Características epidemiológicas y quirúrgicas en pacientes con secuelas de enfermedad de Fournier / Reconstructive techniques in Fournier's disease sequels

Introducción: La gangrena de Fournier actualmente se define como una forma específica de fascitis necrotizante sinérgica, rápida, progresiva y de origen multibacteriano, que afecta principalmente la fascia muscular de región perineal, genital o perianal e incluso de pared abdominal; con punto de partida genitourinario, colorrectal o idiopático. Todo ello, acompañado de gangrena de piel de estas áreas debida a trombosis de vasos sanguíneos subcutáneos. Objetivos: Describir las características epidemiológicas y quirúrgicas de los pacientes secuelares de la enfermedad de Fournier en la Unidad de Cirugía Plástica del Hospital de Clínicas en un período de 2 años. Materiales y métodos: Estudio observacional, descriptivo, de corte transversal, temporalmente retrospectivo, tipo serie de casos. El tipo de muestreo fue no probabilístico a conveniencia. Se presentan 18 pacientes secuelares de enfermedad de Fournier reconstruidos en la Unidad de Cirugía Plástica de Hospital de Clínicas entre los años 2020 y 2021. Resultados: Durante el periodo del estudio se realizaron 395 cirugías en el Servicio de Cirugía Plástica del Hospital de Clínicas, de los cuales 18 pacientes fueron intervenidos quirúrgicamente por secuelas de enfermedad de Fournier, lo que representa el 5% del total. En lo que respecta a las variables demográficas, la edad osciló entre los 37 y 85 años con mayor afectación en la sexta década de la vida con un promedio de 61 años. El 94% de los pacientes fue de sexo masculino; el 89% de los pacientes tenía como patología de base la diabetes mellitus tipo 2, seguido de la obesidad en el 72% y la hipertensión arterial en el 56% de los casos; el 83% de los casos estuvo afectada la región escrotal seguido de la región perineal con el 56% de los pacientes y el pene en el 50% de los casos. La técnica reconstructiva empleada en mayor frecuencia fueron los colgajos en 10 pacientes, seguido del injerto de piel en 8 pacientes, y el cierre primario en 6 pacientes, cabe mencionar que en algunos pacientes se emplearon varias técnicas reconstructivas siguiendo el concepto de reconstrucción por sub-unidades anatómicas, entre los colgajos los más utilizados fueron el colgajo de perforante de la circunfleja femoral medial (perforante de gracilis) con el 50% de los casos seguido del colgajo de transposición fasciocutáneo de la pudenda interna con el 30%, y por último el colgajo de avance fasciocutáneo con el 20% (Tabla 3). La estancia hospitalaria promedio fue de 3 días, con un mínimo de 1 día y un máximo de 5 días post operatorio. Se reportó como complicación la dehiscencia de sutura en 3 pacientes, no se observó complicaciones en el 77% de los casos. Conclusión: Las secuelas de la enfermedad de Fournier sometidos a cirugías representan el 5% del total de cirugías realizadas en nuestro Servicio, son más prevalentes en la sexta década de la vida, afecta más al sexo masculino con diabetes mellitus tipo 2 como patología de base, las técnicas reconstructivas empleadas en las secuelas son variables de acuerdo a las regiones anatómicas afectadas y pueden abarcar desde el cierre primario hasta la utilización de colgajos para su reparación.

Introduction: Fournier's gangrene is currently defined as a specific form of synergistic, rapid, progressive and multibacterial necrotizing fasciitis, which mainly affects the muscular fascia of the perineal, genital, or perianal region and even the abdominal wall; with genitourinary, colorectal, or idiopathic starting point. All of this, accompanied by skin gangrene in these areas due to thrombosis of subcutaneous blood vessels. Objectives: To describe the epidemiological and surgical characteristics of the sequelae patients of Fournier's disease in the Plastic Surgery Unit of the Hospital de Clínicas in a period of 2 years. Materials and methods: Observational, descriptive, cross-sectional, temporally retrospective, case series type study. The type of sampling was non-probabilistic at convenience. Eighteen sequelae patients of Fournier's disease reconstructed in the Plastic Surgery Unit of Hospital de Clínicas between 2020 and 2021 are presented. Results: During the study period, 395 surgeries were performed in the Plastic Surgery Service of the Hospital de Clínicas, of which 18 patients underwent surgery for sequelae of Fournier's disease, which represents 5% of the total. Regarding demographic variables, age ranged between 37 and 85 years with greater impact in the sixth decade of life with an average of 61 years. 94% of the patients were male; 89% of the patients had type 2 diabetes mellitus as an underlying pathology, followed by obesity in 72% and high blood pressure in 56% of cases; In 83% of the cases, the scrotal region was affected, followed by the perineal region in 56% of the patients and the penis in 50% of the cases. The most frequently used reconstructive technique was flaps in 10 patients, followed by skin grafting in 8 patients, and primary closure in 6 patients. It is worth mentioning that in some patients several reconstructive techniques were used following the concept of reconstruction by sub- anatomical units, among the flaps the most used were the medial femoral circumflex perforator flap (gracilis perforator) with 50% of the cases followed by the fasciocutaneous transposition flap of the internal pudendal with 30%, and finally the fasciocutaneous advancement flap with 20% (Table 3). The average hospital stay was 3 days, with a minimum of 1 day and a maximum of 5 days postoperatively. Suture dehiscence was reported as a complication in 3 patients; no complications were observed in 77% of the cases. Conclusion: The sequelae of Fournier's disease undergoing surgeries represent 5% of the total number of surgeries performed in our Service, they are more prevalent in the sixth decade of life, it affects more males with type 2 diabetes mellitus as the underlying pathology, the reconstructive techniques used in the sequelae are variable according to the anatomical regions affected and can range from primary closure to the use of flaps for repair.

Standardization of reconstructions with flaps after Fournier's gangrene / Padronização das reconstruções com retalhos após gangrena de Fournier

Introduction: Fournier's gangrene is characterized by tissue necrosis, which requires treatment employing debridement and antibiotics with wounds of varying sizes. The objective is to standardize the surgical techniques of reconstructions with flaps used to treat wounds after Fournier's gangrene. Method: A study was conducted by searching the PubMed/Medline, SciELO, and LILACS databases. Results: In wounds with skin loss of 25% to 50%, a local advancement cutaneous flap or a pudendal flap from the thigh was used; in wounds, greater than 50%, a superomedial thigh flap or myocutaneous flap from the gracilis muscle was used, with the aim of to enable proper reconstruction. Conclusion: Advancement and pudendal thigh flaps were used for wounds with up to 50% loss of scrotal skin substance, while the myocutaneous gracilis flap and supero-medial flap of the thigh were indicated for wounds with more than 50% of the total scrotal surface affected, after Fournier gangrene.

Introdução: Gangrena de Fournier é caracterizada por necrose tecidual, que necessita de tratamento por meio de desbridamento e antibióticos, com feridas de dimensões variadas. O objetivo é padronizar as técnicas cirúrgicas de reconstruções com retalhos utilizadas no tratamento das feridas após gangrena de Fournier. Método: Realizou-se estudo por meio da busca nas bases de dados PubMed/Medline, SciELO e LILACS. Resultados: Nas feridas com perdas cutâneas de 25% a 50%, foram utilizados retalho cutâneo local de avanço ou retalho pudendo da coxa, nas maiores de 50% foram necessárias as confecções do retalho superomedial da coxa ou retalho miocutâneo do músculo grácil, com intuito de possibilitar a reconstrução adequada. Conclusão: Os retalhos de avanço e pudendo da coxa foram utilizados para feridas com perda de substância cutânea escrotal de até 50%, enquanto os retalhos miocutâneo de músculo grácil e superomedial da coxa foram indicados para as feridas com mais de 50% da superfície escrotal total acometida, após gangrena de Fournier.

Implementación artesanal del sistema VAC en pacientes con Gangrena de Fournier: serie de casos

La fascitis necrosante es una infección de los tejidos blandos profundos que provoca la destrucción progresiva de la fascia muscular y subcutánea. Una de sus presentaciones es la Gangrena de Fournier (GF) para el cual el diagnóstico debe de ser preciso y asociado a desbridamiento quirúrgico precoz y antibioticoterapia de amplio espectro. Si existe retraso del manejo, la repercusión en el pronóstico es negativa. Entre las opciones actuales para el tratamiento destaca una técnica para mejorar la limpieza y granulación del área cruenta mediante el uso del dispositivo tecnológico y el sistema de cierre asistido por vacío (VAC). Describimos el manejo y la técnica de la terapia VAC implementado artesanalmente en una serie de casos de pacientes masculinos con diagnóstico de GF, en respuesta a los escasos recursos económicos de los pacientes que generalmente son afectados en nuestro medio; proponiendo una opción más económica, segura y replicable para nuestro entorno.

Necrotizing fasciitis is a deep soft tissue infection that causes progressive destruction of the muscle fascia and subcutaneous . One of its presentations is Fournier's Gangrene (FG) for which the diagnosis must be accurate and associated with early surgical debridement and broad-spectrum antibiotic therapy. If management is delayed, the impact on prognosis is negative. Current treatment options include a technique to improve cleaning and granulation of the cruciate area using a technological device and the vacuum assisted closure system (VAC). We describe a handmade technique of VAC therapy implemented in a series of cases of male patients diagnosed with FG, in response to the scarce economic resources of patients who are generally affected in our environment; proposing a more economical, safe and replicable option for our environment.

Reconstrução escrotal após gangrena de Fournier / Scrotal reconstruction after Fournier's gangrene

Introdução: Gangrena de Fournier é uma infecção polibacteriana, geralmente causada por bactérias anaeróbias e aeróbias, sendo caracterizada por fasciite necrosante escrotal e perineal. Seu tratamento é embasado em intervenção cirúrgica com excisão da área necrótica e antibioticoterapia precoces. Diversas são as estratégias de reconstrução do defeito resultante do desbridamento, devendo ser salientado que perdas teciduais maiores do que 50% costumam ser reconstruídas com retalhos. Métodos: Análise retrospectiva da série de casos de reconstrução escrotal após gangrena de Fournier procedidos pelos autores ao longo de 2020, totalizando oito pacientes. Resultados: O retalho mais utilizado foi o fasciocutâneo de coxa, que apresentou taxa de necrose parcial de 14,29%, sem necrose total. Em um dos casos foi possível reconstruir uma uretra esponjosa com músculo grácil sem fistulização, evitando que o paciente fosse submetido a uma uretrostomia definitiva. Quanto às complicações, foi comum a ocorrência de intercorrências menores que necessitaram de procedimentos revisionais simples. Destaca-se a prevalência de 75% de diabetes mellitus em nossa casuística, o que pode ter interferido negativamente no processo cicatricial. Conclusão: A reconstrução escrotal com retalhos é importante para acelerar a cicatrização da ferida proveniente do desbridamento de gangrena de Fournier e para manter o aspecto de bolsa necessário para a termorregulação do testículo. Nossa opção primária foi o retalho fasciocutâneo de coxa, que se mostrou seguro. Pequenas intercorrências foram frequentes nesta série, sem comprometimento do resultado final.

Introduction: Fournier's gangrene is a polybacterial infection, usually caused by anaerobic and aerobic bacteria, characterized by scrotal and perineal necrotizing fasciitis. Its treatment is based on surgical intervention by excision of the necrotic area and early antibiotic therapy. There are several strategies to reconstruct the defect resulting from debridement, and it should be noted that tissue losses greater than 50% are usually reconstructed with flaps. Methods: Retrospective analysis of the series of cases of scrotal reconstruction after Fournier's gangrene performed by the authors throughout 2020, totaling eight patients. Results: The most used flap was thigh fasciocutaneous flap, which presented a partial necrosis rate of 14.29%, without total necrosis. In one of the cases, it was possible to reconstruct a spongy urethra with gracilis muscle without fistulization, preventing the patient from undergoing a definitive urethrostomy. As for complications, the occurrence of minor complications that required simple revision procedures was common. The prevalence of 75% of diabetes mellitus in our series is highlighted, which may have negatively interfered with the healing process. Conclusion: Scrotal reconstruction with flaps is important to accelerate wound healing from Fournier gangrene debridement and to maintain the pouch aspect necessary for testicular thermoregulation. Our primary option was thigh fasciocutaneous flap, which proved to be safe. And minor complications were frequent in this series, without compromising the final result.

Conceptos para la identificación y abordaje dela gangrena de Fournier / Concepts for the identification and approach of Fournier's gangrene

Introducción. La gangrena de Fournier es una fasciitis necrosante fulminante y progresiva, de origen infeccioso sinérgico polimicrobiano, que afecta las regiones perianal, perineal, genital y abdominal. Su incidencia es mayor en hombres, la edad promedio de presentación reportada está en los 54,7 ± 15,6 años, su mortalidad es del 3-67 %, aunque hay estudios que informan una mortalidad en hombres del 7,5 % y en las mujeres del 12,8 %. Métodos. Se hizo una revisión de la literatura en las bases de datos y fuentes de información PubMed, Scielo y Google Scholar, publicados entre 1950 y 2018, utilizando términos como "fournier gangrene", "fasciitis, necrotizing", "wound infection", "therapy"[subheading] y "GRADE approach". Se realizó una segunda revisión para artículos latinoamericanos en español hasta 2020 usando las mismas fuentes y palabras claves. Resultados. Se seleccionaron artículos que reportaron definiciones, datos históricos, actualizaciones en diagnóstico y terapéutica para hacer una revisión actualizada. Para el uso de las imágenes se solicitó consentimiento informado. Conclusión. La gangrena de Fournier continúa siendo una emergencia quirúrgica potencialmente letal. Gracias a las investigaciones realizadas se ha avanzado en su tratamiento, mejorando los resultados. Es importante analizar los factores de riesgo en cada paciente y su etiología para establecer el tratamiento más adecuado.

Introduction. Fournier's gangrene is a fulminant and progressive necrotizing fasciitis of synergistic polymicrobial infectious origin that affects the perianal, perineal, genital and abdominal regions. Its incidence is greater in men, the average age of reported presentation is 54.7 ± 15.6 years; its mortality is 3-67%, although there are studies that report a mortality of 7.5% in men and 12.8% in women. Methodology. A review of the literature was carried out in the databases and information sources: PubMed, Scielo, and Google Scholar, published between 1950 and 2018 using terms such as "Fournier Gangrene", "Fasciitis, Necrotizing", Wound Infection, "therapy"[Subheading] and "GRADE Approach". A second review was performed for articles in Latin American Spanish up to 2020 using the same sources and keywords. Results. Articles that reported definitions, historical data, diagnostic and therapeutic updates were selected, performing an updated review. Informed consent was requested for the use of images.Conclusion. Fournier's gangrene continues to be a potentially lethal surgical emergency, thanks to the research carried out, progress has been made in its treatment, improving results. It is important to analyze the risk factors for each patient and its etiology to establish the most appropriate treatment

Síndrome de Fournier: implementação do processo de Enfermagem à luz da teoria de Wanda Horta / Fournier's syndrome: implementation of the Nursing process according to the theory of Wanda Horta / Síndrome de Fournier: implementación del proceso de Enfermería a la luz de la teoría de Wanda Horta

Objetivo: Descrever a experiência de discentes do curso de graduação em Enfermagem da Universidade Federal de Alagoas durante a implementação do Processo de Enfermagem a um indivíduo acometido pela Síndrome de Fournier. Métodos: Estudo descritivo, do tipo relato de experiência, baseado na vivência dos estudantes de enfermagem, durante a atividades curriculares de Estágio Supervisionado em uma Unidade de Terapia Intensiva de um hospital público alagoano. A experiência ocorreu ao longo do mês de outubro de 2019. A implementação do Processo de Enfermagem foi guiada à luz da Teoria das Necessidades Humanas Básicas, proposta por Wanda Aguiar Horta. Resultados: Foi implementado o Processo de Enfermagem, com base em suas seis fases, que identificou os problemas do indivíduo e possibilitou o levantamento das intervenções necessárias para efetivar o cuidado, conforme a teoria sugere. A implementação dessa ferramenta científica, de maneira dinâmica e inter-relacionada, proporcionou uma assistência hospitalar mais segura e humanizada ao indivíduo. Conclusão: O cumprimento das seis fases do Processo de Enfermagem permitiu aos enfermeirandos vivenciarem a experiência hospitalar de forma enriquecedora, pelo fato de ter contribuído não apenas com a evolução satisfatória do paciente assistido, mas também com o fortalecimento do trabalho em equipe e da Enfermagem enquanto ciência aplicada. (AU)

Objective: To describe the experience of undergraduate Nursing students at the Federal University of Alagoas during the implementation of the Nursing Process to an individual affected by Fournier's Syndrome. Methods: Descriptive study, of the experience report type, based on the experience of Nursing students, during the curricular activities of the Supervised Internship in an Intensive Care Unit of a public hospital in Alagoas. The experience occurred throughout the month of October, 2019. The implementation of the Nursing Process was guided according to the Theory of Basic Human Needs, proposed by Wanda Aguiar Horta. Results: The Nursing Process was implemented, based on its six phases, which identified the individual's problems and enabled the survey of the necessary interventions to carry out care, as the theory suggests. The implementation of this scientific tool, in a dynamic and interrelated way, provided safer and more humanized hospital care to the individual. Conclusion: The fulfillment of the six phases of the Nursing Process allowed the Nursing students to undergo the hospital experience in an enriching way, because it contributed not only to the satisfactory evolution of the assisted patient, but also to the strengthening of the teamwork and of Nursing as an applied science. (AU)

Objetivo: Describir la experiencia de estudiantes universitarios de Enfermería de la Universidad Federal de Alagoas durante la implementación del Proceso de Enfermería a una persona afectada por el Síndrome de Fournier. Metodos: Estudio descriptivo, tipo de informe de experiencia, basado en la experiencia de estudiantes de Enfermería durante las actividades curriculares de pasantías supervisadas, en una Unidad de Cuidados Intensivos de un hospital público en Alagoas. La experiencia ocurrió durante todo el mes de Octubre de 2019. La implementación del Proceso de Enfermería se guió a la luz de la Teoría de las Necesidades Humanas Básicas, propuesta por Wanda Aguiar Horta. Resultados: El proceso de enfermería se implementó, en base a sus seis fases, que identificaron los problemas del individuo y permitieron la encuesta de las intervenciones necesarias para llevar a cabo la atención, como sugiere la teoría. La implementación de esta herramienta científica, de manera dinámica e interrelacionada, brindó una atención hospitalaria más segura y humanizada al individuo. Conclusión: El cumplimiento de las seis fases del Proceso de Enfermería permitió a los estudiantes de Enfermería vivir la experiencia hospitalaria de manera enriquecedora, debido a que contribuyó no solo a la evolución satisfactoria del paciente asistido, sino también al fortalecimiento del trabajo en equipo y de la Enfermería como ciencia aplicada. (AU)

Estudio clínico-epidemiológico sobre gangrena de Fournier en un hospital de Luanda. Enero de 2016 a diciembre de 2021

RESUMEN Fundamento: la gangrena de Fournier es una infección polimicrobiana grave ocasionada por microorganismos que actúan de modo sinérgico y determinan una fascitis necrosante progresiva en escroto y periné con manifestaciones de sepsis que pueden evolucionar a choque séptico y fallo de órganos. Objetivo: caracterizar clínica e epidemiológicamente la gangrena de Fournier en pacientes diagnosticados en una unidad hospitalaria de referencia. Métodos: estudio retrospectivo, observacional y descriptivo a partir del análisis de los expedientes clínicos de 64 pacientes masculinos con gangrena de Fournier, diagnosticados en el Hospital Militar Principal/Instituto Superior de Luanda, República de Angola de enero de 2016 a diciembre de 2020. Las variables de estudio fueron: edad, hábitos tóxicos, comorbilidad, manifestaciones clínicas, extensión, localización así como su evolución. Las variables cuantitativas fueron expresadas en medias, mediana y rango, mientras que las variables cualitativas se expresaron en términos de números absolutos y porcentajes. Resultados la edad promedio fue 45,09 años; 36 pacientes (56,2 %) consumen bebidas alcohólicas y 14 (21,87 %) declararon hábitos tabáquicos. La principal comorbilidad fue la diabetes mellitus en 21(32,8 %). El dolor con aumento de volumen del escroto predominó en 43(67,2 %) sujetos; el desbridamiento quirúrgico precoz con antibióticoterapia fue la clave de manejo. Fallecieron cinco pacientes. Conclusiones: la gangrena de Fourner es una enfermedad grave que puede presentar repercusión sistémica y muerte. La piedra angular en el tratamiento es el desbridamiento quirúrgico precoz apoyado en medidas de soporte. La serie presentada mostró un manejo multidisciplinario adecuado y eficaz.

ABSTRACT Background: Fournier's gangrene is a serious polymicrobial infection caused by microorganisms that act synergistically and determine a progressive necrotizing fasciitis in the scrotum and perineum with manifestations of sepsis that can progress to septic shock and organ failure. Objective: to characterize clinically and epidemiologically Fournier's gangrene in patients diagnosed in a reference hospital unit. Methods: retrospective, observational and descriptive study based on the analysis of the clinical records of 64 male patients with Fournier's gangrene, diagnosed at the Hospital Militar Principal/Instituto Superior de Luanda, Republic of Angola from January 2016 to December 2020. Study variables were: age, toxic habits, comorbidity, clinical manifestations, extension, location as well as its evolution. The quantitative variables were expressed as means, median and range, while the qualitative variables were expressed in terms of absolute numbers and percentages. Results: the average age was 45.09 years; 36 patients (56.2%) consume alcoholic drink and 14 (21.87%) declared smoking habits. The main comorbidity was diabetes mellitus in 21 (32.8%). Pain with increased scrotal volume predominated in 43 (67.2%) subjects; early surgical debridement with antibiotic therapy was the key to management. Five patients died. Conclusions: Fourner's gangrene is a serious disease that can present systemic repercussions and death. The cornerstone of treatment is early surgical debridement supported by support measures. The series presented showed adequate and effective multidisciplinary management.

Abdomen agudo por vesícula biliar duplicada y complicada

RESUMEN Introducción: Las malformaciones de la vía biliar son extremadamente infrecuentes y en muchas ocasiones son un hallazgo en el acto quirúrgico. Cuando se presenta, el cuadro clínico es similar al del paciente que tiene vesícula sin malformaciones congénitas. Objetivo: Describir un caso de abdomen agudo por duplicidad de vesícula biliar complicada. Caso clínico: Paciente de 46 años, antecedentes de dispepsias, que acudió al cuerpo de guardia con dolor abdominal agudo. Se diagnostica gangrena vesicular y se decide tratamiento quirúrgico. En el transoperatorio, se constató doble sistema vesicular, uno con zona de necrosis y el otro con cambios inflamatorios crónicos. Se realiza colecistectomía a ambos órganos. La evolución fue favorable. Conclusiones: La ocurrencia de un abdomen agudo en un paciente con duplicidad vesicular es infrecuente. Se presenta el caso pues contribuye a profundizar en el conocimiento sobre la conducta a seguir en esta enfermedad.

ABSTRACT Introduction: Bile duct malformations are extremely rare, and generally do not present complications that justify urgent surgical intervention. When it occurs, the clinical picture is similar to that of a patient with a gallbladder without congenital malformations. Objective: Describe a case of acute abdomen due to complicated gallbladder duplication. Clinical case: 46-year-old patient with a history of dyspepsia, who came the emergency with acute abdominal pain. Gallbladder gangrene is diagnosed, and surgical treatment is decided. During surgery, a double vesicular system was found, one area of ​​necrosis and the other with chronic inflammatory changes. Cholecystectomy is performed on both organs. The evolution was favorable. Conclusions: The occurrence of an acute abdomen in a patient with gallbladder duplication is infrequent. The case is presented that contributes to deepen the knowledge about the course of action in this disease.

Aplicação do ultrassom point of care e relevância da anatomia na fasciite necrosante / Application of point of care ultrasound and relevance of anatomy in necrotizing fasciitis

Introdução: O ultrassom tem sido utilizado na atualidade na medicina intensiva. A fasciite necrosante quando não diagnosticada e tratada rapidamente apresenta progressão rápida e alta mortalidade. O objetivo é apresentar a importância da anatomia na fasciite necrosante e o uso do ultrassom no diagnóstico precoce. Métodos: Apresentou-se a aplicação do ultrassom point of care e a relevância da anatomia na fasciite necrosante. Resultados: As comunicações anatômicas entre as fáscias das regiões escrotal, perineal, peniana e abdominal permitem a disseminação do processo infeccioso decorrente da gangrena de Fournier para as regiões adjacentes. O ultrassom possibilitou o diagnóstico precoce na fasciite necrosante. Conclusão: As comunicações entre as fáscias das regiões escrotal, perineal, peniana e abdominal contribuíram para a progressão do processo infeccioso decorrente da gangrena de Fournier e o ultrassom possibilitou o diagnóstico precoce.

Introduction: Ultrasound is currently being used in intensive care medicine. When not diagnosed and treated quickly, necrotizing fasciitis has a rapid progression and high mortality. The objective is to present the importance of anatomy in necrotizing fasciitis and the use of ultrasound in early diagnosis. Methods: The application of point-of-care ultrasound and the relevance of anatomy in necrotizing fasciitis were presented. Results: The anatomical communications between the fasciae of the scrotal, perineal, penile and abdominal regions allow the spread of the infectious process resulting from Fournier's gangrene to the adjacent regions. Ultrasound enabled early diagnosis of necrotizing fasciitis. Conclusion: Communications between the fasciae of the scrotal, perineal, scrotal, penis and abdominal regions contributes to the progression of the infectious process resulting from Fournier gangrene and ultrasound permitted earlier diagnose.

Experiencia y manejo de dos casos de gangrena de Fournier en pacientes pediátricos en el Instituto Nacional de Salud del Niño - San Borja / Experience and management of two cases of fournier's gangrene in pediatric patients at the Instituto Nacional de Salud del Niño - San Borja, Lima, Peru

RESUMEN La gangrena de Fournier es una patología que se encuentra predominantemente en varones adultos y extremadamente rara en niños. Se han descrito múltiples factores predisponentes en los niños, incluyendo la circuncisión, la dermatitis del pañal, la presencia de abscesos, traumatismos anorrectales y deficiencias inmunológicas. Los signos y síntomas característicos incluyen edema e hiperemia de rápida evolución en la región perineal acompañados de dolor intenso y fiebre. Una vez que se diagnostica la gangrena de Fournier, se debe instaurar tratamiento de forma inmediata, antibióticos endovenosos de amplio espectro y debridamiento quirúrgico temprano del tejido desvitalizado. A continuación presentamos un reporte de casos que incluye las características clínicas y epidemiológicas de dos pacientes pediátricos con gangrena de Fournier que recibieron tratamiento médico y quirúrgico en el Instituto Nacional de Salud del Niño de San Borja.

ABSTRACT Fournier's gangrene is a condition mainly found in adults and it very rarely occurs in children. Multiple predisposing factors have been identified for children, including circumcision, diaper dermatitis, the occurrence of abscesses, anorectal trauma, and immune deficiency. Characteristic signs and symptoms include rapidly progressing edema and hyperemia in the perineal region, accompanied by intense pain and fever. Once Fournier's gangrene is diagnosed, therapy must be immediately instituted, using wide spectrum intravenous antibiotics and early surgical debridement of devitalized tissues. We present a case report including clinical and epidemiological characteristics of two pediatric patients with Fournier's gangrene who received medical and surgical therapy at the Instituto Nacional de Salud del Niño in San Borja, Lima, Peru.

Perforación del recto por espina de pescado / Rectal perforation caused by a fish bone

RESUMEN La ingestión de cuerpos extraños (en su mayoría espinas de pescado y huesos de pollo) durante la alimentación es frecuente. En gran parte de los casos ocurre accidentalmente, de manera inadvertida, habitualmente silente, en personas alcohólicas, con enfermedad mental o que usan prótesis dental. Generalmente pasan a través del tubo digestivo sin causar daño, y son expulsadas cerca de los siete días después de la ingestión. En cambio, en algunos pacientes puede ocasionar oclusión o perforación del tubo digestivo. Entre las zonas más afectadas están: la región ileocecal y la rectosigmoidea, por su angulación. Se presenta un paciente de 54 años de edad, bebedor habitual y fumador, con perforación del recto por espina de pescado, la cual fue ingerida de forma inadvertida días anteriores. Se le realizó una transversostomía para descompresión; posteriormente desarrolló una gangrena de Fornier en la región genital, y se le realizó una necrectomía y orquiectomía derecha.

ABSTRACT Foreign body ingestion (mostly fish bones and chicken bones) during feeding is common. In most cases, it occurs accidentally, inadvertently, usually silently, in people who are alcoholics, mentally ill, or who wear dental prostheses. They generally pass through the digestive tract without causing damage, and are expelled about seven days after ingestion. On the other hand, in some patients it can cause occlusion or perforation of the digestive tract. The ileocecal and rectosigmoid regions are the most affected areas, due to their angulation. We present a 54-year-old male patient, a habitual drinker and smoker, with a rectal perforation caused by a fish bone, which was inadvertently ingested days before. A decompressing transversostomy was performed; later he developed Fornier's gangrene in the genital region, and a necrosectomy and right orchiectomy were performed.

Caracterización clínica de pacientes con gangrena de Fournier del Hospital General Docente "Dr. Agostinho Neto", 2008-2018 / Clinical characterization of patients with Fournier's gangrene at the Hospital General Docente "Dr. Agostinho Neto", 2008-2018 / Caracterização clínica de pacientes com gangrena de Fournier no Hospital Geral de Ensino "Dr. Agostinho Neto", 2008-2018

RESUMEN Introducción: La gangrena de Fournier se define como una forma específica de fascitis necrotizante Tipo I, que constituye una emergencia urológica, poco frecuente y de elevada mortalidad. Objetivo: Caracterizar la gangrena de Fournier en los pacientes atendidos en el servicio de Urología del Hospital General Docente "Dr. Agostinho Neto" en el periodo enero 2008 - diciembre 2018. Método: Se realizó un estudio descriptivo de variables demográficas y clínicas (edad, sexo, mortalidad, comorbilidad, causas desencadenantes, sitio primario de la infección, sitio de extensión de la infección, estadía hospitalaria) en 20 pacientes. La historia clínica fue la fuente de información primaria. Los datos fueron procesados mediante el programa estadístico SPSS versión 20.0, y se utilizó la estadística descriptiva para determinar las frecuencias absolutas y relativas (porcentajes) y media. Resultados: El 100 % correspondió a varones con un promedio de edad de 64,0 años (27-92); la mortalidad fue del 40 %. La diabetes mellitus fue la comorbilidad más frecuente en 10 pacientes (50,0 %), 12 (60,0 %) tenían más de un proceso comórbido. Las lesiones cutáneas constituyeron la causa primaria en 11 (55,0 %), y los escrotos fueron el principal sitio de origen de la infección en el 55,0 %. El promedio de estadía hospitalaria fue de 37,7 días (7-75 días). Conclusiones: La correcta evaluación de las variables demográficas y clínicas es necesaria para establecer un correcto diagnóstico y plan de tratamiento.

ABSTRACT Introduction: Fournier's gangrene is defined as a specific form of Type I necrotizing fasciitis, which constitutes a rare urological emergency with high mortality. Objective: To characterize Fournier's gangrene in patients treated in the Urology service of the Hospital General Docente "Dr. Agostinho Neto" in the period from January 2008 to December 2018. Method: A descriptive study of demographic and clinical variables (age, gender, mortality, comorbidity, triggering causes, primary site of infection, site of extension of the infection, hospital stay) was carried out in 20 patients. The medical history was the primary source of information. The data were processed using the statistical program SPSS, version 20.0, and descriptive statistics were used to determine the absolute and relative frequencies (percentages) and mean. Results: 100% corresponded to men with an average age of 64.0 years (27-92); mortality made a 40%. Diabetes mellitus was the most frequent comorbidity, in 10 of the patients (50.0%); 12 patients (60.0%) had more than one comorbid process. Skin lesions were the primary cause in 11 (55.0%), and the scrotum was the main site of origin of infection in 55.0%. The mean hospital stay was 37.7 days (7-75 days). Conclusions: The correct evaluation of the demographic and clinical variables is necessary to establish a correct diagnosis and treatment plan.

RESUMO Introdução: A gangrena de Fournier é definida como uma forma específica de fasceíte necrosante tipo I, que se constitui em uma rara emergência urológica com alta mortalidade. Objetivo: Caracterizar a gangrena de Fournier em pacientes atendidos no serviço de Urologia do Hospital Geral Universitário "Dr. Agostinho Neto" no período de janeiro de 2008 a dezembro de 2018. Método: Estudo descritivo de variáveis demográficas e clínicas (idade, sexo, mortalidade, comorbidade, causas desencadeantes, sítio primário de infecção, extensão do sítio de infecção, internação) em 20 pacientes. O histórico médico foi a principal fonte de informação. Os dados foram processados no programa estatístico SPSS versão 20.0, e a estatística descritiva foi utilizada para determinar as frequências absolutas e relativas (percentuais) e a média. Resultados: 100% corresponderam a homens com idade média de 64,0 anos (27-92); a mortalidade foi de 40%. Diabetes mellitus foi a comorbidade mais frequente em 10 pacientes (50,0%), 12 (60,0%) apresentaram mais de um processo comórbido. Lesões cutâneas foram a causa primária em 11 (55,0%), e o escroto foi o principal sítio de origem da infecção em 55,0%. O tempo médio de internação foi de 37,7 dias (7-75 dias). Conclusões: A correta avaliação das variáveis demográficas e clínicas é necessária para estabelecer um correto diagnóstico e plano de tratamento.

Flegmasía cerulea dolens. tratamiento con fibrinolisis sistémica / Phlegmasia cerulea dolens. Treatment with systemic fibrinolysis

Resumen La flegmasia cerulea dolens es una complicación rara y poco frecuente de la trombosis venos a profunda. Los principales factores predisponentes son los procesos neoformativos, estados de hiper coagulabilidad, insuficiencia cardíaca congestiva, embarazo, inmovilización prolongada y cirugías. Se caracteriza por edema masivo, dolor intenso y cianosis. Sin tratamiento evoluciona con isquemia, necrosis y amputación del miembro comprometido. No existe consenso en su tratamiento, pero éste debe ser rápido, multidisciplinario y agresivo. La anticoagulación con heparina, la fibrinólisis sistémica, la trombectomía percutánea con fibrinólisis local, la trombectomía quirúrgica, la fasciotomía, la colocación de filtro de vena cava inferior y la amputación son algunos de los tratamientos propuestos.

Abstract Phlegmasia cerulea dolens (FCD) is a rare complication of deep vein thrombosis. Its cause is unknown. The main predisposing factors for the disease are neoformative processes, hypercoagulable states, congestive heart failure, pregnancy, prolonged immobilization, and surgeries on the affected limb. FCD is characterized by massive edema, severe pain, and cyanosis. The diagnosis is clinical. It is associated in most cases with pulmonary embolism and can lead to loss of the compromised limb if not treated in time. So far there is no consensus on its treatment. In clinical practice the use of anticoagulation with heparin, local thrombolysis, systemic fibrinolysis, surgical thrombectomy, fasciotomy, and inferior vena cava filter are described. In irreversible cases amputation is required. We present the case of a patient with FCD, the treatment performed and the evolution.

Tratamiento quirúrgico de la gangrena de Fournier / Surgical management of Fournier's gangrene

Resumen Objetivo: Describir el manejo quirúrgico realizado para la reconstrucción genitoperineal (RGP) en pacientes con secuelas de Gangrena de Fournier (GF). Materiales y Método: Corresponde a una serie de casos retrospectiva de pacientes con secuelas de GF a los que se les realizó RGP entre los años 2011 y 2019. Se realizó un análisis descriptivo con las variables de técnica quirúrgica, edad, sexo, comorbilidades, subunidades anatómicas afectadas, origen anatómico de la gangrena de Fournier, número de procedimientos quirúrgicos, procedimiento de colostomía, terapia de presión negativa, Flexi-Seal®, bacterias aisladas, duración de estancia hospitalaria, tipo de procedimientos reconstructivos y complicaciones. Resultados: Se realizó RGP a 43 pacientes (81,1% hombres), con un promedio de edad de 59,1 (17-86 años), 72,7% eran diabéticos. El número de subunidades involucradas se asocia directamente y significativamente en relación al número de intervenciones quirúrgicas. Las técnicas utilizadas para la reconstrucción en orden de frecuencia fueron: colgajos (23%), cierre parcial más injerto dermoepidérmico de grosor parcial (IPP) (20%), cierre parcial (16%) e IPP (16%), cierre por segunda intención (10%), colgajo más IPP (7%) y cierre parcial para cierre por segunda intención de zona restante (5%). Discusión: La elección de reconstrucción se basa en las características del defecto, es decir, el tamaño, la ubicación y profundidad, así como la disponibilidad de tejido local. De preferencia optar por cierres primarios sin tensión, seguido de colgajos y de IPP. Conclusión: La RGP es un desafío para el cirujano plástico. Las técnicas descritas han demostrado ser seguras y reproducibles para el tratamiento quirúrgico de la gangrena de Fournier.

Aim: To describe the surgical management performed for genital-perineal reconstruction (GPR) in patients with sequelae of Fournier gangrene (FG). Materials and Method: It is based on a retroactive series of cases of patients with effects of FG who were given GPR between 2011 and 2019. We performed a descriptive analysis using the variables surgical technique, age, sex, comorbidities, anatomical subunits affected, anatomic origin of the Fournier's gangrene, number of surgical procedures, colostomy procedure, negative pressure therapy, Flexi-Seal®, bacteria isolated, hospital stay, type of reconstructive procedures and complications. We performed GPR on 43 patients (81.1% male), with a mean age of 59.1 (17-86 years); 72% were diabetic. The number of subunits involved was directly and significantly associated with the number of surgical interventions. Results: The reconstruction techniques most used were, in descending order: flaps (23.2%), wound closure and split-thickness skin graft (STSG) (23.2%), primary closure (16.2%), STSG (16.2%), secondary closure (9.3%), flap and STSG (6.9%) and partial wound closure for healing of the remaining area for a second intention (4.6%). Discussion: The reconstruction choice is based on the characteristics of the defect, that is, the size, location and depth, as well as the availability of local tissue. Preferably opt for primary closures without tension, followed by flaps and IPP. Conclusion: The RGP is a challenge for the plastic surgeon. The techniques described have proven safe and reproducible for the surgical treatment of Fournier Gangrene.

Gangrena de Fournier vulvar

La gangrena de Fournier es una enfermedad infecciosa rara y potencialmente fatal, caracterizada por fascitis necrótica rápidamente progresiva de la región genital, perineal y/o perianal. Afecta cualquier edad y género. La gangrena de Fournier vulvar tiene baja incidencia en las mujeres, pero tasa alta de mortalidad, debido a las diferencias en la anatomía genital femenina. La sospecha clínica es fundamental para el diagnóstico, debido a la baja frecuencia de presentación. El tratamiento debe ser agresivo, con administración rápida de antibióticos de amplio espectro y enfoque interdisciplinario temprano por parte de múltiples especialidades médicas. Por ello, es necesario comprender completamente la fisiopatología de la condición para aumentar la tasa de supervivencia del paciente. Se presenta un caso de gangrena de Fournier vulvar.

Fournier's gangrene is a rare and potentially fatal infectious disease characterized by rapidly progressive necrotic fasciitis of the genital, perineal and/or perianal region. It affects any age and gender. Vulvar Fournier's gangrene has a low incidence in women, but a high mortality rate, due to differences in female genital anatomy. Clinical suspicion is essential for diagnosis, due to the low frequency of presentation. Treatment should be aggressive, with prompt administration of broad-spectrum antibiotics and early interdisciplinary approach by multiple medical specialties. Thus, a complete understanding of the pathophysiology of the condition is necessary to increase the patient's survival rate. A case of vulvar Fournier's gangrene is presented.

Peritonitis aguda secundaria a cistitis gangrenosa posparto

La cistitis gangrenosa es una enfermedad infecciosa extremadamente rara. Su etiología es multifactorial y el principal factor precipitante es la sobredistensión de la vejiga debida a obstrucción. La afección vesical varía desde necrosis de mucosa y submucosa hasta necrosis de toda la pared, que puede ocasionar peritonitis aguda. El diagnóstico es difícil debido a su baja incidencia y a la sintomatología inespecífica, similar a la de otras afecciones infecciosas urinarias. Ello resulta en un diagnóstico tardío y mayor morbimortalidad. El manejo quirúrgico temprano y agresivo es fundamental para disminuir la frecuencia de complicaciones asociadas a esta condición. Se presenta un caso de peritonitis aguda secundaria a cistitis gangrenosa posparto.

Gangrenous cystitis is an extremely rare infectious disease. Its etiology is multifactorial and the main precipitating factor is overdistention of the bladder due to obstruction. Bladder involvement varies from mucosal and submucosal necrosis to necrosis of the entire wall, which can lead to acute peritonitis. Diagnosis is difficult due to its low incidence and nonspecific symptomatology, similar to that of other urinary infectious conditions, resulting in late diagnosis and increased morbidity and mortality. Early and aggressive surgical management is essential to reduce frequency of complications associated with this condition. A case of acute peritonitis secondary to postpartum gangrenous cystitis is presented.

Gangrenous mastitis in sheep caused by multidrug-resistant Staphylococcus haemolyticus / Mastite gangrenosa em ovinos causada por Staphylococcus haemolyticus multirresistente

Mastitis is a multifactorial disease and considered one of the most critical problems in the dairy industry worldwide. The condition is characterized by reduced milk and several abnormalities in the mammary gland. This study aimed to report an outbreak of gangrenous mastitis caused by multidrug-resistant Staphylococcus haemolyticus in a Santa Inês sheep herd. Eighteen sheep were affected, and five of them with severe clinical pictures were examined. The clinical and pathological picture were variable and characterized by apathy, anorexia, emaciation, opaque and brittle hair, apparent and congested episcleral vessels, and hyperthermia. These ewes had enlarged, firm, and painful mammary glands. Macroscopically, these lesions consisted of severe gangrenous mastitis, and microscopically, the primary lesions consisted of necrosis, thrombosis, and fibrosis of the mammary parenchyma. Milk samples from one of the five severely affected ewes were collected and cultured under aerobic or microaerophilic incubation at 37°C for 24 hours on sheep blood agar. The obtained colonies were then submitted to MALDI-TOF for speciation. The colonies were also submitted to an antimicrobial susceptibility test, genotyping of virulence factors and resistance genes were also performed. The isolates showed antimicrobial multiresistance since they were resistant to seven out of 13 tested antibiotics. The isolates were also positive for two staphylococcal enterotoxigenic genes (sec and see) and fibronectin-binding protein B (fnbB).(AU)

A mastite é uma doença multifatorial e é considerada um dos problemas mais importantes na indústria de laticínios no mundo todo. A condição é caracterizada pela redução de leite e várias anormalidades na glândula mamária. O objetivo deste estudo foi relatar um surto de mastite gangrenosa causada por Staphylococcus haemolyticus multirresistente em um rebanho ovino Santa Inês. Dezoito ovelhas foram afetadas e cinco delas com quadro clínico severo foram examinadas. O quadro clínico-patológico era variável quanto a severidade e consistia em apatia, anorexia, magreza, pelos opacos e quebradiços e vasos episclerais aparentes e ingurgitados. As ovelhas apresentavam glândulas aumentadas, firmes e dolorosas. Macroscopicamente, as principais lesões consistiam em mastite gangrenosa e microscopicamente havia necrose do parênquima glandular, trombose e fibrose. Amostras de leite de uma das cinco ovelhas severamente afetadas foram coletadas e cultivadas sob incubação aeróbica ou microaerofílica a 37°C por 24 horas em ágar sangue de ovelha. As colônias obtidas foram então submetidas ao MALDI-TOF para especiação. Além disso, as colônias foram submetidas a um teste de suscetibilidade antimicrobiana e foi realizada a genotipagem de fatores de virulência e genes de resistência. Os isolados apresentaram multirresistência antimicrobiana por serem resistentes a sete dos 13 antibióticos testados. Os isolados também foram positivos para dois genes enterotoxigênicos estafilocócicos (sec e see) e proteína B de ligação à fibronectina (fnbB).(AU)

Gangrena isquémica de miembro inferior en paciente con COVID-19 / Ischemic gangrene of low limb in patient with COVID-19

En diciembre de 2019 en la ciudad china de Wuham se reportaron los primeros casos de una nueva enfermedad asociada al SARS-Cov2, denominada COVID-19 y declarada como pandemia por la OMS, con alta letalidad en pacientes mayores de 60 años, que reportaban, en algunos casos, una predisposición a desarrollar microtrombosis y/o trombosis en el sistema arterial y venoso. Cuba presentó su primer caso en abril de 2020, con un comportamiento similar, por lo que nuestro sistema de salud aplicó medidas efectivas, así como puso en práctica el conocimiento acumulado por la comunidad científica. En este sentido, se presenta un caso de gangrena isquémica de miembro inferior en paciente con COVID-19, de interés científico. A la paciente de 42 años se le diagnosticaron COVID-19 y otras comorbilidades, así como un cuadro respiratorio agudo severo, asociado con un proceso de microtrombosis y lesiones de gangrena isquémica distal de los dedos del miembro inferior izquierdo, por la producción de microtrombosis relacionadas con excesiva inflamación, activación plaquetaria, disfunción endotelial y estasis. Según protocolos aplicados en Cuba, la paciente logró sobrevivir a dichas complicaciones. Este caso da a conocer una complicación no relatada en toda su magnitud hasta el momento, lo cual debe ser reportado y conocido como interés científico teórico-práctico de nuestros profesionales de la salud(AU)

In December, 2019 in the Chinese city of Wuhan were reported the first cases of a new disease associated to SARS-CoV-2, called COVID-19 and it was declared as a pandemic by WHO. This disease had high lethality in patients older than 60 years whom in some cases reported predisposition to develop microthrombosis and/or thrombosis in the arterial and venous system. Cuba presented its first case in April, 2020 with a similar behaviour, then our health system implemented effective measures and put into practice all the knowledge accumulated by the scientific community. In this sense, it is presented a scientific interest case of ischemic gangrene of low limb in a patient with COVID-19. The 42 years old female patient was diagnosed with COVID-19 and other comorbidities, as well as with a severe acute respiratory condition, associated to a microthrombosis process and lesions of distal ischemic grangrene of left low limb´s toes, due to the microthrombosis related with excesive inflammation, platelets activation, endothelial dysfunction and stasis. Thanks to the protocols applied in Cuba, the patient survived to those complications. This case shows a complication that is not fully described to the moment, something which must be reported and known as theoric-practical scientific interest of our health professionals(AU)

Fournier's gangrene by perianal abscess / Gangrena de Fournier por abscesso perianal

ABSTRACT Objective: To describe and analyze the cases of Fournier's Gangrene caused by perianal abscess treated in a tertiary hospital in western Paraná, correlating possible factors that influence mortality, with emphasis on late diagnosis and therapy. Methods: A retrospective and descriptive case series was carried out based on the analysis of medical records of patients with Fournier's Gangrene due to perianal abscess from January 2012 to December 2017. Results: Thirty-one patients with Fournier's Gangrene due to perianal abscess were treated in the period: 26 men and 5 women. Mean age was 53.51 ± 14.5 years. The most prevalent comorbidity in this group was type 2 diabetes mellitus, showing a strong correlation with mortality. The mean time from disease progression, from the initial symptom to the admission at the service, was 9.6 ± 6.81 days. All patients were submitted to antibiotic therapy and surgical treatment, with a mean of 3.25 ± 2.89 procedures/patient. Seven (22.58%) patients died and all of them showed signs of sepsis on admission; only 2 patients with sepsis did not die. Conclusion: The presence of sepsis on admission and type 2 diabetes mellitus were strongly correlated with mortality.

RESUMO Objetivo: Descrever e analisar os casos de gangrena de Fournier por abscesso perianal atendidos em hospital terciário do oeste do Paraná, correlacionando possíveis fatores que influenciem a mortalidade, com ênfase ao diagnóstico e terapêuticas tardias. Métodos: Realizou-se um estudo de série de casos, retrospectivo e descritivo baseado na análise de prontuários de pacientes portadores de gangrena de Fournier devido a abscesso perianal no período de Janeiro de 2012 à Dezembro de 2017. Resultados: Foram tratados 31 pacientes com gangrena de Fournier por abscesso perianal no período, sendo 26 homens e 5 mulheres. A média de idade foi de 53,51 ± 14,5 anos. A comorbidade de maior prevalência neste grupo foi diabete melitus tipo 2, demonstrando forte correlação com mortalidade. A média do tempo de evolução da doença, do sintoma inicial até entrada no serviço, foi de 9,6 ± 6,81 dias. Todos os pacientes foram submetidos à antibioticoterapia e tratamento cirúrgico com média de 3,25 ± 2,89 procedimentos/paciente. Sete (22,58%) pacientes evoluíram para óbito e todos estes apresentavam sinais de sepse na admissão; apenas 2 pacientes com sepse não evoluíram a óbito. Conclusão: Presença de sepse a admissão e diabete melitus tipo 2 foram fortemente correlacionadas com mortalidade.