Gangrena de Fournier: revisión de factores determinantes de mortalidad / Mortality risk factors in Fournier gangrene: a literature review

La gangrena de Fournier es una fascitis necrosante polimicrobiana que afecta el periné, el escroto y/o el área perianal con una tasa de mortalidad actual del 20% al 40%. El objetivo de esta revisión es describir los factores pronósticos de mortalidad reportados en la literatura mundial, para lo cual se realizó la búsqueda de artículos indexados en Medline, utilizando los respectivos términos MeSH para la búsqueda, así como una búsqueda manual de las referencias encontradas en los artículos primarios. Se reportan diversos factores con significación estadística; sin embargo, el índice de Laor predomina como herramienta de mayor significación a la hora de determinar la mortalidad de los pacientes.

Fournier gangrene is a necrotizing fasciitis caused by facultative microorganisms that affects the perineal area, the scrotum or the perianal area. It has a 20% to 40% mortality. We performed a literature review to determine its determinants of mortality. Among all factors, the Laor index (which includes temperature, heart rate, respiratory rate, serum sodium, potassium and creatine, blood leukocyte count, packed red cell volume and bicarbonate) predominates as the best tool to assess mortality risk.

Síndrome de Fournier: Reconstrução de bolsa testicular com retalho fasciocutâneo de região interna de coxa / Fournier gangrene: Reconstruction of the scrotal sac with a fasciocutaneous flap from the internal thigh region

INTRODUÇÃO: A síndrome de Fournier é uma infecção multibacteriana de rápida progressão em região perineal. Seu tratamento inclui desbridamento, antibioticoterapia de amplo espectro e terapia com oxigênio em câmara hiperbárica. O desbridamento agressivo tipicamente resulta em perda da cobertura cutânea de toda bolsa escrotal, expondo ambos os testículos. No tratamento, é necessária a utilização de retalhos bem vascularizados para o reestabelecimento das funções. MÉTODO: Apresentamos a aplicação de um retalho fasciocutâneo, aproveitando a rica rede arterial da região interna da coxa para a reconstrução perineal, proposto por Ferreira et al., o qual permite o tratamento de amplos defeitos. CONCLUSÃO: O retalho descrito para reconstrução perineal é bastante versátil. Suas vantagens incluem a possibilidade de ser utilizado em diversas situações clínicas, baixo acometimento de gangrena na região doadora, reconstrução em único estágio e a espessura do retalho adequada para reconstrução desta região.

INTRODUCTION: Fournier gangrene is a rapidly progressing multi-bacterial infection in the perineal region. The treatment of this condition includes debridement, broad-spectrum antibiotic therapy, and oxygen therapy in a hyperbaric chamber. Aggressive debridement typically results in the loss of skin coverage of the entire scrotal sac, and the exposure of both testes. During treatment, it is essential to use well-vascularized flaps to ensure the recovery of function. METHOD: We describe the application of a fasciocutaneous flap-which takes advantage of the rich arterial network of the internal region of the thigh-in the perineal reconstruction method proposed by Ferreira et al. that allows for the treatment of large defects. CONCLUSION: The flap is quite versatile. Its advantages include its utility in various clinical situations, low risk of gangrene in the donor area, single-stage reconstruction, and adequate flap thickness for reconstruction.

Factores de riesgo para mortalidad en gangrena de Fournier / Mortality prognostic factors in Fournier gangrene

Background: Fournier gangrene corresponds to a necrotizing fasciitis that affects the genital and perianal region. It has a high mortality and a special score, FGSI (Fournier Gangrene Severity Index Score), which includes nine laboratory and clinical parameters was devised to evaluate its prognosis. Aim: To determine predictors of mortality among patients with Fournier gangrene. Material and Methods: Prospective study of 31 patients aged 58 +/- 13 years (25 males) with Fournier gangrene. The inclusion criteria was the presence of perianal inflammation with redness, pain swelling and appearance of a rapidly progressing necrosis with fever, tachycardia and leukocytosis. Results: Eight patients died. Length of hospital stay ranged from 1 to 187 days and the number of required surgical procedures ranged from 1 to 17. The FGSI score was 7.1 +/- 4. These three factors had a prognostic value for mortality. Conclusions: Among patients with Fournier gangrene, length of hospital stay, number of required surgical procedures and FGSI are predictive of mortality.

Introducción: La Gangrena de Fournier fue descrita por Fournier en 1883, es una fasceitis necrotizante que afecta la región perianal y genital. El objetivo del presente trabajo es analizar los factores de riesgo de mortalidad en pacientes portadores de Gangrena de Fournier y su relación con el score pronóstico FGSI (Fournier Gangrene Severity Index Score). Material y Método: Estudio prospectivo entre enero de 2000 y diciembre de 2007 en el Hospital Barros Luco Trudeau, que incluyó 31 pacientes con gangrena de Fournier, el 80 por ciento de sexo masculino y una edad promedio de 58,2 años. Se analizaron los factores de riesgo y se calculó el índice de gravedad. Se realizó el análisis estadístico univariado y multivariado de cada uno de los factores y del índice de gravedad. Resultados: En el análisis univariado y multivariado los días de hospitalización, que variaron entre 1 y 187 (p = 0,055), el número de cirugías entre 1 y 7 (p = 0,031) y el score de gravedad que estuvo entre 1 y 17 (p = 0,017), fueron los factores significativos como factores de riesgo de mortalidad. Conclusiones: La Gangrena de Fournier presenta una alta mortalidad. El número de días hospitalizados y el número de cirugías realizadas son factores de riesgo para mortalidad y el score de gravedad es una herramienta importante y simple para predecir el riesgo de mortalidad.

Experiencia en el manejo de la gangrena de fournier: Servico de Cirugía I / Experience in the management of fournier's gangrene: Servico de Cirugía I

Presentar la experiencia de nuestro servicio en el manejo de la gangrena de Fournier entre los años 1996 a 2006. Estudio retrospectivo y descriptivo. Se estudiaron a todos los pacientes ingresados por gangrena de Fournier en el Servicio de Cirugía Uno del Hospital Vargas de Caracas, entre enero de 1996 y diciembre 2006. Se estudiaron un total de 10 pacientes que habían presentado gangrena de Fournier, todos pertenecían al género masculino. El grupo etario más afectado fue el grupo entre 51 y 60 años con un 40 por ciento (cuatro casos). En cuanto al foco primario se observó con más frecuencia el de origen anorrectal con un 50 por (cinco casos). El número de limpiezas realizadas fue entre uno y cinco, con promedio de 2,7 limpiezas quirúrgicas por pacientes. Se realizaron colostomías derivativas al 80 por ciento de los pacientes, cistostomías al 30 por ciento, se manejo la vía urinaria al 70 por ciento con sonda de Foley, se realizaron injertos al 70 por ciento de los enfermos. No hubo decesos en esta serie de pacientes. La gangrena de Fournier debe ser diagnósticada en forma rápida, manejada en forma agresiva y con medidas de soporte que permitan un adecuado control metabólico e infeccioso.

Relation between the area affected by Fournier's gangrene and the type of reconstructive surgery used: a study with 80 patients

OBJECTIVE: To assess the affected skin area and the reconstructive techniques used in 80 patients affected by Fournier's gangrene. MATERIALS AND METHODS: Eighty patients ranging in age from 19 to 85 years (mean = 51) affected by Fournier's gangrene were studied. When admitted to the emergency room the patients were submitted to clinical and laboratory examinations to analyze the gravity of the case. All patients were submitted to an extensive debridement of the lesion, urinary derivation by cystostomy and colostomy whenever necessary. RESULTS: Only 13 patients (16.25 percent) died. From the 67 remaining patients, in 44 (65.6 percent) debridement was restricted to the scrotum, in 10 (14.9 percent) there has been scrotum and penile lesions and in 13 (19.3 percent) there has been a debridement of the scrotum and the perineal region. In 11 cases (16.4 percent) there was no need for reconstructive surgery with wound closing by second intention, in 16 cases (23.8 percent) reconstructive surgery was performed with mobilization of local skin, in 19 (28.3 percent) we have used skin grafts, 20 patients (29.8 percent) needed reconstructive surgery with the use of skin flaps and in 1 case (1.4 percent) there has been the use of skin flaps and grafts simultaneously. CONCLUSIONS: Fournier's gangrene is a serious pathology and should be treated aggressively with an extensive debridement of the area with necrosis. The use of precocious reconstructive surgery of the genitals present good results and tends to greatly reduce the length of hospital stay and improve the psychological conditions of these patients.

Fournier gangrene. Approaches to diagnosis and treatment

To investigate the factors associated with patients with Fournier's gangrene, and to clarify the effect of diabetes mellitus [DM] as a comorbid disease on morbidity and mortality of patients with Fournier's gangrene. Twenty-six Fournier's gangrene patients who were admitted to the Emergency Department of Ankara Numune Teaching and Research Hospital, Ankara, Turkey from 1997 to 2003 were examined retrospectively. The mean age of the patients was 52.8 years. There were 8 female [30.8%] and 18 male [69.2%] patients. The etiological causes were as follows: diseases of the perianal region, history of operations, trauma and injections. Major comorbid disease states were diabetes mellitus [DM] and hypertension. The lesions in Fournier's gangrene were most commonly located in the perineum and genital region. Female patients with diabetes mellitus had significantly unusual extensive involvement, especially abdominal wall involvement. The most frequently isolated pathogen was Escherichia coli, while staphylococcal infection was most commonly seen in the presence of DM. Colostomy was performed on 53.8% of the patients, and cystostomy on 7.6% of the patients. Average time of staying at the hospital was 25 days with a mortality rate of 34.6%. Patients with DM had high mortality rates and stayed longer at the hospital than the non-diabetic patients. In addition to early diagnosis, early and aggressive debridement and administration of multiple wide spectrum antibiotics chosen for the causative agent are the golden standard for decreasing the mortality and morbidity. Diabetes mellitus has been found to be an important factor to increase mortality rates of patients with Fournier's gangrene

Reconstrução peno-escrotal após Síndrome de Fournier / Penil scrotal reconstruction after Fournier’s Gangrene

A reconstrução do escroto, com adeqüada proteção dos testículos, representa um desafio após síndrome de Fournier. Os autores relatam o caso, de um paciente de 20 anos, apresentando lesão extensa acometendo escroto e pênis, devido a síndrome de Fournier. O tratamento do pênis consistiu de enxerto de pele, disposto de forma helicoidal, para evitar retrações. O escroto foi reconstruído utilizando-se um retalho fasciocutâneo de região supéro-medial da coxa, de pedículo inferior, 43 dias após o primeiro desbridamento. O resultado mostrou-se satisfatório, funcional e esteticamante, apesar do tratamento não estar finalizado.

Scrotal reconstruction with adequate protection of the testicles remains the challenge following Fournier’s gangrene. The author report on a 20-years-old man presented with an extensive defect of the scrotum and penile caused by Fournier’s gangrene. The penile coverage was gained by grafts helicoidally placed to avoid retractions. The scrotum was reconstructed using a fasciocutaneous supermedial thigh inferiored based flap, 43 days after the first debridement.The results were satisfactory both functionally and cosmetically, although the treatment is not complete.

Gangrena de Fournier: experiencia con 38 pacientes / Fourmier gangrene: experience with 38 patients

La enfermedad de Fournier (EF) es una infección fulminante extensa que suele abarcar genitales, perineo y pared abdominal. La finalidad de este artículo es exponer la experiencia de los autores con el tratamiento medicoquirúrgico de esta entidad durante un periodo de 20 meses. Ingresaron 38 pacientes portadores de EF en la unidad en que trabajan los autores. Se administró a todos un triple esquema de tratamiento con agentes antimicrobianos. Se sometieron a drenaje y desbridación de la región lesionada, y de manera subsecuente a curaciones exhaustivas y aplicación de miel no procesada. En algunas lesiones se efectuaron injertos una vez limpias, y otras se suturaron de manera tardía. Los límites de edad variaron entre 33 y 86 años (media de 54 años) con estancia hospitalaria de 1 a 45 días (media 17 días). De estos pacientes, 25 (65 por ciento padecían diabetes mellitus, 11 (15 por ciento) habían experimentado orquiepididimitis reciente, y solamente dos (5 por ciento) tenían como origen traumatismo escrotal y uretral. A todos se les efectuaron drenajes y desbridación quirúrgica, y se les aplicó miel no procesada una vez desbridadas y limpias sus lesiones. A 25 de los pacientes (65.7 por ciento se les realizó cistostomía, y en 8 (21 por ciento) se efectuó una orquiectomía del lado afectado. A cinco pacientes (13 por ciento) se les aplicaron injertos libres de dermis de muslo. Los restantes se suturaron de manera tardía. Un paciente (2.6 por ciento falleció por sepsis generalizada y descontrol metabólico. El manejo de esta entidad continúa siendo agresivo ya que estos pacientes necesitan desbridación, cistostomía y/o colostomía, curaciones exaustivas, antimicrobianos en triple esquema y aplicaciones de miel no procesada y en algunos casos aplicación de injertos cutáneos libres

Gangrena de Fournier: relato de um caso / Fournier's gangrene

A grangrena de Fournier é uma urgência urológica rara e grave. É uma infecçäo necrótica do pênis e/ou escroto que pode se estender a parede abdominal. Foi descrita em l883 por A. J. Fournier, um médico francês, e estudada, mais tarde, por Milliam (l9l7) e Nativelle (l930). Esta patologia pode ocorrer em todas as idades, entretanto é mais freqüente entre homens idosos. Há muitos fatores predisponentes, por exemplo, parafimose, cirurgia recente, diabetes, traumas e infecçäo local. Os autores reconhecem a importância desta doença e acrescentam mais um caso à literatura