Review

Fourniers gangrene
5
Devajit Chowlek Shyam
a,
*, Amy Grace Rapsang
b
a
Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences,
India
b
Department of Anesthesiology & Intensive Care, North Eastern Indira Gandhi Regional Institute of Health and
Medical Sciences, India
a r t i c l e i n f o
Article history:
Received 2 November 2012
Received in revised form
30 January 2013
Accepted 1 February 2013
Available online 8 April 2013
Keywords:
Aetiology
Complications
Fourniers gangrene
Necrotising fascitis
Pathogenesis
Treatment
a b s t r a c t
Fourniers gangrene (FG) is a synergistic polymicrobial gangrenous infection of the peri-
neum, scrotum and penis which is characterised by obliterative endarteritis of the
subcutaneous arteries, resulting in gangrene of the subcutaneous tissue and the overlying
skin. FG affects all ages and both genders, with a male preponderance. It is a rare but life-
threatening disease, and despite therapeutic advances in recent years, the mortality rate is
3%e67%, with an incidence of 1:7500e1:750,000. Anorectal, genitourinary and cutaneous
sources of infection are the most common causes of FG, with diabetes mellitus being the
most common risk factor. The clinical condition presents evolution from 2 to 7 days and is
characterised by uneasiness, local swelling and discomfort, fever, crepitus and sometimes
frank septic shock. Current imaging techniques for initial evaluation of the disease include
radiography, Ultrasonography (USG), Computed Tomography (CT) and Magnetic Resonance
Imaging (MRI). However, the diagnosis of FG is usually clinical and imaging can be helpful
in uncertain diagnosis and when clinical ndings are ambiguous. Treatment of FG is based
on a multimodal approach which includes intensive uid resuscitation to stabilise the
patient and correction of electrolyte imbalance, if any. This is followed by extensive de-
bridements and resections in order to remove all necrotic and infected tissue, wide spec-
trum antibiotics and reconstructive surgery, whenever required. However, despite all the
advances in treatment today, FG remains a surgical emergency, hence, early recognition
with aggressive haemodynamic stabilisation, parenteral broad spectrum antibiotics and
urgent surgical debridement are the mainstay of treatment.
2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and
Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction
Fourniers gangrene (FG) is a synergistic polymicrobial
necrotising fascitis of the perineum, scrotum and penis
which is characterised by obliterative endarteritis of the sub-
cutaneous arteries, resulting in gangrene of the subcutaneous
tissue and the overlying skin.
1
The anaerobic microorganisms
that accumulate in the subcutaneous tissue produce
5
Work attributed to: Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences.
* Corresponding author. Flat B1A, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences Campus, Mawdiang-
diang, Shillong 793018, Meghalaya, India. Tel.: 91 9774016977.
E-mail address: devajit_cs@yahoo.com (D.C. Shyam).
Available online at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges
of Surgeons of Edinburgh and Ireland
www. t hesurgeon. net
t he s ur g e o n 1 1 ( 2 0 1 3 ) 2 2 2 e2 3 2
1479-666X/$ e see front matter 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of
Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.surge.2013.02.001
hydrogen and nitrogen, aided by the conditions of low oxygen
pressure, limited vascular supply and bacterial overgrowth,
resulting clinically in crepitus of the affected areas.
2
The rst
author who described this disease was Baurienne in 1764,
3
and in 1883, a French venereologist Jean Alfred Fournier
described FG as a disease with an abrupt onset in a young
healthy male subject, rapid progression to gangrene, and the
absence of a discernible cause.
4
Many terms have beenused to
describe this clinical condition, such as idiopathic gangrene of
the scrotum, periurethral phlegmon, streptococcal scrotal
gangrene, phagedena, and synergistic necrotising cellulitis.
5e7
Presently, FG affects all ages and both genders,
8
with a
male preponderance (male: female is 10:1),
9,10
and although it
has a broad age range, it mainly affects patients over the age of
50 years.
11
It is rarely seen in the paediatric age group, and
little is known about the disease in the newborn period and
infancy.
12,13
FG is a rare but life-threatening disease and despite the
therapeutic advances in recent years, the mortality rate is 3%e
67%,
14
with an incidence of 1:7500e1:750,000.
15
Differential
diagnosis includes cellulitis, strangulated hernia, scrotal
abscess, streptococcal necrotising fasciitis, vascular occlusion
syndromes, herpes simplex, gonococcal balanitis and
oedema, pyoderma gangrenous, allergic vasculitis, poly-
arteritis nodosa, necrolytic migratory erythema, warfarin
necrosis and ecthyma gangrenosum.
5
Predisposing factors
Many conditions believed to contribute to the development of
the disease are diabetes mellitus, alcoholism, immunosu-
pression, local trauma, genitourinary infections, acquired
immunodeciency syndrome,
16
malignant neoplasms,
17
liver
and renal disease.
18
In all these conditions, there was a
decrease in the host immunity that determined the develop-
ment of the infection. Diabetes mellitus is the most commonly
associated co-morbid condition (20%e70%),
19
but controversy
still exists as to whether or not diabetes mellitus is associated
with increased mortality. In a study by Barreda et al.
19
and
Yanar et al.
20
there was no increase in the mortality in diabetic
patients. In their study, Nisbet and Thompson
21
concluded
that diabetes is a risk factor for the occurrence of FG, but that
it does not affect the prognosis. But if diabetes mellitus is
associated with chronic alcoholism, then it carries a bad
prognosis.
22
Immunosupression is also a very important
contributing factor especially in post-transplant patients
23
and in patients receiving bone marrow transplantation,
24
because in such patients, their immunosuppressive state
favours bacterial, viral and fungal infection.
Aetiology
FG has an identiable cause in approximately 95% of cases,
2
and the most common initial port of entry is local trauma or
extension of a urinary tract or a perianal infection.
14
The most
common sites of origin are urethral, anorectal and skin in-
fections,
25
which later on spread to the abdominal wall thus
leading to vascular thrombosis (secondary to endarteritis
obliterans) and resulting in the normal microbial ora to
penetrate into the sterile spaces by fascial dissection.
19
In a
study on 65 cases by Cakmac et al.
25
the most common aeti-
ology was haemorrhoidectomy in male and perianal abscess
in female patients. In another study of 45 patients with FG,
Basoglu et al.
26
reported that the most common aetiology was
perirectal abscess followed by scrotal carbuncle and throm-
bosed haemorrhoid. Table 1
1,27e34
showed a list of causes
attributed to the development of FG.
FG has also been reported following surgery for a perfo-
rated duodenal ulcer,
35
foreign body perforation of the
rectum,
36
inammatory bowel disease,
12
Crohns disease,
37
vasectomy,
38,39
circumcision,
40
intracavernosal cocaine in-
jection,
5
genital piercing,
5
coital injury,
5,41
genital mutilation
5
and third degree burns.
42
Sengoku et al.
43
reported a case of FG
which progressed rapidly after prostatic massage, done after
the diagnosis of prostatitis was made. FG is also reported after
renal transplantation.
23
Walther et al.
44
reported one case of
FG associated with prosthetic penile implant after renal
transplantation. A less commonly reported cause is bone
marrow transplantation in patients with bone marrow ma-
lignancy.
24
The reason for this could be that the immuno-
suppressive state of such patients favours bacterial, viral and
fungal infection.
In women the common sites of origin are Bartholin ab-
scess, vulvar and perineal wounds, episiotomy, hysterectomy
and septic abortion.
45
In the paediatric age group, the reported
aetiological factors are omphalitis, strangulated hernia, pre-
maturity, diaper rash, varicella infection, circumcision, peri-
neal skin abscesses, trauma, insect bites, surgeries/invasive
Table 1 e Table showing a list of causes of Fourniers
gangrene.
Causes of Fourniers gangrene
1,8,27e34
:
1 Idiopathic
2 Penis and scrotum:
Surgery of the penis and scrotum
Phlebitis of dorsal penis vein
Chronic skin infections/fungal infections of the scrotum
Self inicted banding of penis
Boils
3 Genitourinary tract:
Urethral strictures
Urethral dilatation
Transurethral instrumentation
Transrectal prostate biopsy
Urethral calculi
Bladder cancer inltrating the urethra
4 Anorectal/Colorectal:
Ischiorectal, perianal, and intersphincteric abscesses
[especially those inadequately treated]
Anal abscess
Fistula in ano
Diverticular perforation
Carcinoma of the sigmoid colon and rectum
Perforated acute appendicitis
Internal hemorrhoids ligated with rubber bands
Anal dilatation
Malignancies
Rectal or anal surgery
t he s ur g e on 1 1 ( 2 0 1 3 ) 2 2 2 e2 3 2 223
procedures in the perineal region, urethral instrumentation,
burns and systemic infections.
12,13,18
Pathogenesis and organisms involved
FG is a polymicrobial infection in which both aerobic and
anaerobic organisms may be present, although not all bacteria
involved can be identied in cultures.
46
The characteristic
obliterated endarteritis with vascular thrombosis resulting in
subcutaneous tissue necrosis and gangrene of the skin can be
explained by certain factors exhibited by the causative
organisms, such as the synergistic activity of aerobic bacteria
(causing platelet aggregation and inducing complement
xation, thereby causing acceleration of coagulation) and the
anaerobic organisms (promoting the formation of clots by
producing heparinase and collagenase).
45
Other organisms like Bacteroides inhibit the phagocytosis
of aerobic bacteria; hence FG is a destructive infection of the
relatively non-pathogenic organism
45
(which in combination
with local and systemic factors can acquires high virulence).
Generally, the infection is caused by three or more germs, the
most common being Escherichia coli, Proteus, Enterococcus and
anaerobes.
16,47
The most commonly isolated anaerobic
microorganism is Bacteroides fragilis.
16,48
Morua et al.
45
reported polymicrobial infection with E. coli
as the most common pathogen (48%) followed by Enterococcus
fecalis (28%). Other organisms are Pseudomonas aeruginosa,
Streptococcus fecalis, Staphylococcus aureus, Candida spp, Cory-
nebacterium spp, Streptococcus agalactice, Staphylococcus coa-
gulosa negative, E. cloaca, Acinetobacter bauminii, Klebsiella
pneumoniae, Morganella morganii, Proteus vulgaris, Streptococcus
beta-hemolitica spp, Citrobacter fruendi, Proteus mirabilis, Strep-
tococcus viridans, Staphylococcus saprophyticus, Streptococcus sal-
ivarius salira aureus and Streptococcus spp. In a study by
Kumagai et al.
28
intra-operative tissue cultures as well as post-
operative cultures of blood and pus and necrotic tissue
revealed E. coli, serotype O-6. In another study of FG by Sen-
goku et al.
43
cultures of the pus and the necrotic tissue from
the scrotum were positive for B. fragilis and several aerobes
including S. aureus, P. aeruginosa, K. pneumoniae, Enterococcus
spp and Staphylococcus epidermidis. Cheung et al.
49
reported M.
morganii and Peptostreptococcus spp; and Mulholland et al.
35
reported S. viridans, E. coli, Bacteroides spp. and diphthe-
roids. Lichtenstein et al.
50
reported mixed aerobic (P. vulgaris,
E. coli, Pseudomonas pyocyanea, S. aureus, non-haemolytic
Streptococcus spp, Beta-haemolytic Streptococcus spp) and
anaerobic (Clostridium welchii, non-Clostridial organisms,
anaerobic Streptococcus spp and Bacteroides spp) organisms.
The highest rates of isolation indiabetic patients have been
reported to be Streptococcus spp., Staphylococcus spp. and
mixed anaerobic ora.
21
In children, the causative organisms usually are Strepto-
cocci, Staphylococci and anaerobes.
51
In a case of neonatal FG
reported by Dey et al.
18
culture from wound swab showed
growth of S. aureus and Klebsiella species.
Necrotising fasciitis of soft tissue due to fungi although
rare,
52
has been reported.
52e54
Candida albicans has been re-
ported as the primary microorganism.
54
In a case report by
Loulergue et al.
52
C. glabrata is the causative organism, and
Jensen et al.
53
reported E. coli, E. fecalis, Candida glabrata and
Candida tropicalis as the causative organisms. Another rare
organism that was reported is Lactobacillus gasseri.
55
Clinical features
FG is a necrotising fasciitis with a natural history that begins
with a rupture of the skin, thus creating an entry point for mi-
croorganisms due to the decompensation of the cutaneous
defence mechanisms.
56
Local ischaemia, favoured by throm-
bosis leads to decrease in tissue oxygenation, thereby resulting
in spreading of the infection to deep tissue planes, thus pro-
ducing purulent necrotising fasciitis.
56
The characteristic odour
in FG is attributed to the role of anaerobes in this infection,
which is considered pathogonomic of their participation.
11
The clinical conditionpresents withgradual evolutionfrom
2 to 7 days whichis characterisedby uneasiness, local swelling
and discomfort, fever, crepitus, erythema, local hardening of
tissue surface areas progressing to ecchymosis and necrosis
along with drainage of purulent material and gangrene of the
genitals, anaemia, electrolyte abnormalities, hyperglycemia,
leukocytosis and sometimes frank septic shock.
9,16,29,45,57
In
patients with severe clinical presentation, progression of the
gangrenous process to malodorous drainage and sloughing in
affected sites were present, thus resulting in deterioration of
the patients conditions.
16
The local discomfort, scrotal pain,
redness, oedema and crepitus due to subcutaneous emphy-
sema may extendup to the axillae, thighs andperianal tissues,
implying that there may be anaerobic infection in the area.
9
If
the anorectal area is the portal of entry, then most patients
presented with perianal pain and swelling, whereas urinary
retention and testicular or scrotal pain are present if the
infection launches from the genitourinary tract.
29
The testes
and spermatic cords are usually spared fromthe infection due
to their independent blood supply, but in 21% of the patients,
there will be a need for orchidectomy of the affected side
because the testis will become nonviable.
40
Horta et al.,
58
described four characteristic phases of FG:
- First phase (24e48 h): non-specic symptoms associated
with local hardening, pruritis, oedema and erythema of the
affected tissues.
- Second (invasive) phase: this phase is short with local and
regional inammatory manifestations.
- Third (necrotic) phase: rapid worsening of the general state,
evolving to septic shock in 50% of the cases. Necrosis can
sometimes spread to the anterior abdominal wall, under-
arms and thighs.
- Fourth phase (the spontaneous restoration phase): healing
with deep granulation followed by epithelialisation (over
several months) and progressive reestablishment of general
parameters.
The most pathogonomic anatomical involvement is ne-
crosis and suppuration of subcutaneous tissue, fat, arteries,
veins, supercial fascia, muscle, and deep fascia accompanied
by fat necrosis, focal haemorrhaging and inammation of
the dermis and subcutaneous fat. The reticular dermis and
subcutaneous fat is often oedematous and inltrated by
t he s ur g e o n 1 1 ( 2 0 1 3 ) 2 2 2 e2 3 2 224
abundant polymorphonuclear cells.
56
Considering rapidity of
the spread of the gangrenous area that is reported to be up
to 2e3 cm/h, prompt diagnosis and appropriate emergent
management seems to be vital.
16
Diagnosis and investigations
The diagnosis of FG is primarily based on clinical ndings.
Examination of the genitalia and perineum and a digital rectal
examination should be done. Fluctuance, crepitance, localised
tenderness and wounds raises the possibility of FG. The mean
time of diagnosis is six days with the conventional methods,
but with identication of necrotising fasciitis in frozen section
biopsy specimens, diagnosis can be made in twenty-one
hours.
10,59
The common laboratory ndings are non-specic, in most
cases showing anaemia (due to lack of functioning erythro-
cyte mass secondary to thrombosis and sepsis),
9,60
leukocy-
tosis,
9,45
thrombocytopaenia (whichcan occur as a decrease in
clotting factors),
45
electrolyte abnormalities, such as hypo-
natremia and hypokalemia,
9,10,29,60
hypocalcaemia (which is
secondary to the destruction of triglycerides by bacterial li-
pases and release of the free fatty acids that are chelators of
the ionised form of the calcium),
61
hyperglycemia,
29
elevated
serum creatinine level,
60
azotaemia and hypoalbuminemia.
10
Blood cultures are positive in 20% of the cases.
58
Kuo et al.
62
suggested that the diagnosis of FG should be
based on the following criteria: soft tissue infections with
involvement of the scrotum, perineum and perianal areas,
presence of air inltrating the subcutaneous tissue (demon-
strated by physical examination or radiological ndings),
surgical ndings of gangrenous and necrotic tissue and his-
tologically proven necrotising fasciitis.
Imaging
Conventional radiology can be very helpful in assessing pa-
tients suspected of FG in order to detect gas in soft tissue
which could raise a possibility of necrotising fascitis. Current
imaging techniques for initial evaluation of the disease
include radiography, Ultrasonography (USG), Computed To-
mography (CT), and Magnetic Resonance Imaging (MRI).
However the diagnosis of FG is usually based clinically and
imaging can be helpful in uncertain diagnosis and when
clinical ndings are ambiguous.
Radiography
Radiographs can detect the presence of soft tissue air in the
region overlying the scrotum and perineum before clinical
crepitus is detected. They can also demonstrate signicant
swelling of scrotal soft tissue and subcutaneous emphysema,
if present; but if absent, this does not exclude the diagnosis of
FG.
63
However, deep fascial gas is rarely seen and therefore
represents a signicant weakness of this modality in the
diagnosis and evaluation of FG.
64
Ultrasonography (USG)
A USG nding in FG is a diffuse swelling and a thickened,
oedematous scrotal wall (or sometimes phallus),
demonstrating reverberation artefacts, causing dirty shad-
owing that represents gas within the scrotal wall, which may
be seen prior to clinical crepitus.
63e65
USG can also detect
peritesticular uid. However, the testes and epididymides are
often normal in size and echo texture due to their separate
blood supply. (The scrotal blood supply is from pudendal
arterial branches of the femoral artery, whereas the testicular
blood supply is from testicular branches of the aorta.) USG is
also useful in differentiating FG from inguino-scrotal incar-
cerated hernia. The scrotal contents can be examined along
with Doppler blood ow and soft-tissue air is also more
obvious than radiographic lms. But even though USG is bet-
ter than radiography in this context, CT is superior to both
USG and radiography in demonstrating FG, its extent, and its
underlying causes.
63
Garc a et al.
66
reported the usefulness of
ultrasound in the detection of FG in the early stages and
concluded that the use of ultrasound in cases with acute
scrotal inammation of a torpid course permits early detec-
tion of FG. However, even though USG is cost effective (and
therefore should be used as a primary imaging technique for
the diagnosis of FG), most of the time it could not be done
because of skin necrosis.
Computed Tomography (CT)
Although the diagnosis of FG is often made clinically, CT can
lead to an early diagnosis and proper assessment of the
extent of the disease. CT ndings include asymmetric fascial
thickening, uid collections, abscess formation, subcutane-
ous emphysema (secondary to gas-forming bacteria) and can
also show the origin and extent of infection.
63,64
It is also
highly sensitive and specic in detection of abnormal gas
collection.
64
Subcutaneous emphysema is the hallmark of FG
but is not seen in all cases (90% of patients with FG have been
reported to have subcutaneous emphysema, so that at least
10% do not demonstrate this nding), but if present, it dis-
sects along the fascial planes and can extend from the
scrotum and perineum to the inguinal region, thighs and
abdominal wall.
63,64,67
However, subcutaneous emphysema is
rarely seen in CT because the infection usually progresses
rapidly and the early stage with lack of subcutaneous
emphysema is very brief.
67
CT plays an important role in
diagnosis, demonstrating the underlying cause and in the
evaluation of the extent of the disease for planning appro-
priate surgical intervention. The extent of fascial thickening
and fat-stranding seen in CT lms has been found to correlate
well with the affected tissue during surgery.
63,67
Contrast
enhanced CT also allowed differentiation between necrotic
and viable tissue and hence, can offer a diagnosis even before
the onset of clinical manifestation in order to improve sur-
gical planning and intervention.
68
CT can help in the evalu-
ation of both the supercial and the deep fascia (in contrast to
radiographs) and it is also helpful in differentiating FG from
other less aggressive entities such as soft-tissue oedema or
cellulitis, which may appear similar to FG on physical ex-
amination.
63
Post treatment follow-up CT is valuable in
assessing improvement or worsening of the disease in order
to decide if additional treatment and surgery are needed.
Compared with radiography and USG, CT provides a higher
specicity for the diagnosis of FG and superior evaluation of
disease extent.
63
t he s ur g e on 1 1 ( 2 0 1 3 ) 2 2 2 e2 3 2 225
Magnetic Resonance Imaging (MRI)
MRI is very useful for specifying the range of necrotic fasciitis
and offers an important diagnostic adjunct to management of
FG.
69
MRI can accurately detect the extent of inammation
process in patients with fasciitis and it is superior to USG or
plain radiography. It is also more helpful than CT in planning
any operative intervention.
70
In a case reported by Yoneda
et al.
71
pelvic CT was done for a patient presenting with gluteal
pain. CT revealed an abscess including gas in the right buttock
for which drainage was performed immediately, but the pa-
tient developed endotoxic shock. MRI was then done and
revealed a strong inammation along the fascia and necrot-
ising fascitis of the buttock through the femur. Wide incision
was then performed and the patient condition improved.
Since FG requires immediate and aggressive treatment, MRI
can be used as an early diagnostic tool for FG.
Mortality predictors and prognosis indices
In a study of 1641 males with FG (treated at 593 hospitals) by
Sorensen et al.
72
increased mortality was associated with
increasing patient age, four specic co-morbidities (hyper-
tension, congestive heart failure, renal failure and coagulop-
athy), certain procedures required during admission
(colostomy, penectomy, mechanical ventilation and dialysis),
increased length of hospital stay and cases presenting to
urban institutions and teaching hospitals. Each operation that
a patient required also increased the unadjusted odds of death
by 27%(likely reecting more severe FG). In contrast, requiring
orchiectomy was associated with a 70% decreased mortality
risk. On the other hand, the patients ethnicity or race and the
number of surgeries did not predict mortality.
Clayton and co-workers
73
found that survival of patients
with necrotising fasciitis was associated signicantly with a
blood urea nitrogen level of less than 50 mg/dL at
presentation.
It is also suggested that hypoalbuminemia might be a
noticeable factor for the prediction of the mortality rate.
74,75
Even though hyperglycemia has been found to affect
adherence, chemotaxis, and bactericidal activities of phago-
cytes and detrimental effects on cellular immunity,
2
no sig-
nicant increase in the mortality rate was found among the
diabetic patients when compared to non-diabetic
patients.
19,20
Some authors
74,76
found that anorectal or colonic source of
sepsis worsened the prognosis as the anatomical area is
awash with different types of organisms of varying virulence
as well as synergism. Testicular necrosis in FG is another in-
dicator of severe disease (as this points to retroperitoneal
sepsis which causes thrombosis of the testicular blood ves-
sels), thereby limiting adequate drainage, unless drainage is
instituted through a laparotomy.
77
Sepsis and its complica-
tions also account for the majority of deaths in FG.
77
Extension
of the necrosis appears to be one of the important prognostic
factors. Some studies showed that patients with a gangrene
area less than 3% rarely die, while patients presenting with a
gangrene area larger that 5% have a poor prognosis.
58,78
However, other studies reported that the extension of the
gangrene does not relate to a poorer prognosis.
73
In addition, Lopez-Samano et al.
79
recommended uti-
lisation of the APACHE II score as a very useful tool to deter-
mine the prognosis of FG.
Prognostic indicators include Fourniers Gangrene Severity
Index (FGSI), Laboratory Risk Indicator for Necrotizing Fasciitis
(LRINEC) and affected area calculation.
1. Fourniers Gangrene Severity Index (FGSI): Laor et al.
80
established a prognostic index, the FGSI (Fourniers
Gangrene Severity Index), to determine the severity and the
prognosis of the disease in patients with FG. This index
includes patients vital signs and metabolic parameters
(temperature, heart rate, respiratory rate, serum sodium,
serum potassium, serum creatinine, serum bicarbonate,
haematocrit and white blood cell count) and computes a
score relating to the severity of disease at that time. A
score >9 is suggested to have a 75%probability of death and
an index score 9 is associated with 78% survival.
9
This
index was subsequently validated by Yeniyol and
Tuncer.
81,82
However, its accuracy is controversial, and
hence cannot be relied upon to predict survival.
83,84
Janane
et al.
85
described 70 cases of FG where FGSI was used. They
concluded that FGSI score did not predict the disease
severity and the patients survival; metabolic aberrations
and extent of the disease seemed to be more important risk
factors for predicting FG severity and patient survival.
However, in a study by Unalp et al.
86
multivariate analysis
revealed that FGSI 9 was a prognostic factor in their pa-
tients. They found that mortality rates of 66.7 and 1.7%
correlates with FGSI 9 and FGSI 9, respectively, and they
concluded that FGSI may be helpful in predicting the type of
patients who need extra aggressive initial debridement and
intensive care therapy. In another study of 25 patients by
Yeniyol et al.
81
the mean nal FGSI for survivors and those
who died was 0.0 0.8 and 17 3.8 respectively, and they
concluded that FGSI is a useful method for evaluating
therapeutic options. In another study of 25 patients of FGby
Lin et al.
87
the mean FGSI for survivors was 4.41 as
compared to 12.75 for those who died. They also found that
patients with FGSI value of >9 has an 87.5% probability of
death and a score of 9 was associated with an 88% sur-
vival. In yet another study of 50 patients by Morua et al.
45
a
mean FGSI of 9.8 for patients who died and 5.64 for survi-
vors was reported. Hence, FGSI can be used as an added tool
in evaluating therapeutic options.
2. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC):
The LRINEC score is a weighted point system of multiple
laboratory markers often used to stratify patients into
low, moderate, or high risk for Necrotising Soft-Tissue
Infections (Table 2).
88,89
3. Affected area calculation/Extension of the necrosis: Patients
with an affected area of less than 3% have a low risk of
progression from the infectious stage, and the risk is high if
the area is above 5%.
58
Complications
Reported complications are renal failure, acute respiratory
distress syndrome, heart failure, cardiac arrhythmias, septic
t he s ur g e o n 1 1 ( 2 0 1 3 ) 2 2 2 e2 3 2 226
metastasis,
19
urinary tract infection, stroke and acute
thrombo-embolic disease of the lower extremities.
90
Surgical
complications include wound infections, stoma-related com-
plications, prolonged ileus (7days) and eventration or evis-
ceration.
90
Long term complications include pain (50% of the
patients), impaired sexual function (due to penile deviation/
torsion, loss of sensitivity of the penile skin or pain during
erection), stool incontinence and impaired cosmesis.
5
How-
ever, despite extensive scarring (after reconstructive surgery)
most patients considered their cosmetic result as well as their
quality of life to be satisfactory.
91
Treatment
FG has a potential for severe complications, hence early
diagnosis is imperative. Paty et al.
16
stated that Mortality rate
of FG can be reduced by intensive care and appropriate anti-
biotic therapy (with the coverage of aerobic gram-positive and
gram-negative bacteria as well as anaerobic microorganisms)
combined with surgical treatment. The spread of tissue
gangrene is rapid at the rate of 2e3 cm/h, hence early diag-
nosis and emergency surgical treatment is of utmost
importance.
16
Treatment of FGis based on a multimodal technique which
includes intensive uid resuscitation to stabilise the patient
and correction of electrolyte imbalance, if any. Rivers et al.
92
suggested that if initial crystalloid uid resuscitation is
insufcient to raise the mean arterial pressure to 65 mmHg
and the CVP to 8e12 mmHg, then the use of vasopressors and
inotropes are recommended. And when invasive monitoring
might be indicated, it is rational start to blood transfusion
when the haematocrit is below 30%. This is followed by
extensive debridements and resections in order to remove all
necrotic and infected tissue and the use of wide spectrum
antibiotics,
46
since FG is a well known polymicrobial infection,
with mixed aerobes and anaerobes, although not all bacteria
involved can be identied in cultures.
41
Hence triple therapy
with penicillins (for the streptococcal species), metronidazole
or clindamycin (for the anaerobes), third generation cepha-
losporins with aminoglycosides (for the gram negative
organisms) is essential.
40
Monotherapy with carbapenems or
broad spectrum beta-lactams ureidopenicillins (piper-
acillinetazobactam) is also equally effective, and simple to
administer.
93
In starting empirical therapy an important
consideration is that antibiotic therapy may cause a possible
fungal infection to get out of control.
9
Hence, if the initial
tissue stain using potassium hydroxide shows the presence of
a fungus or if the fungus is grown in the culture, then addition
of anti-fungal, e.g. amphotercin B is necessary.
5
Some surgeons recommend debridement for both nec-
rosed tissues and tissues with doubtful viability and extension
to healthy areas, even though this leads to larger tissue loss
thereby prolonging wound healing and extending the pa-
tients recovery period.
57
To delineate the actual extent of
necrosis, the separation of the skin from subcutaneous tissue
with a haemostat is a strategy wherein the debridement
should end at the level where the planes are not easily sepa-
rated.
31
Multiple surgical debridements are usually required,
with an average of 3.5 procedures per patient.
75
Since FG is
dynamic, sometimes the necrotic tissue cannot be removed
100% with the rst debridement,
45
therefore it requires more
aggressive treatment before being considered as a resolved
infection. Surgical wounds are usually left open and the use of
Dakins solution (sodium hypochlorite) or irrigation with
hydrogen peroxide will provide mechanical cleaning of the
wound and promote destruction of anaerobic organisms,
thereby aiding in the separationof the sloughand accelerating
the development of granulation tissue.
9,40
Aseptic wound
dressing and evaluation is of vital importance. The surgical
wound can heal by secondary intention or may need further
aps or grafts.
94
Different techniques have been performed to
provide skin cover including free skin grafts, axial groin or
myocutaneous aps, testes transplantation etc. Reconstruc-
tive surgery of the genitals gives good results, reduces the
length of hospital stay and improves the psychological con-
dition of the patients. The goal of genitalia reconstruction in
FGis efcient coverage of skinloss with maintenance of penile
functions (erection, ejaculation and voiding)
95,96
and should
be considered only after an improvement of the patients
clinical condition.
96
Many surgeons use the remaining pre-
puce or the scrotal skin to cover the skin defects,
96
however,
aps give superior cosmetic aspects, even though the
donating sites are limited and the procedure is associated
with a higher morbidity.
94
Black PC et al.
94
reported the use of
meshed unexpanded split-thickness skin grafting (STSGs) for
skin defects. In their study, the graft uptake was 100% and the
cosmetic outcome was satisfactory with preserved erectile
function and ejaculation in potent patients. In a study by
Horta et al.
58
in the urology division in Hospital de Sao Joao
between 1999 and 2001, 67% of the patients needed some type
of reconstructive surgery like partial and total skin grafting;
transposition of the testicles and spermatic cords into a per-
manent subcutaneous pouch either on the upper thigh or
vascularised pedicles; tissue expansion techniques; and
island or peninsula-shaped musculo-cutaneous pedicles, e.g.
pediculated gracilis ap for extensive and deep perineal
Table 2 e Laboratory Risk Indicator for Necrotizing
Fasciitis (LRINEC).
88,89
Variable Value Points
C-reactive proteins (mg/L) <150 0
>150 4
WBC (cells/mm
3
) <15 0
15e25 1
>25 2
Haemoglobin (g/dl) >13.5 0
11e13.5 1
<11 2
Serum sodium (mmol/L) 135 0
<135 2
Serum creatinine (mg/dl) 1.6 0
>1.6 2
Plasma glucose (mg/dl) 180 0
>180 2
Risk Probability Total score
Low <50% 5
Moderate 50e75% 6e7
High >75% 8
t he s ur g e on 1 1 ( 2 0 1 3 ) 2 2 2 e2 3 2 227
defects. They found that vascularised fascia and musculo-
cutaneous pedicles are by far the best treatment options and
they concluded that fascio-cutaneous pedicles, e.g. the
superomedial fascio-cutaneous pediculated thigh ap, are an
excellent option for scrotal reconstruction and give good
aesthetic results.
Gas within the testis (produced by bacteria), apparent in
X-ray lms, should warn that these patients will almost
certainly need orchiectomy.
31
Due to their independent blood
supply, the testes and spermatic cords are usually spared
fromthe infection but orchiectomy of the affected side may be
needed in 21% of patients, as the testis will become nonvi-
able.
40
Patients requiring orchiectomy were also associated
with a 70% decreased mortality risk.
72
The technique of urinary diversion in FG is still contro-
versial. Some authors recommended urinary diversion in all
patients (in the form of suprapubic cystostomy) as this will
allow the sites of urethral/penile pathology to heal without
the inuence of urine on them,
4
while others suggested that
urinary diversion should be reserved for patients with
extensive urethral involvement.
97
Colostomy and faecal
diversion are sometimes needed to decrease faecal
contamination (especially in the presence of infective
sphincteric destruction/rectal perforation) and faster wound
healing.
21,98
In their study, Akcan et al.
90
concluded that
preventive colostomy does not reduce the number of de-
bridements that are required; however, diverting colostomy
may lead to early oral intake and thus may help to improve
the wound healing process with better nutrition and less
contamination of wounds. They also found that the co-
lostomy procedure did not prolong the hospital or the
Intensive Care Unit stay. In a study by Chen et al.
99
in pa-
tients with FG due to anorectal disease, patients who
received a primary diverting colostomy had a lower mortality
rate as compared with those who received secondary co-
lostomy. Hence urinary or faecal diversion may be necessary
depending upon the foci of origin of the disease.
16
Typically
the bladder and rectum are spared by FG due to their non-
perineal blood supply.
31
Through and through drainage seems to have certain
advantages in FG, as reported by Watanabe et al.
100
where
multiple Penrose-drains were subcutaneously placed after
limited removal of necrotic tissue. They concluded that since
extensive debridement (which is commonly performed) has
certain disadvantages such as the need for skin grafting and
the chance of secondary wound infection, which can be
avoided by using multiple Penrose-drains, whereby narrow
excision of necrotic tissue and drainage of involved areas can
be done, resulting in minimal skin defects.
Adequate nutritional status or energy intake throughout
the treatment process is also necessary.
93
The choice of the anaesthetic technique in FG is inuenced
by the extent of the region involved. General anaesthesia is
preferable for controlling physiologic homeostasis,
101
since FG
is known to be aggressive thus producing marked systemic
toxicity. Koitabashi et al.
102
suggested the avoidance of spinal
anaesthesia in the presence of lumbar subcutaneous gas.
Some authors advocate the use of hyperbaric oxy-
gen
10,103e105
Vacuum Assisted Closure (VAC),
106,107
honey,
27,108
or lyophilized collagenase.
22
Hyperbaric Oxygen Therapy (HBOT)
Hyperbaric Oxygen Therapy (HBOT) was rst used intra-
operatively by Boerema, a Dutch cardiovascular surgeon
109
when he and his colleagues found out that when surgery is
performed in a pressurised environment, vessels could be
clamped for a longer period of time and certain cardiac repairs
could also be made.
109
On HBOT, 100% O
2
is delivered at high
pressure (2e2.5 absolute atmosphere),
111
thus increasing the
tissue O
2
tension or level and improving tissue resilience
110
which in turn
- Stimulate leukocyte bactericidal action
109
- Enhance broblast replication
109
- Increase collagen formation
109
- Promote neovascularisation
109
- Remove toxin produced by anaerobes
111
- Increase exibility of red blood cells
111
- Preserve intracellular adenosine
111
- Promote rapid growth of capillaries
111
- Facilitate the transport of some antibiotic agents across the
bacterial cell wall, thus improving overall
effectiveness
112,113
- Promote vasoconstriction, resulting in the control of
bleeding and the improvement in wound healing and
immune function.
111
Combined with local wound care, hyperbaric oxygen en-
hances tissue growth and viability.
111
Innecrotising soft tissue
infections, hypoxia occurs as a result of regional tissue
ischaemia and systemic shock, leading to compromised
leukocyte function, which in turn retards wound healing. In
such conditions, HBOT increases the partial pressure of oxy-
gen in these tissues thereby maintaining tissue oxygenation
even in the absence of haemoglobin.
111
Contraindications to HBOT include pneumothorax, ther-
apy with doxorubicin (high mortality in animal models), cis-
plastin (which decreases the production of superoxide
dismutase which is protective against damaging effects of
high partial O2 pressure).
109
Side effects of HBOT are barotrauma of the middle ear,
seizures, loss of respiratory drive in hypercapnic patients and
vasoconstriction; therefore, frequent periods of breathing in
room air are interposed when patients are on HBOT.
109,114
The use of hyperbaric therapy with oxygen as an adjuvant
treatment to this pathology has been described with satis-
factory results,
46
but limitation in the availability and transfer
of the patients to units offering this service restricts its
application for patients with FG.
40,41
HBOT in FG is commonly initiated as soon as patients are
stabilised (following initial debridement) and continued until
the wound is healed.
114
Hollanbaugh et al.
103
recommended
prompt initiationof HBOTafter primary surgical debridement.
In the rst twenty-four hours post-operatively, three HBO
dives are recommended followed by two dives per day for
seven days. This is followed by one dive per day till ve days
after surgical closure of the perineal wounds. However, con-
troversy still exists as to whether HBOT in FG is benecial and
cost effective
115
and the efciency of the method in the
treatment of FG remains questionable.
83
While some studies
t he s ur g e o n 1 1 ( 2 0 1 3 ) 2 2 2 e2 3 2 228
have shown improved survival with HBOT,
10,103e105
others
have shown no advantage of adjuvant HBOT in FG. In a study
by Mehl et al.
10
patients with FG who had associated hyper-
baric chamber with clinical surgical treatment had a mortality
rate of 11.5% and for those who underwent only medical and
surgical treatment, the index is 37.5%; hence they concluded
that patients who underwent HBOT had a proportionally
lower mortality rate when compared to those who did not
receive it. In a study by Hollanbaugh et al.
103
HBOT has been
afrmed with a statistically proven surgical advantage in 26
cases of FG. Mortality rate was 7% with HBOT as compared to
42% in patients without HBOT. Riseman et al.
104
reviewed 29
cases with necrotising fascitis and found that the mortality
was signicantly lower in the HBOT group when compared to
the untreated group and the number of debridements per
patient was also lower in HBOT group. In a study of 11 patients
with FG, Pizzorno et al.
105
observed no mortality in patients
treated with HBOT. In contrast, Shupak et al.
115
reviewed pa-
tients treated with HBOT and found that the mortality rate
was 36% for the treated group as compared to 25% for the
untreated group. Their average number of surgical de-
bridements per patient was also lower in the untreated group
and they concluded that HBOT offers no advantage in
decreasing the morbidity and the mortality when used as an
adjuvant treatment for necrotising fascitis. Similarly, Thar-
akaram and Keckes
116
stated that HBOT worsens the prog-
nosis of patients with FG.
Honey
The medicinal property of honey has been known for many
years, and its use as an adjuvant method for accelerating
wound healing in FG has been reported.
27
Honey is a viscous
supersaturated sugar solution with a high caloric density
which inhibits bacterial growth due to its low pH, high vis-
cosity, hygroscopic action and the presence of inhibine and
antioxidants.
27
In a study in patients with FG by Sub-
rahmanyam and Ugane
27
the honey-treated group of patients
showed faster clearing of slough as well as appearance of
healthy granulation tissue as compared to the eusol dressing
group. However, they concluded that multicentric trials are
needed before it is recommended for routine use.
Lyophilized collagenase
The use of lyophilized collagenase (an enzyme that digests
and debrides necrotic tissues) has also been described. After
control of the active infection, enzymatic debridement with
topical lyophilized collagenase can be performed twice daily
until denite reconstruction can be performed.
22
Vacuum Assisted Closure (VAC)
VAC is a technique in which the wound is exposed to sub-
atmospheric pressure for some time to promote debride-
ment and healing, leading to increased perfusion, broblast
migration, and cell mitosis and proliferation, thus promoting
rapid wound closure, removing infected materials/exudates,
reducing localised oedema and drawing the wound edges
together.
106
It is also shown to reduce the wound surface
area,
117
reduce the frequency of dressing change,
106
increase
patient comfort and decrease hospital stay
118
; but their
placement can pose signicant challenges.
106
A VAC device
usually consists of a sterile, open-cell foam sponge that is
placed in the wound and then covered with a transparent
adhesive drape that creates an airtight environment. Non-
collapsible tubing is used to connect this device to a portable
pump that provides continuous negative pressure.
106
Silberstein et al.
106
described the use of VAC in FG, wherein
a large sponge was cut into several pieces and stapled into the
wound. A drape (which was cut into several pieces and placed
over the sponge) was then applied and after cutting a small
hole in the drape, the vacuum tubing was placed along with
application of a suction device. Shimada et al.
107
reported
successful free skin grafting with the use of negative-pressure
bolster for a case of FG which was done in conjunction
with cystostomy, surgical debridement and broad-spectrum
antibiotics. Hence, VAC can be used as an adjuvant for the
treatment of FG.
Conclusion
Controversies over FG persist, but these do not affect the
treatment options. In most cases, an anorectal or genitouri-
nary disease creates an entry point for a mixed polymicrobial
infection, which usually consists of local non-pathogenic or-
ganisms. Despite all the advances in treatment today, FG re-
mains a surgical emergency. FGis a rare but severe and rapidly
progressive condition with considerable morbidity and mor-
tality, and hence it should be treated with aggressive uid
resuscitation along with appropriate antibiotics (both local
and systemic) and repeated extensive debridement of the
involved area to improve survival. Since prognosis is mainly
related to early diagnosis, a high index of suspicion and early
diagnosis leads to a more favourable outcome. Radiography
can be helpful when the clinical picture is ambiguous.
Reconstructive surgery (whenever required) gives satisfactory
results, reduces the hospital stay and helps to improve the
psychological condition of these patients. In addition to an
aggressive multidisciplinary treatment approach, nutritional
support should be taken care of and the risk factors that
precipitate or facilitate the development of the primary
infection should be looked for and should be taken care of at
the appropriate time.
Acknowledgement
None.
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