|Year : 2012 | Volume
| Issue : 2 | Page : 74-78
Fournier's gangrene: A study of 18 cases
Gurjit Singh, Iqbal Ali, Pragnesh Bharpoda, Neha Jindal
Department of General Surgery, Padmashree Dr. D. Y. Patil Hospital and Research Centre, PIMPRI, Pune, Maharashtra, India
|Date of Web Publication||3-Apr-2013|
Department of General Surgery, Padmashree Dr. D. Y. Patil Hospital and Research Centre, Sant Tukaram Nagar, Pimpri, Pune 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Fournier's gangrene (FG) refers to necrotizing fasciitis affecting the perineal, rectal or genital areas. This can have a fulminant presentation, and its clinical course is unpredictable. It can be fatal unless there is prompt recognition and aggressive surgical treatment. We report our experience and results in the management of FG.
Materials and Methods: We conducted a prospective analysis of cases of FG presenting to our institute from April 2007 to September 2009. All patients with signs and symptoms of FG were admitted and evaluated. A policy of aggressive surgical debridement under the cover of broad spectrum antibiotics was adopted, often in multiple sittings. Supportive therapy was also provided. Skin grafting and thigh pouch implantation were undertaken where indicated.
Results: There were a total of 18 patients. Seven patients were in the age group of 50-59 years. There was delay of 11-15 days in reporting after onset of symptoms in 44.4% of cases. The main pre-disposing risk factors were age above 50 years (61.1%) and diabetes mellitus (33.3%). The route of infection was mostly cutaneous (27.7%). All infections were polymicrobial aerobic infections, and the commonest organisms were Escherichia coli and Klebsiella species. Aggressive surgical debridements were done, often in multiple sittings. The average number of procedures per patient was 3.27 with a range of 2-4.
Conclusion: Early and aggressive surgical management are essential to ensure a successful outcome in FG.
Keywords: Debridement, diabetes mellitus, Fournier′s gangrene, necrotizing fasciitis
|How to cite this article:|
Singh G, Ali I, Bharpoda P, Jindal N. Fournier's gangrene: A study of 18 cases. Arch Int Surg 2012;2:74-8
| Introduction|| |
The term Fournier's gangrene (FG) refers to a polymicrobial necrotizing fasciitis with or without gangrene, affecting the perineal, rectal or genital areas. It was first described by Jean Alfred Fournier in the year 1883.  Even though this has been previously described as an idiopathic condition, a definite cause can be found in more than 98% of cases presently due to improved diagnostic facilities. A number of predisposing risk factors have been identified. These include, diabetes mellitus, trauma, alcoholism, advanced age, malignancy, and immunosuppression. , The routes of infection may be rectal, urethral or cutaneous. In one of the series, 10-30% of mortality rate has been reported indicating rapidly progressive nature of disease.  We report our experience and results in the management of FG.
| Materials and Methods|| |
A prospective analysis of patients presenting with FG to our institute from April 2007 to September 2009 was conducted. The study was approved by the institutional ethical committee.
All patients with signs and symptoms of FG were included and evaluated. The key points in the clinical features included age and sex, comorbidities, pre-disposing risk factors, triggering factors and the offending micro-organisms. Baseline blood investigations were done to assess the level of systemic toxicity. All the cases were subjected to emergency debridement under the cover of broad spectrum antibiotics. The antibiotics used were Ceftriaxone 1.5 g IV q12 hourly, Gentamycin 80 mg IV q12 hourly and Metronidazole 500 mg IV q8 hourly. Both the pus samples and tissue samples were sent for aerobic and anaerobic culture and antibiotic sensitivity. No attempt at primary closure was made. Hydrogen peroxide was used at the time of first debridement. This was followed by Eusol dressings until slough had separated and Povidone Iodine dressings done until the wound was healthy and ready for graft. Nutritional support and blood transfusions were given as indicated. Further management was based on the condition of the wound. If the wound showed signs of infection, re-debridement was done. This was continued till the raw area showed healthy granulation tissue. Following this, skin cover was provided. One case necessitated thigh pouch implantation of testis.
| Results|| |
A total of 18 cases of necrotizing fasciitis were encountered during our study period. All the patients were males. Maximum number of patients belonged to the group between 50 years and 59 years [Table 1].
The time period between the onset of first clinical symptom and presentation was 6-15 days in majority of the patients [Figure 1]. The earliest presentation was on 5 th day, and the longest presentation was on 24 th day after the onset of symptoms.
|Figure 1: Duration between onset of first symptom and presentation to the hospital|
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The most common pre-disposing factor noted in our study was advanced age (61.1%), followed by diabetes mellitus (33.33%) [Figure 2]. The other risk factors identified were steroid use, chronic alcohol abuse and underlying malignancy. No pre-disposing factor was identified in five cases.
|Figure 2: Pre-disposing risk factors in patients with Fournier's gangrene|
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A triggering factor for infection was identifiable in only 10 cases [Table 2]. Three of these patients gave history of previous needle insertions for draining some scrotal swellings, probably hydrocele [Figure 3]. Two patients gave history of haemorrhoidectomy for prolapsed haemorrhoids, and one gave history of drainage for perineal abscess. The other triggering factors were traumatic laceration of the perineum, catheterization, and dilatation procedure for urethral stricture.
Leucocytosis was observed in 16 patients and anemia in 10 patients [Figure 4]. Most of the infections were polymicrobial in nature, and the commonest organisms were Escherichia More Details coli, Klebsiella, and Streptococcus [Table 3]. No case of anaerobic infection was identified in the study.
Debridement was carried out as early as possible [Table 4]. An early and aggressive approach was followed, based on a high index of suspicion. This was often done in repeated sittings based on the condition of the wound [Figure 5]. Primary closure was not done in this study, and the common reconstructive procedures used were skin grafting, delayed primary suturing and secondary suturing once the wound showed healthy granulation tissue [Figure 6]. The average number of surgeries per patient was 3.27, ranging between 2 times and 4 times.
Four patients in this study developed systemic complications. The commonest complication noted in this study was septicaemia, which was found in three cases. Renal dysfunction was noted in one patient. There was no mortality.
| Discussion|| |
In the present study, 18 cases of FG have been studied over a period of two and a half years. The disease was first reported by Fournier in 1883, and since then Paty, et al.,  calculated approximately 500 cases, which were reported in literature until 1992. Other researchers have reported 600 cases of FG in world literature since 1996.  This increase in the number of cases is likely to be due to better diagnosis of cases because of a high index of suspicion by the clinicians.
In our study, we noted that the majority of patients were in the elderly age group, with maximum patients at more than 50 years [Table 1]. This matches well with the reported literature on this disease.  No female case was encountered in this study. However, in a study, 31.6% of patients were females, due to vulvar and bartholin gland abscesses and also following episiotomy and hysterectomy.  One of the risk factor for mortality in patients with FG is female gender, which is due to association with frequent involvement of the retroperitoneal space and abdominal cavity in inflammatory process. 
The time period between the onset of the first symptom and surgical intervention is known to be an important prognostic factor in determining the morbidity and mortality.  The typical patient presents between 2 days and 7 days after the onset of the symptom.  However, in our study, majority of patients presented between 11 days and 15 days after the onset of symptoms. The late presentation may be due to the social stigma associated with the infection and the lack of awareness among the people. The incidence of complications was higher in patients who presented late to the hospital. However, in spite of the relatively late presentation, there was no mortality in this study, which may be attributed to policy of aggressive management.
The most important pre-disposing risk factors that we encountered among our patients were advanced age and diabetes mellitus, the others being steroid use, chronic alcohol abuse, and underlying malignancy. These factors have been well cited in the literature. , Several western studies have reported acquired immunodeficiency syndrome as a significant comorbid condition, however, this was not found in our study.
The route of infection was cutaneous in majority of our patients [Table 2]. We encountered three cases where repeated drainage of scrotal swelling, probably hydrocele, using a needle was the triggering factor for infection. There were two cases each of injury to the perineal skin, urethral instrumentation, catheterization and following hemorrhoidectomy respectively. Khan and Saleem  had reported similar proportion of cases through the three routes. In a meta-analysis, the portal of entry was found to be colorectal in 21%, dermatological in 19%, urogenital in 19% whereas in 36% of cases no definite portal of entry was established.  Other rare causes reported in literature are following vasectomy,  circumcision and herniorrhaphy. 
Leucocytosis was the commonest laboratory finding recorded in our study. Anemia was also present in a significant number of patients. These values tally well with the existing literature.  All the cases of FG in our study were aerobic polymicrobial infections, with the commonest organisms being E. coli and Klebsiella species [Table 3]. These organisms have been recorded as common causative organisms in several studies. , In contrast to the findings of Khan, et al.,  no case of anaerobic infection was reported in our study.
Diagnosis of FG is clinical. However, imaging by plain radiography, ultrasonography (US) and computed tomography (CT) scan can help in clinching the diagnosis in certain clinical setting like demonstrating air before crepitus is detected clinically, to differentiate cellulitis, inguinoscrotal incarcerated hernia, torsion of testis and to define extent of lesion. CT is superior to both radiography and US in demonstrating FG, its extent and its underlying causes.  However, its routine use is not recommended. None of the imaging modalities were employed in management of our cases because the diagnosis was easily made clinically and confirmed at the first debridement.
The main aspects of treatment of FG are resuscitation, broad-spectrum intravenous antibiotics, radical surgical debridement followed by multiple debridements if needed, and adequate supportive therapy.  The policy of management followed in our study included, early and aggressive debridement under the cover of broad spectrum antibiotics. Repeated debridements were done in many cases till a healthy granulating wound was achieved. The mean number of surgical procedures per patient in our study was 3.27 [Table 4], which clearly indicated our aggressiveness in treating this disease. We also provided supportive therapy in the form of nutritional supplements including parenteral nutrition and blood transfusions to patients where indicated. Literature supports the use of hyperbaric oxygen as a promoter of wound healing,  However, we did not use it in our study due to the lack of this facility in our institute. Other surgical procedures such as diversion procedures (cystostomy and colostomy) and orchidectomy  were not required in our study. The commonest reconstructive procedure used in our study was skin grafting, which has been used in several studies. 
Attempt is made to predict severity and outcome in FG patients. A study of 51 patients suggested that extent of disease and number of surgical debridements was not predictive of the outcome.  Fournier's Gangrene Severity Index (FGSI) was formulated by Laor, et al. by modifying Acute Physiology and Chronic Health Evaluation II (APACHE II) severity score. They found that a FGSI score of more than 9 had a 75% probability of death and a score of less than or equal to 9 was associated with 78% probability of survival. There is no universal agreement on clinical variable which may predict poor outcome in FG.  They have concluded that metabolic derangements at presentation in patients with FG, can be assessed by simple and objective method like FGSI. Findings of another study showed that FGSI did not reflect the severity of FG but factors like low bicarbonate and high sodium levels and old age were factors that predicted the outcome.  We did not evaluate FGSI in our study.
Despite having risk factors like old age, uncontrolled diabetes, delay in presentation and multi-organ failure, patients have been reported to have recovered with appropriate and aggressive management.  The systemic complications that developed in our patients were septicaemia and renal dysfunction. However, there was no mortality in our study, which can be attributed to our early and aggressive management philosophy. The reported mortality in FG has been 0-67%,  whereas most studies quote it to be around 10-30%. 
| Conclusion|| |
FG is a comparatively common form of necrotizing fasciitis with a rapidly deteriorating clinical course and high morbidity and mortality. The mainstay of management in FG is early and aggressive surgical debridements, often repeated as needed, under the cover of broad spectrum antibiotics, along with supportive therapy and reconstructive procedures at appropriate time. A high-index of suspicion and aggressive management are essential to ensure a successful outcome in this disease.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]