Management of equivocal (early) Fournier’s gangrene

Abstract

Background: Fournier’s gangrene (FG) is an acute progressive necrotizing fasciitis of the genital area and perineum with possible extension to the abdominal wall. Surgical debridement is the gold standard management modality of established patients. Equivocal (early) FG represents a challenge in diagnosis. The objective of this study was to compare conservative management and early exploration in cases of equivocal (early) FG. Methods: This was an observational study where data of all patients diagnosed as early FG in our departments over 4 years (2011–2015) were enrolled. Patients were divided into two groups: group 1 with conservative treatment, and group 2 managed with urgent exploration with longitudinal hemiscrotal incision starting from external inguinal ring. All patients’ demographics, vital signs, laboratory finding and clinical findings were reported. Results: A total of 28 patients were enrolled in the study. Group 1 was managed with conservative treatment (17 patients) and group 2 underwent urgent exploration (11 patients). Overall, four patients (23.5%) out of 17 patients of group 1 showed a good response to conservative management without any surgical debridement. A total of 13 patients (76.5%) developed gangrenous discoloration and needed surgical debridement later. In group 2, four patients (36.4%) underwent scrotal exploration and release incision only without debridement and showed an excellent clinical outcome. A total of four patients (36.4%) underwent debridement with excision of doubtful deep subcutaneous and fascial tissues. The remaining three patients (27.2%) underwent debridement of necrotic fascia. The hospital stay was significantly shorter in group 2 patients than group 1 (7.5 ± 3.75 versus 13.4 ± 5.19 days p < 0.05). The mean number of debridement sessions was 3.74 ± 0.69 in group 1 versus 1.82 ± 0.34 in group 2. Conclusions: Early exploration and debridement in equivocal (early) FG has a better clinical outcome with reduced hospital stay and number of debridement sessions than conservative treatment with delayed debridement.

Practical Review of the Current Management of Fournier’s Gangrene

“…The optimal window for surgery from time of presentation to the emergency department has been determined to be within the first 14.35 hours. 39 El-Shazly et al 48 found higher rates of patients requiring more aggressive surgical debridement due to disease progression in those who had longer delays in getting to the operating room (76.5% versus 27.2%, respectively). The authors also reported that patients with conservative management had significantly greater body surface area affected, required more serial debridement, and longer hospital stays than their counterparts who underwent urgent exploration.…”

“…The authors also reported that patients with conservative management had significantly greater body surface area affected, required more serial debridement, and longer hospital stays than their counterparts who underwent urgent exploration. 48 Zhang et al 25 reported that debridement should continue until reaching normal-appearing fascia. Surgeons should have a low threshold to return to the operating room and perform further debridement if there is evidence of continued progression.…”

Fournier’s Gangrene Diagnosis and Treatment: A Systematic Review

“…Our search yielded 223 articles based on the applied criteria and filters. After screening and assessment of the results based on inclusion criteria and study objectives, 37 articles were included for the presentation, symptoms, or treatment of FG [ 2 , 5 - 7 , 10 - 11 , 13 - 42 ]. In these included articles, a total of 3,224 patients were evaluated, including 3,093 males and 131 females.…”

“…The review indicated that the main symptoms were scrotal and labial pain, fever, abscesses, crepitus, erythema, and cellulitis. The gold standard for treatment was found to be emergent surgical debridement, broad-spectrum antibiotics, and the administration of intravenous (IV) fluids [ 2 , 5 - 7 , 10 - 11 , 13 - 42 ].…”

“…These microbes collaborate to release enzymes that cause tissue necrosis [ 6 ]. The bacterial organisms that cause this necrotic infection release collagenases, which cause rapid tissue destruction at a rate of one inch per hour [ 3 ], allowing the infection to quickly spread from the genital region to the anterior abdominal wall and vital organs [ 7 ].…”