondary to septic shock (four patients) or multiple organ failure (one patient). The evolution was favorable in 40 other patients in the series, requiring an initial management in intensive care unit, and surgical treatment. The average hospital stay was 17 days. After the acute phase, all patients underwent a surgery for skin coverage, ranging from guided healing (two patients) to musculocutaneous flap of the gracilis (six patients) via the secondary suture (four patients), the burying the testes (18 patients) and half thick skin graft, with a functional and aesthetic result was acceptable, and minimal sequelae. In our series, the most predictive prognostic factors would be the delay of care, sepsis on admission and associated diseases.

Fournier's gangrene: a dreadful disease

BACKGROUND

Although there is much consensus, certain controversies still exist regarding the pathology of Fournier's gangrene. The purpose of this study was to determine the prevalence of the disease in the catchment area of the three teaching hospitals, to identify the systemic predisposing factors and local aetiological factors, and to assess the recommended role of aggressive surgical debridement as a part of treatment.

MATERIALS AND METHODS

This prospective study was conducted in the surgical departments of three tertiary care hospitals of the Khyber Medical University, Peshawar, Pakistan, from 1 January 2002 to 30 June 2007. Detailed history and examination of all patients were carried out to reach the diagnosis of Fournier's gangrene. After initial resuscitation, patients were treated aggressively, including surgical debridement.

RESULTS

Sixty patients were studied in the study period. The male to female ratio was 5:1. The age range was 20-75 years with mean 47+17.4 (SD) years. The socioeconomic status of patients was poor (the average income was less than $50 per week) in 36 (60%) and 24 (40%) were middle class (the average income being $50-100 per week). Thirty-nine patients (65%) presented in the hot humid months of the year. Extent of the disease was scrotum in 18 patients (30%), perineum in 30 (50%) and abdominal wall in 12 (20%). Systemic predisposing factors identified in our study were diabetes mellitus in 20 (33.33%) patients, chronic alcohol abuse in two (3.33%) and long-standing steroid therapy in four (6.67%) while in 34 patients (56.67%) no cause was identified. The local aetiological origin of Fournier's gangrene was urogenital in 14 (23.33%) patients, anorectal in 10 (16.67%) and cutaneous in 8 (13.33%) and no local pathologies could be identified in 28 (46.67%) patients. The mean time interval between first symptom and initial treatment was 2.5 days with a range of 1-7 days. Number of debridement sessions per patient was 2-6 (mean, 3.15). Mean hospital stay was 31+7 (SD) with a range of 10-50 days. Morbidity was 80%. Four patients (6.67%) died. Three of these patients presented to hospital 5-6 days too late.

CONCLUSION

Fournier's gangrene is not an uncommon disease in South Asia. Systemic predisposition such as diabetes mellitus, long-standing steroid therapy, chronic alcoholism and even the hot humid season can contribute to this dreadful disease. Local causes in the form of urogenital, anorectal and cutaneous disorders may trigger this disease in some patients. Early recognition of disease and aggressive surgical debridement are the main treatments.

Fournier gangrene: role of imaging

Fournier 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 gangrene is often made clinically, emergency computed tomography (CT) can lead to early diagnosis with accurate assessment of disease extent. CT not only helps evaluate the perineal structures that can become involved by Fournier gangrene, but also helps assess the retroperitoneum, to which the disease can spread. Findings at CT include asymmetric fascial thickening, subcutaneous emphysema, fluid collections, and abscess formation. Subcutaneous emphysema is the hallmark of Fournier gangrene but is not seen in all cases. Compared with radiography and ultrasonography, CT provides a higher specificity for the diagnosis of Fournier gangrene and superior evaluation of disease extent; however, diagnosis and evaluation can also be performed with these other modalities. The administration of broad-spectrum antibiotics and aggressive surgical débridement of the nonviable tissue are both essential for successful treatment. An awareness of the CT features of Fournier gangrene is imperative for prompt diagnosis and effective treatment planning.

Fournier's gangrene: exists and it is still lethal

BACKGROUND

Fournier's gangrene is an aggressive form of necrotizing fascitis of the perineal, perianal or genital regions, caused by a polymicrobial infection that includes virulent organisms.

PATIENTS AND METHODS

Eleven cases of Fournier's gangrene were treated in our department during the last 20 years. Portals of entry were ischiorectal abscess, perirectal abscesses, scrotal abscess and trauma in the perianal area. The documents were analyzed according to clinical and epidemiologic patterns.

RESULTS

We dispensed systemic chemotherapy with broad-spectrum antibiotics, and performed surgical debridement for all patients. In addition, one patient was treated by local use of 100% oxygen, with excellent results in wound healing. All patients made a full recovery, except one who died of sepsis.

CONCLUSION

These cases are presented with some notes underlying the reasons for the persisting incidence and mortality of this disease.

Management of Fournier's gangrene: review of 45 cases

PURPOSE

Fournier's gangrene is a fatal synergistic infectious disease with necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and the vulva in women.

METHODS

The clinical and operative records of 45 patients with Fournier's gangrene during a 14-year period were analyzed.

RESULTS

The etiology of the infection was identified in 39 patients. The most common causes were colorectal diseases and urogenital diseases. Four patients died with an overall mortality of 8.8%. The mortality rate was higher in patients with diabetes mellitus, but it was not statistically different. The age, duration of the symptoms, and the presence of rectal abscess were not found to be significant factors regarding mortality rate.

CONCLUSIONS

Surgery with extensive debridement of all necrotic tissue is the main stay of treatment.

Factors affecting mortality of Fournier's gangrene: review of 70 patients

BACKGROUND

Fournier's disease is a potentially fatal, acute, gangrenous infection of the scrotum, penis or perineum associated with a synergistic bacterial infection of the subcutaneous fat and superficial fascia.

METHODS

The clinical records of 70 patients treated for Fournier's gangrene were evaluated retrospectively to determine prognostic indices and to stress Fournier's Severity Index (FSI), influencing outcome.

RESULTS

The mortality rate in this study was 22.8%. Length of the hospitalization time and FSI were detected as effective factors on mortality of Fournier's gangrene (P < 0.05) by Binary Logistic Regression analysis and the area under the receiver operating characteristic curve of these variables was also found to be significant (P < 0.001). The average FSI was determined as 4.66 +/- 2.31 in survivors and 11.56 +/- 2.68 in non-survivors and 5.11 +/- 2.83 in patients with primary genito-urinary infection but 7.56 +/- 4.35 in primary anorectal infection. The FSI was also found predictive of hospitalization time and number of debridements among survivors.

CONCLUSION

Fournier's Severity Index is a simplified way of comparing patients with this disease and may also have some significance in predicting outcome. The FSI is a more significant and predictive tool that should be popularized to predict the prognosis in Fournier's gangrene.

Fournier's gangrene: a review of 43 reconstructive cases

BACKGROUND

Fournier's gangrene is a rare and potentially fatal infectious disease characterized by necrotic fasciitis of the perineum and abdominal wall, along with the scrotum and penis in men and the vulva in women. Fournier's gangrene is a true surgical emergency. Skin loss can be very incapacitating and difficult to repair.

METHODS

The authors reviewed retrospectively the clinical records of a series of 43 patients with Fournier's gangrene between the years 1985 and 2003 who, after initial treatment by the Departments of Urology and Surgery, were referred to the Department of Plastic Surgery for reconstruction. The following parameters were evaluated: age, gender, interval between onset of symptoms and diagnosis, clinical symptoms, lesion site, results of bacteriologic cultures, cause and predisposing factors, treatment and reconstructive procedures, length of hospital stay, and outcome.

RESULTS

The mean patient age was 56.6 years. Fifteen patients (34.9 percent) had diabetes mellitus. The cause of Fournier's gangrene was found in 32 patients (74.4 percent). The most common presentation was scrotal swelling, and scrotal involvement was found in 40 cases (93.0 percent). All of the patients underwent surgical debridement, and several reconstruction techniques were used. The mean length of hospital stay was 73.6 days. Two patients died.

CONCLUSIONS

Management of this infectious entity should be aggressive. Several techniques that are used to reconstruct the lost tissue have shown good results. The superomedial thigh skin flap has proven to be a reliable method of resurfacing large scrotal defects. Reconstructive surgery makes the return to a normal social life possible in many cases.

A life-threatening infection: Fournier's gangrene

Fournier's gangrene is a life-threatening disorder in which infection of the perineum and scrotum spreads along fascial planes, causing soft tissue necrosis. If urgent surgery is delayed, the disease will soon result in septic shock, multiorgan failure, and death. In this study, we present 21 patients with Fournier's gangrene who were treated in period between 1994 and 2001. Patients' charts were reviewed retrospectively and are discussed in the light of literature. All patients received aggressive surgical debridment. Penicillin or Ceftriaxone, aminoglicoside and metronidazole were administered intravenously. Of the 21 patients, 5 had scrotal carbuncle, 1 had urethral stricture, 1 had chronic indwelling urethral catheterization, 2 had perirectal abscess, and 1 had hemorrhoidectomy. In eleven patients we couldn't identify any cause. Twelve patients had diabetes mellitus, and two had chronic alcoholism. Escherichia coli was isolated in 12 purulent tissue cultures, and Bacteroides fragilis in eight. Seventeen patients survived, whereas four died. Fourier's gangrene is considered a surgical emergency. Early surgical intervention is essential, as the gangrene can spread rapidly at rates reaching 2 mm per hour. So that Fournier's gangrene is an abrupt, rapidly progressive, gangrenous infection of the external genitalia and perineum and is a real urologic emergency.

[Perineo-scrotal gangrene: apropos of 31 cases]

Fournier's gangrene is a fascitis of the perineum and of the external genitalia. It is a serious infection with rapid evolution and a severe prognosis. It is also unpredictable towards the necrosis. It concerns a series of 31 cases of the perineal scrotal gangrene supervised in the department of surgical visceral emergency of the Ibn Rochd University hospital of Casablanca between 1992 and 2000. In this investigation, the male predominance is important and the mean age is 49 years. The diagnostic delay is 12 days. The symptomatology was dominated by edema and erythema signs, fever and pain. The skin necrosis was seated in the perineum and the scrotum. A septic shock was noticed in six patients and a condition of deep coma in two other patients. Etiology of gangrene was of coloproctologic origin in 15 cases and of urogenital origin in five patients. The bacteriological parietal swabs was positive in 11 cases. The therapeutic take-in-charge consisted of urgent measures of reanimation for six patients. The likely wide spectrum antibiotic therapy consisting of a triple association (beta lactam antibiotic, nitrite-imidazole compound and aminoglycoside) with a secondary adaptation that was recommended for all patients. All the patient underwent surgical debridement of the necrotic tissue with incisions and drainage of the involved areas of the of all the operated-on patients, 26 had colostomy, five among them had both colostomy and cystostomy. The overall evolution was favorable except in eight cases of death. In all, the authors insist on the positive diagnosis as well as the early take-in-charge of the disease to avoid complications of local or general order and recommended the preventive treatment with the precocious treatment of the causing infection.