Outcome of Reconstructive Procedures in Fournier's Gangrene

Original Article
OUTCOME OF RECONSTRUCTIVE PROCEDURES
IN FOURNIER’S GANGRENE
MAHESH KUMAR, ABDUL RAZAQUE SHAIKH*, ABDUL RAZAK MEMON,
BILAL FAZAL SHAIKH
Dept. of Plastic & Reconstructive Surgery, Liaquat University of Medical & Health Sciences, Jamshoro, Hyderabad
Dept. of Surgery, Liaquat University of Medical & Health Sciences, Jamshoro, Hyderabad*
ABSTRACT
Objective: To determine the outcome of the reconstructive procedures utilized for the genital area wound following
Fournier’s gangrene and their complications.
Design & Duration: Interventional study from January 2004 to December 2006.
Setting: Dept. of Surgery and Dept. of Plastic & Reconstructive Surgery at Liaquat University Hospital, Jamshoro.
Patients: A total of 18 patients with Fournier’s gangrene.
Methodology: Data was collected through a pre-designed proforma. Initially all the patients were managed in the
Surgical ward and later on they were shifted to the Plastic Surgery & Reconstructive ward for further management.
Results: Split thickness skin graft (SSG) was carried out in 12 cases (66.66%), followed by primary closure in six
(33.33%) and medial thigh flaps two (11.11%) cases. Partial skin loss was seen in six (33.33%) and complete loss
in one (5.55%) patient. Diabetes mellitus was the commonest co-morbidity found with Fournier’s gangrene.
Conclusion: Skin grafting is an easy option with acceptable aesthetic and functional results. Primary closure of the
scrotal wound by stretching and expanding is ideal when upto 1/3rd of the residual scrotal skin is available.
KEY WORDS: Fournier’s Gangrene, Reconstruction, Split Thickness Skin Graft, Thigh Flaps
INTRODUCTION
Fournier’s gangrene was first described in 1883 by Jean
Alford Fournier. It is a potentially fatal and very rapidly
progressing synergistic polymicrobial infection of the
genitals and perineum that may extend to the anterior
abdominal wall. 1,2 This mixture of aerobic and anaerobic
organisms may result from urological intervention and
anorectal injury. 3
Clinical presentations vary from pain at perineal region
with minimum evidence of cutaneous necrosis to a rapidly
spreading necrosis of skin and soft tissue, even
to sepsis without any apparent source of infection. 4
Predisposing factors are diabetes mellitus, local trauma,
Correspondence:
Prof. Abdul Razaque Shaikh, Prof. of Surgery,
Flat No. 208, Tayyab Medical, Sadar, Hyderabad.
Phones: 0333-2608753.
117
paraphimosis, periurethral extravasation of urine, perirectal
and perianal infections, and surgeries like circumcision
and herniorrhaphy. 1
The treatment of the disease includes wide excision of
devitalized tissue and multiple debridements with broad
spectrum antibiotics 5 followed by proper dresssings.
Reconstruction of the genital area wound should be
started once the infection has subsided, and the wound
is healthy and granulating.
The options of reconstruction of the genital area wound
includes split skin grafting, groin flap, medial thigh flap
based on medial circumflex femoral artery and gracilis
musculocutaneous flap. 6-10
This study was conducted to determine the outcome of
the management of Fournier’s gangrene in our setup.
PATIENTS & METHODS
A total of 18 patients suffering from Fournier’s gangrene
were managed in the Dept. of Surgery and the Dept. of
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Outcome of Reconstructive Procedures in Fournier’s Gangrene M. Kumar, A. R. Shaikh, et al
Cause
Urological
Anorectal
Unknown
Table I. Aetiology of Fournier’s Gangrene
Plastic & Reconstructive Surgery at Liaquat University
Hospital, Jamshoro from January 2004 to December
2006.
Detailed history and examination of the cases was carried
out and appropriate investigations done. After preparation
surgical debridement was performed followed
by dressings till infection had subsided and the wound
had healthy granulations. The wound was finally covered
by either the approximation of skin, split skin grafts or
flaps.
RESULTS
Eighteen patients with Fournier’s gangrene were managed
during the study period. All were male with ages
ranging between 30-60 years, mean age was 42 years.
The causes were urological (urethral stricture with dilatation,
traumatic catheterization) in 10 (55.55%) cases
and anorectal (fissure-in-ano, hemorrhoidectomy) in
two (11.11%) cases (Table I). Associated diseases were
diabetes mellitus in three (16.66%) and hypertension
Site Involved
Scrotum alone
Scrotum + penis
Number
10
Scrotum + penis + perineum
Scrotum + perineum
Scrotum + penis + pubic region
2
6
%
55.55
11.11
33.33
No. of Patients
7
5
3
2
1
118
Complication
Partial skin loss
Complete skin loss
Hematoma
Partial dehiscene
in two (11.11%) patients.
As far as the site was concerned, scrotum was involved
in all cases (100%), followed by penis in nine (50%)
cases (Table II). Split thickness skin graft (SSG) was
the commonest procedure done in 12 (66.66%) cases
followed by primary closure in six (33.33%) and medial
thigh flaps in two (11.11%) cases. Two patients out of
18 had exposed testis which were burried in thigh followed
by medial thigh flaps and scrotoplasty six months
later (Figs. 1-3).
Partial skin loss was seen in six (33.33%) and complete
loss in on (5.55%) patient; they were re-grafted after
one week. No flap loss or mortality was seen in this
study (Table III).
DISCUSSION
All patients with Fournier’s gangrene treated at Liaquat
University Hospital were males. The absence of females
Primary closure 3 cases (42.85%)
S.S.G 3 cases (42.85%)
Medial Thigh flap 1 cases (14.28%)
Primary closure 1 cases (20%)
S.S.G 3 cases (60%)
Medial Thigh flap 1 cases (20%)
S.S.G + Primary closure of perineum
3 cases (100%)
S.S.G + Primary closure with local flaps
2 cases (100%)
S.S.G + Primary closure with local flaps
2 cases (100%)
Table III. Postoperative Complications
Table II. Regions involved and the procedures performed
Procedure Performed
No.
6
1
1
1
%
%
33.33
5.55
5.55
5.55
38.88
27.77
16.66
11.11
5.55
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Outcome of Reconstructive Procedures in Fournier’s Gangrene M. Kumar, A. R. Shaikh, et al
Fig. 1. (A) Preoperative (B) 1 week postoperative S.S.G (C) 2 weeks postoperative S.S.G
Fig. 2. (A) Preoperative (B) Postop. Primary closure (C) Postop. Pr. closure 2 weeks
Fig. 3. (A) Preoperative (B) Postop. Medial thigh flap (C) Postoperative 2 weeks
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Outcome of Reconstructive Procedures in Fournier’s Gangrene M. Kumar, A. R. Shaikh, et al
in this study may be due to social or religious grounds.
However, the low incidence of females can also be attributed
to better drainage of the perianal region through
vaginal secretions. 16
All 18 patients with Fournier’s gangrene were initially
treated in the surgical ward with dressings, debridements
and antibiotics. Once the wounds granulate and become
infection free, they were sent to the plastic surgery ward
for further management. In our study no patient died
due to Fournier’s gangrene though the literature mentions
a mortality rate varying between 3-67%. 12,13
In this study the cause may be decreased host resistance
and ascending infection from perirectal site and urethra.
Diabetes is the leading cause of Fournier’s gangrene
due to increased propensity of tissue ischemia caused
by small blood vessel disease. 14 In our study also diabetes
was the main co-morbid condition. Pizzomo et al
described an increased incidence (upto 50%) of Fournier’s
gangrene with diabetes mellitus. 15
None of the patients in our study required orchidectomy,
penectomy or colostomy. Split thickness skin grafting
was the ideal procedure in this series, which was done
in 11 (61.11%) cases. Stretch and expansion of residual
scrotal skin with primary closure was done in 4 (22.22%)
patients; when up to 1/3rd of scrotum is intact it can be
expanded to resurface the entire scrotum. 18
In this study we used the superiomedial thigh fasciocutaneous
flap in 2 (11.11%) patients. The testes were
burried in a pouch in the superio-medial aspect of the
thigh in those patients who had complete scrotal loss
following Fournier’s gangrene. This flap is based on
the medial circumflex artery perforators, deep external
pudendal artery and anterior branch of obturator artery. 9
It is a safe and single stage procedure with good aesthetic
results and provides sensory coverage because of genital
branch of genitofemoral nerve and ilioinguinal nerve. 16
The musculocutaneous flap was not utilized in our
study.
Six (33.33%) cases out of 18 had partial and 5.55%
complete skin loss. The latter was seen in one diabetic
patient who was re-grafted after one week. Skin grafting
was found to be a technically easy option with satisfactory
cosmetic and functional results. 6 Hyperbaric oxygen
therapy was not done in this study though it has a vital
role in the management. 15,17
CONCLUSION
Split thickness skin grafting is an ideal procedure for
genital area resurfacing; primary closure of scrotum by
120
stretching and expanding should be used when up to
1/3rd of the residual scrotum is available. Superiomedial
thigh flap is reliable with less complication as comparative
to other flaps. Partial thickness skin loss is the
common complication of skin grafting.
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