Fournier's gangrene current approaches

Abstract

Fournier's gangrene is a rare but highly mortal infectious disease characterised by fulminant necrotising fasciitis involving the genital and perineal regions. The objective of this study is to analyse the demographics, clinical feature and treatment approaches as well as outcomes of Fournier's gangrene. Data were collected retrospectively from medical records and operative notes. Patient data were analysed by demographics, aetiological factors, clinical features, treatment approaches and outcomes. Twelve patients (five female and seven male) were enrolled in this study. The most common aetiology was perianal abscess (41·6%). Wound cultures showed a mixture of microorganisms in six (50%) patients. For faecal diversion, while colostomy was performed in six cases (50%), Flexi‐Seal was used in two cases (16·6%). In four patients (33·4%), no faecal diversion was performed. Negative pressure wound therapy (NPWT) system was effective in the last four patients (33·4%). The mean hospitalisation period in patients who used NPWT was 18 days, while it was 20 days in the others. NPWT in Fournier's gangrene is a safe dressing method. It promotes granulation formation. Flexi‐Seal faecal management is an alternative method to colostomy and provides protection from its associated complications. The combination of two devices (Flexi‐Seal and NPWT) is an effective and comfortable method in the management of Fournier's gangrene in appropriate patients.

Introduction

Fournier's gangrene is a serious infectious disease characterised by progressive, serious, fulminant and sometimes fatal necrotising fasciitis involving subcutaneous tissues of the genital, perineal and perianal regions 1, 2. This is one of the surgical emergencies with a high mortality rate of 40% 2. Fournier's gangrene is a synergetic infectious disease caused by polymicrobial involvement of both aerobic and anaerobic organisms that cause an ultimate thrombosis of the small subcutaneous vasculature, and hence regional skin necrosis 3, 4. Early diagnosis of Fournier's gangrene is vital for identifying accurate treatment method.

The immediate treatment of Fournier's gangrene starts with extensive debridement and broad‐spectrum antibiotic therapy 4. After initial surgical debridement, occasionally a series of debridement is required. An effective dressing is also important. In recent years, negative pressure wound therapy (NPWT) has gained popularity for wound management in Fournier's gangrene 5. In an attempt to protect the wound from faecal discharge, however, colostomy is routinely performed mostly in wounds close to the perianal region. Flexi‐Seal Faecal Management System (Convatec, Geensboro, NC) is a recent and an alternative faecal diversion method to colostomy and helps keep the wound clean 6, 7.

In this study, we aimed to review our experience in Fournier's gangrene treatment, and to evaluate the current treatment methods.

Materials and methods

A retrospective study was carried out to evaluate our experiences with Fournier's gangrene treatment. The data were provided from two centres (Department of General Surgery of Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey; Department of General Surgery, Canakkale Onsekiz Mart University, Medical School, Canakkale, Turkey). Twelve patients with Fournier's gangrene enrolled. Physical and operative findings were collected from medical records and operative notes. The diagnosis of Fournier's gangrene was established based on clinical history and physical examination at presentation. The symptoms were necrosis in the perineal and genital regions. Patients with lack of data, and with perianal, periurethral and scrotal abscesses were excluded from this study.

The patients were evaluated according to demographics (age, gender), duration of symptoms, aetiological factors, predisposing factors, comorbidities, source of infection, duration of symptoms, results of bacteriologic cultures, number of debridements, duration of treatment, faecal diversion methods (Colostomy or Flexi‐Seal Faecal Management System), number of surgical resections and dressing methods (wet or negative aspiration system). The parameters were recorded for each patient.

Treatment approach

After being diagnosed with Fournier's gangrene, all patients received urgent resuscitation with fluid, and broad‐spectrum parenteral antibiotics, and blood transfusions, if needed. All patients underwent immediate extensive surgical debridement with resection of all necrotic tissues until viable tissue was identified. During this initial step, no patient in this series received any different treatment modality. Postoperatively, the wound was closely monitored, and dressings were changed when the wound became wet in the conventional treatment method, or every 48 hours when NPWT was used. Patients returned to the operating room within the next 24 hours for evaluation of the wound. Another debridement was performed if the necrosis seemed to continue, followed by a wound dressing (conventional dressing in the first eight patients and NPWT in the last four patients). Colostomy (in six patients) or Flexi‐Seal (in two patients) were performed in patients with infection of perirectal origin or anal sphincter involvement. After stabilising the patient clinically, and achieving a clean site, a reconstruction was performed (Figure 1).

Figure 1.

(A) The patient with Fournier's gangrene in the emergency room. (B) The patient in the operating theatre just before performing initial debridement. (C) The wound progressed after first debridement, with a more viable tissue appearance. (D) The wound was cleaner following a second debridement and NPWT. (E) Patient after wound closure in the operating room. (F) Surgical site at first postoperative month.

Results

A total of 12 patients (7 male and 5 female) were included in this study. The patients' age ranged between 33 and 79 years (mean 62·4). The demographic and clinical characteristics of the patients are shown in Table 1.

Table 1.

Patient demographics

Patient s	Age	Sex	Aetiology	Comorbidities	Initial symptoms
P1	64	F	Perianal abscess	Diabetes	Fever, perianal pain
P2	73	M	Steroid enemas	Ulcerative colitis	Fever, scrotal swelling + necrosis
P3	73	F	Perianal abscess	Diabetes, chronic renal failure	Shock + extending necrosis
P4	68	F	Idiopathic	–	Perineal pain, fever
P5	70	M	Perianal abscess	Diabetes	Perineal pain, necrosis
P6	72	M	Perianal abscess	Diabetes	Anal pain, necrosis
P7	79	M	Rectal cancer	Neoadjuvant radiotherapy for rectal cancer	Perineal skin necrosis, fever, pain
P8	73	F	Vulvar abscess	Diabetes	Extensive necrosis spreading from perianal area to abdominal wall
P9	54	M	Rectal cancer	Neoadjuvant radiotherapy	Perianal swelling, pain, crepitus
P10	43	F	Bartholin duct abscess	–	Anal pain, perineal swelling, fever
P11	47	M	Hidradenitis suppurativa	Alcoholism	Perianal pain, perineal necrosis
P12	33	M	Perianal abscess + pilonidal cyst with abscess	Diabetes	Perineal skin necrosis, fever, septic shock

Aetiological origins were perianal abscess in five patients (41·6%), rectal tumours in two patients (16·6%), Bartholin abscess in one patient (8·3%), vulvar abscess in one patient (8·3%), steroid enema treatment for ulcerative colitis in one patient (8·3%), hidradenitis suppurativa in one patient (8·3%) and no aetiological factor was identified in one patient. For wound protection, eight patients needed rectal diversion. A colostomy was performed in six of the patients (50%). Alternatively, the Flexi‐Seal Faecal Management System was used in two patients (16·6%).

Tissue cultures from the wounds as well as the antibiograms were obtained in all of the patients. In the majority of the patients (n = 6, 50%), a mixture of microorganisms were isolated (Table 2). From the point of view of debridement, NPWT patients had an average of three surgical interventions, while conventional wound‐care patients had an average of seven.

Table 2.

Results of culture, features of disease and treatment approaches

Patients	Bacterial culture results	Involved area	Dressing method	Faecal diversion	Length of hospitalisation
P1	Pseudomonas	P, G, AW	CD	No	20
P2	Acinetobacter	P, PA, G	CD	No	19
P3	Escherichia coli	PA, G	CD	Colostomy	23
P4	Enterococcus	P, G	CD	No	21
P5	Methicillin‐resistant Staphylococcus aureus	P, G	CD	Colostomy	22
P6	Methicillin‐resistant S. aureus + Proteus	P, PA, AW	CD	Colostomy	17
P7	Pseudomonas	P, PA, G	CD	No	19
P8	Methicillin‐resistant S. aureus + Acinetobacter	P, G	CD	Colostomy	22
P9	Enterococcus	P, PA	NPWT	Colostomy	18
P10	Enterococcus + Acinetobacter	P, PA	NPWT	Flexi‐Seal	15
P11	Corynebacterium + E. coli	P, PA	NPWT	Flexi‐Seal	13
P12	Acinetobacter, methicillin‐resistant S. aureus + E. coli	P, PA, G, L	NPWT	Colostomy	26

P, perineal; PA, perianal; G, genital; AW, abdominal wall; L, lower back region; NPWT, negative pressure wound therapy; CD, conventional dressing.

The mean hospitalisation duration of patients in NPWT group was 18 days, while it was 20 days in the conventional wound‐care group. These related parameters are shown in Table 2.

Discussion

Fournier's gangrene is an acute, rapidly progressive and sometimes fatal infection involving the perineum and genitalia 8. It can affect all age groups (mean 50) with a male predominance 9, 10. The predisposing factors are diabetes mellitus, alcoholism, immunodeficiency and malignancy 8. Immediate debridement of all necrotic tissues 8, 11, use of broad‐spectrum antibiotics and management of underlying comorbidities are also of paramount importance in treatment 4. In addition to these basic procedures, when the anal sphincter and/or perianal region are involved, a faecal diversion should be considered 4.

The medical management of Fournier's gangrene shows similarity to the treatment of severe sepsis. Stabilising the haemodynamics is vital. In the wound management of Fournier's gangrene, proper dressing and simultaneous exploration help the physician not overlook any changes in the wound. Thus, any surgical decision can be taken immediately. A conventional wet‐to‐dry dressing is one of the well‐known and accepted methods. This has few disadvantages such as frequent requirement of change, in addition to numerous advantages such as popular, inexpensive and keeping the wound clean 12, 13. Alternatively, a relatively new method, called NPWT, can also be used in the wound management of Fournier's gangrene 12, 13, 14. This system is suggested for other chronic wounds as well. One exception here might be to choose the lower limit of pressure, which is originally recommended to be between 50 and 125 mm Hg 5, 15.

Once the necrosis is eliminated, NPWT helps wound healing physiologically. The negative pressure leads to an increased blood supply, and thus migration of inflammatory cells into the wound region 16. This also promotes and accelerates the formation of granulation tissue by the removal of bacterial contamination, end products, exudates, and debris when compared with traditional dressing 13. A recent study demonstrated the positive effects of NPWT on serum fibronectin levels, which is an adhesion molecule, promoting the migration of inflammatory cells and remodelling phases 16. Along with its well‐documented physiological effects, there are some other advantages such as needing less frequent change, and being less painful 12, 13.

The bacteria that cause the destructive infection in Fournier's gangrene are usually a mixture of causative microorganisms of colorectal origin. The debrided region is usually near the anus, which is prone to faecal contamination 17. Hence, a faecal diversion is a considerable choice in the treatment of Fournier's gangrene. Mostly, a colostomy is used for rectal diversion in patients with severe perineal involvement and wounds close to the anus. Recently, Flexi‐Seal Faecal Management System has been introduced for faecal diversion. It is an alternative method to colostomy with economic benefit and patient comfort for short‐term faecal diversion 6, 18. It was originally designed for intensive care patients with a rectal tube that allows diversion of faecal matter from the rectum to a collector bag. In this way, it avoids faecal leakage, and thus keeps the wound clean 19. In Fournier's gangrene, also, this system can successfully be used in an effort to achieve faecal diversion. This device not only protects the wound from faecal contamination it also avoids the complications of colostomy 17.

There are several limitations in the combined use of NPWT and faecal diversion, including very deep wounds with extensive perianal involvement and local factors around the wound preventing the negative pressure treatment system to set. Finally, this combination has not routinely been used in clinical practice yet.

In conclusion, in our limited series of Fournier's gangrene cases, the combined use of NPWT and Flexi‐Seal has promising results in wound management. In our practice, this combination occupies the first rank in the treatment of Fournier's gangrene. However, longer follow‐ups with larger series of patients are required to better evaluate and, when required, modify this combination.