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Fournier’s Gangrene – debridement only ?

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

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Fournier’s Gangrene – debridement only ?

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  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 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, 1998. 81(3): p. 347-55.

  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. 50-60

  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: 1339-52 Meleney FL. Hemolytic streptococcus gangrene. Arch Surg 1924; 9: 317-64

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

  15. Colostomy? 1990-2001 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: • 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? 1990-2001 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

  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

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