Fournier’s Gangrene – debridement only ?

Jackie Leung

Prince of Wales Hospital

Joint Hospital Surgical Grand Round

Case

• M/57

• DM– poor control (HbA1c 9.9%)

• ESRF – renal transplant in 1998– on immunosuppressant

• HT

• Gout

Case

• Admitted to Med on 24/11/2011

• c/o fever, Rt groin pain

• PE:– Fever 38.5C– BP 188/104 P115– Right groin, scrotum & medial thigh tender

erythematous swelling with crepitus

• Clinical diagnosis?

Fournier’s Gangrene

• Background– Definition, epidemiology, bacteriology

• Treatment– Debridement– Fecal diversion - colostomy– Indication– Timing

Definition

• J.A Fournier – a French Venerealogist

• First described 5 cases in 1883– Young men– genital gangrene– No apparent cause

Laucks SS. Fournier’s Gangrene. Surg Clin North Am 1994; 74: 1339, V52.t

Definition

• Infective necrotizing fasciitis affecting the perianal, perineal and genital regions

British Journal of Urology (1998), 81, 347–355

Epidemiology

• 5th-6th decades of life• Male >> female (10:1)• Incidence: 1/7500• Mortality 3-45%

Etiology

• 90% of cases can be identified

• Anorectal (30-50%)– Perianal abscess

• Urogenital (20-40%)– Urethral stricture, Indwelling catheter

• Perineal trauma (20%)– circumcision

Smith, G.L., C.B. Bunker, and M.D. Dinneen, Fournier’s gangrene.Br J Urol, 1998. 81(3): p. 347-55.

Risk factors

Vick R. Carson CC, Fournier's disease. Urologic Clinics of North America. 26(4):841-9

Bacteriology

• Synergistic

• Polymicrobial

• Aerobes and anaerobes

C.F.Heyns,P.D.Theron. Fournier’s gangrene. Emergency Urology, p. 50-60

Presentation & Diagnosis

• Clinical diagnosis

• Crepitus 50-62%

Paty R, Smith AD. Gangrene and Fournier’s gangrene. Urol Clin North Am 1992; 19: 149–62

Presentation & Diagnosis

• Investigations:– Concomitant

disease– Doubtful

diagnosis

Treatment

• Resuscitation

• Broad-spectrum antibiotics– Penicillins, Metronidazole, 3rd generation

cephalosporins

• Surgical Debridement – introduced by Meleney in 1920s– Repeated if necessary

Laucks SS II. Fournier’s gangrene. Surg Clin North Am 1994; 74: 1339-52Meleney FL. Hemolytic streptococcus gangrene. Arch Surg 1924; 9: 317-64

Treatment

• Urinary diversion– Urethral catheter– Suprapubic catheter

• Fecal diversion?

Colostomy?

• 18 Colostomy– 14 during 1st debridement– 4 on D5, 7, 7, 8

Dis Colon Rectum 2003; 46: 649–52.

Mortality: Stoma: 7/18 (38.9%),No stoma: 2/27 (7.4%)P=0.009

1990-2001

Colostomy?

• 57 cases (1985 – 1996)– Fecal diversion is not a prognostic factor– Early colostomy may reduce mortality

Colostomy

• Indications:– Anal sphincter involvement– Colonic or rectal perforation– Decrease wound contamination– Facilitate nursing care

• Timing?

E. Villanueva Experience in management of Fournier’s gangrene Tech Coloproctol (2002)6:5-13

Colostomy?

• 18 Colostomy– 14 during 1st debridement– 4 on D5, 7, 7, 8

Dis Colon Rectum 2003; 46: 649–52.

Mortality: Stoma: 7/18 (38.9%),No stoma: 2/27 (7.4%)P=0.009

1990-2001

Colostomy – When?

• 8 cases– 4 colostomies– 1 in 1st

debridement– 3 in D3, 5, 5

Colostomy – When?

• 4 cases (1998-2003)• Colostomy on 2nd look OT (D2,3,5,5)• Improved POSSUM scores• Mostly required 2nd debridement• <10% of ICU patients had BO in first 48hrs

Colostomy – When?

• No consensus yet

• Trend: on subsequent debridement, when physiological condition improved

• Alternatives?

Alternatives

• 2 cases• Flexi-Seal Fecal Management System

Alternatives

• 1 case

• ActiFlo rectal catheter

Alternatives

Case (cont’d)

• Urgent Surg, Uro, Ortho consultation

• Admitted to ICU

• Multiple OT x debridement

• Loop transverse colostomy on 2nd OT

• After multiple debridements

• PTSG on 16/1/2012

Summary

• Fournier’s Gangrene

• Uncommon but lethal condition

• Debridement

• Colostomy