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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
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.
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
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
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?
• 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?
Case (cont’d)
• Urgent Surg, Uro, Ortho consultation
• Admitted to ICU
• Multiple OT x debridement
• Loop transverse colostomy on 2nd OT
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