Fournier’s gangrene: our experience with 50 patients and analysis of factors affecting mortality
© Benjelloun et al.; licensee BioMed Central Ltd. 2013
Received: 29 January 2013
Accepted: 19 March 2013
Published: 1 April 2013
Fournier’s gangrene is a rare, rapidly progressive, necrotizing fasciitis of the external genitalia and perineum. Case series have shown a mortality rate of 20% to 40% with an incidence of as high as 88% in some reports. In this study we aimed to share our experience in the management of Fournier’s gangrene and to identify risk factors that affect mortality.
The medical records of 50 patients with Fournier’s gangrene who presented at the University Hospital Hassan II of Fez from January 2003 to December 2009 were reviewed retrospectively to analyze the outcome and identify the risk factors and prognostic indicators of mortality.
Ten males and five females were enrolled in the study. The mean age was 54 years (range 23–81). The most common predisposing factor was diabetes mellitus (34%). E. coli was the most frequent bacterial organisms cultured. All patients were treated with a common approach of resuscitation, broad-spectrum antibiotics, and wide surgical excision. The mortality rate was 24%. The advanced age, renal failure on admission, extension of infection to the abdominal wall, occurrence of septic shock and need for postoperative mechanical ventilation are the main prognostic factors of mortality. In multivariate analysis, none of these variables is an independent predictor of mortality.
Fournier’s gangrene is still a very severe disease with high mortality rates. Early recognition of infection associated with invasive and aggressive treatment is essential for attempting to reduce these prognostic indices.
Fournier’s gangrene (FG) is a rare, rapidly progressive, fulminant form of necrotizing fasciitis of the genital, perianal and perineal regions, which may extend up to the abdominal wall between the fascial planes . It is secondary to polymicrobial infection by aerobic and anaerobic bacteria with a synergistic action [2–4]. The cause of infection is identifiable in 95% of cases, mainly arising from anorectal, genito-urinary and cutaneous sources . Predisposing factors such as diabetes and Immunosuppression lead to vascular disease and suppressed immunity that increase susceptibility to polymicrobial Infection. Diagnosis is based on clinical signs and physical examination. Radiological methods may help to delineate the extent of the disease but false negatives may happen. Dissemination of the disease was found to be a major determinant of patients’ outcomes in previous reports [6, 7]. It may reflect the aggressiveness of the involved infectious agents or reflects the degree of patients’ immunosuppression. Several reports tried to evaluate the usefulness of diverse scoring systems. Fournier’s Gangrene Severity Index (FGSI) has become a standard for researchers, being routinely published in FG literature and is considered as a good predicting tool [8, 9]. The mortality rate for FG is still high, at 20–50% in most contemporary series [10, 11]. Fortunately, it is a rare condition, with a reported incidence of 1.6/100,000 males with peak incidence in the 5th and 6th decades. However, the incidence is rising, most likely due to an increase in the mean age of the population, as well as increased numbers of patients on immunosuppressive therapy or suffering from human immunodeficiency virus (HIV) infection, especially in Africa [12, 13]. Early diagnosis, aggressive resuscitation of the patient, administration of broad-spectrum antibiotics and aggressive radical surgical debridement(s), are the key of successful treatment. In this study, we aimed to investigate patients with FG and to identify risk factors that affect mortality.
Materials and methods
The medical records of 50 consecutive patients admitted to the University Hospital Hassan II of Fez, Morocco, General Surgery Department, with a diagnosis of Fournier’s gangrene during the 7-year period between January 2003 and December 2009 were retrospectively reviewed. The inclusion criteria included patients undergoing wide surgical excision of scrotal and/or perineal necrosis along with other involved areas with a postoperative diagnosis of Fournier’s gangrene. Excluded were patients who had a local superficial inflammation of the perianal or urogenital regions as they were treated in Urology Department. Mortality was defined as disease-related death during the hospital stay and survival was measured in days. The prognostic variables used in the outcome analysis were the patient’s age, female gender, history of diabetes, the interval between the onset of symptoms and the initial debridement, renal failure, need for postoperative mechanical ventilation and occurrence of septic shock. Statistical analysis was performed using SPSS® 10.0 for Windows®. Mortality was accepted as disease-related death during the hospitalization period. The correlation of prognostic variables and mortality were studied by univariate analysis using chi-squared test and Fisher’s exact probability test. Statistically significant variables were entered into multivariate regression analysis using logistic regression. P values were reported as the result of two-tailed testing and P values less than 0.05 were considered as statistically significant. The study was performed according to the declaration of Helsinki and approved by the Local Ethical Committee.
Etiology in 50 patients with Fournier’s gangrene
Strangulated inguinal hernia
Impact of diabetes on the outcome variables in patients with Fournier’s gangrene
Diabetic patients n =17
Non-diabetic patients n =33
Number of debridements (median values)
Length of hospital stay (median values)
The most common symptoms at the time of admission were deterioration of the generally state (44%), perineal necrosis (92%), fever (60%), perineal or genital pain (76%), septic shock (22%). the average time of symptoms prior to referral to treatment was 11 days, ranging from 4 to 25 days.
Computer Tomography of the pelvis was performed in only 2 patients (4%).
Regarding the exams performed on admission, complete blood count showed the presence of a hyperleukocytosis (> 10.000/mm3) in 39 patients (78%). The degree of anemia was severe necessitating blood transfusion in 9 patients (18%). Renal failure on admission (blood urea >0.5 g/l) was higher among the patients who died when compared to the survival group (p < 0.001).
As for the location and extent of the injury, it was observed that FG was confined to the perineal area in 5 patients (10%), affecting the scrotum in 35 (70%) individuals. The gangrene extended to the abdominal wall in 9 patients (18%) and thorax in 1 patient (2%). It was found that the extension of the infection to the abdominal wall was a predictor of mortality (p < 0.003 ) (50% in the non survivors compared to 7% in the survivors). The most frequent bacterial organisms cultured from the wound sites were Escherichia coli (85.6%) and Klebsiella (40.5%). Before surgery, all patients underwent aggressive fluid resuscitation and were treated mostly with parenteral broad-spectrum triple antimicrobial agents, using a third-generation cephalosporin, an amino glycoside and metronidazole and received hemodynamic support when required. Mechanical ventilation, continuous monitoring, and inotropic support were applied when necessary in patients with cardiopulmonary failure due to sepsis. All patients underwent radical surgical debridement, ranging from 1 to 10 procedures, with an average of 2.5. Debridement consisted of excision of all necrotic tissue, cleansing with hydrogen peroxide, then saline and drainage. Along with the initial radical debridement, 5 patients (10%) underwent fecal diversion, with loop colostomy. Orchidectomy was carried out unilaterally for gangrenous testes in one patient (2%). It’s interesting to notice that mortality rate was 52.63% in the single-debridement group and 66.66% in repeated debridements; however, these rates were not significantly different (p = 0.08). Mechanical ventilation, due to sepsis was applied in 11 patients (22%). It was significantly higher in non survivor patients (91.6%) comparing to the survivors (0%) (p < 0.001). Patients had a median hospital stay of 21 (range, 4–66) days. The median hospitalization time (MHT) for the surviving patients was 26.00 days compared to 8.00 days for the non-survivors (P < 0.001).
Comparison of the patients’ characteristics between survivors and non-survivors
Survivors n = 38
Non-survivors n = 12
Age (years, mean ± SD)
44.36 ± 16.05
57.5 ± 19.24
Duration of symptoms (days, median values)
Presence of Diabetes Mellitus
Extension of the infection to the abdominal wall
Number of debridements (median values)
Need of Mechanical ventilation
Fournier’s gangrene is still a very severe disease with a high mortality rate. The advanced age, renal failure on admission, extension of infection to the abdominal wall, occurrence of septic shock and need for postoperative mechanical ventilation are the main prognostic factors of mortality. Early recognition of infection associated with invasive and aggressive treatment is essential for attempting to reduce these prognostic indices.
We would like to thank Dr. Awad Jarar (Colorectal surgery. Cleveland Clinic. OHIO. USA) for his critical revision and help to finalize this work.
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