1
|
Huang S, Chen DC, Perera M, Lawrentschuk N. Role of diverting colostomy and reconstruction in managing Fournier's gangrene-a narrative review. BJU Int 2024; 134:534-540. [PMID: 38626885 DOI: 10.1111/bju.16365] [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] [Indexed: 09/25/2024]
Abstract
OBJECTIVE To examine the role of bowel diversion and reconstructive surgeries in managing Fournier's gangrene (FG) to facilitate multidisciplinary collaboration between urologists, colorectal and plastic surgery teams. METHODS A review of the literature was conducted using the databases Medline, Embase, PubMed in June 2023. The review included studies that evaluated the outcomes of FG following reconstructive surgeries or diverting colostomies. RESULTS The existing evidence suggests that bowel diversion and colostomy formation could reduce the need for further debridement, shorten the time to wound healing, and facilitate skin graft or flap uptake in patients with FG. Additionally, the psychological impact of a stoma was shown not to be a major concern for patients. However, stoma carries a risk of perioperative complications and therefore may prolong the length of hospital stay. In reviewing the evidence for reconstruction in FG, large and deep defects seem to benefit from skin grafts or flaps. Noticeably, burial of testicles in thigh pockets has grown out of favour due to concerns regarding the thermoregulation of the testicles and the psychological impact on patients. CONCLUSION The use of bowel diversion and reconstructive surgeries in managing FG is case dependent. Therefore, it is important to have close discussions with colorectal and plastic surgery teams when managing FG.
Collapse
Affiliation(s)
- Siyu Huang
- University of Melbourne, Parkville, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David C Chen
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Young Urology Researchers Organisation (YURO), Melbourne, Victoria, Australia
| | - Marlon Perera
- University of Melbourne, Parkville, Victoria, Australia
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Nathan Lawrentschuk
- University of Melbourne, Parkville, Victoria, Australia
- Department of Urology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- EJ Whitten Prostate Cancer Research Centre, Epworth HealthCare, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
Susini P, Marcaccini G, Efica J, Giuffrè MT, Mazzotta R, Caneschi C, Cuomo R, Nisi G, Grimaldi L. Fournier's Gangrene Surgical Reconstruction: A Systematic Review. J Clin Med 2024; 13:4085. [PMID: 39064124 PMCID: PMC11278345 DOI: 10.3390/jcm13144085] [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: 06/06/2024] [Revised: 06/28/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Fournier's gangrene (FG) is a rare form of necrotizing fasciitis of the perineal, genital, or perianal region. It is characterized by an aggressive course and high mortality rate, over 20%. FG demands immediate treatment including resuscitation maneuvers, intravenous antibiotic therapy and early surgical debridement. Background/Objectives: The gold-standard treatment for FG is surgical reconstruction. However, up to date, no precise guidelines exist. Thus, we decided to systematically review the literature, focusing on FG contemporary approaches to reconstructive surgery, aiming to analyze the various reconstructive strategies and their specific indications. Methods: A systematic review was carried out according to the PRISMA statement by searching various databases from April 2014 to April 2024, using the terms ''Fournier Gangrene OR Fournier Gangrene Reconstruction OR Fournier Gangrene Treatment OR Fournier Gangrene Plastic Surgery OR Necrotizing Fasciitis OR Necrotizing Fasciitis AND Reconstruction". The eligibility criteria included original studies aimed at discussing FG reconstruction with at least three clinical cases. Results: The final synthesis included 38 articles, and 576 reconstructions were described. Of these, 77.6% were minimally invasive strategies (direct closure, secondary healing, grafts, and local random flaps), while more invasive reconstructions (loco-regional flaps based on known vascular anatomy) were adopted in 22.4%. No free flaps were reported. Conclusions: FG requires immediate medical interventions including broad-spectrum antibiotic therapy, surgical debridement, adjuvant therapies, and reconstructive surgeries. Taking into account the anatomical characteristics of the inguinal-crural region, skin grafts and local random flaps could offer versatile and effective reconstructions for most FG cases, while the more invasive strategies should be reserved for very few cases. Future research is warranted to define an FG dedicated reconstruction protocol.
Collapse
Affiliation(s)
- Pietro Susini
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (G.M.); (J.E.); (M.T.G.); (R.C.); (G.N.); (L.G.)
| | - Gianluca Marcaccini
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (G.M.); (J.E.); (M.T.G.); (R.C.); (G.N.); (L.G.)
| | - Jessica Efica
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (G.M.); (J.E.); (M.T.G.); (R.C.); (G.N.); (L.G.)
| | - Maria Teresa Giuffrè
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (G.M.); (J.E.); (M.T.G.); (R.C.); (G.N.); (L.G.)
| | - Ruggero Mazzotta
- Division of General Cardiology, Careggi University Hospital, 50134 Florence, Italy;
| | - Corso Caneschi
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, 50134 Florence, Italy;
| | - Roberto Cuomo
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (G.M.); (J.E.); (M.T.G.); (R.C.); (G.N.); (L.G.)
| | - Giuseppe Nisi
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (G.M.); (J.E.); (M.T.G.); (R.C.); (G.N.); (L.G.)
| | - Luca Grimaldi
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (G.M.); (J.E.); (M.T.G.); (R.C.); (G.N.); (L.G.)
| |
Collapse
|
3
|
Alhoukail A, Alrawaf T, Alotaibi A, Alanazi H. Necrotizing Fasciitis in COVID-19 Patient: A Case Report of Atypical Early Presentation. Cureus 2023; 15:e37290. [PMID: 37168208 PMCID: PMC10166124 DOI: 10.7759/cureus.37290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/13/2023] Open
Abstract
A 48-year-old male, known to have hypertension (HTN), ischemic heart disease (IHD) post-percutaneous coronary intervention (PCI) before one year, and morbid obesity (BMI: 60), presented to the emergency department complaining of right thigh pain and swelling that started two days before. The swelling got increasingly worsen over the previous days, associated with dyspnea, for which he sought medical attention in another hospital. He was found to have a picture of sepsis where they offered him irrigation and debridement (I&D) but he refused and presented to our institution in a hemodynamically unstable condition. The patient underwent immediate surgery with subsequent intensive care unit (ICU) admission as a case of necrotizing fasciitis complicated by sepsis. Later he was found to have coronavirus disease 2019 (COVID-19) infection.
Collapse
Affiliation(s)
- Amro Alhoukail
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
| | - Talal Alrawaf
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
| | - Abdullah Alotaibi
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
| | - Hassan Alanazi
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
| |
Collapse
|
4
|
Paladini A, Cochetti G, Tancredi A, Mearini M, Vitale A, Pastore F, Mangione P, Mearini E. Management of Fournier's gangrene during the Covid-19 pandemic era: make a virtue out of necessity. Basic Clin Androl 2022; 32:12. [PMID: 35850577 PMCID: PMC9294754 DOI: 10.1186/s12610-022-00162-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background Fournier’s gangrene (FG) is a necrotizing fasciitis caused by aerobic and anaerobic bacterial infection that involves genitalia and perineum. Males, in their 60 s, are more affected with 1.6 new cases/100.000/year. Main risk factors are diabetes, malignancy, inflammatory bowel disease. FG is a potentially lethal disease with a rapid and progressive involvement of subcutaneous and fascial plane. A multimodal approach with surgical debridement, antibiotic therapy, intensive support care, and hyperbaric oxygen therapy (HBOT) is often needed. We present the inpatient management of an FG case during the Covid-19 pandemic period. A narrative review of the Literature searching “Fournier’s gangrene”, “necrotizing fasciitis” on PubMed and Scopus was performed. Case presentation A 60 years old man affected by diabetes mellitus, with ileostomy after colectomy for ulcerative colitis, was admitted to our Emergency Department with fever and acute pain, edema, dyschromia of right hemiscrotum, penis, and perineal region. Computed tomography revealed air-gas content and fluid-edematous thickening of these regions. Fournier’s Gangrene Severity Index was 9. A prompt broad-spectrum antibiotic therapy with Piperacillin/Tazobactam, Imipenem and Daptomycin, surgical debridement of genitalia and perineal region with vital tissue exposure, were performed. Bedside daily surgical wound medications with fibrine debridement, normal saline and povidone-iodine solutions irrigation, iodoform and fatty gauze application, were performed until discharge on the 40th postoperative day. Every 3 days office-based medication with silver dressing, after normal saline and povidone-iodine irrigation and fibrinous tissue debridement, was performed until complete re-epithelialization of the scrotum on the 60th postoperative day. Conclusions FG is burdened by a high mortality rate, up to 30%. In the literature, HBOT could improve wound restoration and disease-specific survival. Unfortunately, in our center, we do not have HBOT. Moreover, one of the pandemic period problems was the patient’s displacement and outpatient hospital management. For all these reasons we decided for a conservative inpatient management. Daily cleaning of the surgical wound allowed to obtain its complete restoration avoiding surgical graft and hyperbaric oxygen chamber therapy, without foregoing optimal outcomes.
Collapse
Affiliation(s)
- Alessio Paladini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Giovanni Cochetti
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy.
| | - Angelica Tancredi
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Matteo Mearini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Andrea Vitale
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Francesca Pastore
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Paolo Mangione
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Ettore Mearini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| |
Collapse
|
5
|
David R, Traeger L, Kahokehr A, Miller J, Ashrafi A. A prospective case series of Fournier's gangrene at a tertiary centre involving adjacent organs. ANZ J Surg 2021; 91:2817-2823. [PMID: 34125473 DOI: 10.1111/ans.17005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/24/2021] [Accepted: 06/01/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Recent studies of patients with Fournier's gangrene (FG) highlight the importance of early surgical intervention in improving mortality rates. We prospectively determined subgroups of patients with FG at high risk of severe local morbidity. METHODS We prospectively evaluated all patients diagnosed with FG at a tertiary hospital (1 January 2018 to 1 January 2021). Data were collated on demographics, comorbidity, infection source, treatment and clinical outcomes. RESULTS We identified 14 consecutive male patients with a median (interquartile range) age of 57 (50-64) years. Most common risk factors were diabetes (n = 10, 71%) and obesity (n = 10, 71%). Median (range) HbA1c was 11.20 (7.5-15.3), and body mass index of 41.25 (23.7-70.0). Seven patients had adjacent organ involvement (AOI), involving the corporal bodies (57%) and testes (43%). The most common suspected source was dermatological (50%), followed by genitourinary (29%) and gastrointestinal (GI) (21%). Median (interquartile range) hospital length of stay (LOS) was 32 (8.5-30.75) days. Patients with AOI were more likely to have a suspected GI source, need mechanical ventilation (p = 0.023), a significantly longer LOS (p = 0.015) and time to wound closure (p = 0.04). Patients with suspected dermatological origin of infection, had a significantly lower rate of AOI (p = 0.029), mechanical ventilation (p = 0.029) and a shorter LOS (p = 0.035). CONCLUSION In our prospective series, FG is associated with a high rate of AOI and suspected non-dermatological origin of infection, which confers significant perioperative morbidity including the need for mechanical ventilation, LOS and longer time from initial debridement to wound closure.
Collapse
Affiliation(s)
- Rowan David
- Urology Department, Lyell McEwin Hospital, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Luke Traeger
- Colorectal Department, Lyell McEwin Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Arman Kahokehr
- Urology Department, Lyell McEwin Hospital, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - John Miller
- Urology Department, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Akbar Ashrafi
- Urology Department, Lyell McEwin Hospital, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
6
|
Parkin CJ, Acland G, Ilie V, Clayton S, Merei J, Latif E. Sigmoid diverticulitis leading to Fournier's gangrene. ANZ J Surg 2020; 91:E123-E125. [PMID: 32687238 DOI: 10.1111/ans.16164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Cameron J Parkin
- Department of Urology, Gosford Hospital, Central Coast Local Health District, Central Coast Region, New South Wales, Australia
| | - George Acland
- Department of Urology, Gosford Hospital, Central Coast Local Health District, Central Coast Region, New South Wales, Australia
| | - Victor Ilie
- Department of Urology, Gosford Hospital, Central Coast Local Health District, Central Coast Region, New South Wales, Australia
| | - Siobhan Clayton
- Department of Urology, Gosford Hospital, Central Coast Local Health District, Central Coast Region, New South Wales, Australia
| | - Jamal Merei
- Department of General Surgery, Gosford Hospital, Central Coast Local Health District, Central Coast Region, New South Wales, Australia
| | - Edward Latif
- Department of Urology, Gosford Hospital, Central Coast Local Health District, Central Coast Region, New South Wales, Australia
| |
Collapse
|
7
|
Zingaro MD, Boni A, Vermandois JARD, Paladini A, Lepri E, Ursi P, Cirocchi R, Turco M, Gaudio G, Nogara A, Mearini E. Fournier's Gangrene and Intravenous Drug Abuse: an Unusual Case Report and Review of The Literature. Open Med (Wars) 2019; 14:694-710. [PMID: 31934634 PMCID: PMC6947763 DOI: 10.1515/med-2019-0114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 07/09/2019] [Indexed: 12/29/2022] Open
Abstract
Fournier's gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes. In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia. Fournier's gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.
Collapse
Affiliation(s)
- Michele Del Zingaro
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Andrea Boni
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | | | - Alessio Paladini
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Emanuele Lepri
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Pietro Ursi
- Department of General Surgery and Surgical Specialties “Paride Stefanini”;, Sapienza University of Rome, Rome, Italy
| | - Roberto Cirocchi
- Division of General Surgery, Department of Surgical and Biochemical Sciences, University of Perugia, Perugia, Italy
| | - Morena Turco
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Gianluca Gaudio
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Andrea Nogara
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Ettore Mearini
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| |
Collapse
|