Management of equivocal (early) Fournier’s gangrene

Abstract

Background:

Fournier’s gangrene (FG) is an acute progressive necrotizing fasciitis of the genital area and perineum with possible extension to the abdominal wall. Surgical debridement is the gold standard management modality of established patients. Equivocal (early) FG represents a challenge in diagnosis. The objective of this study was to compare conservative management and early exploration in cases of equivocal (early) FG.

Methods:

This was an observational study where data of all patients diagnosed as early FG in our departments over 4 years (2011–2015) were enrolled. Patients were divided into two groups: group 1 with conservative treatment, and group 2 managed with urgent exploration with longitudinal hemiscrotal incision starting from external inguinal ring. All patients’ demographics, vital signs, laboratory finding and clinical findings were reported.

Results:

A total of 28 patients were enrolled in the study. Group 1 was managed with conservative treatment (17 patients) and group 2 underwent urgent exploration (11 patients). Overall, four patients (23.5%) out of 17 patients of group 1 showed a good response to conservative management without any surgical debridement. A total of 13 patients (76.5%) developed gangrenous discoloration and needed surgical debridement later. In group 2, four patients (36.4%) underwent scrotal exploration and release incision only without debridement and showed an excellent clinical outcome. A total of four patients (36.4%) underwent debridement with excision of doubtful deep subcutaneous and fascial tissues. The remaining three patients (27.2%) underwent debridement of necrotic fascia. The hospital stay was significantly shorter in group 2 patients than group 1 (7.5 ± 3.75 versus 13.4 ± 5.19 days p < 0.05). The mean number of debridement sessions was 3.74 ± 0.69 in group 1 versus 1.82 ± 0.34 in group 2.

Conclusions:

Early exploration and debridement in equivocal (early) FG has a better clinical outcome with reduced hospital stay and number of debridement sessions than conservative treatment with delayed debridement.

Introduction

Fournier’s gangrene (FG) is a fulminant infective necrotizing fasciitis of the perineum and genital region with possible extension to the perianal region or lower part of anterior abdominal wall [Thwaini et al. 2006]. A French dermatologist named Jean-Alfred Fournier first described the disease in 1883 [Fournier, 1883].

Comorbidities with immunocompromised status disorders are usually identified in patients with FG; the commonest comorbidity is diabetes mellitus (20–70%) [Morpurgo and Galandiuk, 2002]. Alcoholics and HIV patients are also at potential risk to develop FG [Clayton et al. 1990; Elem and Ranjan, 1995].

The source of infection may be through either genital or perineal skin, anorectal infection or genitourinary tract infection [Eke, 1995].

Clinical presentation in FG varies from gradual onset and slow progression to acute onset and fulminant course [Laor et al. 1995].

FG usually starts as a cellulitis commonly in the scrotum, perineum, or perianal region. Local symptoms are scrotal swelling, erythema of scrotal skin and pain with generalized constitutional symptoms. Eventually, skin with gangrenous discoloration and crepitus formation draws the full blown picture of the disease [Patty and Smith, 1992].

Urgent surgical debridement is crucial to warrant a good outcome since delayed intervention carries a poor prognosis [Elliott et al. 2000].

Hence, early diagnosis and management of FG is important to avoid the serious complications of the disease. Diagnosis of equivocal (early) FG is difficult as the clinical picture is relatively similar to cellulitis. So, a high degree of suspicion is needed for early diagnosis [Laucks, 1994].

The debate in equivocal FG diagnosis is the decision of early exploration versus conservative treatment. While early exploration helps detection of subcutaneous and fascial gangrenous changes, it carries the risk of doing unneeded surgery, anesthetic complications, prolonged hospitalization and the need for further plastic surgeries. On the other hand, conservative management is less invasive but carries the risk of progression of gangrenous changes and deterioration of the case.

Our aim of this study is to study the management outcome of equivocal (early) FG.

Patients and methods

A total of 72 patients presented to our institutions for FG treatment over the study period (2011–2015). Of those patients, 35 (49%) were excluded due to evident gangrenous skin changes, crepitus or detected subcutaneous gases by KUB (Plain X ray) or CT (Computerized Tomography) (in established FG). Of the remaining 37 patients (51%) who met the inclusion criteria (redness and swelling of scrotal skin with fever), 28 agreed to participate in the study, while nine patients refused to participate. We prospectively randomized those 28 patients (by a sealed envelope method) into two groups: group 1 received conservative management and group 2 underwent early exploration. Institutional board review approval was obtained for the study.

Diagnosis was established based on history and clinical examination.

Empiric broad spectrum parenteral antibiotics were started for all patients and were changed later on according to swab culture results. For group 1 patients, daily follow up included checking any gangrenous discoloration or crepitus formation, suggesting established FG. For group 2 patients, urgent surgical exploration was performed through exploratory bilateral vertical hemiscrotal incisions starting from the external inguinal ring downwards (Figure 1). If there were no necrotic fascia or doubtful subcutaneous tissues, the wound was kept open without closure with daily dressing and follow up. Doubtful subcutaneous and fascial tissues were excised if found with debridement of necrotic tissues with subsequent daily dressing and debridement until formation of healthy granulation tissues occurred (Figure 2). Patients with skin defects underwent delayed reconstructive surgery through either mobilized skin flaps or free skin grafts according to the surface area of the skin defect.

Figure 1.

Exploratory scrotal incision shows suppurative necrotic subcutaneous tissues.

Figure 2.

Formation of granulation tissue after debridement of gangrenous tissues.

The duration of symptoms before admission was recorded. The following vital parameters were also recorded: heart rate, temperature, respiratory rate, blood pressure, laboratory findings (serum sodium, potassium, bicarbonate, hematocrit and total leukocytic count and creatinine), and number of surgical debridement sessions. The extent of gangrenous area in relation to total body surface area, was calculated using burn injuries nomograms. The penis, scrotum and perineum each account for 1% surface area, and each ischiorectal fossa accounts for 2.5%. We used FG Severity Index (FGSI) score for the assessment of FG severity on presentation. It included presence and severity of sepsis on admission. FGSI was calculated from clinical parameters (temperature, heart and respiratory rate) and laboratory parameters (serum sodium, potassium, bicarbonate creatinine level, and hematocrit and leukocytic count). Each parameter was given 0–4 points, and FGSI was calculated by summation of the total points of all parameters. As suggested by Laor and coworkers [Laor et al. 1995], the cutoff point is 9, with FGSI >9 indicating the probability of death is 75%, and with ⩽9 indicating the probability of survival is 78%. Sepsis was diagnosed according to definitions issued by the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) Consensus Conference Committee in 1992 [Laucks, 1994] when: (1) an infection was clinically or microbiologically detected, and (2) a systemic host reaction was present (hyperthermia > 38.0°C; or hypothermia < 36.0°C; or, tachycardia > 90 beats/min; leukocytosis > 12,000/l; or leukopenia < 4,000/l; or tachypnea > 20 breaths/min), and infection-induced organ dysfunction was detected (metabolic acidosis (pH < 7.36), acute encephalopathy, thrombocytopenia (< 60,000/l), arterial hypotension (<100 mmHg systolic), or renal dysfunction (serum creatinine > 1.5 mg/dl; or oliguria < 500 ml/day).

Statistical software package (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis, performing a Student’s t test for quantitative data and Chi-square test and Fisher’s exact test for qualitative data. A p value < 0.05 was considered significant.

Results

All patients in our series were males. Group 1 underwent conservative management (17 patients) and group 2 underwent urgent exploration (11 patients). A total of 4 patients (23.5%) out of 17 patients of group 1 showed a good response to conservative management without any surgical debridement. Overall, 13 patients (76.5%) developed gangrenous discoloration and needed surgical debridement. A total of four patients (36.4%) of group 2 underwent scrotal exploration and release incision only without debridement and showed excellent clinical outcome. Overall, four patients (36.4%) underwent exploration with excision of doubtful deep subcutaneous and fascial tissues. The remaining three patients (27.2%) underwent exploration and debridement of necrotic subcutaneous tissues and fascia. Differences in FGSI were not statistically significant (7 ± 1.6 versus 6 ± 1.5 for groups 1 and 2, respectively). The hospital stay was significantly shorter in group 2 patients than group 1 (7.5 ± 3.75 versus 13.4 ± 5.19 days p < 0.05). The mean number of debridement surgeries was 3.74 ± 0.69 in group 1 versus 1.82 ± 0.34 in group 2. There was also a statistically significant difference between the two groups regarding the percentage of the affected area in relation to total body surface area (5.1 ± 1.84% in group 1 versus 2.6% ± 0.89 in group 2) (p < 0.05). There were no mortalities in both groups as shown in Table 1.

Table 1.

Patient demographics, laboratory and operative results.

Variable	Group 1 (n = 17 ) Conservative group		Group 2 (n = 11) Exploration		p value
	Mean	SD	Mean	SD
Age	57.2	10.42	56.43	9.82	>0.05
BMI	31.73	4.25	31.24	6.54	>0.05
Duration of symptoms before admission (days)	1.87	0.63	3.75	1.64	<0.05
Duration to exploration	3.2	1.5	1.5	0.7	<0.05
Area affected %	5.1	1.84	2.6	0.89	<0.05
FGSI	7	1.6	6	1.5	>0.05
Number of debridement sessions	3.74	0.69	1.82	0.34	>0.05
Total days of hospital stay	13.41	5.19	7.51	3.75	<0.05
Blood glucose	12.24	6.54	10.65	5.83	<0.05
WBCs	17.35	4.62	13.34	5.7	>0.05
Hematocrit	0.43	0.03	0.37	0.04	>0.05
Serum creatinine	115.74	53.82	105.57	46.57	<0.05
HbA1c	8.36	1.36	7.05	1.47	>0.05
Bilirubin	1.24	0.35	1.35	0.07	>0.05

BMI, body mass index; FGSI, Fournier’s gangrene Severity Index; HbA1c, glycated hemoglobin; SD, standard deviation; WBCs, white blood cells.

There were no statistically significant differences between group 1 and group 2 regarding age, body mass index (BMI), the mean duration of symptoms before admission, blood glucose, glycated hemoglobin (HbA1c), hematocrit value, total leukocytic count on admission, serum bilirubin and serum creatinine (p > 0.05). Patients who developed sepsis were higher in group 1 (four patients, 23.5% versus 1 patient, 9%) (p < 0.05).

The most common organisms detected in our series were E. coli and Bacteroides followed by Enterococcus, mixed infection, Staphylococcus and Pseudomonas, respectively. Skin grafts were needed to close scrotal skin defects in nine patients (52.9%) of group 1 and in three patients (27%) in group 2 (p < 0.05).

Discussion

FG is a rapidly progressive, potentially lethal acute infective necrotizing fasciitis affecting genitalia, perianal, and perineal regions. It occasionally extends to the anterior abdominal wall. Despite advanced treatment strategies, the mortality rate is still high (average 20–30%) [Mallikarjuna et al. 2012].

Early detection and urgent surgical debridement represent the cornerstones of management of FG with a good outcome [Ersoz et al. 2012; El-Shazly et al. 2014].

The infection in FG commonly starts as a cellulitis at the sites of entry of infection, depending on the source of infection, commonly in the scrotum, perineum or perianal region. It is difficult to differentiate early FG from skin cellulitis as there is still no sure sign of gangrene as skin discoloration or crepitus [Thwaini et al. 2006; Patty and Smith, 1992; Alonso et al. 2000; Ferreira et al. 2007]. If subcutaneous fasciitis is not treated early, necrosis of subcutaneous tissues progresses to extensive fulminant necrosis [Laucks, 1994; Chennamsetty et al. 2015]. Untreated patients may deteriorate rapidly to severe sepsis and multi-organ failure and possibly death [Sutherland and Meyer, 1994].

Diagnosis of FG at this stage is relatively challenging and needs a high degree of suspicion. Early diagnosis and urgent surgical intervention achieve a better outcome [Elliott et al. 2000; El-Shazly et al. 2014].

Cases with early exploration had a lower possibility to develop sepsis and had a shorter hospital stay than cases with conservative management.

In our study, cases with conservative management needed more sessions of debridement and had larger skin defects and consequently more skin grafts than cases with early exploration and debridement.

In this study we advocate an aggressive early surgical approach to explore such equivocal patients in a context similar to exploration of equivocal torsion testicle.

Early exploration will detect early suppurative and necrotic changes in subcutaneous tissues and fascia before it appears at the skin. It may stop progression of the disease into the fulminant stage. Exploratory scrotal incision will decrease the pressure of inflamed edematous subcutaneous tissues on the fascia and subsequent gangrenous changes.

A limitation of this study is the relatively small number of patients. However, it describes a clinical scenario that is not well addressed in the literature.

Conclusion

Early exploration and debridement in equivocal (early) FG has a better clinical outcome with a reduced hospital stay, lower number of debridement sessions and less need of skin grafting than conservative treatment with delayed debridement.