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Susini P, Marcaccini G, Efica J, Giuffrè MT, Mazzotta R, Caneschi C, Cuomo R, Nisi G, Grimaldi L. Fournier's Gangrene Surgical Reconstruction: A Systematic Review. J Clin Med 2024; 13:4085. [PMID: 39064124 DOI: 10.3390/jcm13144085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/28/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Fournier's gangrene (FG) is a rare form of necrotizing fasciitis of the perineal, genital, or perianal region. It is characterized by an aggressive course and high mortality rate, over 20%. FG demands immediate treatment including resuscitation maneuvers, intravenous antibiotic therapy and early surgical debridement. Background/Objectives: The gold-standard treatment for FG is surgical reconstruction. However, up to date, no precise guidelines exist. Thus, we decided to systematically review the literature, focusing on FG contemporary approaches to reconstructive surgery, aiming to analyze the various reconstructive strategies and their specific indications. Methods: A systematic review was carried out according to the PRISMA statement by searching various databases from April 2014 to April 2024, using the terms ''Fournier Gangrene OR Fournier Gangrene Reconstruction OR Fournier Gangrene Treatment OR Fournier Gangrene Plastic Surgery OR Necrotizing Fasciitis OR Necrotizing Fasciitis AND Reconstruction". The eligibility criteria included original studies aimed at discussing FG reconstruction with at least three clinical cases. Results: The final synthesis included 38 articles, and 576 reconstructions were described. Of these, 77.6% were minimally invasive strategies (direct closure, secondary healing, grafts, and local random flaps), while more invasive reconstructions (loco-regional flaps based on known vascular anatomy) were adopted in 22.4%. No free flaps were reported. Conclusions: FG requires immediate medical interventions including broad-spectrum antibiotic therapy, surgical debridement, adjuvant therapies, and reconstructive surgeries. Taking into account the anatomical characteristics of the inguinal-crural region, skin grafts and local random flaps could offer versatile and effective reconstructions for most FG cases, while the more invasive strategies should be reserved for very few cases. Future research is warranted to define an FG dedicated reconstruction protocol.
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Affiliation(s)
- Pietro Susini
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Gianluca Marcaccini
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Jessica Efica
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Maria Teresa Giuffrè
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Ruggero Mazzotta
- Division of General Cardiology, Careggi University Hospital, 50134 Florence, Italy
| | - Corso Caneschi
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, 50134 Florence, Italy
| | - Roberto Cuomo
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Giuseppe Nisi
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Luca Grimaldi
- Plastic Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
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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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Hughes T, Bowen D, Saeed K, Juliebø-Jones P, Somani B. Management of Fournier's gangrene: a practical guide for clinicians. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 37769264 DOI: 10.12968/hmed.2023.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Fournier's gangrene is a localised form of necrotising fasciitis affecting the external genitalia, perineal and perianal regions. Although rare, it is associated with high rates of morbidity and mortality, so clinician awareness is essential for prompt treatment. Risk factors include diabetes mellitus, hypertension, chronic alcoholism and immunosuppression. Perineal pain in patients with sepsis should be treated with a high level of suspicion and early surgical referral is required as prompt debridement can improve outcomes. Repeated surgical intervention and antimicrobial therapy are often needed and recovery can take a long time, with a long-term impact on quality of life. This article discusses the natural history of Fournier's gangrene, aetiology, risk factors, investigations and treatments with an algorithm to support clinical practice.
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Affiliation(s)
- Thomas Hughes
- Department of Urology, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - Daniel Bowen
- Department of Urology, Mid and South Essex NHS Foundation Trust, Chelmsford, UK
| | - Kordo Saeed
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | | | - Bhaskar Somani
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Ghabisha S, Ahmed F, Al-Wageeh S, Badheeb M, Alyhari Q, Altam A, Alsharif A. Prognostic determinants and treatment outcomes of Fournier's Gangrene treatment in a resource-limited setting: A retrospective study. Arch Ital Urol Androl 2023; 95:11450. [PMID: 37491981 DOI: 10.4081/aiua.2023.11450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/08/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Fournier's gangrene (FG) is a destructive necrotizing infection with a generally poor prognosis. This study aims to share our experience in handling FG patients in a resource-limited setting and identify prognostic factors for FG mortality. METHODS A retrospective study of thirty-six patients diagnosed with FG and treated at our teaching hospital between Jun 2010 to Oct 2022 was conducted. Laboratory and nonlaboratory data and patients' outcomes were gathered. A univariate analysis was computed for identifying prognostic factors for FG mortality. RESULT The main age was 68.30 ± 5.61years and most (69.4%) were older than 65 years. The overall survival was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age (p = 0.02), delayed in hospital presentation (p = 0.024), involvement of larger area (p = 0.001), a history of diabetes mellitus (p < 0.006), end-stage renal disease (p = 0.018), heart failure (p = 0.005), cerebrovascular accident (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidities (p = 0.001), septic conditions at admission (p = 0.048), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mortality in patients with FG. CONCLUSIONS Fournier's gangrene is a fulminant condition with a high mortality rate, especially in resource-limited settings. In this study, the mortality rate was 36.1%. Advanced age, delayed in hospital presentation, involvement of larger area, a history of diabetes mellitus, end-stage renal disease, heart failure, cerebrovascular accident, liver cirrhosis, presence of multiple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality.
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Affiliation(s)
- Saif Ghabisha
- Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb.
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb.
| | - Saleh Al-Wageeh
- Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb.
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport.
| | - Qasem Alyhari
- Department of General Surgery, School of Medicine, Ibb University of Medical Sciences, Ibb.
| | - Abdulfattah Altam
- Department of General Surgery, School of Medicine, 21 September University, Sana'a.
| | - Afaf Alsharif
- Department of Gynaecology, School of Medicine, Jeblah University for Medical and Health Sciences, Ibb.
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Huang C, Zhong Y, Yue C, He B, Li Y, Li J. The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:23. [PMID: 36966323 PMCID: PMC10040118 DOI: 10.1186/s13017-023-00490-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND To determine the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), we conducted a meta-analysis of the available evidence. METHODS Data sources were PubMed, Embase, Web of Science, Cochrane Library, and reference lists. The study included observational trials that compared HBO with non-HBO, or standard care. The primary outcome was the mortality rate. Secondary outcomes were the number of debridement, amputation rate and complication rate. Relative risks or standardized mean differences with 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively. RESULTS A total of retrospective cohort and case-control studies were included, including 49,152 patients, 1448 who received HBO and 47,704 in control. The mortality rate in the HBO group was significantly lower than that in the non-HBO group [RR = 0.522, 95% CI (0.403, 0.677), p < 0.05]. However, the number of debridements performed in the HBO group was higher than in the non-HBO group [SMD = 0.611, 95% CI (0.012, 1.211), p < 0.05]. There was no significant difference in amputation rates between the two groups [RR = 0.836, 95% CI (0.619, 1.129), p > 0.05]. In terms of complications, the incidence of MODS was lower in the HBO group than in the non-HBO group [RR = 0.205, 95% CI (0.164, 0.256), p < 0.05]. There was no significant difference in the incidence of other complications, such as sepsis, shock, myocardial infarction, pulmonary embolism, and pneumonia, between the two groups (p > 0.05). CONCLUSION The current evidence suggests that the use of HBO in the treatment of NSTI can significantly reduce the mortality rates and the incidence rates of complications. However, due to the retrospective nature of the studies, the evidence is weak, and further research is needed to establish its efficacy. It is also important to note that HBO is not available in all hospitals, and its use should be carefully considered based on the patient's individual circumstances. Additionally, it is still worthwhile to stress the significance of promptly evaluating surgical risks to prevent missing the optimal treatment time.
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Affiliation(s)
- Chengzi Huang
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yilian Zhong
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chaochi Yue
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bin He
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yaling Li
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jun Li
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, 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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Raizandha MA, Hidayatullah F, Kloping YP, Rahman IA, Djatisoesanto W, Rizaldi F. The role of hyperbaric oxygen therapy in Fournier's Gangrene: A systematic review and meta-analysis of observational studies. Int Braz J Urol 2022; 48:771-781. [PMID: 35594328 PMCID: PMC9388173 DOI: 10.1590/s1677-5538.ibju.2022.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose: Management of Fournier’s Gangrene (FG) includes broad-spectrum antibiotics with adequate surgical debridement, which should be performed within the first 24 hours of onset. However, this treatment may cause significant loss of tissue and may delay healing with the presence of ischemia. Hyperbaric oxygen therapy (HBOT) has been proposed as adjunctive therapy to assist the healing process. However, its benefit is still debatable. Therefore, this systematic review and meta-analysis aimed to evaluate the effect of HBOT as an adjunct therapy for FG. Materials and Methods: This study complied with the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol to obtain studies investigating the effect of HBOT on patients with FG. The search is systematically carried out on different databases such as MEDLINE, Embase, and Scopus based on population, intervention, control, and outcomes criteria. A total of 10 articles were retrieved for qualitative and quantitative analysis. Results: There was a significant difference in mortality as patients with FG who received HBOT had a lower number of deaths compared to patients who received conventional therapy (Odds Ratio 0.29; 95% CI 0.12 – 0.69; p = 0.005). However, the mean length of stay with Mean Difference (MD) of -0.18 (95% CI: -7.68 – 7.33; p=0.96) and the number of debridement procedures (MD 1.33; 95% CI: -0.58 – 3.23; p=0.17) were not significantly different. Conclusion: HBOT can be used as an adjunct therapy to prevent an increased risk of mortality in patients with FG.
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Affiliation(s)
- Muhammad Achdiar Raizandha
- Department of Urology, Faculty of Medicine, Universitas Airlangga, Universitas Airlangga Teaching Hospital, Surabaya, East Java, Indonesia
| | - Furqan Hidayatullah
- Department of Urology, Faculty of Medicine, Universitas Airlangga, Universitas Airlangga Teaching Hospital, Surabaya, East Java, Indonesia
| | - Yudhistira Pradnyan Kloping
- Department of Urology, Faculty of Medicine, Universitas Airlangga, Universitas Airlangga Teaching Hospital, Surabaya, East Java, Indonesia
| | - Ilham Akbar Rahman
- Department of Urology, Faculty of Medicine, Universitas Airlangga, Universitas Airlangga Teaching Hospital, Surabaya, East Java, Indonesia
| | - Wahjoe Djatisoesanto
- Department of Urology, Faculty of Medicine, Universitas Airlangga, Universitas Airlangga Teaching Hospital, Surabaya, East Java, Indonesia
| | - Fikri Rizaldi
- Department of Urology, Faculty of Medicine, Universitas Airlangga, Universitas Airlangga Teaching Hospital, Surabaya, East Java, Indonesia
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Indications for Emergent Hyperbaric Oxygen Therapy. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00251-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Erickson BA, Flynn KJ. Management of Necrotizing Soft Tissue Infections (Fournier’s Gangrene) and Surgical Reconstruction of Debridement Wound Defects. Urol Clin North Am 2022; 49:467-478. [DOI: 10.1016/j.ucl.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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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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Malik G, Agarwal T, Costantini M, Pal S, Kumar A. Oxygenation therapies for improved wound healing: Current trends and technologies. J Mater Chem B 2022; 10:7905-7923. [DOI: 10.1039/d2tb01498j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Degree of oxygenation is one of the important parameters governing various processes, including cell proliferation, angiogenesis, extracellular matrix production, and even combating the microbial burden at the wound site, all...
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