Fournier's gangrene: its management remains a challenge

Vacuum sealing drainage to treat Fournier's gangrene

BACKGROUND

Vacuum sealing drainage (VSD) is widely applied in complex wound repair. We aimed to compare traditional debridement and drainage and VSD in treating Fournier's gangrene (FG).

METHODS

Data of patients surgically treated for FG were retrospectively analyzed.

RESULTS

Of the 36 patients (men: 31, women: 5; mean age: 53.5 ± 11.3 [range: 28-74] years) included in the study, no patients died. Between-group differences regarding sex, age, BMI, time from first debridement to wound healing, number of debridements, FGSI, and shock were not statistically significant (P > 0.05). However, lesion diameter, colostomy, VAS score, dressing changes, analgesic use, length of hospital stay, and wound reconstruction method (χ² = 5.43, P = 0.04) exhibited statistically significant differences. Tension-relieving sutures (6 vs. 21) and flap transfer (4 vs. 2) were applied in Groups I and II, respectively.

CONCLUSION

VSD can reduce postoperative dressing changes and analgesic use, and shrunk the wound area, thereby reducing flap transfer in wound reconstruction.

Prognostic determinants and treatment outcomes of Fournier's Gangrene treatment in a resource-limited setting: A retrospective study

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.

A Comprehensive Literature Review of Fournier's Gangrene in Females

Fournier gangrene (FG) is a rare but rapidly progressing disease with a higher mortality rate in women as compared to men. This study aims to perform a literature review about FG in females and associated mortality and morbidity. We searched databases including MEDLINE (Ovid), the National Library of Medicine (Medical Subject Headings (MeSH)), the Cochrane Database of Systematic Reviews (Wiley), as well as Embase (Ovid), Scopus, and Global Index Medicus (WHO), and reviewed literature from 2002 to 2022 and selected 22 studies that met our study's inclusion criteria, which included 134 female patients with a mean age of 55±6 years. The perineal abscess was a more common nidus (n=41, 35%; 95%CI 23-39%) than vulvar pathology (n=29, 22%; 95%CI 15-30%). The most common initial presentation was cellulitis (n=62, 46%; 95%CI 38-55%), followed by perineal pain (n=54, 40%; 95%CI 32-50%), fever (n=47, 35%; 95%CI 27-43%), and septic shock (n=38, 28%; 95%CI 21-37%). Escherichia coli was the most frequently identified bacteria (n=48, 36%; 95%CI 28-46%). All patients had treatment with a mean of three (SD 2) debridement and those with negative pressure dressings received fewer debridements than those who received a conventional dressing. However, of those who had surgical intervention, 28 (20%; 95%CI 14-29%) patients underwent diversion colostomy. General surgeons performed 78% (n=104) of cases out of which 20% (n=20) were consulted by obstetrician-gynecologists, 14% (n=18) were treated by urologists, and only 8% (n=10) by plastic surgeons. The mean length of stay in the hospital was 24±11 days, and the gross mortality rate was 27 (20%; 95%CI 14-28%). In conclusion, while females have a low incidence rate of FG, they carry a higher mortality rate. Lack of cardinal signs and delayed presentation to the hospital from the onset of symptoms are some possible causes for the increased mortality rate along with the disease process being under-recognized in women. A high index of clinical suspicion is essential to avoid delay in the definitive management coupled with an early surgical consult and establishing a common general care pathway could minimize mortality and morbidity.

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

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.

Fournier's gangrene in an eight-day-old male neonate, a case report

INTRODUCTION AND IMPORTANCE

Fournier's gangrene is necrotizing fasciitis of the scrotum and perineal area. It is a polymicrobial infection of perianal origin characterized by rapid necrotizing spread along fascial planes to abdominal wall and flank area. The very rare nature of this illness in neonates makes it important to take a lesson in subsequent management of similar cases.

CASE PRESENTATION

An eight days old male neonate come with compliant of high-grade intermittent fever, scrotal swelling, crying during urination and irritability of 3 days duration. Objectively he has temperature of 38.8 degree Celsius, pulse rate of 172 and blackish ulcerated scrotum with minimal puss discharge. Blood work showed leukocytosis and scrotal ultrasound ruled out other pathology.

CLINICAL DISCUSSION

Identifiable causes constitute about 80% of the cases. Culture from the puss in our case showed polymicrobial cause. Mortality is mainly due severe sepsis, coagulopathy and renal failure. Medical management include optimization of cardiorespiratory status with cautious resuscitation, respiratory support and inotropic support with severe cases. Prompt surgical debridement, incision and drainage help reduce ongoing infection and systemic toxicity.

CONCLUSION

The poor hygiene and immature immune response are the likely predisposing factors. Medical management with broad spectrum antibiotics and surgical debridement are cornerstones for good recovery.

Fournier’s gangrene: the current state of the problem and our treatment experience

The OBJECTIVE of the study was to analyze the results of treatment of patients with lightning scrotal gangrene (Fournier’s gangrene).METHODS AND MATERIAL. The work is based on the analysis of the results of treatment of 31 patients with Fournier’s gangrene aged 32 to 82 years. In 19 (61.3 %) patients, the most probable nosological causes of Fournier’s gangrene were diseases of the anorectal zone, in 10 – pathology of the urogenital sphere. In 2 patients, Fournier’s gangrene developed as a result of a closed injury (1) and a gunshot wound (1) of the perineum and scrotum. A limited (slowly progressing) form of the disease was observed in 18 (58.1 %) patients, a common form with a lightning (9) and rapidly progressing (4) course – in 13 (41.9 %). 6 (19.3 %) patients suffered from diabetes mellitus of varying severity. In all patients, the clinical manifestations of the disease and laboratory parameters were characterized by the phenomena of generalized surgical infection with signs of systemic inflammatory response syndrome and endotoxicosis. In 93.5 % of patients, causative microflora was represented by various associations of both facultative-anaerobic and obligateaerobic gram-negative and obligate-facultative anaerobic gram-positive microorganisms. The growth of anaerobic gramnegative non-clostridial flora was also obtained.RESULTS. Out of 31 patients, 6 (19.3 %) patients died who had a common form of FG with a lightning and rapidly progressing clinical course in the format of systemic inflammatory response syndrome and systemic endotoxicosis with an outcome in organ-system dysfunction. The causes of death were: septic shock (in 1), progressive systemic endotoxicosis (sepsis) with the outcome of multiple organ failure (in 3) and pulmonary embolism (in 2).CONCLUSION. Multidisciplinary approach to solving organizational and therapeutic and tactical tasks with the participation of doctors of related specialties, active surgical tactics in the format of «aggressive surgery», providing for the widest possible excision of necrotic and non-viable tissues, performed in combination with programmed (stage-by-stage) sanitation necrectomy, pathogenetically justified correction of violations of the homeostasis system, rational antibacterial therapy, a comprehensive system of local wound treatment and plastic replacement of lost integumentary tissues are priority ways to optimize the results of treatment of patients with Fournier’s gangrene.