Fournier's gangrene: evolution of representations about pathogenesis, current state diagnosis and treatment


Cite item

Full Text

Open Access Open Access
Restricted Access Access granted
Restricted Access Subscription or Fee Access

Abstract

The article is devoted to one of the rare forms of necrotizing fasciitis - Fournier’s gangrene (FG). In chronological order, key aspects related to epidemiology, etiology, pathogenesis, classification, clinic, diagnosis and treatment are highlighted, according to extensive literature. It is postulated that according to modern scientific provisions, Fournier gangrene is a private clinical model of critical conditions in surgery, which is characterized by progressive purulent-necrotic lesion and putrefactive decay of soft tissue and fascial structures and is accompanied by phenomena of systemic endotoxicosis (sepsis) and high mortality, varying from 35 to 76-86%. It is declared that the trigger pathogenetic mechanism of the development of FG is disseminated thrombosis of the microcirculatory bed of the superficial fascia of the scrotum due to intravascular invasion of various strains of causative microbes. The methods of clinical, laboratory and instrumental diagnostics and methods of treatment are described, taking into account modern achievements of evidence-based medicine. Based on a multifactorial analysis of literature data and their own experience, the authors stated that the cornerstone that completely affects the outcome of treatment and prognosis of the disease is a multidisciplinary approach to solving diagnostic and therapeutic and tactical tasks with the participation of doctors of related specialties (surgeon, resuscitator, radiologist, cardiologist, coloproctologist, urologist, microbiologist). It is shown that the unshakable priority of treating patients with FG is still urgent surgical intervention in the format of «aggressive surgery», which provides for extremely wide excision of necrotic and non-viable tissues, followed by programmed (stage-by-stage) rehabilitation necrectomy. The issues of laser irradiation and hydropressive wound treatment with ozonated saline solution are touched upon. Adjuvant wound treatment using vacuum therapy and hyperbaric oxygenation are given.

Full Text

Restricted Access

About the authors

S. A Aliyev

Azerbaijan Medical University

Email: sadayaliyev1948@mail.ru
MD, Professor of the Department of Surgical Diseases No. 1 Baku, Azerbaijan

E. S Aliev

Azerbaijan Medical University

Candidate of Medical Sciences Baku, Azerbaijan

References

  1. Maier S., Eskmann C. Fournier’s gangrene as special form of necrotizing fasciitis. Chirurg 2020; 91(4): 307-312. PMID: 31965200. https://doi.org/10.1007/s00104-19-01095-5.
  2. Muchuweti D., Muguti E., Mungazi S.G. Spontaneous closure of an extensive postdebridement perineal wound a newly diagnosed diabetic patient presenting with necrotizing fasciitis. Clin Case Rep. 2020;8(6): 1044-1047. PMID: 32577261. https://doi.org/10.1022/ccr3/2805
  3. Brum T., Rath E, Madsen M.B., Oppegaard O, Nekhludov M, Arnell P., Karlsson Y, Babbar A, Bergey F. et al. Risk factors and predictors of mortality in streptococcal necrotizing soft-tissue infections: a multicenter prospective study. Multicenter Study 2021; 72(2): 293-300. PMID: 31923305. https://doi.org/10.1093/cid/ciaa027
  4. Jones J. Surgical memoirs of the war of the rebellion: investigation upon the nature, causes and treatment of hospital gangrene as prevailed in the Confederate armies 1861-1865, US Sanitary Commission, New York. NY, USA.1871.
  5. Wilson B. Necrotizing fasciitis. Am. Surg. 1952;18:146.
  6. Fournier J.A. Gangrene foudroyante de la verge. Medicin Pratique 1883;4: 589-597.
  7. Baurienne H. Sur une plaie contuse qui s’est terminee par la sphacele de la scrotum. J. Med. Chir Pharm 1764; 20:251-256.
  8. Kranz J., Wagenlehner F.M.E., Steffens J., Hakenberg O.W., Schneidewind L. Contemporary practice patterns in the treatment of Fournier’s gangrene in German academic medicine and their implications for planning a registry study. Urologe A. 2021; 60(5): 610-616. PMID: 33559696. https://doi.org/10.1007/s00120-021-01461-4
  9. Grabinska A., Michalczyk L, Banaczyk B, Syrylo T, Zabkowsky T. Management protocol of Fournier’s gangrene in sanitary regime caused by SARS-Cov-2 pandemic-a case report. World Journal of Clinical Cases 2021:9(5):1215-1220. PMID: 33644187. https://doi.org/10.12998/wjcc.v9.15.1215.
  10. Temiz M. Fournier’s gangrene. Emerg Med. 2014;4(3): 1-2. https: //doi.org/10.4172/2165-7548.1000183.
  11. Short B. Fournier gangrene: an historical reappraisal.Intern Med J. 2018:48(9):1157-1160. https://doi.org/10.1111/imj.1430.
  12. Growell W, Roberts R, Tarry S. Fungal Fournier’s gangrene in an immunecompromised patients. Urol Case Rep 2016;4:1-3. PMlD: 26793562 https://doi.org/10.1016/j.eucr2015.09.009.
  13. Magdaleno-Tapial J., Valenzuela-Onate C, Martinez-Domenech A, Sancher-Carazo J.L., Perez-Feriols. A image gallery: Fournier gangrene in a patient with severe hidradenitis suppurativa. Br. J. Dermatol 2019;18(3):59. PMID: 31240692. https://doi.org/10.1111/bjd.18052
  14. Castillejo Becerra C.M., Jaeger Ch.D, Rose J.R., Beecroft N.J., Shah N.C., Posid T, Jenkins L.C., Baradaran N. Microorganisms and antibiogram patterns in Fournier’s gangrene: contemporary experience from a single tertiary care center [published online ahead of print, 2020 Jun 30]. 2020;204(6):1249-1255. PMID: 32602771. https://doi.org/10.1097/ju0000000000001194
  15. Ischida T, Shinozaki H, Ozawa H, Kobayashi T, Kato S., Wakabayashi T. et al. A case of Fournier’s gangrene caused by small intestinal perforation during bevacizumab combination chematotherapy. Gan To Kagaku Ryoho 2016;43(7):909-911. PMID: 27431640.
  16. Yoshino Y, Funahashi K, Okada R., Miura Y, Suzuki T, Koda T. et al. Severe Fournier’s gangrene in a patient with rectal cancer: case report and literatre review. World J. Surg. Oncol 2016;14(1):234. PMID: 27585438. https://doi.org/10.1186/s12957-016-0989-z
  17. George J., Haboubi H.N., Skinner P. Perforated rectal cancer presenting as Fournier’s gangrene in a confused older patient. Reports 2018:1(3)17. https://doi.org/10.3390/reports1030017
  18. Kobayashi D., Masubuchi M., Takase T., Ichikawa T., Deguchi T., Yaguchi T. Fournier’s gangrene caused by penetration of a rectal cancer followed by neoadjuvant chemotherapy. Surg. Case Rep. 2018;4(1):123. PMlD: 30259251. https://doi.org/10.1186/s40792-018-0526-0
  19. Hyun D.W., Lee B.C., Coi J.B., Park Y.M., Jung H.J., Jo H.J. Fournier’s gangrene in a rectal cancer patient.International Journal of Surgery Case Reports 2020;67:150-153. PMID: 32062122. https://doi.org/10.1016/j.ijscr2020.01.040
  20. Chernyadyev S.A.,Ufimtseva M.A., Vischnevskaya I.F., Bochkarev Y.M., Ushakov A.A., Beresneva T.A., Galimzyanov F.V., Khodakov V.V. Fournier’s gangrene: literature review and clinical cases. Urol.Int. 2018;101:91-97. https://doi.org/10.1159/000490108
  21. Del Zingaro M., Boni A., Rossi de Vernmandois J.A., Paladini A. Fournier’s gangrene and intravenous drug abuse: an unusual case report and review of the literature. Open Medicine (Wars) 2019;14(1):694-710. PMID: 31934634. https://doi.org/10.1515/med-2019-0114
  22. Mann A.J., Reinoso D.B., Gennit T., Limenez J. Fournier’s gangrene in the setting of underlying carcinoma: a case report and review of the literature. Cureus 2020;12:9:10317. PMID: 33052278. https://doi.org/10.7759/cureus.10317
  23. Emre A., Sertkaya M., Akbulut S., Duman Y., Kale I.T. Neglected Fournier’s gangrene caused by Acinebacter baumannii: a rare case report. Case Rep. Surg. 2016;2016:84:61354. PMID: 27725892. https://doi.org/10.1155/2016/8461354.
  24. Choi H., Kim Y.S., Na Ch.H., Shin B.S. Fournier’s gangrene: a rare complication of sweet’s syndrome. Ann Dermatol 2017;29(3):387-389. PMID: 28566930. https://doi.org/10.5021/ad2017.29.3.387
  25. Althunayyan S., Karamitosos E. Fournier’s gangrene in a obese female in third trimester of pregnancy. Saudi Med. 2018;39(4):415-418. PMID: 29619495. https://doi.org/10.15537/smj.2018.4.21780
  26. Ward L., Eisenson D., Fils J.L. Fournier’s gangrene of the penis in a 12-year-old patient secondary to phimosis. R.I.Med. J. 2016;99(12):45-46. PMID: 27903000.
  27. Zhang N., Yu X., Zhang K., Liu T. A retrospective case series of Fournier’s gangrene: necrotizing fasciitis in perineum and perineum and perineal region. BMC Surgery 2020;20:259. https://doi.org/10.1186/s1286-020-00916-3
  28. Ayanoglu B.T., Degertekin H., Gunduz O., GUrler A, Erdogan F.G., Ozis S.E. A rare case of yuvenile-outset Behget’s disase: Fournier’s gangrene followed by intestinal involvement. Annals of pediatric Surgery 2017;13:56-58. https://doi.org/10.1097/01.XPS.0000489158.014185
  29. Mostaghim A, Dhanani M., Ingalls R.R. Fournier’s gangrene as an initial manifestation of acute promyelocytic leukemia, a case report and review of the literature. SAGE Open Med Case Rep. 2019;1:7:2050313X19834425. PMID: 30854206. https://doi.org/10.1177/2050313X19834425
  30. Moussa M., Chakra M.A. Isolated penile Fournier’s gangrene: a case report and literature review.Int. J. Surg Case Rep. 2019;62:65-68. PMID: 31450216. https://doi.org/10.1016/j.ijscr2019.08.012
  31. Lutz Sh., Gerber D. Oral-sex-associated Fourniers gangrene following contact with commercial sex worker. Chest Journal 2020,158:4:806. https://doi.org/10.1016/j.chest.2020.08.806
  32. Paradimitriou G., Koukoulaki M., Vardas K., Grigorakis A, Vogas V., Drakopoulos S. Fournier’s gangrene due to perioperative iatrogenic colon perforation in a renal transplant recipient. Case Report 2015;26(6):1257-1261. PMID: 26586068. https://doi.org/10.4103/1319-2442/168665
  33. Coffee R.K., Setiawan K., Rosadi B.A., Lawanto T.R. Fournier’s gangrene in a 65 years old obese female with uncontrolled type 2 diabetes mellitus - a case report. JBN (Journal Bedah Nasional) 2020;4(1):1-6. PMID: https://doi.org/10.24843/JBN.2020.V04.101.P01.
  34. Provensano D., Lo Bianco S., Zanghi M., Campione A, Vecchio R., Zanghi G. Fournier’s gangrene as a rare complication in patient with uncontrolled type 2 diabetes treated with surgical debridement: a case report and literature review.International Journal of Surgery Case Reports 2021;79:462-465. PMID: 33767263. https://doi.org/10.1016/j.ijscr.2021.01.098.
  35. Goh T., Goh L.G., Ang C.H., Wong H. Early diagnosis of necrotizing fasciits. BJS. 2014;101(1):119-125. PMID: 24338771. https://doi.org/10.1002/bjs.9371.
  36. Ngugi P., Magoha G., Nyuga P. et al. Fournier’s gangrene in the HIV era. African Health Science 2014;14(4):1063-1068. PMID: 25834518 https://doi.org/10.4314/ahs.v14i4.38.
  37. Singer M., Deutschman C.S., Seymour C.W., Shankar-HariM., Annane D., Bauer M., Bellomo R., Bernard G.R. et al. The third International consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;35(8):801-810. PMID: 2690338. https://doi.org/10.1001/jama.2016.02.87.
  38. Rachana K., Biswas R., Bhat P., Sistla S., Kumar S., Kate V. Rare isolation of Fusobacterium from a case of Fournier’s gangrene. Anaerobe 2019;57:82-85. PMID: 30951829. https://doi.org/10.1016/j.anaerobe.2019.03.020
  39. Montrief T., Long B., Koytman A., Anerbach J. Fournier’s gangrene: a review for emergency clinicans. Clinical Reviews in emergency medicine. 2019;57(4):488- 500. PMID: 31472943. https://doi.org/10.1016/j.jemermed2019.06.023
  40. Sparenborg J.D., Brems J.A., Wood A.M., Hwang J.J., Venkatesan K. Fournier’s gangrene: a modern analysis of predictors of outcomes. Transl. Androl. Urol. 2019;8(4):374-378. PMID: 31555561. https://doi.org/10.21037/tau.2019.03.09
  41. Arora A., Rege S., Surpam S., Gothwal K., Norwade A. Predicting mortality in Fournier gangrene and validating the Fournier Gangrene Severity Index: our experience with 50 patients in a tertiary. Care Center in India. Urologia internationalis 2019;102(3):311-318. PMID: 30799427. https://doi.org/10.1159/000495144
  42. Hsiao C.T., Chang C.P., Huang T.Y., Chen Y.C., Fann W.C., Spratley J. Prospective validation of the laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for necrotizing fasciitis of the extremities. PloS One 2020;15(1):e 0227748. PMID: 31978094. https://doi.org/10.1371/journal.pone0227748
  43. Ballard D.H. Presence of deep fascial fluid in imaging necrotizing fasciitis: importance of this feature in diagnosing necrotizing fasciitis without imaging manifestations of soft tissue gas. Ultrasound Med. Biol. 2019; 45(11):3081. PMID: 31477369. https://doi.org/10.1016/j.ultrasmedbio.2019.08.004
  44. Ballard D.H, Mazheri P., Paptis C.A., Lubner M.G., Menias Ch.O., Pickharde P.J., Mellnick V.M. Fournier gangrene in men and women: appearance on CT, ultrasound, and MRI and what the surgeon wants to know. Canadian Association of Radiologists Journal 2020;7(1):30-39. PMID: 32063012. https://doi.org/10.1177/0846537119888396
  45. Misiakos E.P., Bagias G., Patapis P., Sotiropoulos D., Kanavidis P., Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014;1:36. PMID: 25593960. https://doi.org/10:3389/fsurg.2014.00036
  46. Takahashi W., Nakada T.-A., Yazaki M., Oda Sh.Interleukin-6 levels act as a diagnostic marker for infection and a prognostic marker in patients with organ dysfunction in inteusive care units. Shock. 2016;46(3);254--260. PMID: 27172160. https://doi.org/10.1097/SHK0000000000000616
  47. Zil-E-Ali A., Fayyaz M., Fatima Arooj, Ahmed Z. Diagnosing necrotizing fasciitis using procalcitonin and laboratory risk indicator: Brief Overview. Cureus 2018;10(16):2754. PMID: 30094111. https://doi.org/10.7759/cureus2754
  48. Wong C.H., Khin L.W., Heng K.S., Tan K-Ch., Low Ch-O. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004;32(7): 1535-1541. PMID: 15241098. https://doi.org/10.1097/01.CCM.0000129486.35458.7D.
  49. Laor E, Palmer L.S., Tolia B.M., Reid R.E., Winter H.I. Outcome prediction in patients with Fournier’s gangrene. J Urol. 1995;154(1):89-92. PMID: 77764 64. https: //doi.org/10.1016/s0022-5347(01)67236-7
  50. Konikovski O.E., Osadchyi A.V, Androsov S.I. et al. Therapeutic tactic in the deep forms of rectal abscess, complicated by Fournie gangrene. Wiadomosci Lekarskie 2020;73(2):293-297. PMID: 32248162. https://doi.org/10.36740/WLek202002116.
  51. Boughanmi F., Ennaceur F., Korbi I., Chaka A, Noomen F., Zonari Kh. Fournier’s gangrene: its management remains a challenge. Pan. African Medical Journal 2021;38:23. PMID: 33777291. https://doi.org/10.1164/pamj2021.38.2325863https://doi.org/10.1164/pamj2021.38.23
  52. Stevens D.L., Bisno A.L., Chambers H.F., Dellinger E.P., Goldstein E.J., Gorbach S.L. et al. Practice guidlines for the diagnosis and management of skin soft tissue in infections: 2014 Update by the infectious diseases society of America. Clin Infect Dis 2014;59(2): 10-52. PMID: 24973422. http://doi.org/10.1093/cid/ciu.444
  53. Hakkarainen T.W., Kopare N.M., Fellow B., Evans H.L. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg 2014;51(8):344-362. PMID: 25069713. https://doi.org/10.1067/j.cpsurg.2014.06.001
  54. Syllaios A., Davakis S., Karydakis L., Vailas M., Garmpis N., Mpaili E., Kyros E, Felekouras E, Papalampros A. Treatment of Fournier’s gangrene with vacuum-assisted closure therapy as enhanced recovery treatment modality. In vivo (Athens Greece) 2020;34(3);1499-1502. PMID: 32354953 https: //doi.org/10.2187/invivo.11936
  55. Iacovelli V., Cipriani Ch., Sandri M., Filippone R., Ferracci A, Micali S., Rocco B., Puliatti S. et al. The role of vacuum-assisted closure (VAC) therapy in the management of Fournier’s gangrene: a retrospective multi-institutional cohort study. World Journal of Urology 2021;39(1):121-128. PMID: 32236663. https://doi.org/10.1007/s00345-020-03170-7
  56. Thrane F.J., Ovesen Th. Scarce evidence of efficacy of hyperbaric oxygen therapy in necrotizing soft tissue infection: a systematic review. Infect Dis. 2019;51:485- 492. PMID: 30985236. https://doi.org/10.1080/23744235.2019.1597983
  57. Agwu N.P., Muhammad A.S., Abdullahi A.-A., Bashir B., Legbo J.N., Mungadi I.A. Pattern and outcome of management of Fournier’s gangrene in a resource-constrain setting. Urol. Ann. [serial online] 2020:12(3):248-253. PMID: 33100750. https://doi.org/10.4103/UA_62_19
  58. Eskitaycioglu T., Ozyazgan i, Coruh A, GUnay G.K., Altiparmak M., Yontar Y. et al. Experience of 80 case with Fournier’s gangrene and “trauma” as a trigger factor in the ethiopathogenesis. Ulus Trauma Acil Cerrahi Derg. 2014;20(4):265-274. PMID: 25135021. https://doi.org/10.5505/tjtes.2014.67670
  59. Louro J.M., Albano M., Baltazar J., Vaz M., Diogo S., Rmos S., Cabral L. Fournier’s gangrene: 10-year experience of a plastic surgery and burns department at a tertiary Hospital. Acta Med. Port 2019;321(5):368-374. PMID: 31166897. https://doi.org/10.20344/amp.11003
  60. Andresson A.E., Egerod I., Knudsen V.E., Fagerdahe A.-M. Singh, symptoms and diagnosis of necrotizing fasciitis experienced by survivorus and family: a qualitative nordic multi-center study. BMC Infect Dis 2018;18:429. PMID: 30153808. https://doi.org/10.1186/s12879-018-3355-7
  61. El-Qushayri A.E., Khalaf K.M., Dahy A, Mahmoud A.R., Benmelouka A.Y., Ghozy Sh., Mahmoud M.U. et al. Fournier’s gangrene mortality: A 17-year systematic review and meta-analysis.International Journal Infections Diseases 2020;92:218-225. PMID: 31962181. https://doi.org/10.1016/j.ijid.2019.12.030
  62. Auerbach J., Bornstein K., Ramzy M., Cabrera J., Montrief T., Long B. Fournier’s gangrene in the emergency department: diagnostic dilemmas, treatments and current perspectives. Open Access Emerg Med 2020; 12:353-364. PMID: 33204184. https://doi.org/10.2147/OAEM.S238699
  63. Radcliffe R.S., Khan M.A. Mortality associated with Fournier’s gangrene remains unchanged over 25 years. BJU.Int. 2020;125(4):610-616. PMID: 31975540. https://doi.org/10.1111/bju.14998
  64. Ozkan O.F., Koksal N., Altinli E, Celik A, Uzun M.A., Cikman O., Akbas A., Ergun E. et al. Fournier’s gangrene-current approaches.Int. Wound J. 2016;13(5):713-716. PMID: 25145578. https://doi.org/10.1111/iwj.12357
  65. Sheth H., Rao Sh.A., Venkataramani K. Contemporary nonsurgical approach for fecal diversion in a case of Fournier’s gangrene. BMJ. Case Rep. 2017; PMID: 29275388. https://doi.org/10.1136/bcr-2017-222282
  66. Алиев C.А., Алиев Э.С., Зейналов Б.М. Гангрена Фурнье в свете современных представлений. Хирургия Журнал им. Н.И. Пирогова, 2014;4:34-39
  67. Алиев С.А., Алиев Э.С., Мирзоев Р.А., Мирзоева К.А. Гангрена Фурнье - разновидность клинической модели критических состояний в хирургии. Вестник хирургии. 2015; 174( 1): 84-89

Supplementary files

Supplementary Files
Action
1. JATS XML
Download

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies