Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature

Abstract

Necrotising fasciitis (NF) is characterised by rapidly spreading necrosis of the soft tissue and fascia. It is rare but can be fatal when not managed properly. The aim of this study is to evaluate the diagnosis, treatment and results such as mortality, morbidity and reconstructive options of NF localised in the central part of the body. The main goal is to emphasise upon the clinical symptoms for early diagnosis which is the most important factor in saving the lives of these patients. Between January 2000 and December 2010, 30 patients with NF localised in central parts of the body were treated. Six of the patients were female (20%) and the others were male (80%). The mean age was 54·03 years (ranged between 26 and 83 years). The average time from the onset of symptoms to diagnosis was 6 days, ranging from 2 to 11 days. The localisation of NF was perineum in 24 patients (80%); inguinal and thigh region in 5 patients (16·7); and back in 1 patient (3·3%). The hospitalisation time was varying between 17 and 32 days (mean 23 days). Six patients (20%) died and 24 patients (80%) survived. All non-survivors had risk factors and secondary comorbidities such as immunosuppression, chronic cardiac failure, and diabetes with high glucose level. Survivors also underwent repeated debridement operation 2-4 times. Reconstructive procedures were split-thickness skin graft (STSG) in eight patients (33·3%), fasciocutaneous flaps in four patients (16·6%), fasciocutaneous flap + STSG in six patients (25%), scrotal flap + STSG in two patients (6·6%), scrotal flap in two patients (6·6%) and musculocutaneous flap + STSG in one patient (3·3%). There was no major complication such as flap and graft loss, after reconstructive procedures. Early diagnosis of NF may be the lifesaving factor. Amuputation can save the patient's life in the case of NF in the extremities; however, this is not an option for NF in central parts of the body. In these cases, when NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

Fournier’s gangrene: A retrospective analysis of 26 cases in a Canadian hospital and literature

“…As a corollary, it has become evident that a second-look procedure under general anesthesia was not always mandatory since most survivors underwent only one surgical debridement under anesthesia. It has been suggested that all patients should undergo a second look under general anesthesia and that these patients have a lower mortality rate, 3 but our data did not support this statement. While the repeated nature of debridements may be considered the accepted standard of care in these patients, this is not always predictive of outcome.…”

“…1 However, considerable variability exists and authors have reported mortality rates ranging from 10% to 80%. [2][3][4][5][6][7][8][9] To our knowledge no prospective studies have been done on FG. Retrospective research has been directed to identifying both risk factors associated with the onset of FG and prognostic factors relating to patient survival.…”

Infección necrotizante de la pared abdominal postcesárea

“…El diagnóstico precoz y la intervención quirúr-gica temprana son los dos factores más importantes que influyen en la sobrevida de los pacientes 4 Una herramienta útil para detectar tempranamente una FN es el LRINEC score (laboratory risk indicator for necrotizing fasciitis), una escala de puntuación diseñada a partir de los valores séricos de glucosa, creatinina, sodio, hemoglobina, glóbulos blancos y proteína C reactiva que nos sirve para distinguir las FN de otras infecciones de partes blandas. Los pacientes con puntuaciones mayores de 6 deben ser evaluados con especial cuidado, ya que se asocia a un valor predictivo positivo del 92% y un valor predictivo negativo del 96% para detectar FN.…”

“…Sin embargo, el LRINEC score no puede ser interpretado de manera aislada, ni tampoco servir para la toma de decisiones por sí solo. La exploración quirúrgica basada en un alto índice de sospecha continúa siendo el procedimiento de referencia (gold standard) para el diagnóstico 1,4 .…”

“…Los intervalos de tiempo para los nuevos desbridamientos no han sido estandarizados, si bien en la literatura se describen cirugías programadas cada 24-48 horas 4 . En pacientes con grandes defectos de pared y sepsis abdominal se recomienda el cierre temporal del abdomen.…”