Experience in Management of Fournier’s Gangrene: A Report of 24 Cases

Fournier’s gangrene (FG) is an extremely aggressive and rapidly progressive polymicrobial soft tissue infection of the perineum,anal area or genitalial regions with a high mortality rate.The objectives of this study were to share our experience with the management of this serious infectious disease over the last 15 years.This retrospective study examined 24 patients diagnosed as having FG who were admitted to our hospital between March 1996 and December 2011.The gender,age,etiology,predisposing factors,laboratory findings,treatment modality,hospitalization time and spread of gangrene of the subjects were all recorded and analyzed.The results showed that the mean age of the patients was 48.33 years,the male-to-female ratio was 5:1 and the mortality rate was 20.8% (5/24).The most common predisposing factor was diabetes mellitus in 10 patients (41.6%),followed by alcohol abuse,obesity,neoplasms and immunosuppression.The most common etiology was peri-anal and peri-rectal abscesses (45.8%),followed by lesions of urogenital origin (33.3%) and cutaneous (8.3%) origin.No local pathologies could be identified in 3 (12.5%) patients.The most commonly isolated microorganisms were Escherichia coli (62.5%),followed by Enterococcus,Pseudomonas aeruginosa and Staphylococcus aureus.The median admission Fournier’s gangrene severity index (FGSI) score for survivors was 5.63±1.89 against 13.6±3.64 for non-survivors which was designed for predicting the disease severity in the series.Early diagnosis and immediate extensive surgical debridement were significant prognostic factors in the management of Fournier gangrene.Individualized reconstructive modalities for wound coverage were useful in that they repaired the tissue defect and improved the quality of life.We are led to conclude that Fournier’s gangrene is a severe condition with a high mortality.The Fournier’s gangrene severity index (FGSI) score at admission serves as a good predictor for the disease severity.Early diagnosis,surgical debridement and aggressive fluid therapy are significant prognostic factors in the management of Fournier gangrene.Individualized reconstructive surgery modalities for wound coverage are useful to correct the tissue defect and improve the quality of life.

Fournier’s Gangrene: Experience with Two Severe Cases

Fournier’s Gangrene is a formidable rare disease characterized by high mortality rates despite optimal medical and surgical management. It is an acute surgical emergency and requires a high degree of suspicion. The mainstay of treatment is swift open drainage and early aggressive surgical debridement of all necrotic tissue, followed by targeted antibiotic therapy. The authors report on two patients who were admitted to the surgical ward. Both presented with initial perianal sepsis complicated by painful swollen scrotum with rapid progression of gangrene of the scrotal skin and subcutaneous tissue, extensive cellulitis of the perineum, and in one patient crepitation of the anterior abdominal wall. A diagnosis of Fournier’s Gangrene was made and they were both managed by prompt resuscitation, broad-spectrum antibiotics, extensive debridement of all necrotic tissue in theatre, daily wound dressing, and repeated neurectomy on the ward. One of the patients had a colostomy done and the other a cystostomy to divert feces and relieve chronic urinary retention respectively. These patients were successfully treated despite the severity of their conditions which was complicated by severe sepsis in the face of limited diagnostic capabilities and resources, using a multidisciplinary approach and basic clinical monitoring as a guide.

Severe acute pancreatitis: Clinical course and management

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (> 50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis- Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.