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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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Dupont M, Leal C, Tenreiro N, Marques R, Pinto-de-Sousa J. Fournier Gangrene Management: Is a Stoma Mandatory? Cureus 2023; 15:e39450. [PMID: 37378202 PMCID: PMC10292068 DOI: 10.7759/cureus.39450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/29/2023] Open
Abstract
Fournier gangrene is a rare life-threatening surgical emergency mainly due to a polymicrobial infection of the perineal, genital, or perianal region. It is characterized by rapid tissue destruction and systemic signs of toxicity. It is more frequent in males and immunocompromised patients, such as patients with poorly controlled diabetes, alcoholism, or human immunodeficiency virus (HIV) infection. Treatment often involves surgical intervention, broad-spectrum antibiotic therapy, fecal diversion surgery, and negative pressure wound therapy (NPWT). Delays in diagnosis are associated with high mortality due to rapid progression to septic shock.
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Affiliation(s)
- Margarida Dupont
- General Surgery, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - Clara Leal
- General Surgery, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - Nadia Tenreiro
- General Surgery, Centro Hospitalar de Trás-Os-Montes e Alto Douro, Vila Real, PRT
| | - Rita Marques
- General Surgery, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
| | - João Pinto-de-Sousa
- General Surgery, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, PRT
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Zhang KF, Shi CX, Chen SY, Wei W. Progress in Multidisciplinary Treatment of Fournier's Gangrene. Infect Drug Resist 2022; 15:6869-6880. [PMID: 36465810 PMCID: PMC9717591 DOI: 10.2147/idr.s390008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/10/2022] [Indexed: 07/27/2023] Open
Abstract
Fournier's gangrene (FG) is a life-threatening and special form of necrotizing fasciitis, characterized by occult onset, rapid progress and high mortality, occurring mainly in men over 50 years of age. Risk factors of FG include diabetes, HIV infection, chronic alcoholism and other immunosuppressive state. FG was previously considered as an idiopathic disease, but in fact, three quarters of the infections originated from the skin, urethra and gastrointestinal tract. Initial symptoms of FG are often inconsistent with severity and can progress promptly to fatal infection. Although the treatment measures of FG have been improved in recent years, the mortality does not seem to have decreased significantly and remains at 20% - 30%. The time to identify FG and the waiting period before surgical debridement are directly related to the prognosis. Therefore, in addition to the combination of intensive fluid resuscitation and broad-spectrum antibiotics, treatment of FG should particularly emphasize the importance of early surgical debridement assisted with fecal diversion and skin reconstruction when necessary. This paper is to briefly summarize the progress in the definition, epidemiology, clinical manifestations, diagnosis, treatment and prognosis of Fournier's gangrene in recent years, more importantly, illustrates the importance of multidisciplinary cooperation in the management of FG.
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Affiliation(s)
- Ke-Fan Zhang
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Chuan-Xin Shi
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Si-Yu Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, People’s Republic of China
| | - Wei Wei
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
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Bowen D, Juliebø-Jones P, Somani BK. Global outcomes and lessons learned in the management of Fournier's gangrene from high-volume centres: findings from a literature review over the last two decades. World J Urol 2022; 40:2399-2410. [PMID: 36059020 DOI: 10.1007/s00345-022-04139-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/15/2022] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION Fournier's Gangrene (FG) carries a high mortality and morbidity with underreported short and long-term outcomes. Our aim was to perform a review of the recent literature to evaluate the short and long-term outcomes in patients with FG in the acute setting from large-scale studies. METHODS A PubMed search was performed between January 2000 and December 2021 for studies reporting on patients with FG. Exclusion criteria included small samples (n < 100), review articles and animal studies. Primary outcomes of interest were mortality, number of operative episodes for surgical debridement and admission to intensive care unit (ICU). Other outcomes assessed included rate of faecal and urinary diversion, orchidectomy rate, penectomy rate and length of hospital stay. RESULTS From a total of 1182 studies, 18 were eligible for inclusion and included in this review. In total, data were analysed from 13,903 FG patients. Mean inpatient mortality rate was 7.3% (range 4.7-40.4%). Mean number of surgical debridement operations performed was 1.8 (range 1.5-4.2). On average, 6.8% (range 3.6-50.5%) and 7% (range 1.2-53.2%) underwent faecal and urinary diversions, respectively. Mean rate of orchidectomy was 5.6%, with rate of penectomy being lower at 0.2%. The mean length of hospital stay was 18.5 days (range 13.0-26.6). On average, 17.5% (range 10.1%-67.5%) required ICU admission for at least a single-system support. CONCLUSION Our review from the past twenty years of literature suggests that the mortality for FG, whilst still high, has fallen compared to previous years. Whilst inpatient metrics are well-covered in the literature there is a lack of large-scale studies detailing long-term patient outcomes.
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Affiliation(s)
- Daniel Bowen
- University Hospital Southampton NHS Trust, Southampton, UK
| | - Patrick Juliebø-Jones
- Department of Urology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - B K Somani
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK.
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Escudero-Sepúlveda AF, Cala-Duran JC, Belén-Jurado M, Tomasone SE, Carlino-Currenti VM, Abularach-Borda R, Roccuzzo C, Puche-Burgos JFDJ, Acosta-Maestre JE. Conceptos para la identificación y abordaje de la gangrena de Fournier. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La gangrena de Fournier es una fasciitis necrosante fulminante y progresiva, de origen infeccioso sinérgico polimicrobiano, que afecta las regiones perianal, perineal, genital y abdominal. Su incidencia es mayor en hombres, la edad promedio de presentación reportada está en los 54,7 ± 15,6 años, su mortalidad es del 3-67 %, aunque hay estudios que informan una mortalidad en hombres del 7,5 % y en las mujeres del 12,8 %.
Métodos. Se hizo una revisión de la literatura en las bases de datos y fuentes de información PubMed, Scielo y Google Scholar, publicados entre 1950 y 2018, utilizando términos como "fournier gangrene", "fasciitis, necrotizing”, “wound infection”, "therapy"[subheading] y “GRADE approach". Se realizó una segunda revisión para artículos latinoamericanos en español hasta 2020 usando las mismas fuentes y palabras claves.
Resultados. Se seleccionaron artículos que reportaron definiciones, datos históricos, actualizaciones en diagnóstico y terapéutica para hacer una revisión actualizada. Para el uso de las imágenes se solicitó consentimiento informado.
Conclusión. La gangrena de Fournier continúa siendo una emergencia quirúrgica potencialmente letal. Gracias a las investigaciones realizadas se ha avanzado en su tratamiento, mejorando los resultados. Es importante analizar los factores de riesgo en cada paciente y su etiología para establecer el tratamiento más adecuado.
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Paladini A, Cochetti G, Tancredi A, Mearini M, Vitale A, Pastore F, Mangione P, Mearini E. Management of Fournier's gangrene during the Covid-19 pandemic era: make a virtue out of necessity. Basic Clin Androl 2022; 32:12. [PMID: 35850577 PMCID: PMC9294754 DOI: 10.1186/s12610-022-00162-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background Fournier’s gangrene (FG) is a necrotizing fasciitis caused by aerobic and anaerobic bacterial infection that involves genitalia and perineum. Males, in their 60 s, are more affected with 1.6 new cases/100.000/year. Main risk factors are diabetes, malignancy, inflammatory bowel disease. FG is a potentially lethal disease with a rapid and progressive involvement of subcutaneous and fascial plane. A multimodal approach with surgical debridement, antibiotic therapy, intensive support care, and hyperbaric oxygen therapy (HBOT) is often needed. We present the inpatient management of an FG case during the Covid-19 pandemic period. A narrative review of the Literature searching “Fournier’s gangrene”, “necrotizing fasciitis” on PubMed and Scopus was performed. Case presentation A 60 years old man affected by diabetes mellitus, with ileostomy after colectomy for ulcerative colitis, was admitted to our Emergency Department with fever and acute pain, edema, dyschromia of right hemiscrotum, penis, and perineal region. Computed tomography revealed air-gas content and fluid-edematous thickening of these regions. Fournier’s Gangrene Severity Index was 9. A prompt broad-spectrum antibiotic therapy with Piperacillin/Tazobactam, Imipenem and Daptomycin, surgical debridement of genitalia and perineal region with vital tissue exposure, were performed. Bedside daily surgical wound medications with fibrine debridement, normal saline and povidone-iodine solutions irrigation, iodoform and fatty gauze application, were performed until discharge on the 40th postoperative day. Every 3 days office-based medication with silver dressing, after normal saline and povidone-iodine irrigation and fibrinous tissue debridement, was performed until complete re-epithelialization of the scrotum on the 60th postoperative day. Conclusions FG is burdened by a high mortality rate, up to 30%. In the literature, HBOT could improve wound restoration and disease-specific survival. Unfortunately, in our center, we do not have HBOT. Moreover, one of the pandemic period problems was the patient’s displacement and outpatient hospital management. For all these reasons we decided for a conservative inpatient management. Daily cleaning of the surgical wound allowed to obtain its complete restoration avoiding surgical graft and hyperbaric oxygen chamber therapy, without foregoing optimal outcomes.
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Affiliation(s)
- Alessio Paladini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Giovanni Cochetti
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy.
| | - Angelica Tancredi
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Matteo Mearini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Andrea Vitale
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Francesca Pastore
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Paolo Mangione
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
| | - Ettore Mearini
- Department of Medicine and Surgery, Urology Clinic, University of Perugia, 06129, Perugia, Italy
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Practical Review of the Current Management of Fournier’s Gangrene. Plast Reconstr Surg Glob Open 2022; 10:e4191. [PMID: 35295879 PMCID: PMC8920302 DOI: 10.1097/gox.0000000000004191] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/18/2022] [Indexed: 12/18/2022]
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Relationship between diversional stoma and mortality rate in Fournier's gangrene: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:2581-2590. [PMID: 33864128 DOI: 10.1007/s00423-021-02175-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/11/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Fournier's gangrene (FG) is a rare potentially lethal necrotising infection of the perineum. While the gold standard management is early and aggressive surgical debridement, the evidence in the literature is unclear as to the role and outcomes of diversional stoma. METHODS A systematic review was conducted to identify studies investigating the relationship between stoma formation and FG. Meta-analyses were performed using a random-effects model. RESULTS Twenty-seven studies (n=1482) were included. There was no significant difference in disease severity scores between the stoma and no stoma groups. Mortality rate was significantly higher in patients who required diversional stoma (OR 1.71, 95% CI 1.13-2.59, p=0.01). Significantly more surgical procedures were performed on patients who underwent stoma formation, and the total hospital cost was also higher in this group. This study may have been limited by bias in patients with more fulminant course or sphincter damage requiring stoma as a medical necessity. CONCLUSION These findings suggest that the use of diversional stoma in FG is a predictor of poor outcomes. This study demonstrated that mortality rate remained high and a diversional stoma did not reduce risk of mortality as suggested by smaller case series. Its use should therefore be individualised based on disease severity and sphincter damage.
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Zingaro MD, Boni A, Vermandois JARD, Paladini A, Lepri E, Ursi P, Cirocchi R, Turco M, Gaudio G, Nogara A, Mearini E. Fournier's Gangrene and Intravenous Drug Abuse: an Unusual Case Report and Review of The Literature. Open Med (Wars) 2019; 14:694-710. [PMID: 31934634 PMCID: PMC6947763 DOI: 10.1515/med-2019-0114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 07/09/2019] [Indexed: 12/29/2022] Open
Abstract
Fournier's gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes. In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia. Fournier's gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.
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Affiliation(s)
- Michele Del Zingaro
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Andrea Boni
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | | | - Alessio Paladini
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Emanuele Lepri
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Pietro Ursi
- Department of General Surgery and Surgical Specialties “Paride Stefanini”;, Sapienza University of Rome, Rome, Italy
| | - Roberto Cirocchi
- Division of General Surgery, Department of Surgical and Biochemical Sciences, University of Perugia, Perugia, Italy
| | - Morena Turco
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Gianluca Gaudio
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Andrea Nogara
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Ettore Mearini
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
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Could Forming a Stoma Alongside from the Principal Surgery Predict Mortality Among Operative Parameters? Indian J Surg 2019. [DOI: 10.1007/s12262-018-1844-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Planellas Giné P, Rodríguez-Hermosa JI, Codony Bassols C, Marinello F, Salvador Roses H, Gil Garcia J, Gómez Romeu N, Julià Bergkvist D, Farrés Coll R, Codina-Cazador A. Role of derivative colostomy in Fournier’s gangrene: Analysis of 46 cases. SURGICAL PRACTICE 2017. [DOI: 10.1111/1744-1633.12255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Pere Planellas Giné
- Department of Colorectal Surgery; University Hospital Dr Josep Trueta; Girona Spain
| | | | - Clara Codony Bassols
- Department of Colorectal Surgery; University Hospital Dr Josep Trueta; Girona Spain
| | - Franco Marinello
- Department of Colorectal Surgery; University Hospital Dr Josep Trueta; Girona Spain
| | | | - Júlia Gil Garcia
- Department of Colorectal Surgery; University Hospital Dr Josep Trueta; Girona Spain
| | - Núria Gómez Romeu
- Department of Colorectal Surgery; University Hospital Dr Josep Trueta; Girona Spain
| | | | - Ramon Farrés Coll
- Department of Colorectal Surgery; University Hospital Dr Josep Trueta; Girona Spain
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Ioannidis O, Kitsikosta L, Tatsis D, Skandalos I, Cheva A, Gkioti A, Varnalidis I, Symeonidis S, Savvala NA, Parpoudi S, Paraskevas GK, Pramateftakis MG, Kotidis E, Mantzoros I, Tsalis KG. Fournier's Gangrene: Lessons Learned from Multimodal and Multidisciplinary Management of Perineal Necrotizing Fasciitis. Front Surg 2017; 4:36. [PMID: 28740847 PMCID: PMC5502266 DOI: 10.3389/fsurg.2017.00036] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/21/2017] [Indexed: 01/27/2023] Open
Abstract
Background Fournier’s gangrene (FG) is a rapidly evolving necrotizing fasciitis of the perineum and the genital area, the scrotum as it most commonly affects man in the vast majority of cases. It is polymicrobial in origin, due to the synergistic action of anaerobes and aerobes and has a very high mortality. There are many predisposing factors including diabetes mellitus, alcoholism, immunosuppression, renal, and hepatic disease. The prognosis of the disease depends on a lot of factors including but not limited to patient age, disease extent, and comorbidities. The purpose of the study is to describe the experience of a general surgery department in the management of FG, to present the multimodal and multidisciplinary treatment of the disease, to identify predictors of mortality, and to make general surgeons familiar with the disease. Methods The current retrospective study is presenting the experience of our general surgery department in the management of FG during the last 20 years. The clinical presentation and demographics of the patients were recorded. Also we recorded the laboratory data, the comorbidities, the etiology, and microbiology and the therapeutic interventions performed, and we calculated the various severity indexes. Patients were divided to survivors and non-survivors, and all the collected data were statistically analyzed to assess mortality factors using univariate and then multivariate analysis. Results In our series, we treated a total of 24 patients with a mean age 58.9 years including 20 males (83.4%) and 4 females (16.6%). In most patients, a delay between disease onset and seeking of medical help was noted. Comorbidities were present in almost all patients (87.5%). All patients were submitted to extensive surgical debridements and received broad-spectrum antibiotics until microbiological culture results were received. Regarding all the collected data, there was no statistically significant difference between survivors and non-survivors except the presence of malignancy in non-survivors (p = 0.036) and the lower hemoglobin (p < 0.001) and hematocrit (p = 0.002) in non-survivors. However, multivariate analysis did not reveal any predictor of mortality. Conclusion Early diagnosis, aggressive thorough surgical treatment, and administration of the proper antibiotic treatment comprise the cornerstone for the outcome of this disease. In small populations like in the present study, it is difficult to recognize any predictors of mortality and even the severity indexes, which take into account a lot of data cannot predict mortality.
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Affiliation(s)
- Orestis Ioannidis
- Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Loukiani Kitsikosta
- Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitris Tatsis
- Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Skandalos
- Department of Surgery, General Hospital "Agios Pavlos", Thessaloniki, Greece
| | - Aggeliki Cheva
- Department of Pathology, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - Aikaterini Gkioti
- Department of Microbiology, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - Ioannis Varnalidis
- Department of Plastic Surgery, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - Savvas Symeonidis
- Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Natalia Antigoni Savvala
- Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Styliani Parpoudi
- Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George K Paraskevas
- Department of Anatomy, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Efstathios Kotidis
- Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Mantzoros
- Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Necrotizing Fasciitis Secondary to a Primary Suture for Anoperineal Trauma by Motorcycle Accident in a Healthy Adult. Case Rep Emerg Med 2015; 2015:956156. [PMID: 26347831 PMCID: PMC4546953 DOI: 10.1155/2015/956156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/28/2015] [Indexed: 11/18/2022] Open
Abstract
A 41-year-old man experienced a swollen scrotum three days after a motorcycle accident and presented to our hospital. He had had a primary suture repair for anoperineal trauma in an outside hospital at the time of the injury. He presented to us with general fatigue, low grade fevers, and perineal pain. Abdominal computed tomography showed subcutaneous emphysema from the scrotum to the left chest. The sutured wound had foul-smelling discharge and white exudate. We made the diagnosis of necrotizing fasciitis and immediately opened the sutured wound and performed initial debridement and lavage with copious irrigation. We continued antibiotics and lavage of the wound until the infection was controlled. Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days. Our experience indicates that anoperineal injuries should not be closed without careful and intensive follow-up due to the potential of developing necrotizing fasciitis.
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Bruketa T, Majerovic M, Augustin G. Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options. World J Gastroenterol 2015; 21:9002-9020. [PMID: 26290629 PMCID: PMC4533034 DOI: 10.3748/wjg.v21.i30.9002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 05/08/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023] Open
Abstract
Fournier’s gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.
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Abstract
We aimed to present our clinical experience with FG treatment. Fournier's gangrene (FG) is a rare but serious disease characterized by progressive necrosis in the genitourinary and perineal region. The retrospective study included 43 patients. Patients were divided into 2 groups as survivors and nonsurvivors. Included in the analysis were data pertaining to demographics, predisposing factors, comorbidities, results of bacteriologic analyses, number of debridements, duration of treatment, FG Severity Index (FGSI) score, fecal diversion methods (trephine ostomy or Flexi-Seal Fecal Management System-FMS), and dressing methods (wet or negative aspiration system). In the nonsurvivor group, urea, WBC, and age were significantly higher, whereas albumin, hematocrit, platelet count, and length of hospital stay (LOHS) were significantly lower compared to the survivor group. Mean FGSI was lower in survivors in comparison with nonsurvivors (5.00 ± 1.86 and 10.00 ± 1.27, respectively; P < 0.001). We conclude that FGSI is an important predictor in the prognosis of FG. Vacuum-assisted closure (VAC) should be performed in compliant patients in order to enhance patient comfort by reducing pain and the number of dressings. Fecal diversion should be performed as needed, preferably by using FMS. The trephine ostomy should be the method of choice in cases where an ostomy is necessary.
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