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

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Presentation on theme: "Fournier’s Gangrene – debridement only ? Jackie Leung Prince of Wales Hospital Joint Hospital Surgical Grand Round."— Presentation transcript:

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

2 Case M/57 DM –poor control (HbA1c 9.9%) ESRF –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 –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 Infective necrotizing fasciitis affecting the perianal, perineal and genital regions British Journal of Urology (1998), 81, 347–355

7 Epidemiology 5 th -6 th 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 Vick R. Carson CC, Fournier's disease. Urologic Clinics of North America. 26(4):841-9

10 Bacteriology 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, 3 rd 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 –Urethral catheter –Suprapubic catheter Fecal diversion?

15 Colostomy? 18 Colostomy –14 during 1 st 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=

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

17 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

18 Colostomy? 18 Colostomy –14 during 1 st 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=

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

20 Colostomy – When? 4 cases ( ) Colostomy on 2 nd look OT (D2,3,5,5) Improved POSSUM scores Mostly required 2 nd debridement <10% of ICU patients had BO in first 48hrs

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 2 nd OT

26 After multiple debridements PTSG on 16/1/2012

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


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