Fascitis necrosante como causa de muerte en trauma de recto. Reporte de caso / Necrotizing fasciitis as a cause of death in rectal trauma. Case report

Introducción. La perforación del recto por trauma cerrado es poco frecuente y se asocia a fracturas pélvicas. En pacientes con perforaciones de recto no traumáticas se ha reportado fascitis necrosante en miembros inferiores, en la mayoría de los casos asociada a alta mortalidad. Caso clínico. Hombre de 36 años con trauma cerrado abdomino-pélvico y perforación de recto inferior, quien recibió manejo quirúrgico mediante derivación intestinal y fijación pélvica. Evolucionó con hematoma escrotal sobreinfectado, inestabilidad hemodinámica, signos de fascitis necrosante y choque séptico 4 días posterior a su ingreso. Resultados. Se tomó muestra para cultivo del hematoma escrotal que reportó E. coli. La patología del desbridamiento escrotal informó necrosis de coagulación en toda la muestra. Conclusión. El tacto rectal debe realizarse siempre ante la presencia de enfisema subcutáneo al examen físico o en la tomografía, para un diagnóstico temprano y manejo quirúrgico multidisciplinario oportuno, según el caso. La presencia de enfisema subcutáneo debe aumentar la sospecha de perforación de recto. Hay pocos reportes de fascitis secundaria a perforación de recto por trauma cerrado, por lo que no se conoce con precisión la mortalidad asociada.

Introduction. Rectal perforation due to blunt trauma is rare and associated with pelvic fractures. Signs of necrotizing fasciitis in lower limbs have been reported in non-traumatic rectal perforations, in most cases associated with high mortality. Case report. A 36-year-old man presents blunt abdomino-pelvic trauma and perforation of the lower rectum. Surgical management by intestinal diversion and pelvic fixation is performed. 4 days after admission, evolves with over-infected scrotal hematoma, hemodynamic instability, signs of necrotizing fasciitis and septic shock. Results. A sample for culture was taken from a scrotal hematoma that reported E. coli. Pathology of scrotal debridement reported coagulation necrosis in the entire specimen. Discussion. Digital rectal examination should always be performed in the presence of subcutaneous emphysema on physical examination or CT scan for early and multidisciplinary diagnosis and surgical management as appropriate. Conclusion. The presence of subcutaneous emphysema should raise the suspicion of rectal perforation. There are few reports of rectal perforation due to blunt trauma and fasciitis, so the associated mortality is not precisely known.

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.

The role of hyperbaric oxygen therapy in Fournier's Gangrene: A systematic review and meta-analysis of observational studies

ABSTRACT Purpose: Management of Fournier's Gangrene (FG) includes broad-spectrum antibiotics with adequate surgical debridement, which should be performed within the first 24 hours of onset. However, this treatment may cause significant loss of tissue and may delay healing with the presence of ischemia. Hyperbaric oxygen therapy (HBOT) has been proposed as adjunctive therapy to assist the healing process. However, its benefit is still debatable. Therefore, this systematic review and meta-analysis aimed to evaluate the effect of HBOT as an adjunct therapy for FG. Materials and Methods: This study complied with the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol to obtain studies investigating the effect of HBOT on patients with FG. The search is systematically carried out on different databases such as MEDLINE, Embase, and Scopus based on population, intervention, control, and outcomes criteria. A total of 10 articles were retrieved for qualitative and quantitative analysis. Results: There was a significant difference in mortality as patients with FG who received HBOT had a lower number of deaths compared to patients who received conventional therapy (Odds Ratio 0.29; 95% CI 0.12 - 0.69; p = 0.005). However, the mean length of stay with Mean Difference (MD) of -0.18 (95% CI: -7.68 - 7.33; p=0.96) and the number of debridement procedures (MD 1.33; 95% CI: -0.58 - 3.23; p=0.17) were not significantly different. Conclusion: HBOT can be used as an adjunct therapy to prevent an increased risk of mortality in patients with FG.

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.

Shock séptico secundario a fascitis necrotizante abdominal tras drenaje de absceso interesfintérico perianal / Septic shock secondary to abdominal necrotizing fascitis after drainage of perianal intersphyteric abscess

Resumen Objetivo: El objetivo de este manuscrito es presentar el caso de un varón de 41 años que debuta con shock séptico y fascitis necrotizante abdominal en el posoperatorio del desbridamiento de un absceso perianal para focalizar la atención del lector en la posible evolución clínica hacia gangrena de Fournier. Materiales y Método: Tras la intervención, el paciente refiere aumento de temperatura y sensación de crepitación subcutánea a nivel abdominal, junto con empeoramiento clínico y hemodinámico, evidenciándose evolución tórpida hacia gangrena de Fournier extendida a región abdominal. Resultados: Tras la reintervención, el paciente presentó una evolución favorable aunque requirió sucesivas curas y desbridamientos quirúrgicos. Conclusiones y Discusión: Cabe destacar la importancia de una exploración clínica completa y detallada previa a cualquier intervención quirúrgica, así como el diagnóstico temprano en situaciones de shock séptico que permitan inicio de antibioterapia precoz y control del foco eficaz.

Aim: The objective of this manuscript is to present the case of a 41-year-old man with septic shock and abdominal necrotizing fasciitis after drainage of an interesphinteric perianal abscess to focus the reader's attention on the possible clinical evolution towards Fournier's gangrene. Materials and Method: After the intervention, the patient reported an increase in temperature and a sensation of subcutaneous crepitus at the abdominal level, with clinical and hemodynamic worsening, showing a torpid evolution towards Fournier's gangrene extended to the abdominal area. Results: After the reoperation, the patient presented a favorable evolution, although he required successive cures and surgical debridements. Conclusions and Discussion: It is worth highlighting the importance of a complete and detailed clinical examination prior to any surgical intervention, as well as the early diagnosis in situations of septic shock that allow early initiation of antibiotic therapy and effective control of the focus.

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.

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.

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.

Infective characteristics of Fournier gangrene and evaluation of effect of negative pressure wound therapy / 中华创伤杂志

Objective:To summarize the infective characteristics of Fournier's gangrene (FG) and evaluate the effect of negative pressure wound therapy (NPWT).Methods:A retrospective case control study was conducted to analyze the clinical data of 31 patients with FG admitted to Peking University First Hospital from May 2010 to September 2020, including 29 males and 2 females, aged 21-78 years [(55.2±2.0)years]. A total of 29 patients were caused by infectious diseases of the perianal and urinary system, and the rest two patients were caused by vulvar infection and retroperitoneal abscess. A total of 23 patients were treated with NPWT (Group A) and 8 patients were treated with conventional dressing (Group B). Characteristics of pathogen, drug-resistance rate, medical treatment and prognosis for all patients were summarized. The hospitalization duration, numbers of operation and wound healing time were compared between two groups.Results:Monomicrobial infection was identified in 14 patients, while polymicrobial infection in 15 patients, fungal infection in 1 and culture-negative in 1. Escherichia coli, Enterococcus faecalis, Enterococcus faecium, Klebsiella pneumoniae and Staphylococcus haemolyticus were the most common pathogenic bacteria. The resistance rate of gram-negative bacilli to third-generation cephalosporins was 37%. Staphylococcus haemolyticus were methicillin-resistant Staphylococcus. The carbapenem antibiotics combined with vancomycin antibiotics were used for all patients as the empirical anti-infection treatment. Three patients died, and the rest 28 patients were followed up for 3 to 12 months [(10.8±2.6)months] after discharge. All the wounds were healed well without recurrence. In Group A and Group B, the hospitalization duration was (37.4±15.0)days and (47.0±16.0)days, respectively ( P>0.05); the number of operation was 3(3, 6) times and 13(4, 17)times, respectively ( P<0.05); the wound healing time was (38.9±17.8)days and (61.8±14.2)days, respectively ( P<0.05). Conclusions:Enterobacteriaceae, Enterococcus and Staphylococcus haemolyticus are the most common pathogenic bacteria for FG, among which the proportion of drug-resistant bacteria is relatively high. NPWT is an effective adjuvant therapy for wound management with reduced operation times and short wound healing time compared to conrentional method.

Risk factors and interventions: Fournier gangrene in a tertiary hospital: A 10-year experience

@#<p style="text-align: justify;"><strong>Objective.</strong> The study aimed to describe the patient demographic characteristics, clinical factors, surgical interventions, and quality of care parameters in non-survivors and survivors of Fournier's gangrene (FG).</p><p style="text-align: justify;"><strong>Methods.</strong> A total of 131 cases of Fournier's gangrene (FG) were included in a retrospective chart review in the Philippine General Hospital over 10 years using the Department of Surgery research database. We collected data for various direct and derived variables from the identified population. The primary outcome was mortality rate, while other factors studied were genital and colorectal manipulation, bowel diversion, laboratory parameters (white blood cell count, creatinine, hemoglobin).</p><p style="text-align: justify;"><strong>Results.</strong> The mortality rate was 15%. Diabetes mellitus was common comorbidity among patients with Fournier's disease. The following were statistically more common in the non-survivor group: female sex, concomitant bowel diversion surgery. Admission data in the non-survivor group showed a lower serum hemoglobin, a higher serum creatinine, and an increased percentage of patients with an abnormal white blood cell count; these did not statistically differ between cohorts, however. The median time to first antibiotic infusion was six hours. The median time to surgery was 13 hours.</p><p style="text-align: justify;"><strong>Conclusions.</strong> Among patients with Fournier's gangrene, the proportion of women and those undergoing bowel diversion was higher in those who did not survive. The time of infusion of antibiotics or time to surgery did not differ significantly between survivors and non-survivors.</p>

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.

Gangrena de Fournier. Reporte de caso / Fournier's Gangrene. A Case Report

Resumen La gangrena de Fournier es una fascitis necrotizante tipo II que produce trombosis de los pequeños vasos subcutáneos, lo que genera que se propague a través de la piel del periné, área perianal y región genital. La mayoría de los casos tienen un foco perianal o colorectal en la mayoría de los casos y en una menor proporción se origina del tracto urogenital. La tasa de mortalidad varía entre el 7.8 y 50%1-3, únicamente el diagnóstico oportuno disminuye la morbilidad y mortalidad de este padecimiento. El tratamiento incluye desbridamiento quirúrgico de todo el tejido necrótico y el uso de antibióticos de amplio espectro.

Abstract Fournier's Gangrene is a type II necrotizing fascitis that leads to thrombosis of small subcutaneous vessels and spreads through the perianal and genital regions and the skin of the perineal. Most cases have a perianal or colorectal focus and in a smaller proportion it originates from the urogenital tract. The mortality rate varies between 7.8 and 50%1-3, only timely diagnosis decreases the morbidity and mortality of this condition. Treatment includes surgical debridement of all necrotic tissue and the use of broad-spectrum antibiotics.