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Ji H, Shen W, Zhou X, Zhang L, Zhao X, Tang Q, Guo C. Clostridium ramosum alone caused Fournier's gangrene in an older Chinese patient with abnormal interleukin levels: A rare case report. Heliyon 2024; 10:e33244. [PMID: 39021985 PMCID: PMC11253045 DOI: 10.1016/j.heliyon.2024.e33244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/03/2024] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
Clostridium ramosum is an uncommon Clostridium but is one of the essential anaerobic bacteria that makes up the intestinal microbiota. A highly variable body temperature, the white blood cell count, or an elusory prognosis can reflect Clostridium ramosum infection, especially in patients with Fournier's gangrene. Fournier's gangrene is a rare soft-tissue infection with necrosis that occurs mainly in the perianal and genital regions, males being more susceptible. Here, we report a 70-year-old Chinese man with Fournier's gangrene and high levels interleukins who suffered from Clostridium ramosum infection, identified and verified by matrix-assisted laser desorption ionization/time-of-flight mass spectrometry (MALDI-TOF MS) and 16S rRNA sequencing. Fournier's gangrene severity index (FGSI) of the patient was measured once the patient was admitted to hospital. His FGSI was 6, indicating no abnormal condition. He had abnormally high interleukin (IL)-6, IL-8, and IL-10 levels, associated with severe inflammatory conditions. Despite the patient's resuscitation and standardized treatment with antimicrobial drugs, the symptoms did not improve. The patient's condition deteriorated, and he died on hospitalization day 5. Abnormally elevated IL-6, IL-8, and IL-10 levels were a novel finding in a case of Clostridium ramosum infection, leading to Fournier's gangrene. In the present case, a perianal abscess was the predisposing condition for Fournier's gangrene. Close attention should be paid to the isolation and identification of pathogenic Clostridium ramosum during the bacteriological examination of patients with perianal abscesses. IL-6, IL-8, and IL-10 may be critical biomarkers that supplement the FGSI for diagnosing Clostridium ramosum infection leading to Fournier's gangrene in immunosuppressed persons.
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Affiliation(s)
- Hongjian Ji
- Department of Pharmacy, Jiangsu Vocational College of Medicine, Jiangsu, People's Republic of China
| | - Wei Shen
- Department of Pharmacy, Suqian Hospital, Jiangsu Province Hospital, Jiangsu, People's Republic of China
| | - Xiaohua Zhou
- Department of Internal Medicine, Yancheng Third People's Hospital, Jiangsu, People's Republic of China
| | - Linlin Zhang
- Department of Pharmacy, First People's Hospital of Yancheng, Jiangsu, People's Republic of China
| | - Xin Zhao
- Department of Pharmacy, Nanjing Gaochun People's Hospital, Jiangsu, People's Republic of China
| | - Qinfang Tang
- Department of Laboratory Medicine, Yancheng Third People's Hospital, Jiangsu, People's Republic of China
| | - Cheng Guo
- Department of Pharmacy, Jiangsu Vocational College of Medicine, Jiangsu, People's Republic of China
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Wirjopranoto S, Affandi MR, Ashari FY, Azmi YA, Soetanto KM. Evaluating prognostic indicators for in-hospital mortality in Fournier's gangrene: a 7-year study in a tertiary hospital. Arch Ital Urol Androl 2024; 96:12387. [PMID: 38818786 DOI: 10.4081/aiua.2024.12387] [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: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Fournier's Gangrene Scoring Index (FGSI), Simplified FGSI (SFGSI), Uludag FGSI (UFGSI), Laboratory Risk Indicator for Necrotizing (LRINEC), Neutrophil-Lymphocyte ratio (NLR), and Platelet-lymphocyte ratio (PLR) have been devised to assess the risk of mortality in Fournier's Gangrene (FG) patients. However, the effectiveness of these indicators in predicting mortality at the time of admission remains uncertain. The aim of this study is to assess the prognostic efficacy of FG's various indicators on in-hospital mortality. METHODS This study analyzed 123 patients from Dr. Soetomo General Hospital's emergency department in Indonesia from 2014 to 2020. Data included demographics, wound cultures, and parameters like FGSI, UFGSI, SFGSI, NLR, PLR, and LRINEC. In-hospital mortality status was also recorded. The data was subjected to comparative, sensitivity, specificity and regression analyses. RESULTS In our study of 123 patients, the median age was 52, with a mortality rate of 17.9%. The majority of patients were male (91.1%) and the most common location was scrotal (54.5%). Non-survivors had a shorter median stay (6.5 days) compared to survivors (14 days). Diabetes was the most prevalent comorbidity (61.8%). The highest sensitivity and specificity were found in FGSI and UFGSI indicators. Multivariate logistic regression identified LoS and FGSI as independent predictors of mortality. CONCLUSIONS FGSI and UFGSI, upon admission, demonstrated the highest sensitivity and specificity, with hospital stay duration and FGSI as key mortality determinants.
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Affiliation(s)
- Soetojo Wirjopranoto
- Faculty of Medicine, Universitas Airlangga, Surabaya; Department of Urology, Faculty of Medicine, Universitas Airlangga- Dr. Soetomo General Academic Hospital, Surabaya.
| | | | - Faisal Yusuf Ashari
- Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom; Department of Biomedical Sciences, Faculty of Medicine Universitas Airlangga, Surabaya.
| | - Yufi Aulia Azmi
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Netherlands; Department of Urology, Faculty of Medicine, Universitas Airlangga- Dr. Soetomo General Academic Hospital, Surabaya.
| | - Kevin Muliawan Soetanto
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok.
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Vanguardia MKR, Lew C, Prabhakaran S, Kong JCH. Fournier's gangrene: 15-year retrospective study at a tertiary hospital. BJS Open 2024; 8:zrae022. [PMID: 38626185 PMCID: PMC11020226 DOI: 10.1093/bjsopen/zrae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/23/2023] [Accepted: 01/29/2024] [Indexed: 04/18/2024] Open
Affiliation(s)
- Maria Kristina Rey Vanguardia
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Chen Lew
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Swetha Prabhakaran
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph C H Kong
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Bowen D, Hughes T, Juliebø-Jones P, Somani B. Fournier's gangrene: a review of predictive scoring systems and practical guide for patient management. Ther Adv Infect Dis 2024; 11:20499361241238521. [PMID: 38510990 PMCID: PMC10952983 DOI: 10.1177/20499361241238521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
This article aims to provide a practical guide for patient management and an overview of the predictive scorings for Fournier's gangrene (FG) that are available to aid clinicians. A literature was performed reviewing currently used scoring systems for FG and presenting a practical guide for its management based on the available evidence. There are four specific scoring systems available for the assessment of FG although few other non-specific and generic tools also exist. These specific tools include Laboratory Risk Indicator for Necrotizing Fasciitis, Fournier's Gangrene Severity Index, Uludag Fournier's Gangrene Severity Index, and Simplified Fournier's Gangrene Severity Index and help calculate expected mortality. Our proposed algorithm covers primary assessment, resuscitative interventions, initial investigations, urgent care, post-operative care, and long-term follow-up. The management of the FG patient can be divided into initial resuscitation, surgical debridement, ongoing ward management with antibiotic therapy, wound reconstruction, and long-term follow-up. Each facet of care is vital and requires multidisciplinary team expertise for optimal outcomes. Whilst mortality continues to improve, it remains significant, reflecting the severe and life-threatening nature of FG. More research is certainly needed into how this care is individualised, and to ensure that long-term outcomes in FG include quality of life measures after discharge.
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Affiliation(s)
- Daniel Bowen
- Department of Urology, Mid and South Essex NHS Foundation Trust, Broomfield, UK
| | - Thomas Hughes
- Department of Urology, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | | | - Bhaskar Somani
- University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
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Shiratori T, Nakamura M, Naito A, Yamamoto M, Okura Y, Yamakawa J, Kume H, Suzuki M. Clinical features and treatment outcomes of Fournier's gangrene in a single tertiary emergency hospital: Simplified Fournier's Gangrene Severity Index score is a predictor for death. Glob Health Med 2023; 5:362-365. [PMID: 38162432 PMCID: PMC10730922 DOI: 10.35772/ghm.2023.01051] [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: 04/15/2023] [Revised: 10/08/2023] [Accepted: 11/15/2023] [Indexed: 01/03/2024]
Abstract
To assess the predictive reliability of the Simplified Fournier's Gangrene Severity Index Score (SFGSI) for mortality in Japanese patients with Fournier's gangrene (FG), we compared the clinical features and outcomes of a patient sample with the SFGSI. The medical records of 36 patients diagnosed with FG at our hospital between October 2007 and September 2022 were reviewed retrospectively. Clinical and laboratory variables, including SFGSI, were evaluated and predictive factors for fatality were investigated using multivariate logistic regression analysis. The median age and body mass index were 65 and 24.2, respectively. Eight patients had cooccurring chronic kidney disease and 23 had diabetes. None were taking sodium-glucose co-transporter-2 (SGLT-2) inhibitors. The causative organisms were diverse, and no specific trends in causative organisms were observed. 26 patients underwent debridement of necrotic tissue including eight colostomies, two orchiectomies, and one cystectomy. Multivariate logistic regression analysis revealed that SFGSI alone was an independent predictor of case fatality, with an odds ratio of 20.167 (95% CI: 1.66-245.53). In conclusion, the fatality rate was 19.4%, which was comparable to that reported in other studies. The SFGSI was an independent predictor of mortality in this study.
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Affiliation(s)
- Taichi Shiratori
- Department of Urology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masaki Nakamura
- Department of Urology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Akihiro Naito
- Department of Urology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masahiro Yamamoto
- Department of Urology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yoshihiro Okura
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Jun Yamakawa
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, The University of Tokyo Hospital, Tokyo, Japan
| | - Motofumi Suzuki
- Department of Urology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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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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Tazeoglu D, Benli S, Colak T. Temperature-Neutrophils-Multiple Organ Failure Grading as a Prognostic Indicator in Fournier Gangrene. Surg Infect (Larchmt) 2023; 24:749-754. [PMID: 37768832 DOI: 10.1089/sur.2023.110] [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] Open
Abstract
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.
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Affiliation(s)
- Deniz Tazeoglu
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Sami Benli
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Tahsin Colak
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
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Azmi YA, Alkaff FF, Renaldo J, Wirjopranoto S, Prasetiyanti R, Soetanto KM, Salamah S, Purba AKR, Postma MJ. Comparison of different scoring systems for predicting in-hospital mortality for patients with Fournier gangrene. World J Urol 2023; 41:2751-2757. [PMID: 37580468 PMCID: PMC10581919 DOI: 10.1007/s00345-023-04552-3] [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: 06/04/2023] [Accepted: 07/23/2023] [Indexed: 08/16/2023] Open
Abstract
PURPOSE To compare different scoring systems for predicting in-hospital mortality in patients with Fournier gangrene (FG). METHODS A comprehensive literature search was performed to find all scoring systems that have been proposed previously as a predictor for in-hospital mortality in patients with FG. Data of all patients with FG who were hospitalized in one of Indonesia's largest tertiary referral hospitals between 2012 and 2022 were used. The receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of the scoring systems. RESULTS Ten scoring systems were found, i.e., Fournier's Gangrene Severity Index (FGSI), Uludag FGSI, simplified FGSI, NUMUNE Fournier score (NFS), Laboratory Risk Indicator for Necrotizing Fasciitis, age-adjusted Charlson comorbidity index, sequential organ failure assessment (SOFA), quick SOFA, acute physiology and chronic health evaluation II, and surgery APGAR score (SAS). Of 164 FG patients included in the analyses, 26.4% died during hospitalization. All scoring systems except SAS could predict in-hospital mortality of patients with FG. Three scoring systems had areas under the ROC curve (AUROC) higher than 0.8, i.e., FGSI (AUROC 0.905, 95% confidence interval (CI) 0.860-0.950), SOFA (AUROC 0.830, 95% CI 0.815-0.921), and NFS (AUROC 0.823, 95% CI 0.739-0.906). Both FGSI and SOFA had sensitivity and NPV of 1.0, whereas NFS had a sensitivity of 0.74 and an NPV of 0.91. CONCLUSION This study shows that FGSI and SOFA are the most reliable scoring systems to predict in-hospital mortality in FG, as indicated by the high AUROC and perfect sensitivity and NPV.
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Affiliation(s)
- Yufi Aulia Azmi
- Department of Urology, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Firas F Alkaff
- Division of Pharmacology and Therapy, Department of Anatomy, Histology, and Pharmacology, Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia.
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands.
| | - Johan Renaldo
- Department of Urology, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
| | - Soetojo Wirjopranoto
- Department of Urology, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Rinta Prasetiyanti
- Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Kevin Muliawan Soetanto
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sovia Salamah
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Department of Public Health and Preventive Medicine, Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia
| | - Abdul Khairul Rizki Purba
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Division of Pharmacology and Therapy, Department of Anatomy, Histology, and Pharmacology, Faculty of Medicine Universitas Airlangga, Surabaya, Indonesia
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Institute of Science in Healthy Ageing and Healthcare (SHARE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Unit of Pharmacotherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
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Tufano A, Dipinto P, Passaro F, Anceschi U, Franco G, Flammia RS, Proietti F, Antonelli L, Di Pierro GB, Prata F, Rullo R, Perdonà S, Leonardo C. The Value of Fournier's Gangrene Scoring Systems on Admission to Predict Mortality: A Systematic Review and Meta-Analysis. J Pers Med 2023; 13:1283. [PMID: 37763051 PMCID: PMC10532663 DOI: 10.3390/jpm13091283] [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: 08/05/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
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.
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Affiliation(s)
- Antonio Tufano
- Department of Maternal-Infant and Urological Sciences, “Sapienza” Rome University, Policlinico Umberto I Hospital, 00162 Rome, Italy; (P.D.); (G.F.); (R.S.F.); (F.P.); (L.A.); (G.B.D.P.)
| | - Piervito Dipinto
- Department of Maternal-Infant and Urological Sciences, “Sapienza” Rome University, Policlinico Umberto I Hospital, 00162 Rome, Italy; (P.D.); (G.F.); (R.S.F.); (F.P.); (L.A.); (G.B.D.P.)
| | - Francesco Passaro
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Umberto Anceschi
- Department of Urology, “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (U.A.); (C.L.)
| | - Giorgio Franco
- Department of Maternal-Infant and Urological Sciences, “Sapienza” Rome University, Policlinico Umberto I Hospital, 00162 Rome, Italy; (P.D.); (G.F.); (R.S.F.); (F.P.); (L.A.); (G.B.D.P.)
| | - Rocco Simone Flammia
- Department of Maternal-Infant and Urological Sciences, “Sapienza” Rome University, Policlinico Umberto I Hospital, 00162 Rome, Italy; (P.D.); (G.F.); (R.S.F.); (F.P.); (L.A.); (G.B.D.P.)
| | - Flavia Proietti
- Department of Maternal-Infant and Urological Sciences, “Sapienza” Rome University, Policlinico Umberto I Hospital, 00162 Rome, Italy; (P.D.); (G.F.); (R.S.F.); (F.P.); (L.A.); (G.B.D.P.)
- Department of Urology, “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (U.A.); (C.L.)
| | - Luca Antonelli
- Department of Maternal-Infant and Urological Sciences, “Sapienza” Rome University, Policlinico Umberto I Hospital, 00162 Rome, Italy; (P.D.); (G.F.); (R.S.F.); (F.P.); (L.A.); (G.B.D.P.)
| | - Giovanni Battista Di Pierro
- Department of Maternal-Infant and Urological Sciences, “Sapienza” Rome University, Policlinico Umberto I Hospital, 00162 Rome, Italy; (P.D.); (G.F.); (R.S.F.); (F.P.); (L.A.); (G.B.D.P.)
| | - Francesco Prata
- Department of Urology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy;
| | - Roberta Rullo
- Obstetrics and High-Risk Pregnancy Unit, Department of Woman, Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy;
| | - Sisto Perdonà
- Istituto Nazionale Tumori di Napoli, IRCCS “Fondazione G. Pascale”, Via M. Semmola, 80131 Naples, Italy;
| | - Costantino Leonardo
- Department of Urology, “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (U.A.); (C.L.)
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10
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[Outcome, quality of life and functional assessment after perineal and external genitalia gangrene]. Prog Urol 2023; 33:247-253. [PMID: 36935331 DOI: 10.1016/j.purol.2023.02.008] [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: 01/14/2022] [Revised: 12/22/2022] [Accepted: 02/24/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION External genitalia gangrene is a well-known uncommon disease; however, mortality remains important. Recent literature focuses on early management. The object of this study was to assess quality of life and disease-specific function, in the medium- and long-term. METHOD We evaluated retrospectively adult inpatients with external genitalia gangrene who had a surgical debridement between 2010 and 2020 at CHU de Poitiers. Preoperatory FGSI Score was calculated for patients included. In a second phase, surviving patients at 2020 who had agreed to take part in the follow-up were assessed by clinical examination, and asked to complete Short-Form 36 test and two additional disease-specific questionnaire (USP, IIEF5). RESULTS The patients consisted of 33 men. Mean age was 61.18. Eleven patients (33%) died primarily from external genitalia gangrene. Median FGSI score was 6 (1-13). We were able to reach 11 patients (33%) for secondary clinical revaluation. Time before revaluation was 3months to 8years. All parts of SF-36 were significantly low. Mean USP score was 1.27±2.68/4.54±4.43/0.72±1.84. Nine patients (81%) suffered erectile dysfunction without any sexual intercourse possible. CONCLUSION Patients with external genitalia gangrene experience severe deterioration of their quality of life. Multidisciplinary healthcare process should systematically be carried out, as so as early screening of vulnerability risks factors, to improve functional outcomes and quality of life.
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Lin TY, Su CC, Chang YC, Chen IH, Ou CH, Cheng YS. The sufficient multidisciplinary specialists under a government-led health care system associated with the downward mortality trend of Fournier's gangrene in Taiwan. Int J Urol 2023; 30:182-189. [PMID: 36305805 DOI: 10.1111/iju.15081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To explore the trends in Fournier's gangrene (FG) incidence and mortality rate in Taiwan and to investigate the contributing factors to such changes. METHODS Between 2002 and 2016, hospitalized FG patients who underwent subsequent surgical intervention were included in this retrospective study. Incidence, outcomes, age-adjusted Charlson Comorbidity Index (ACCI), hospitalization cost, surgical timing, and the number of multidisciplinary specialists involved in the first-line management of FG in each year were collected. Simple linear regression and Pearson correlation coefficient (r) were used for the subsequent analysis. RESULTS The national cohort enrolled 2183 FG patients from 2002 to 2016 in Taiwan. The age-standardized incidence rate of FG was between 0.4 and 0.8 per 100 000 population, and overall mortality was 7.8% in these 15 years. We illustrated the downward trendline of FG mortality with a 0.62 coefficient of determination. The mortality of FG patients who underwent surgery within 24 h and after 24 h were found to be 8.3 ± 3.9% and 14.6 ± 25.2%, respectively (p = 0.02). The numbers of urologists, anesthesiologists, emergency doctors, and physicians per 100 000 population had a strong negative linear correlation with FG mortality (r = 0.8, p < 0.001). ACCI score had a moderate linear relationship with FG mortality (r = 0.57, p = 0.027). The hospitalization cost showed a weak linear correlation with FG mortality (r = -0.03, p = 0.92). CONCLUSIONS We demonstrated the downward trend of the FG mortality rate in Taiwan from 2002 to 2016. Besides underlying comorbidities and surgical timing, sufficient multidisciplinary specialists are essential for the survival benefit of FG patients in Taiwan experience.
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Affiliation(s)
- Tsung-Yen Lin
- Division of Urology, Department of Surgery, Dou-Liou Branch, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Yunlin, Taiwan
| | - Chien-Chou Su
- Clinical Innovation and Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ching Chang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan
| | - I-Hung Chen
- Division of Urology, Department of Surgery, Dou-Liou Branch, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Yunlin, Taiwan
| | - Chien-Hui Ou
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Sheng Cheng
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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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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Asimakopoulos AD, Colalillo G, Miano R, Germani S. Fournier's gangrene with prostatic and bladder trigone colliquation: a suggested treatment algorithm. BMJ Case Rep 2022; 15:e251448. [PMID: 36162966 PMCID: PMC9516075 DOI: 10.1136/bcr-2022-251448] [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: 11/04/2022] Open
Abstract
Fournier's gangrene (FG) is an infectious necrotising fasciitis of the perineum and genital regions with a high mortality rate. We report the case of a man in his 70s with FG who presented with bladder trigone and prostate colliquation. Bulbar and penile urethra were also injured with multiple fenestrations. Bilateral percutaneous nephrostomy positioning followed by the placement of occluding ureteral catheters preceded the surgical debridement of the necrotic tissues and protective colostomy. There followed periodic sessions of surgical debridement and VAC therapy. The persistent perineal urinary leak required the crafting of a suprapubic surgical cystostomy with bladder neck obliteration through double-layer raphy. The cystostomy maintained the healing tissues free from the constant and damaging urine action. This report describes the successful multistep approach of an FG with deep involvement and colliquation of the bladder neck and prostate reaching the Denonvilliers fascia that ensured the correct healing of tissues.
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Affiliation(s)
| | - Gaia Colalillo
- Unit of Urology, Department of surgical sciences, University Tor Vergata, Rome, Italy
| | - Roberto Miano
- Unit of Urology, Department of surgical sciences, University Tor Vergata, Rome, Italy
| | - Stefano Germani
- Unit of Urology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
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Tutino R, Colli F, Rizzo G, Bonventre S, Scerrino G, Salamone G, Melfa G, Orlando G, Gallo G, Santarelli M, Massani M, Cocorullo G. Which Role for Hyperbaric Oxygen Therapy in the Treatment of Fournier's Gangrene? A Retrospective Study. Front Surg 2022; 9:850378. [PMID: 35465423 PMCID: PMC9018989 DOI: 10.3389/fsurg.2022.850378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/23/2022] [Indexed: 01/10/2023] Open
Abstract
Purpose In Fournier's gangrene, surgical debridement plus antimicrobial therapy is the mainstay of treatment but can cause a great loss of tissue. The disease needs long hospital stays and, despite all, has a high mortality rate. The aim of our study is to investigate if factors, such as hyperbaric therapy, can offer an improvement in prognosis. Methods We retrospectively evaluated data on 23 consecutive patients admitted for Fournier's gangrene at the University Hospital “P. Giaccone” of Palermo from 2011 to 2018. Factors related to length of hospital stay and mortality were examined. Results Mortality occurred in three patients (13.1%) and was correlated with the delay between admission and surgical operation [1.7 days (C.I. 0.9–3.5) in patients who survived vs. 6.8 days (C.I. 3.5–13.4) in patients who died (p = 0.001)]. Hospital stay was longer in patients treated with hyperbaric oxygen therapy [mean 11 (C.I. 0.50–21.89) vs. mean 25 (C.I. 18.02–31.97); p = 0.02] without an improvement in survival (p = 1.00). Conclusion Our study proves that a delay in the treatment of patients with Fournier's gangrene has a correlation with the mortality rate, while the use of hyperbaric oxygen therapy seems to not improve the survival rate, increasing the hospital stay instead.
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Affiliation(s)
- Roberta Tutino
- Chirurgia 3, Dipartimento di Chirurgia Generale e Specialistica, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- *Correspondence: Roberta Tutino
| | - Francesco Colli
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Giovanna Rizzo
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Sebastiano Bonventre
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Gregorio Scerrino
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Giuseppe Salamone
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Giuseppina Melfa
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Giuseppina Orlando
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - Gaetano Gallo
- Department of General Surgery, University of Catanzaro, Catanzaro, Italy
| | - Mauro Santarelli
- Chirurgia 3, Dipartimento di Chirurgia Generale e Specialistica, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marco Massani
- Chirurgia 1, Ospedale Regionale di Treviso, Azienda ULSS 2 Marca Trevigiana, Treviso, Italy
| | - Gianfranco Cocorullo
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
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Pelletier J, Gottlieb M, Long B, Perkins JC. Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician. J Emerg Med 2022; 62:480-491. [PMID: 35115188 DOI: 10.1016/j.jemermed.2021.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/18/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Skin and soft tissue infections are common emergency department (ED) presentations. These infections cover a wide spectrum of disease, from simple cellulitis to necrotizing fasciitis. Despite the commonality, a subset of skin and soft tissue infections known as necrotizing soft tissue infections (NSTIs) can cause significant morbidity and mortality. OBJECTIVE This review evaluates the current evidence regarding the presentation, evaluation, and management of NSTI from the ED perspective. DISCUSSION NSTIs are commonly missed diagnoses. History and physical examination findings are inconsistent, and the risk factors for this high mortality disease are common amongst ED populations. Laboratory evaluation and the Laboratory Risk in Necrotizing Fasciitis (LRINEC) score is helpful but is insufficient to rule out the disease. Imaging modalities including ultrasound, computed tomography, and magnetic resonance imaging are highly sensitive and specific, but may delay definitive management. The gold standard for diagnosis includes surgical exploration. Surgical intervention and empiric broad-spectrum antibiotic coverage are the foundations of treatment. Adjuvant therapies including hyperbaric oxygen and intravenous immunoglobulin have not yet been proven to be beneficial or to improve outcome. CONCLUSION NSTIs are associated with significant morbidity and mortality. Knowledge of the history, examination, evaluation, and management is vital for emergency clinicians.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brit Long
- San Antonio Uniformed Services Health Education Consortium (SAUSHEC); Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - John C Perkins
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
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Eray IC, Dalci K, Gumus S, Yalav O, Saritas AG, Boz A, Rencuzogullari A. The role of C-reactive protein ratio in predicting mortality in patients with Fournier gangrene. Ann Coloproctol 2022:ac.2021.00843.0120. [PMID: 35109644 DOI: 10.3393/ac.2021.00843.0120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/13/2021] [Indexed: 01/08/2023] Open
Abstract
Purpose This study aimed to determine the C-reactive protein (CRP) ratio for the survival of patients with Fournier gangrene (FG). Methods Fifty-two patients with FG between January 2011 and September 2018 were retrospectively analyzed. Data on clinical presentation, Fournier Gangrene Severity Index (FGSI), CRP ratio, management, and outcome were analyzed. The CRP ratio was calculated as preoperative CRP/postoperative CRP value that measured 48 hours after surgical intervention. Possible alternative cutoff points for the FGSI and CRP were determined by receiver operating characteristic (ROC) analyses. The risk factors related to the prognosis were evaluated by univariate and multivariable logistic regression analyses. Results The mean CRP ratios were 6.7±6.6 in the survivor group and 1.2±0.8 in the non-survivor group (P=0.001). FGSI was significantly higher in the non-survivor group compared to survivor group (8.5±2.5 vs. 3.5±2.2, P=0.001). There was a negative correlation between FGSI and CRP ratio (r=-0.51). ROC analysis determined the cutoff value as 1.78 for CRP (sensitivity, 86%; specificity, 82%; AUC, 0.90) to predict death. The incidence of death for patients with CRP ratio of ≤1.78 increased 26.7 fold for those with CRP ratio of >1.78 (95% confidence interval [CI], 4.8-146.5; P=0.001). In the multivariable logistic regression model, CRP ratio (odds ratio [OR], 10.3; 95% CI, 1.5-72.2; P=0.019) and FGSI (OR, 17.8; 95% CI, 2.6-121.1; P=0.003) were independent risk factors for death. Conclusion The CRP ratio is a simple method to use to predict mortality in FG.
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Affiliation(s)
- Ismail Cem Eray
- Division of Colorectal Surgery, Department of General Surgery, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Kubilay Dalci
- Division of Colorectal Surgery, Department of General Surgery, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Serdar Gumus
- Department of Surgical Oncology, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Orcun Yalav
- Division of Colorectal Surgery, Department of General Surgery, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Ahmet Gokhan Saritas
- Division of Colorectal Surgery, Department of General Surgery, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Asli Boz
- Department of Medical Education, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Ahmet Rencuzogullari
- Division of Colorectal Surgery, Department of General Surgery, Çukurova University Faculty of Medicine, Adana, Turkey
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Tarasconi A, Perrone G, Davies J, Coimbra R, Moore E, Azzaroli F, Abongwa H, De Simone B, Gallo G, Rossi G, Abu-Zidan F, Agnoletti V, de'Angelis G, de'Angelis N, Ansaloni L, Baiocchi GL, Carcoforo P, Ceresoli M, Chichom-Mefire A, Di Saverio S, Gaiani F, Giuffrida M, Hecker A, Inaba K, Kelly M, Kirkpatrick A, Kluger Y, Leppäniemi A, Litvin A, Ordoñez C, Pattonieri V, Peitzman A, Pikoulis M, Sakakushev B, Sartelli M, Shelat V, Tan E, Testini M, Velmahos G, Wani I, Weber D, Biffl W, Coccolini F, Catena F. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021; 16:48. [PMID: 34530908 PMCID: PMC8447593 DOI: 10.1186/s13017-021-00384-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy.
| | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Francesco Azzaroli
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Hariscine Abongwa
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Belinda De Simone
- Department of Metabolic, Digestive and Emergency Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, Poissy, France
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Giorgio Rossi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Gianluigi de'Angelis
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Nicola de'Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Bari, Ital - Université Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- Department of Emergency and general Surgery, Pavia University Hospital, Pavia, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Alain Chichom-Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | - Salomone Di Saverio
- General surgery 1st unit, Department of General Surgery, University of Insubria, Varese, Italy
| | - Federica Gaiani
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Mario Giuffrida
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Andreas Hecker
- Department of General & Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Carlos Ordoñez
- Department of Surgery, Fundacion Valle del Lili - Universidad del Valle, Cali, Colombia
| | | | - Andrew Peitzman
- University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Manos Pikoulis
- 3rd Department of Surgery, National & Kapodistrian University of Athens, Athens, Greece
| | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Plovdiv, Bulgaria
| | | | - Vishal Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Edward Tan
- Department of Surgery, Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mario Testini
- Academic Unit of General Surgery "V. Bonomo" Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walter Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, Cesena, Italy
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Usta MA, Ulusahin M, Tayar S, Cekic AB, Kazaz IO, Guner A, Turkyilmaz S. Scoring Systems for the Prediction of Mortality in Patient with Fournier’s Gangrene: an Analysis of 60 Patients. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02421-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Ansari Djafari A, Rahavian A, Javanmard B, Montazeri S, Shahabi V, Hojjati SA, Ghiasy S, Hamidi R, Khoshnevis J. Factors Related to Mortality in Patients with Fournier's Gangrene or Necrotising Fasciitis; a 10-year Cross-Sectional Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e33. [PMID: 34027428 PMCID: PMC8126357 DOI: 10.22037/aaem.v9i1.1123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Fournier's gangrene (FG) is a life-threatening disease, even with early diagnosis and administration of vigorous treatment, its mortality rate is high. This study aimed to evaluate the factors relate to mortality in patients with FG or necrotising fasciitis managed in a referral center. METHODS This retrospective cross-sectional study was conducted on patients managed in a tertiary referral center, Tehran, Iran, from March 2009 to March 2019, with diagnosis of FG or necrotising fasciitis. The correlation between different demographic and clinical parameters with mortality was analysed and reported. RESULTS 73 cases with the mean age of 59.1 ± 15.8 (range: 25 - 88) years were studied (87.7% male). 21 (28.8%) patients died. Escherichia coli (26 cases, 35.6%) was the most frequent microorganism in cultures. Non-survived cases had higher mean age (p = 0.01), higher frequency of hyperlipidaemia (p = 0.02), immunosuppression (p < 0.001), longer hospital stay (p=0.02), lower blood pressure (p=0.01), and lower platelet count (p=<0.001). Based on multivariate analysis, age (p = 0.015; Odds: 0.88 (0.79-0.97)), haematocrit level (p = 0.01; Odds: 1.27 (1.04-1.55)), platelet count (p = 0.03; Odds: 10.11 (1.14-89.35)), and immunosuppression (p = 0.01; Odds: 0.01 (0.0-0.54)) were independent related factors of mortality. CONCLUSIONS The rate of mortality due to FG and necrotizing fasciitis was 28.8%. Based on multivariate analysis, the independent related factors of mortality were older age, lower haematocrit level and platelet count, and presence of immunosuppression.
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Affiliation(s)
- Anahita Ansari Djafari
- Laser Application in Medical Sciences Research Center, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amirhossein Rahavian
- Andrology Research Center, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Babak Javanmard
- Urology Department, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Montazeri
- Urology Department, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Vahid Shahabi
- Urology Department, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyed Ali Hojjati
- Urology Department, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saleh Ghiasy
- Urology Department, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ramin Hamidi
- School of Medicine, 501 Hospital (Imam Reza), AJA University of Medical Science, Tehran, Iran
| | - Jalaluddin Khoshnevis
- Clinical Research Development Unit, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Wöhler A, Schwab R, Güsgen C, Schaaf S, Weitzel C, Jänig C, Willms A. [Diagnosis and Treatment of Severe Fournier's Gangrene: Introduction of a Surgical Approach, Evaluation of Risk Factors, Microbiological Characteristics and Review of the Literature]. Zentralbl Chir 2021; 147:480-491. [PMID: 33556981 DOI: 10.1055/a-1319-1734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fournier's gangrene is a necrotising fasciitis type I occurring in the perineal and genital region. The disease expands progressively and still has poor outcome, especially in critical ill patients. This study's focus was placed on the evaluation of risk factors and comorbidities, on the bacteriological spectrum, laboratory analyses, mortality and the course according to the algorithmic approach. METHOD The medical records were reviewed of 10 patients with severe Fournier's gangrene from 2010 to 2019 who underwent intensive care therapy for at least 48 hours. Ten patients with Fournier's gangrene and sepsis and intensive therapy lasting at least 48 hours were recorded and analysed descriptively. RESULTS The patient cohort consisted of six men and four women with a median age of 62 years (range 42 - 78 years). The median time between the onset of symptoms and hospitalisation was four days (range 3 - 5 days). The commonest aetiological event was a minor trauma. Predisposing factors included diabetes mellitus (30%) and overweight (80% BMI > 25). 90% of patients exhibited polymicrobial infection. All patients had systemic sepsis with SOFA-Score between 3 and 17 points. The mortality rate was 40%. Significant differences between surviving and deceased patients were shown by PCT, INR and aPTT (p < 0.05). CONCLUSION Severe Fournier's gangrene continues to be a major challenge with a high mortality rate. Only rapid diagnosis, urgent extensive surgical debridement and intensive care therapy can lead to a favourable outcome in these critically ill patients. Vacuum-assisted closure can be successfully used in the management of soft-tissue defects.
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Affiliation(s)
- Aliona Wöhler
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Robert Schwab
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Christoph Güsgen
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Sebastian Schaaf
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Carolin Weitzel
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Christoph Jänig
- Klinik für Anästhesie, Intensivmedizin und Notfallmedizin, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
| | - Arnulf Willms
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Deutschland
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Abstract
(Objectives) This study aimed to evaluate the clinical characteristics and the mortality risk factors of 15 patients with Fournier gangrene in the past decade at Teikyo University Hospital. (Materials and methods) We retrospectively assessed 15 patients with Fournier gangrene between May 2009 and April 2019. We compared the demographic characteristics along with several clinical variables including Fournier Gangrene Severity Index of the survivors and nonsurvivors. We also assessed the risk factors associated with mortality. (Results) All patients were men with a median age of 67 years. Among the 15 patients, 9 had diabetes mellitus (60%). Furthermore, 14 patients (93%) underwent surgical debridement, 5 (33%) required orchiectomy, 3 (20%) were treated with cystostomy for urinary diversion, and 3 (20%) needed temporary colostomy for fecal diversion. Three patients died of the disease with a mortality rate of 20%. The nonsurvivors were significantly older (p = 0.043) and had a smaller body mass index (p = 0.038) than the survivors. The scores of clinical risk models, such as the Fournier Gangrene Severity Index, were higher in nonsurvivors than in survivors, with no statistical significance presumably due to the small sample size. (Conclusions) The mortality rate for Fournier gangrene during the past decade at our institution was 20%. Fournier gangrene was a potentially fatal disease even in the 2010s.
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Can we predict poor prognosis in Fournier gangrene? JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.826917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Garg G, Singh V, Sinha RJ, Sharma A, Pandey S, Aggarwal A. Outcomes of patients with Fournier's Gangrene: 12-year experience from a tertiary care referral center. Turk J Urol 2020; 45:S111-S116. [PMID: 32027590 DOI: 10.5152/tud.2019.39586] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/20/2018] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Gaurav Garg
- Department of Urology, King George's Medical University, Lucknow, India
| | - Vishwajeet Singh
- Department of Urology, King George's Medical University, Lucknow, India
| | - Rahul Janak Sinha
- Department of Urology, King George's Medical University, Lucknow, India
| | - Ashish Sharma
- Department of Urology, King George's Medical University, Lucknow, India
| | - Siddharth Pandey
- Department of Urology, King George's Medical University, Lucknow, India
| | - Ajay Aggarwal
- Department of Urology, King George's Medical University, Lucknow, India
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Sparenborg JD, Brems JA, Wood AM, Hwang JJ, Venkatesan K. Fournier's gangrene: a modern analysis of predictors of outcomes. Transl Androl Urol 2019; 8:374-378. [PMID: 31555561 DOI: 10.21037/tau.2019.03.09] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Fournier's gangrene (FG) is a rapidly progressing necrotizing fasciitis that carries a significant morbidity and mortality. The present study sought to identify the predisposing factors related to FG and validate the Fournier's Gangrene Severity Index (FGSI) score as a prognostic tool in the care of the Fournier's patient. Methods Medstar Washington Hospital Center records were searched from January 2003 to February 2015 for all patients with a diagnosis code of FG, n=42. Epidemiologic data was collected for patients and used to calculate an FGSI score. Results The average age was 53.45 yrs and M/F ratio was 39:1. Patients presented with an average 2.675 predisposing factors; the most common was diabetes mellitus (n=21) followed by hypertension (n=18). The most common etiology was periscrotal (n=25) next to perirectal (n=9). Streptococcus was the most common source of infection (n=14). Patients on average required three surgical interventions. The average and median hospitalization period was 19.625 and 11.5 days respectively. Eleven patients developed sepsis. Twenty-four (60%) patients experienced a complication. The overall mortality was 5% (n=2). The average FGSI on admission was 5.368. Multivariate analysis showed FGSI score correlates with more surgical intervention, longer hospitalization, sepsis, complication and mortality. Conclusions The FGSI score predicts a greater likelihood of more surgical interventions, longer hospitalization period, sepsis, complications and mortality within this patient population. Diabetes mellitus continues to be the most common predisposing factors in FG patients. The mortality rate of 5% is much less than the historically reported 20-30% and may reflect improved understanding and care of this aggressive disease.
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Affiliation(s)
| | - Jacob A Brems
- MedStar Georgetown University Hospital, Washington, DC, USA
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Lin TY, Cheng IH, Ou CH, Tsai YS, Tong YC, Cheng HL, Yang WH, Lin YM, Cheng YS. Incorporating Simplified Fournier's Gangrene Severity Index with early surgical intervention can maximize survival in high-risk Fournier's gangrene patients. Int J Urol 2019; 26:737-743. [PMID: 31001902 DOI: 10.1111/iju.13989] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/25/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To determine the optimal surgical timing in high-risk patients with Fournier's gangrene by the Simplified Fournier's Gangrene Severity Index. METHODS From 1989 to 2018, 118 male patients diagnosed with Fournier's gangrene with complete medical records were retrospectively reviewed. Patients' demographics, laboratory parameters at initial diagnosis, Fournier's Gangrene Severity Index and Simplified Fournier's Gangrene Severity Index, and the time interval from emergency room arrival to surgical intervention were collected. The Fournier's gangrene patients were categorized into low-risk (Simplified Fournier's Gangrene Severity Index ≤2) and high-risk groups (Simplified Fournier's Gangrene Severity Index >2). Differences between the variables within the two groups were analyzed. The optimal surgical timing was analyzed with the receiver operating characteristic curve in high-risk Fournier's gangrene patients. RESULTS The overall mortality of 118 Fournier's gangrene patients was 14.4%. After risk stratification with the Simplified Fournier's Gangrene Severity Index scoring system, the mortality of low-risk and high-risk Fournier's gangrene patients was 1.3% and 41.0%, respectively. In the high-risk group, the time interval from emergency room arrival to surgical intervention was the only variable with a significant difference between survivors and non-survivors (P = 0.039). The optimal surgical timing was determined at 14.35 h, which allowed the highest sensitivity (0.688) and specificity (0.762) to affect mortality. The mortality was significantly lower in high-risk Fournier's gangrene patients with early surgical intervention compared with late intervention (23.8% vs 68.8%, P = 0.007). CONCLUSIONS The Simplified Fournier's Gangrene Severity Index is a quick and reliable screening tool for first-line physicians to identify high-risk patients with Fournier's gangrene (Simplified Fournier's Gangrene Severity Index >2) who have poor survival outcomes. We recommended early surgical intervention within 14.35 h to maximize the survival of high-risk Fournier's gangrene patients.
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Affiliation(s)
- Tsung-Yen Lin
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-Hung Cheng
- Division of Urology, Department of Surgery, National Cheng Kung University Hospital, Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan
| | - Chien-Hui Ou
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuh-Shyan Tsai
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yat-Ching Tong
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hong-Lin Cheng
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Horng Yang
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yung-Ming Lin
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Sheng Cheng
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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The utility of peripheral blood leucocyte ratios as biomarkers in infectious diseases: A systematic review and meta-analysis. J Infect 2019; 78:339-348. [PMID: 30802469 PMCID: PMC7173077 DOI: 10.1016/j.jinf.2019.02.006] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/11/2019] [Accepted: 02/18/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess the utility of the neutrophil:lymphocyte (NLR), lymphocyte:monocyte (LMR) and platelet:lymphocyte ratios (PLR) as infection biomarkers. METHODS PubMed/MEDLINE, Embase and Cochrane databases were searched to identify eligible articles. Studies of diagnosis, severity or outcome were included. PROSPERO systematic review registration CRD42017075032. RESULTS Forty studies were included, reporting on bacterial and viral infections, malaria, and critical illness due to sepsis. Ten studies reported an association of higher NLR with bacteraemia, supported by meta-analysis of patient-level data (five studies, n = 3320; AUC 0.72, p<0.0001) identifying a cut-off of >12.65. Two studies reported an association with lower LMR and diagnosis of influenza virus infection in patients with respiratory tract infection. Meta-analysis of patient-level data (n = 85; AUC 0.66, p = 0.01) identified a cut-off of ≤2.06. The directionality of associations between NLR and outcomes in heterogeneous cohorts of critically ill adults with sepsis varied. Potential clinical utility was also demonstrated in pneumonia (NLR), pertussis (NLR), urinary tract infection (NLR), diabetic foot infections (NLR) and Crimean Congo Haemorrhagic Fever (PLR). Longitudinal measurement of LMR during respiratory virus infection reflected symptoms and NLR during sepsis and bacteraemia predicted mortality. CONCLUSIONS Peripheral blood leucocyte ratios are useful infection biomarkers, with the most evidence related to diagnosis of bacteraemia and influenza virus infection. In critical illness due to sepsis, a signal towards an association with NLR and outcomes exists, and NLR should be evaluated in future stratification models. Longitudinal measurement of ratios during infection could be informative. Overall, these biomarkers warrant further recognition and study in infectious diseases.
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Zil-E-Ali A, Fayyaz M, Fatima A, Ahmed Z. Diagnosing Necrotizing Fasciitis Using Procalcitonin and a Laboratory Risk Indicator: Brief Overview. Cureus 2018; 10:e2754. [PMID: 30094111 PMCID: PMC6080743 DOI: 10.7759/cureus.2754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Necrotizing fasciitis is a progressive inflammatory disease that requires an early diagnosis to avoid limb salvage and other deadly manifestations. The current protocol is the microbiological and histopathological sampling of the tissue. Once the diagnosis is made, it should be managed with antimicrobial therapy, debridement, and surgical interventions. Such interventions can be invasive and increase the time to treat, which may increase morbidity. Our article discusses procalcitonin, C-reactive protein, and other markers, such as "pain out of proportion," lactate, creatinine, and creatine kinase, to make a quicker diagnosis before proceeding with invasive procedures. We discussed a similar non-invasive approach called the "Laboratory Risk Indicator for Necrotizing Fasciitis" scoring system that can aid in the early diagnosis of necrotizing fasciitis, which can prompt rapid empiric therapy, reducing the chances of morbidity. This scoring system comprises C-reactive protein, white blood cell count, hemoglobin level, creatinine, sodium, and glucose. Such non-invasive, bedside, and quick tests can help in reducing the time required to make the diagnosis and can affect the course of the disease, hence, improving patient outcomes.
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Affiliation(s)
| | - Muniba Fayyaz
- Department of Internal Medicine, Fatima Memorial Hospital, Lahore, PAK
| | - Arooj Fatima
- Department of Internal Medicine, Fatima Memorial Hospital, Lahore, PAK
| | - Zubair Ahmed
- Medical Student-3, FMH College of Medicine & Dentistry, Lahore, PAK
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Tenório CEL, Lima SVC, Albuquerque AVD, Cavalcanti MP, Teles F. Risk factors for mortality in fournier's gangrene in a general hospital: use of simplified founier gangrene severe index score (SFGSI). Int Braz J Urol 2018; 44:95-101. [PMID: 28853819 PMCID: PMC5815538 DOI: 10.1590/s1677-5538.ibju.2017.0193] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/25/2017] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Carlos Eugênio Lira Tenório
- Serviço de Urologia do Hospital das Clínicas, Departamento de Cirurgia do Centro de Ciências da Saúde da Universidade Federal de Pernambuco, UFPE, Recife, PE, Brasil.,Faculdade de Medicina da Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brasil
| | - Salvador Vilar Correia Lima
- Serviço de Urologia do Hospital das Clínicas, Departamento de Cirurgia do Centro de Ciências da Saúde da Universidade Federal de Pernambuco, UFPE, Recife, PE, Brasil.,Núcleo de Cirurgia Experimental, Programa de Pós-Graduação em Cirurgia, Departamento de Cirurgia, Centro de Ciências da Saúde, Universidade Federal de Pernambuco, UFPE, Recife, PE, Brasil
| | - Amanda Vasconcelos de Albuquerque
- Núcleo de Cirurgia Experimental, Programa de Pós-Graduação em Cirurgia, Departamento de Cirurgia, Centro de Ciências da Saúde, Universidade Federal de Pernambuco, UFPE, Recife, PE, Brasil
| | - Mariana Pauferro Cavalcanti
- Faculdade de Medicina da Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brasil
| | - Flávio Teles
- Faculdade de Medicina da Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brasil
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Surviving Fournier's gangrene: Multivariable analysis and a novel scoring system to predict length of stay. J Plast Reconstr Aesthet Surg 2018; 71:712-718. [DOI: 10.1016/j.bjps.2017.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/27/2017] [Accepted: 12/05/2017] [Indexed: 11/20/2022]
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Chan BYO, Wong BWB, Lo KKY, Yim C, Tse CTY. Fournier's gangrene: A 10-year review and validation of mortality predictors in a Hong Kong major regional centre. SURGICAL PRACTICE 2018. [DOI: 10.1111/1744-1633.12301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Kelly Ka-Yee Lo
- Li Ka Shing Faculty of Medicine; The University of Hong Kong; Hong Kong
| | - Carmen Yim
- Li Ka Shing Faculty of Medicine; The University of Hong Kong; Hong Kong
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Abstract
Necrotizing soft tissue infection of the perineum, or Fournier's gangrene (FG), is a morbid and mortal diagnosis. Despite the severity of FG, the optimal definitive wound closure strategy is unknown, as are long-term wound outcomes. A retrospective review was performed over a 3-year period at a single trauma center. Patients were managed according to our institutional approach focusing on primary wound closure and secondary intention healing in residual wounds. Overall 168 patients were included. Complete primary wound closure was accomplished in 39.9 per cent of patients. Patients undergoing primary wound closure were primarily male (89.6 vs 64.4%, P < 0.001), had lower mean sequential organ failure assessment (SOFA) scores (1.70 ± 2.30 vs 2.98 ± 3.36, P = 0.004), more often had perineum-limited FG (67.2 vs 42.6%, P = 0.003), and required fewer debridements (2.40 vs 2.79, P = 0.02). On logistic regression, predictors of primary closure included gender (odds ratio 4.643, 95% confidence interval 1.885–11.437, P = 0.001) and SOFA score (odds ratio 0.834, 95% confidence interval 0.727–0.957, P = 0.01). Wound healing rates increased over time, to an 82.1 per cent wound healing rate without further intervention at greater than six months of follow-up. Wounds healed with secondary intention ranged from 70 to 9520 cm3 and primary closure ranged from 126 to 6912 cm3, whereas wounds requiring skin grafts ranged from 405 to 16,170 cm3. Complete primary wound closure is often achievable in FG patients. Using this standardized approach to FG wound management, even large wounds and wounds undergoing secondary intention healing will often close with long-term wound care and do not require flap creation or early skin grafting.
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Wang T, Zhao G, Rui YJ, Mi JY. Bilateral femoral posterior neurocutaneous perforater flap successfully treating Fournier gangrene: A case report. Medicine (Baltimore) 2017; 96:e8720. [PMID: 29145312 PMCID: PMC5704857 DOI: 10.1097/md.0000000000008720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
RATIONALE Necrotizing fasciitis (NF), characterized by widespread fascial necrosis, is a rare disease in clinic. Fournier gangrene (FG) is a special type of NF involved of perineum and scrotum. To our knowledge, no article has reported on bilateral femoral posterior neurocutaneous perforater flap treating for FG. PATIENT CONCERNS A 61-year-old Chinese male complained of perineal skin necrosis for 19 days. The patient received treatment in other hospital due to chronic bronchitis on April 15th and body temperature ranged from 38 to 39 °C. Then he received antiinfection therapy. Perianal cutaneous occurred mild necrosis on May 08th. And the necrosis generally deteriorated. He came to our hospital for treating necrosis in area of perineum and scrotum on May 28th. DIAGNOSES He was diagnosed with FG and chronic bronchitis. INTERVENTIONS The patient underwent debridement on June 2nd and received bilateral femoral posterior neurocutaneous perforater flap on June 29th. Besides, the patient was treated with whole-body nutrition support and antibiotic treatment. OUTCOMES One week after the 2nd operation, the flap showed normal color. The result shows good outcome and no recurrence of the clinical symptoms occur till now. LESSONS FG is rare. Bilateral femoral posterior neurocutaneous perforater flap is an effective procedure to treat FG. The outcome of combined therapy is satisfactory.
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Abstract
BACKGROUND Antibiotic management of Fournier's gangrene (FG) is without evidence-based guidelines and is based on expert opinion. The effect of duration of antibiotic therapy on outcomes in FG is unknown. METHODS A retrospective review was performed of FG patients from 2012 to 2015 at a single institution. Patients were managed by our institutional practice of complete primary wound closure as possible, with antibiotic duration according to physician judgment. Patients were stratified into multiple durations of antibiotic administration. RESULTS Overall, 168 patients with FG were included. When examining multiple stratifications of antibiotic therapy of 7 days or less, 8 days to 10 days, 11 days to 14 days, or 15 days or more of antibiotics, there was no significant difference in mortality (p = 0.11), primary closure (p = 0.75), surgical site infection (SSI) (p = 0.52), or Clostridium difficile infection (p = 0.63). There were no cases of recurrent FG in any antibiotic stratification. Mortality was not increased (p = 1.00) and ability to achieve primary closure was not decreased (p = 0.08) with initial antibiotic therapy exclusive of cultured organisms. CONCLUSION Shorter antibiotic courses for patients in whom source control is obtained and initial antibiotic selection exclusive of many resistant organisms were not associated with worse outcomes in FG. LEVEL OF EVIDENCE Therapeutic, level IV.
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Ferretti M, Saji AA, Phillips J. Fournier's Gangrene: A Review and Outcome Comparison from 2009 to 2016. Adv Wound Care (New Rochelle) 2017; 6:289-295. [PMID: 28894636 DOI: 10.1089/wound.2017.0730] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/28/2017] [Indexed: 01/31/2023] Open
Abstract
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%.
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Affiliation(s)
- Mark Ferretti
- Department of Urology, School of Medicine, New York Medical College, Valhalla, New York
| | - Akhil A. Saji
- Department of Urology, School of Medicine, New York Medical College, Valhalla, New York
| | - John Phillips
- Department of Urology, School of Medicine, New York Medical College, Valhalla, New York
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McCormack M, Valiquette AS, Ismail S. Fournier's gangrene: A retrospective analysis of 26 cases in a Canadian hospital and literature review. Can Urol Assoc J 2015. [PMID: 26225189 DOI: 10.5489/cuaj.2445] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We performed a systematic review of all cases of Fournier's Gangrene (FG) at our hospital over a 12-year period. A total of 26 cases were assessed. Our goal was to determine the mortality rate and to identify risk factors associated with FG. We also wanted to examine three potential prognostic factors in relation to patient survival, including the time delay from emergency room admission to surgery, the initial extent of the disease, and the impact of more than one debridement procedure under general anesthesia. The time between emergency room admission and the beginning of surgical debridement was not statistically different between survivors and non-survivors. The extent of surgical debridement was close to the margin of statistical significance (p = 0.07) and can be considered an index of the extent of the disease. FG extending to the thighs or to the abdominal wall carries a worse prognosis. The number of surgical debridement procedures done under anesthesia was statistically different between survivors and non-survivors. Patients were 4.8 times more at risk of dying if they are required to have more than one surgical debridement under general anesthesia. This presumably reflects persistent gangrene following initial surgical debridement, fluid resuscitation, and wide spectrum antibiotic treatment.
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Affiliation(s)
| | | | - Salima Ismail
- Department of Surgery, University of Montreal, Montreal, QC
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Li YD, Zhu WF, Qiao JJ, Lin JJ. Enterostomy can decrease the mortality of patients with Fournier gangrene. World J Gastroenterol 2014; 20:7950-7954. [PMID: 24976731 PMCID: PMC4069322 DOI: 10.3748/wjg.v20.i24.7950] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/08/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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