Fournier's gangrene: a retrospective analysis of 26 cases in a Canadian hospital and literature review.
Fournier's gangrene (FG) is a rapidly spreading polymicrobial necrotizing fasciitis affecting the perineum, scrotum, and penis in men, but it has also been described in women and children. (1) FG can spread to the anorectal area, thighs, and to the abdominal wall. Baurienne first reported the disease in 1764, but it was a French dermatologist, Dr. Jean Alfred Fournier, who described the disease in great detail by reporting 5 cases in 1883. The disease process involves an entry point for microorganisms (rupture of skin) with synergistic polymicrobial infection leading to obliterative endarteritis of subcutaneous arteries, necrosis of skin, subcutaneous tissues, fat, muscles, fasciae with suppuration and gas formation. Although considerable progress has been made in the treatment of this disease, it remains a serious and debilitating condition with a high mortality rate.
In a review of 1726 cases of FG, Elk reported an overall mortality of 16%. (1) However, considerable variability exists and authors have reported mortality rates ranging from 10% to 80%. (2-9) To our knowledge no prospective studies have been done on FG. Retrospective research has been directed to identifying both risk factors associated with the onset of FG and prognostic factors relating to patient survival.
We performed a systematic review of all cases of FG at our hospital over a 12-year period. Our goal was to determine the mortality rate in our hospital and to identify risk factors associated with FG. We also wanted to examine three potential prognostic factors: (1) the time delay from emergency room admission to surgery; (2) the initial extent of the disease; and (3) the impact of more than one debridement procedure under general anesthesia in relation to patient survival.
We reviewed the English medical literature in PubMed with the terms "Fournier's gangrene and review" for the last 15 years to identify recent literature pertaining to the diagnosis and treatment of FG. This review allowed us to identify known risk and prognostic factors to guide our own research. (1-40) Risk factors involve systemic and non-systemic diseases. Systemic risk factors include cardiovascular disease, diabetes, morbid obesity, renal/hepatic failure, alcoholism, active cancer/chemotherapy, HIV, and steroid use. Non-systemic risk factors are related to cutaneous rupture and include urologic diseases, such as urethral strictures, skin surgery or trauma, and anorectal conditions, such as anal abscess. (1-9)
We then retrospectively reviewed the charts of all patients treated for FG from January 2000 to January 2012 at our hospital. The diagnosis of FG was based on clinical examination, which showed skin necrosis and was confirmed under anaesthesia when the skin incision revealed the gray-black appearance of gangrenous tissue along with purulence. A total of 26 cases of FG were assessed. The following data were collected for each patient: (1) demographics (age, occupation, marital status); (2) clinical features (comorbidities, etiologies, microbiological results and antibiotics, time from emergency room admission to surgery); and (3) surgical parameters (duration of surgery, number and extent of debridement surgeries, need of other surgical specialist). Etiologies were classified the following way: active skin or wound infection, abscess (scrotal/perianal), genitourinary source, rectal/colorectal source, trauma, postoperative complication, and undetermined. Lastly, debridement extent was categorized as being peno-scrotal only, extending down to lower limbs or extending up to the abdomen. The 90-day mortality rate was calculated. For this single parameter analysis, one patient was excluded because of missing information. Means, medians, and frequencies were calculated. The statistical significance of differences in the distribution of major variables was tested using the chi-square test. Statistical significance was determined at p < 0.05. All statistical tests were performed using Statistical Package for Social Science (SPSS Inc., 20.0 for Mac).
In total, 26 male patients were diagnosed and treated at our hospital over a 12-year period from 2002 to 2012 (Table 1). Statistical analysis was performed to determine prognostic factors, which may have distinguished survivors and non-survivors. The only statistically significant predictor of mortality in our series was the number of debridement surgeries performed on each patient. Patients were 4.8 times more at risk of dying if they were required to have more than one surgical debridement under general anesthesia.
The median time between admission to the emergency department and the urology consult was available for 21/26 patients and was 5 hours, 7 minutes (range: 30 minutes-97 hours, 48 minutes). The median time from the initial urology consult to surgical debridement was 3 hours, 22 minutes (range: 1-48 hours). One patient was excluded from this analysis because of insufficient information. In one case, the time from the urology consult to surgery was long (48 hours). This delay occurred because initially the patient presented with scrotal cellulitis and it was during repeat physical exams that skin necrosis was noted thus confirming the diagnosis of FG. The time between emergency room admission and the beginning of surgical debridement was not statistically significant between survivors and non-survivors (Table 1). The extent of surgical debridement most often involved the peno-scrotal area (25/26, 96.15% of patients), but both the anal/perineal (13/26, 50%) and the colorectal areas (9/26, 34.6%) were often involved in the fasciitis. Fasciitis extended less often to the lower limbs (5/26, 19.2%) and to the abdominal wall (4/26, 15.4%). Most patients underwent only one surgical debridement (20/26, 76.9 %). Three patients underwent 2 surgical debridements, 2 patients were operated 3 times, and 1 patient was operated 4 times. As expected, microbiological analysis revealed a polymicrobial disease. All but one of the patients was managed with the help of a microbiological consultant. Histological analysis confirmed inflammatory cell infiltration and necrotic tissue.
In our series 5 patients died within a 90-day interval, giving an overall mortality rate of 20%. Specific causes of death involved 2 patients with septic shock, 1 patient with cardiorespiratory arrest during surgery and 1 patient who refused a second surgical intervention and died of septic complications related to FG. This patient was included in our statistical analysis as having undergone only 1 surgical debridement. One patient died within 90 days after surgery, but we were unable to determine the cause of death and no autopsy was performed.
Although considerable progress has been made in the treatment of FG, it remains a serious and debilitating condition with a high mortality rate. We performed a systematic review of 26 case records at our hospital over a 12-year period between 2000 and 2012. Our goal was to determine the mortality rate in our hospital and to identify risk factors associated with FG. We also wanted to examine possible prognostic factors related to patient survival. In particular we wanted to examine the time delay from emergency room admission to surgery, the initial extent of the disease, and the impact of more than one debridement procedure under general anesthesia.
In total, 26 male patients were diagnosed and treated at our hospital over a 10-year period ranging from 2002 to 2012. Statistical analysis of our demographic data did not reveal any significant difference between survivors and non-survivors (Table 1).
Time to surgical debridement
We studied the time lapse between the initial arrival of the patient in the emergency room, the ensuing urology consult, and the start of the surgical debridement for 20/26 patients. Six charts were incomplete. Statistical analysis did not reveal any significant difference between survivors and non-survivors for this parameter. Nonetheless, the delay from onset of symptoms to surgery could be an important prognostic factor. (19,23,31,39)
Extent of disease
Although many studies have reported the extent of disease to be a significant parameter between survivors and nonsurvivors, (21,22,30- 33,39) others have not found this parameter significant. (17,28) Extent of surgical debridement was categorized as being peno-scrotal only, extending down to lower limbs or extending up to the abdomen. The extent of surgical debridement is a reflection of the extent of the disease. Statistical analysis did not reveal any significant difference between survivors and non-survivors in regards to surgical extent. However, this parameter was very close to significance (p = 0.07). FG extending to the thighs or to the abdominal wall carries a worse prognosis.
Number of surgical debridement procedures
Most patients underwent only one surgical debridement (20/26, 76.9%). Three patients underwent 2 surgical debridement procedures, 2 patients were operated 3 times, and 1 patient was operated 4 times. The decision to perform additional surgical debridements was made at the bedside when there was a persistent sign of tissue necrosis or of spreading cellulitis. The number of surgical debridement procedures done under anesthesia was statistically significant different between survivors and non-survivors (p = 0.04, Table 1). Mortality risk was increased in patients who required more than one surgical debridement under general anesthesia. Some authors have reported a relation between the number of surgical debridements and survival, (26) but some authors disagree. (28,34) In our series, patients are 4.8 times more at risk of dying if they were required to have more than one debridement under general anesthesia. This presumably reflects persistent gangrene following initial extensive surgical debridement, intensive fluid resuscitation, and wide spectrum antibiotic treatment. As a corollary, it has become evident that a second-look procedure under general anesthesia was not always mandatory since most survivors underwent only one surgical debridement under anesthesia. It has been suggested that all patients should undergo a second look under general anesthesia and that these patients have a lower mortality rate, (3) but our data did not support this statement. While the repeated nature of debridements may be considered the accepted standard of care in these patients, this is not always predictive of outcome. (34) From our experience, a good visualization of the surgical wound at the patient's bedside and follow-up of the patient's hemodynamic parameters are sufficient to determine the necessity of an additional debridement procedure. If the wound cannot be well-evaluated or if the patient is hemodynamically unstable, then a second-look exam should be done in the operating room.
The 90-day mortality was determined in 25/26 patients. For this single parameter analysis, 1 patient was excluded because of insufficient information. Five deaths occurred in our series, yielding a mortality rate of 20%.
Our retrospective study of 26 consecutive patients at a single institution over a 12-year period helped us study both risk and prognostic factors related to patient survival. Five deaths occurred in our series, yielding a mortality rate of 20%. Statistical analysis of our demographic data (age, occupation, marital status) did not reveal any significant difference between survivors and non-survivors. The time between emergency room admission and the beginning of surgical debridement was not statistically significant between survivors and non-survivors. The extent of surgical debridement was most probably a clinically significant parameter between survivors and non-survivors. FG extending to the thighs or to the abdominal wall carries a worse prognosis. In our series, the extent of surgical debridement is close to the margin of statistical significance. The number of surgical debridement procedures done under anaesthesia was statistically different between survivors and non-survivors. Patients are 4.8 times more at risk of dying if they are required to have more than one debridement surgery under general anesthesia.
Published online June 18, 2015.
Competing interests: The authors declare no competing financial or personal interests.
This paper has been peer-reviewed.
(1.) Eke N. Fournier's gangrene: A review of 1726 cases. Br J Surg 2000;87:718- 28.
(2.) Shyam DC, Rapsang AG. Fournier's gangrene. Surgeon 2013;11:222-32. Epub 2013 Apr 8. http://dx.doi.org/10.1016/j.surge.2013.02.001
(3.) Vayvada H, Demirdover C, Menderes A, et al. Necrotising fasciitis in the central part of the body: Diagnosis, management and review of the literature. Int Wound J 2013;10:466-72. Epub 2012 Jun 13. http://dx.doi.org/10.1111/j.1742-481X.2012.01006.x
(4.) Katusic J, Stimac G, Benko G, et al. Management of fournier's gangrene: Case report and literature review. Acta Clin Croat 2010;49:453-7.
(5.) Montoya Chinchilla R, Izquierdo Morejon E, Nicolae Pietricica B, et al. Fournier's gangrene. Descriptive analysis of 20 cases and literature review [in Spanish]. Actas UrolEsp 2009;33:873-80.
(6.) Sarkis P, Farran F, Khoury R, et al. Fournier's gangrene: A review of the recent literature [in French]. Prog Urol 2009;19:75-84. Epub 2008 Nov 28. http://dx.doi.org/10.1016/j.purol.2008.09.050
(7.) Fajdic J, Bukovic D, Hrgovic Z, et al. Management of Fournier's gangrene-- report of 7 cases and review of the literature. Eur J Med Res 2007;12:169-72.
(8.) Safioleas M, Stamatakos M, Mouzopoulos G, et al. Fournier's gangrene: Exists and it is still lethal. Int Urol Nephrol 2006;38:653-7. http://dx.doi.org/10.1007/s1 1255-005-2946-6
(9.) Thwaini A, Khan A, Malik A, et al. Fournier's gangrene and its emergency management. Postgrad Med J 2006;82:516-9. http://dx.doi.org/10.1136/pgmj.2005.042069
(10.) Laor E, Palmer LS, Tolia BM, et al. Outcome prediction in patients with Fournier's gangrene. J Urol 1995;154:89-92. http://dx.doi.org/10.1016/S0022-5347(01)67236-7
(11.) Garcia Marin A, Turegano Fuentes F, Cuadrado Ayuso M, et al. Predictive factors for mortality in Fournier's gangrene: A series of 59 cases. Cir Esp 2015;93:12-7. http://dx.doi.org/10.1016/j.ciresp.2014.03.017. Epub 2014 May 23.
(12.) Lin TY, 0u CH, Tzai TS, et al. Validation and simplification of Fournier's gangrene severity index. Int J Urol 2014;21:696-701. Epub 2014 Mar 17. http://dx.doi.org/10.1111/iju.12426
(13.) Tuncel A, Keten T, Aslan Y, et al. Comparison of different scoring systems for outcome prediction in patients with Fournier's gangrene: Experience with 50 patients. Scand J Urol 2014;48:393- 9. Epub 2014 Feb 12. http://dx.doi.org/10.3109/21681805.2014.886289
(14.) Vyas HG, Kumar A, Bhandari V, et al. Prospective evaluation of risk factors for mortality in patients of Fournier's gangrene: A single center experience. Indian J Urol 2013;29:161-5. http://dx.doi.org/10.4103/0970-1591.117255
(15.) Sroczy ski M, Sebastian M, Rudnicki J, et al. A complex approach to the treatment of Fournier's gangrene. Adv Clin Exp Med 2013;22:131-5.
(16.) Mallikarjuna MN, Vijayakumar A, Patil VS, et al. Fournier's gangrene: Current practices. ISRN Surg 2012;2012:942437. Epub 2012 Dec 3. http://dx.doi.org/10.5402/2012/942437
(17.) Sallami S, Maalla R, Gammoudi A, et al. Fournier's gangrene: What are the prognostic factors? Our experience with 40 patients [in French]. Tunis Med 2012;90:708-14.
(18.) Aridogan IA, Izol V, Abat D, et al. Epidemiological characteristics of Fournier's gangrene: A report of 71 patients. Urol Int 2012;89:457-61. Epub 2012 Oct 17. http://dx.doi.org/10.1 159/000342407
(19.) Wang L, Han X, Liu M, et al. Experience in management of Fournier's gangrene: A report of 24 cases. J Huazhong Univ Sci Technolog Med Sci 2012;32:719-23. Epub 2012 Oct 18. http://dx.doi.org/10.1007/s11596-012-1024-4
(20.) Roghmann F, von Bodman C, Loppenberg B, et al. Is there a need for the Fournier's gangrene severity index? Comparison of scoring systems for outcome prediction in patients with Fournier's gangrene. BJU Int 2012;1 10:1359-65. Epub 2012 Apr 11. http://dx.doi.org/10.1111/j.1464- 410X.2012.1 1082.x
(21.) Altarac S, Katusin D, Crnica S, et al. Fournier's gangrene: Etiology and outcome analysis of 41 patients. Urol Int 2012;88:289-93. Epub 2012 Mar 14. http://dx.doi.org/10.1159/000335507
(22.) Janane A, Hajji F, Ismail TO, et al. Hyperbaric oxygen therapy adjunctive to surgical debridement in management of Fournier's gangrene: Usefulness of a severity index score in predicting disease gravity and patient survival [in Spanish]. Actas Urol Esp 2011;35:332-8. Epub 2011 Apr 14. http://dx.doi.org/10.1016/j.acuro.2011.01.019
(23.) Marin AG, Riera CN, Gil JM, et al. Assessment of the Fournier's Gangrene Severity Index Score with 34 patients. Am Surg 2011;77:E5-6.
(24.) Backhaus M, Citak M, Tilkorn DJ, et al. Pressure sores significantly increase the risk of developing a Fournier's gangrene in patients with spinal cord injury. Spinal Cord 2011;49:1 143-6. Epub 2011 Jul 26. http://dx.doi.org/10.1038/sc.2011.75
(25.) Simsek Celik A, Erdem H, Guzey D, et al. Fournier's gangrene: Series of twenty patients. Eur Surg Res 2011;46:82-6. Epub 2010 Dec 29. http://dx.doi.org/10.1 159/000322616
(26.) Yilmazlar T, Ozturk E, Ozguc H, et al. Fournier's gangrene: An analysis of 80 patients and a novel scoring system. Tech Coloproctol 2010;14:217-23. Epub 2010 Jun 18. http://dx.doi.org/10.1007/s10151-010-0592-1
(27.) Erol B, Tuncel A, Hanci V, et al. Fournier's gangrene: Overview of prognostic factors and definition of new prognostic parameter. Urology 2010;75:1 193-8. http://dx.doi.org/10.1016/j.urology.2009.08.090
(28.) Lujan Marco S, Budia A, Di Capua C, et al. Evaluation of a severity score to predict the prognosis of Fournier's gangrene. BJU Int 2010;106:373-6. Epub 2009 Nov 17. http://dx.doi.org/10.1111/j.1464-410X.2009.09075.x
(29.) Ulug M, Gedik E, Girgin S, et al. The evaluation of microbiology and Fournier's gangrene severity index in 27 patients. Int J Infect Dis 2009;13:e424-30. Epub 2009 May 2. http://dx.doi.org/10.1016/j.ijid.200 9.01.021
(30.) Corcoran AT, Smaldone MC, Gibbons EP, et al. Validation of the Fournier's gangrene severity index in a large contemporary series. J Urol 2008;180:944-8. Epub 2008 Jul 17. http://dx.doi.org/10.1016/j. juro.2008.05.021
(31.) Kabay S, Yucel M, Yaylak F, et al. The clinical features of Fournier's gangrene and the predictivity of the Fournier's Gangrene Severity Index on the outcomes. Int Urol Nephrol 2008;40:997-1004. Epub 2008 Jun 19. http://dx.doi.org/10.1007/s1 1255-008-9401-4
(32.) Tuncel A, Aydin 0, Tekdogan U, et al. Fournier's gangrene: Three years of experience with 20 patients and validity of the Fournier's Gangrene Severity Index Score. Eur Urol 2006;50:838-43. Epub 2006 Feb 14. http://dx.doi.org/10.1016/j.eururo.2006.01.030
(33.) Yeniyol C0, Suelozgen T, Arslan M, et al. Fournier's gangrene: Experience with 25 patients and use of Fournier's gangrene severity index score. Urology 2004;64:218-22. http://dx.doi.org/10.1016/j.urology.2004.03.049
(34.) Chawla SN, Gallop C, Mydlo JH. Fournier's gangrene: An analysis of repeated surgical debridement. Eur Urol 2003;43:572-5. http://dx.doi.org/10.1016/S0302-2838(03)00102-7
(35.) Ersay A, Yilmaz G, Akgun Y, et al. Factors affecting mortality of Fournier's gangrene: Review of 70 patients. ANZ J Surg 2007;77:43-8. http://dx.doi.org/10.1111/j.1445-2197.2006.03975.x
(36.) Sarkis P, Farran F, Khoury R, et al. Fournier's gangrene: A review of the recent literature [in French]. Prog Urol 2009;19:75-84. Epub 2008 Nov 28. http://dx.doi.org/10.1016/j.purol.2008.09.050
(37.) Park H, Copeland C, Henry S, et al. Complex wounds and their management. Surg Clin North Am 2010;90:1 181-94. http://dx.doi.org/10.1016/j.suc.2010.08.001
(38.) Shyam DC, Rapsang AG. Fournier's gangrene. Surgeon 2013;1 1:222-32. Epub 2013 Apr 8. http://dx.doi.org/10.1016/j.surge.2013.02.001
(39.) Sugihara T, Yasunaga H, Horiguchi H, et al. Impact of surgical intervention timing on the case fatality rate for Fournier's gangrene: An analysis of 379 cases. BJU Int 2012;110(11 Pt C):E1096-100. http://dx.doi.org/10.1111/j.1464-410X.2012.1 1291.x
(40.) Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Critical Care Medicine 2004;32:1535-41. http://dx.doi.org/10.1097/01.CCM.0000129486.35458.7D
Correspondence: Dr. Michael McCormack, Department of Surgery, University of Montreal, Montreal, QC; email@example.com
Michael McCormack, MD, FRCSC; Anne Sophie Valiquette, MD; Salima Ismail, MD
Department of Surgery, University of Montreal, Montreal, QC
Table 1. Statistical analysis Survivors Non-survivors p value (n = 20) (n = 5) Age (mean, median) 55, 57 60, 62 0.69 Etiologies Skin wound/infection 9 (45%) 2 (40%) Abscess 5 (25%) 2 (40%) Postoperative 1 (5%) 0 0.7 complication Genitourinary source 2 (10%) 0 Anorectal/colorectal 2 (10%) 0 source Trauma 1 (5%) 1 (20%) No. debridement surgeries 1 17 (85%) 2 (40%) 0.04 2 or more 3 (15%) 3 (60%) Time (hours) between ER 16.36, 8.95 45.03, 48.0 0.50 admission and surgery (mean, median) Extent of debridement Peno-scrotal [+ or -] 13 (65%) 1 (20%) 0.07 anal/perirenal Beyond 7 (35%) 4 (80%) ER: emergency room.
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|Author:||McCormack, Michael; Valiquette, Anne Sophie; Ismail, Salima|
|Publication:||Canadian Urological Association Journal (CUAJ)|
|Date:||Jun 1, 2015|
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