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

2. Case M/57 DM ESRF HT Gout poor control (HbA1c 9.9%)
renal transplant in 1998
on immunosuppressant HT
Gout

3. 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?

4. Fournier’s Gangrene Background Treatment
Definition, epidemiology, bacteriology
Treatment
Debridement
Fecal diversion - colostomy
Indication
Timing

5. 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

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

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

8. 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, (3): p

9. 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

10. 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
Mycobacterium tuber
Yeasts
Candida albicans
Synergistic
Polymicrobial
Aerobes and anaerobes
C.F.Heyns,P.D.Theron. Fournier’s gangrene. Emergency Urology, p

11. Presentation & Diagnosis
Clinical diagnosis
Crepitus 50-62%
Paty R, Smith AD. Gangrene and Fournier’s gangrene. Urol Clin North Am 1992; 19: 149–62

12. Presentation & Diagnosis
Investigations:
Concomitant disease
Doubtful diagnosis

13. 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:
Meleney FL. Hemolytic streptococcus gangrene. Arch Surg 1924; 9:

14. Treatment Urinary diversion Fecal diversion? Urethral catheter
Suprapubic catheter
Fecal diversion?

15. Colostomy? 18 Colostomy Mortality: 14 during 1st debridement
Dis Colon Rectum 2003; 46: 649–52.
18 Colostomy
14 during 1st debridement
4 on D5, 7, 7, 8
Mortality:
Stoma: 7/18 (38.9%),
No stoma: 2/27 (7.4%)
P=0.009

16. Colostomy?
57 cases (1985 – 1996)
Fecal diversion is not a prognostic factor
Early colostomy may reduce mortality

17. Colostomy Indications: Timing? 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

18. Colostomy? 18 Colostomy Mortality: 14 during 1st debridement
Dis Colon Rectum 2003; 46: 649–52.
18 Colostomy
14 during 1st debridement
4 on D5, 7, 7, 8
Mortality:
Stoma: 7/18 (38.9%),
No stoma: 2/27 (7.4%)
P=0.009

19. Colostomy – When? 8 cases 4 colostomies 1 in 1st debridement
3 in D3, 5, 5

20. 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
Physiological and operative severity score for the enumeration of mortality and morbidities

21. Colostomy – When? No consensus yet
Trend: on subsequent debridement, when physiological condition improved
Alternatives?

22. Alternatives
2 cases
Flexi-Seal Fecal Management System

23. Alternatives
1 case
ActiFlo rectal catheter

24. Alternatives

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

26. After multiple debridements
PTSG on 16/1/2012

27. Summary Fournier’s Gangrene Uncommon but lethal condition Debridement
Colostomy