Fourniers Gangrene debridement only Jackie Leung Prince of

Fournier’s Gangrene – debridement only ? Jackie Leung Prince of Wales Hospital Joint Hospital Surgical Grand Round

Case • M/57 • DM – poor control (Hb. A 1 c 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. 5 C – BP 188/104 P 115 – 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, V 52. t

Definition British Journal of Urology (1998), 81, 347– 355 • Infective necrotizing fasciitis affecting the perianal, perineal and genital regions

Epidemiology • • 5 th-6 th 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 Underlying disorder in patients with Fournier’s gangrene Diabetes mellitis (32 -66%) Chronic alcoholism (25 -66%) Malnutrition Obesity Liver cirrhosis Immunosuppression (Chronic steroid use, organ transplant, malignancy, HIV/AIDS) Tuberculosis Syphilis Vick R. Carson CC, Fournier's disease. Urologic Clinics of North America. 26(4): 841 -9

Bacteriology • Synergistic • Polymicrobial • Aerobes and anaerobes Gram-negative E. coli Klebsiella pneumoniae Pseudomonas aeruginosa Proteus mirabilis Enterobacteria Gram-positive Staphylococcus aureus Beta-hemolytic streptococcus Streptococcus faecalis Staphylococcus epider Anaerobes Bacteroides fragilis Peptococcus Fusobacterium Clostridium perfringe Mycobacteria C. F. Heyns, P. D. Theron. Fournier’s gangrene. Emergency Urology, p. 50 -60 Mycobacterium tuber Yeasts Candida albicans

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, 3 rd generation cephalosporins • Surgical Debridement – introduced by Meleney in 1920 s – Repeated if necessary Laucks SS II. Fournier’s gangrene. Surg Clin North Am 1994; 74: 1339 -52 Meleney FL. Hemolytic streptococcus gangrene. Arch Surg 1924; 9: 317 -64

Treatment • Urinary diversion – Urethral catheter – Suprapubic catheter • Fecal diversion?

Colostomy? 1990 -2001 Dis Colon Rectum 2003; 46: 649– 52. • 18 Colostomy – 14 during 1 st debridement – 4 on D 5, 7, 7, 8 Mortality: Stoma: 7/18 (38. 9%), No stoma: 2/27 (7. 4%) P=0. 009

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? 1990 -2001 Dis Colon Rectum 2003; 46: 649– 52. • 18 Colostomy – 14 during 1 st debridement – 4 on D 5, 7, 7, 8 Mortality: Stoma: 7/18 (38. 9%), No stoma: 2/27 (7. 4%) P=0. 009

Colostomy – When? • 8 cases – 4 colostomies – 1 in 1 st debridement – 3 in D 3, 5, 5

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