Necrotizing fasciitis Chung Wing Yin Max Tuen Mun

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Necrotizing fasciitis Chung Wing Yin Max Tuen Mun Hospital

Necrotizing fasciitis Chung Wing Yin Max Tuen Mun Hospital

Introduction • Primarily infects and spreads along muscle fascia • Causes cutaneous vessel thrombosis

Introduction • Primarily infects and spreads along muscle fascia • Causes cutaneous vessel thrombosis and then skin necorsis • Type 1 – Polymicrobial infection • aerobic + anerobic bacteria – Gas formation in tissue – Occurs in patient with underlying illness eg DM with PVD, alcoholics, ESRF • Type 2 – Monmicrobial infection • Streptococcus Pyogenes, Staphalococcus aureus • Aeromonas hydrophilla, Vibrio vulnificus – No gas formation – May occur in healthy young individual

Introduction Fournier's gangrene • Type 1 polymicronial NF • infection of superficial fascia of

Introduction Fournier's gangrene • Type 1 polymicronial NF • infection of superficial fascia of perineum and genitalia • sources of bacteria: Scarpa's fascia – – Buck's fascia Dartos fascia Colle's fascia Netter Colorectal (30 -50%) Urogenital (20 -40%) others Idopathic • male to female: 10: 1

Diagnosis of necrotizing fasciitis • Clinical features – – – soft tissue edema (75%)

Diagnosis of necrotizing fasciitis • Clinical features – – – soft tissue edema (75%) erythema (72%) severe pain (72%) fever (60%) crepitus (50%) skin bullae or necrosis (38%) picture from Uptodate picture from Current Surgical therapy 10 th edition

Diagnosis of necrotizing fasciitis • Clinical factors that differentiating NF from cellulitis: -recent surgery

Diagnosis of necrotizing fasciitis • Clinical factors that differentiating NF from cellulitis: -recent surgery -pain out of proportion to clinical signs -hypotension -skin necrosis and haemorrhagic bullae -crepitus -rapid deteriotation

Diagnosis of necrotizing fasciitis Laboratory Risk Indicator for Necrotizing Fasciitis score (LRINEC) • 0

Diagnosis of necrotizing fasciitis Laboratory Risk Indicator for Necrotizing Fasciitis score (LRINEC) • 0 -13, with higher scores indicating a higher likelihood of NF score >6 as cut off

Predictor of outcome Fournier's gangrene severity index FGSI>9: 75%probability of death

Predictor of outcome Fournier's gangrene severity index FGSI>9: 75%probability of death

Contrast CT Scan Indications -uncertain diagnosis -delineation of extent of involvement Contrast CT scan

Contrast CT Scan Indications -uncertain diagnosis -delineation of extent of involvement Contrast CT scan findings -general: soft tissue swelling -specific: gas, abscence of fascial enhancement Chih-Sheng Huang; Fournier's gangrene; NEJM (images in clinical medicine) 2017

Treatment v. Pre-op optimization v. Broad spectum antibiotics v. Surgical debridement v. Fecal diversion

Treatment v. Pre-op optimization v. Broad spectum antibiotics v. Surgical debridement v. Fecal diversion v. Negative pressure wound Therapy v. Hyperbaric oxygen therapy v. Reconstruction

Antibiotics usual organisms Preferred regimen Following exposure to freshwater; seawater or seafood Aeromonas hydrophilla,

Antibiotics usual organisms Preferred regimen Following exposure to freshwater; seawater or seafood Aeromonas hydrophilla, A caviae; Vibrio vulnificus IV fluoroquinolone + IV Augmentin Following cuts and abrasion; recent chickenpox; IVDU; healthy adults Group A streptococci IV penicillin G + IV linezolid following intra-abdominal; polymicrobial Enterobacteriaceae, IV imipenem or meropenem or gynaecological or perineal surgery streptococci, anaerobes IV Augmentin + IV levofloxacin IMPACT guideline

Surgical debridement • • dishwater-like exudate and foul smelling involved skin does not bleed

Surgical debridement • • dishwater-like exudate and foul smelling involved skin does not bleed normally involved fascia is friable repeat after 24 -48 hrs picture from Uptodate

Treatment ü Pre-op optimization ü Broad spectum antibiotics ü Surgical debridement v. Fecal diversion

Treatment ü Pre-op optimization ü Broad spectum antibiotics ü Surgical debridement v. Fecal diversion v. Negative pressure wound Therapy v. Hyperbaric oxygen therapy v. Reconstruction

1. Fecal diversion

1. Fecal diversion

Fecal diversion • Indications – wound at perianal region contaminated by feces – incontinence

Fecal diversion • Indications – wound at perianal region contaminated by feces – incontinence due to damaged sphincter – diahorrea due to antibiotic use • Options – stoma (sigmoid colostomy, transverse colostomy, ileostomy) – fecal management system (Flexi-seal system®)

Flexi-seal system®

Flexi-seal system®

Flexi-seal system® • Contraindications – previous rectal surgery, inflammatory bowel disease, obstructive mass, stricture,

Flexi-seal system® • Contraindications – previous rectal surgery, inflammatory bowel disease, obstructive mass, stricture, existing rectal injury • Complications – per rectal bleeding • Evidence – most are case reports – one retrospective study and one prospective study showed it was well tolerated without major complcations (i. e. PRB). It avoided colostomy creation and reduced hospital cost.

2. Negative pressure wound therapy (NPWT)/ Vacuum-assisted closure (VAC) therapy

2. Negative pressure wound therapy (NPWT)/ Vacuum-assisted closure (VAC) therapy

Negative pressure wound therapy • Advantage vs conventional dressing – – – speed up

Negative pressure wound therapy • Advantage vs conventional dressing – – – speed up wound healing reduce frequency of changing dressing less pain greater motility reduce LOS • mechanism – promotes formation of granulation tissue – increases blood supply and brings in inflammatory cells – continuously removes bacteria, end products, exudates, debris.

Feng-Shu Chang et al; Suture technique to prevent air leakage in negative wound pressure

Feng-Shu Chang et al; Suture technique to prevent air leakage in negative wound pressure therapy in Fournier's gangrene; PRSGlobal Open; 2018

3. Hyperbaric oxygen therapy (HBOT)

3. Hyperbaric oxygen therapy (HBOT)

Hyperbaric oxygen therapy (HBOT) • Several retrospective studies showed HBOT can reduce mortality in

Hyperbaric oxygen therapy (HBOT) • Several retrospective studies showed HBOT can reduce mortality in Fournier's gangrene and NF • No RCT available • Facility not available in most centres Stonecutter Island/ Ngon Shuen Chao PYNEH

Hyperbaric oxygen therapy (HBOT) • breathing of 100% oxygen inside a treatment chamber at

Hyperbaric oxygen therapy (HBOT) • breathing of 100% oxygen inside a treatment chamber at a pressure higher than 1 atmospheric absolute • 90 -minute daily session for 30– 40 sessions in total • Mechanishm of action: 1. Bactericidal action § inhibiting anaerobic bacteria, enhancing phagocytosis 2. Promoting wound healing § stimulate angiogenesis, reducing edema, enahnced fibroflast replication and collagen deposition

Hyperbaric oxygen therapy (HBOT) • Contraindications 1. 2. 3. 4. 5. 6. 7. Respiratory:

Hyperbaric oxygen therapy (HBOT) • Contraindications 1. 2. 3. 4. 5. 6. 7. Respiratory: COPD, asthma, pneumothorax Ear: Chronic sinusitis, history of ear surgery Eye: history of optic neuritis Neurologic: seizure disorder Drug therapy: eg doxorubicin, bleomycin, cisplatin Pregnancy Claustrophobia or emotionally unstable

4. Reconstruction

4. Reconstruction

7. Reconstruction • • Delayed primary closure Advancement flap split thickness skin graft fasciocutaneous

7. Reconstruction • • Delayed primary closure Advancement flap split thickness skin graft fasciocutaneous or musculocutantous flaps

Reconstruction delayed primary closure Avinash, et al; Contemporary diagnsis and management of Fournier's gangrene;

Reconstruction delayed primary closure Avinash, et al; Contemporary diagnsis and management of Fournier's gangrene; Ther Adv Urol, 2015, Vol 7(4) 203 -215.

Reconstruction Meshed splitthickness skin graft Avinash, et al; Contemporary diagnsis and management of Fournier's

Reconstruction Meshed splitthickness skin graft Avinash, et al; Contemporary diagnsis and management of Fournier's gangrene; Ther Adv Urol, 2015, Vol 7(4) 203 -215.

Reconstruction Gracillis musculocutantous flaps

Reconstruction Gracillis musculocutantous flaps

Treatment 1. 2. 3. 4. 5. 6. 7. Pre-op optimization Broad spectum antibiotics Surgical

Treatment 1. 2. 3. 4. 5. 6. 7. Pre-op optimization Broad spectum antibiotics Surgical debridement Fecal diversion Negative pressure wound Therapy Hyperbaric oxygen therapy Reconstruction

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