Incorporating Simplified Fournier's Gangrene Severity Index with early surgical intervention can maximize survival in high‐risk Fournier's gangrene patients
Tsung‐Yen LinI‐Hung ChengChien‐Hui OuYuh‐Shyan TsaiYat‐Ching TongHong‐Lin ChengWen‐Horng YangYung‐Ming LinYu‐Sheng Cheng
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Abstract:
To determine the optimal surgical timing in high-risk patients with Fournier's gangrene by the Simplified Fournier's Gangrene Severity Index.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.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).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.Keywords:
Gangrene
Fournier gangrene
Risk Stratification
Fournier's gangrene is a necrotizing fasciitis of the genital and scrotal region due to infectious process. The gangrene is rare. Most cases are diagnosed in elderly patients with immunodeficiency, especially in diabetics or alcoholics. Currently a primary infection focus can be revealed in about 95% cases. The nidus is usually located in the genitourinary tract, lower gastrointestinal tract or skin. Fournier's gangrene is a mixed infection caused by both aerobic and anaerobic bacterial flora. The development and progression of the gangrene is often fulminating and can rapidly cause multiple organ failure and death. Early surgical debridement of necrotic tissues and antibiotics are fundamental in the treatment of Fournier's gangrene. Despite of advanced management mortality is still high and averages 20-30%.
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The aetiology, definition, and management of Fournier's gangrene are an enigma to surgeons and urologists alike. Indeed, controversy surrounds its management. We managed 110 cases of Fournier's gangrene with different modalities and compared their outcomes along with those of contemporary studies.To evaluate aetiology, predisposing factors, and causative organisms plus compare modalities of surgical management of Fournier's gangrene.110 cases of Fournier's gangrene that were admitted and treated in S.S.G. Hospital (Vadodara/Baroda, India) from January 2000 to December 2006 were evaluated.The average duration of symptoms was 3-5 days and the commonest presentation was scrotum swelling plus pain and fever. The most common aetiological factor was trauma and urinary tract infection. The majority (84%) of cases had bilateral scrotal involvement. In the majority (46%) of patients, a mixture of causative organisms were isolated; E. coli was isolated in 17.5% of patients. The fascicutaneous rotation thigh flap procedure gave the best cosmetic results.Review of the cases suggests that the Fournier's gangrene is either an idiopathic condition or secondary to adjacent infection or the operation performed. The condition progresses rapidly but is usually self-limiting and most commonly confined to the genitalia. Adequate diagnosis is imperative and immediate intense and aggressive therapy is necessary. Prompt surgical debridement and administration of appropriate antibiotics (both local and systemic) are necessary to lower mortality and morbidity. Most of the defects can be closed secondarily while some need coverage by skin grafting. Fasciocutaneous rotation thigh flap is the best cosmetically acceptable repair, although it demands surgeons with considerable skill and experience and there are relatively more complications compared with other procedures as well as a longer hospital stay.
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Fournier gangrene
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Fournierâs gangrene is a necrotizing fasciitis encountered in the scrotal and perineal region which progresses rapidly to a life-threatening state. Treatment options are dependent on the origin of the disease and lesion extent and depth. We report our experience of a case of Fournierâs gangrene treated by colostomy and vacuum assisted closure (VAC). A 66-year-old man visited our emergency room with swelling and pain of his left buttock. After wide debridement of the perianal area and left buttock, VAC was applied for continuous drainage and to accelerate granulation. In addition, colostomy was performed to prevent fecal contamination. Four weeks after second debridement (with VAC and colostomy), we performed split thickness skin graft and local flap to successfully cover the wounds. We suggest VAC after early debridement and as a bolster dressing after skin grafting in managing Fournierâs gangrene. We also recommend that if fecal contamination is suspected during the application of VAC, colostomy should be performed at early stage. Key Words: Fournier gangrene; Colostomy; Vacuum
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French venereologist Jean-Alfred Fournier described this gangrene as a fulminant gangrene of the penis and scrotum in young men. He reported five cases in his clinical lectures in 1883 though it was first described by Baurienne in 1764. Fournier’s gangrene is a form of necrotizing fasciitis that affects the genital and surrounding perineal and perianal areas. It’s a life-threatening disease leading to 20 to 80 percent mortality. It destroys tissues quickly and infection progresses to septic shock which kills patient if prompt and aggressive treatment is not started. Common symptoms of Fournier’s gangrene are pain in scrotum and or perineum, redness, fever and weakness. Advanced cases have foul smelling discharge from infected tissues. It is due to polymicrobial infection, both aerobic and anaerobic. Fournier’s gangrene is usually diagnosed clinically but imaging investigations such as X-rays, Ultrasound and CT scan help a lot to reach the diagnosis early. Treatment mainly consists of resuscitation, intravenous antibiotics and debridement. We have treated successfully four cases of advanced Fournier’s gangrene with team work of surgeons, anaesthesiologists, physicians and critical care specialists. Full recovery is possible due to a good team work and understanding the disease.
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To report an uncommon case of Fournier's gangrene caused by a perforated retrocecal acute appendicitis that compromised the scrotum and testis.Herein we describe a patient that was admitted for abdominal pain localized to the right lower flank and generalized virulent sepsis.Resection of the right inguinal cord and testis was performed. The outcome was poor and the patient died of multiorgan failure.Fournier's gangrene basically arises from anorectal and urological pathologies, although occasionally it may arise from an intraabdominal source, which should be ruled out especially when the abdominal examination shows interesting findings.
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Fournier's gangrene is an aggressive form of necrotizing fasciitis of the perineal, perianal or genital regions, usually caused by a polymicrobial infection that includes virulent organisms. Over the last decades, we have treated 9 patients suffering from Fournier's gangrene using systemic chemotherapy with broad-spectrum antibiotics, and with extensive, sometimes serial surgical debridement. Recently in one case, in addition to treatment, we used locally 100% oxygen in daily doses with promising results in healing wound. Herein, we report this case with a brief review of the literature concerning pathogenesis, risk factors, and treatment approaches.
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Fournier gangrene
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Broad spectrum
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Gas gangrene
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Fournier gangrene
Nephrology
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Fourniers gangrene is a genital catastrophe with significant morbidity and mortality. We present a 57 year old patient with fournier's gangrene and perianal abscess. He had serial debridements with daily bedside dressing and secondary closure of the scrotal defect. Further evaluation during the course of treatment revealed diabetes mellitus. We conclude that aggressive multidisciplinary treatment will improve outcome and that the existence of fournier's gangrene coexisting perianal abscess could alert the clinician to the possibility of underlying diabetes mellitus - A common denominator.
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Objective To analyze the anatomic characteristics of Fournier gangrene and to provide references in clinics.Methods The clinical data of 21 patients with Fournier gangrene from January 1997 to June 2011 were reviewed and discussed combined with literature analysis.Results One(1/21,4.76%) patient was died due to multiple organ failure induced by septicopyemia.Coexisting diabetes mellitus was found in three patients(3/21,14.29%).The infection of Fournier gangrene was extended along the superficial fascia in 17 patients(17/21,80.95%) with 1 patient(1/21,4.76 %) experiencing deep fascia infection.The most commonly found bacteria were streptococcal species,escherichia coli,staphylococcus,bacteroides,clostridium,et al.More than two organisms were cultured in 6 patients(6/21,28.57%).Conclusion Familiarity with the anatomic and path physiological characteristics of Fournier gangrene is important in the diagnosis and treatment of Fournier gangrene.
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Deep fascia
Gas gangrene
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Fournier’s gangrene is a rare, rapidly progressive, fulminant form of infective necrotising fasciitis of the genital, perianal and perineal regions. We present a case of Fournier’s gangrene of the penis complicating acute genital ulceration and recurrent paraphimosis that was secondary to contemporaneous COVID-19 and Mpox infection in an otherwise healthy 41-year-old man. It is important for clinicians to be aware of Fournier’s gangrene, as early detection remains the cornerstone of effective tissue and indeed life conserving management.
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