Keywords
Fournier's gangrene
necrotizing fasciitis
emergency department
necrotizing fasciitis
emergency department
How to Cite
Bollano, E., Lilaj, K., Thereska, D., & Dogjani, A. (2023). Fournier’s gangrene in Patients Operated for Hemorrhoidal Prolapse in the Surgical Emergency Department. Albanian Journal of Trauma and Emergency Surgery, 7(2), 1315-1321. https://doi.org/10.32391/ajtes.v7i2.349
Abstract
Fournier's gangrene (FG) is a well known often fatal fasziitis of the pelvic floor following ano-rectal, urologic and gynecologic infections. Although rarely it is described as a complication of operative anal procedures and predisposing factors such as diabetes, alcoholism, immune-defects and consumptive diseases.
Current literature only briefly mentions the potential risk of FG after such a common surgical procedure. However, devastating complications occur more often than expected. This catastrophic complication without a predisposing factor is discussed along with a review of the literature.
The objective of this article is to provide updated and relevant information regarding the recognition, diagnosis and management of FG, from the general surgeon to the emergency department.
This article refers to two complicated cases of Fournier's gangrene. The patients underwent emergency surgical intervention with the diagnosis of hemorrhoidal prolapse with rectal bleeding and accompanying anemia…
Conclusion; The gold standard for treatment was found to be a combination of surgical debridement, broad-spectrum antibiotics, and the administration of intravenous fluids. Further, patient survival was found to be directly related to the time from diagnosis to treatment when they underwent surgical debridement.
The General surgeon must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management.
References
1. Ephimenko NA, Privolnee VV. Furnier's gangrene. Clin Microbiol Antimicrob Chemother. 2008; 10:25–34.
2. Rizos S, Filippou DK, Condilis N, Filippou G, Trigka A, Skandalakis P, et al. Fournier’s gangrene. Ann. Ital. Chir. 2005;76(6):563–7.
3. Nathan B. Fournier's gangrene: a historical vignette. (Letter). Can J Surg 19984172 [PMC free article] [PubMed] [Google Scholar] [Ref list]
4. Fournier J ‐ A. Gangrene foudroyante de la verge. Semaine Medicale 18833345–348. [Google Scholar]
5. Sorensen M.D., Krieger J.N., Rivara F.P., Broghammer J.A., Klein M.B., Mack C.D., Wessells H. Fournier’s Gangrene: Population Based Epidemiology and Outcomes. J. Urol. 2009;181:2120–2126. doi: 10.1016/j.juro.2009.01.034. [PMC free article] [PubMed] [CrossRef] [Google Scholar] [Ref list]
6. Lewis GD, Majeed M, Olang CA, Patel A, Gorantla VR, Davis N, Gluschitz S. Fournier's Gangrene Diagnosis and Treatment: A Systematic Review. Cureus. 2021 Oct 21;13(10):e18948. doi: 10.7759/cureus.18948. PMID: 34815897; PMCID: PMC8605831.
7. Mishra SP, Singh S, Gupta SK. Necrotizing Soft Tissue Infections: Surgeon's Prospective. Int J Inflam. 2013;2013:609628. [PMC free article] [PubMed] [Reference list]
8. Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, Mammen K. Fournier's gangrene and its emergency management. Postgrad Med J. 2006 Aug;82(970):516-9. [PMC free article] [PubMed] [Reference list]
9. Fournier's gangrene mortality: a 17-year systematic review and meta-analysis. El-Qushayri AE, Khalaf KM, Dahy A, et al. Int J Infect Dis. 2020;92:218–225. [PubMed] [Google Scholar] [Ref list]
10. Eke N. Fourniers gangrene: a review of 1726 cases. Br J Surg 200087718–728. [PubMed] [Google Scholar] [Ref list]
11. Wetterauer, C., Ebbing, J., Halla, A., Kuehl, R., Erb, S., Egli, A., Schaefer, D. J., & Seifert, H. H. (2018). A contemporary case series of Fournier's gangrene at a Swiss tertiary care center-can scoring systems accurately predict mortality and morbidity?. World journal of emergency surgery: WJES, 13, 25. https://doi.org/10.1186/s13017-018-0187-0
12. Fournier's gangrene: clinical presentation of 13 cases. Kuzaka B, Wróblewska MM, Borkowski T, Kawecki D, Kuzaka P, Młynarczyk G, Radziszewski P. Med Sci Monit. 2018;24:548–555. [PMC free article] [PubMed] [Google Scholar] [Ref list]
13. Vick R, Carson CC., III Fournier’s disease. Urologic Clinics of North America. 1999;26(4):841–849. [PubMed] [Google Scholar]
14. Cihan, A., Menteş, B. B., Sucak, G., Karamercan, A., Naznedar, R., & Ferahköşe, Z. (1999). Fournier's gangrene after hemorrhoidectomy: association with drug-induced agranulocytosis. Report of a case. Diseases of the colon and rectum, 42(12), 1644–1648. https://doi.org/10.1007/BF02236224
15. Prohorov AV. Furnier's gangrene. Kazan Med J. 2016; 97: 256–261.
16. Chernyadyev SA, Ufimtseva MA, Vishnevskaya IF, Bochkarev YM, Ushakov AA, Beresneva TA, Galimzyanov FV, Khodakov VV. Fournier's Gangrene: Literature Review and Clinical Cases. Urol Int. 2018;101(1):91-97. doi: 10.1159/000490108. Epub 2018 Jun 27. PMID: 29949811; PMCID: PMC6106138.
17. Kincius M, Telksnys T, Trumbeckas D, Jievaltas M, Milonas D. Evaluation of LRINEC scale feasibility for predicting outcomes of Fournier gangrene. Surg Infect (Larchmt) 2016; 17:448–453.
18. 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 literature review. World J Surg Oncol. 2016;14:34. [PMC free article] [PubMed] [Google Scholar]
19. Kaya C, Bozkurt E, Ömero?lu S, Yazici P, Mihmanli M (2017) Fournier’s Gangrene after Hemorrhoidectomy: Case Report and Review of Literature. Gastroenterol Hepatol Open Access 7(2): 00238. DOI: 10.15406/ghoa.2017.07.00238
20. Jeong, H. J., Park, S. C., Seo, I. Y., & Rim, J. S. (2005). Prognostic factors in Fournier gangrene. International journal of urology: official journal of the Japanese Urological Association, 12(12), 1041–1044. https://doi.org/10.1111/j.1442-2042.2005.01204.x
21. Yanar H, Taviloglu K, Ertekin C, et al. Fournier’s gangrene: risk factors and strategies for management. World J Surg. 2006;30(9):1750–1754.
22. Kilic A, Aksoy Y, Kilic L. Fournier’s gangrene: etiology, treatment, and complications. Ann Plast Surg. 2001;47(5):523–527.
23. Gutmann H, Gonen P, Deutsch AA. Complications of anal dilatation for acute anal fissure (letter). Dis Colon Rectum. 1989;32(6):545.
24. Cakmak GK, Irkorucu O, Ucan BH, et al. Fournier’s gangrene after open hemorrhoidectomy without a predisposing factor: report of a case and review of the literature. Case Rep Gastroenterol. 2009;3(2):147–155.
25. Wang YS, Wong CH, Tay YK. Staging of necrotizing fasciitis based on the evolving cutaneous features. Int J Dermatol. 2007;46(10):1036–1041.
26. Wall DB, de Virgilio C, Black S, et al. Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection. Am J Surg. 2000;179(1):17–19.
27. Korkut M, Içöz G, Dayangaç M, Akgün E, et al. Outcome analysis in patients with Fournier’s gangrene: report of 45 cases. Dis Colon Rectum. 2003;46(5):649–652.
28. El Ammari JE, Ahssaini M, El Fassi MJ, et al. Retroperitoneal-necrotizing fasciitis due to chronic pyelonephritis. J Emerg Trauma Shock. 2010;3(4):419–420.
29. Czymek, R., Hildebrand, P., Kleemann, M., Roblick, U., Hoffmann, M., Jungbluth, T., Bürk, C., Bruch, H. P., & Kujath, P. (2009). New insights into the epidemiology and etiology of Fournier's gangrene: a review of 33 patients. Infection, 37(4), 306–312. https://doi.org/10.1007/s15010-008-8169-x
30. Fajdic J, Bukovic D, Hrgovic Z, et al. Management of Fournier’s gangrene - report of 7 cases and review of the literature. Eur J Med Res. 2007;12(4):169–172.
31. Sugihara, T., Yasunaga, H., Horiguchi, H., Fujimura, T., Ohe, K., Matsuda, S., Fushimi, K., & Homma, Y. (2012). Impact of surgical intervention timing on the case fatality rate for Fournier's gangrene: an analysis of 379 cases. BJU international, 110(11 Pt C), E1096–E1100. https://doi.org/10.1111/j.1464-410X.2012.11291.x
32. Bonkat G., Bartoletti R., Bruyère F., Cai T., Geerlings S.E., Köves B., Schubert S., Wagenlehner F. EAU Guidelines on Urological Infections, European Association of Urology. 2021. [(accessed on 12 July 2021)]. Available online: https://uroweb.org/guideline/urological-infections/ [Ref list]
33. Park SJ, Kim DH, Choi CI, Yun SP, Kim JH, Seo HI, et al. Necrotizing soft tissue infection: analysis of the factors related to mortality in 30 cases of a single institution for 5 years. Ann Surg Treat Res. 2016;91:45–50. [PMC free article] [PubMed] [Google Scholar] [Ref list]
34. Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014 Aug;51(8):344-62. [PMC free article] [PubMed] [Reference list]
35. Park SJ, Kim DH, Choi CI, Yun SP, Kim JH, Seo HI, et al. Necrotizing soft tissue infection: analysis of the factors related to mortality in 30 cases of a single institution for 5 years. Ann Surg Treat Res. 2016;91:45–50. [PMC free article] [PubMed] [Google Scholar] [Ref list]
36. Erol B, Tuncel A, Hanci V, Tokgoz H, Yildiz A, Akduman B, Kargi E, Mungan A: Fournier’s gangrene: overview of prognostic factors and definition of new prognostic parameter. Urology 2010; 75:1193–1198. https://doi.org/10.1016%2Fj.urology.2009.08.090
37. Ersay, A., Yilmaz, G., Akgun, Y., & Celik, Y. (2007). Factors affecting mortality of Fournier's gangrene: review of 70 patients. ANZ journal of surgery, 77(1-2), 43–48. https://doi.org/10.1111/j.1445-2197.2006.03975.x
2. Rizos S, Filippou DK, Condilis N, Filippou G, Trigka A, Skandalakis P, et al. Fournier’s gangrene. Ann. Ital. Chir. 2005;76(6):563–7.
3. Nathan B. Fournier's gangrene: a historical vignette. (Letter). Can J Surg 19984172 [PMC free article] [PubMed] [Google Scholar] [Ref list]
4. Fournier J ‐ A. Gangrene foudroyante de la verge. Semaine Medicale 18833345–348. [Google Scholar]
5. Sorensen M.D., Krieger J.N., Rivara F.P., Broghammer J.A., Klein M.B., Mack C.D., Wessells H. Fournier’s Gangrene: Population Based Epidemiology and Outcomes. J. Urol. 2009;181:2120–2126. doi: 10.1016/j.juro.2009.01.034. [PMC free article] [PubMed] [CrossRef] [Google Scholar] [Ref list]
6. Lewis GD, Majeed M, Olang CA, Patel A, Gorantla VR, Davis N, Gluschitz S. Fournier's Gangrene Diagnosis and Treatment: A Systematic Review. Cureus. 2021 Oct 21;13(10):e18948. doi: 10.7759/cureus.18948. PMID: 34815897; PMCID: PMC8605831.
7. Mishra SP, Singh S, Gupta SK. Necrotizing Soft Tissue Infections: Surgeon's Prospective. Int J Inflam. 2013;2013:609628. [PMC free article] [PubMed] [Reference list]
8. Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, Mammen K. Fournier's gangrene and its emergency management. Postgrad Med J. 2006 Aug;82(970):516-9. [PMC free article] [PubMed] [Reference list]
9. Fournier's gangrene mortality: a 17-year systematic review and meta-analysis. El-Qushayri AE, Khalaf KM, Dahy A, et al. Int J Infect Dis. 2020;92:218–225. [PubMed] [Google Scholar] [Ref list]
10. Eke N. Fourniers gangrene: a review of 1726 cases. Br J Surg 200087718–728. [PubMed] [Google Scholar] [Ref list]
11. Wetterauer, C., Ebbing, J., Halla, A., Kuehl, R., Erb, S., Egli, A., Schaefer, D. J., & Seifert, H. H. (2018). A contemporary case series of Fournier's gangrene at a Swiss tertiary care center-can scoring systems accurately predict mortality and morbidity?. World journal of emergency surgery: WJES, 13, 25. https://doi.org/10.1186/s13017-018-0187-0
12. Fournier's gangrene: clinical presentation of 13 cases. Kuzaka B, Wróblewska MM, Borkowski T, Kawecki D, Kuzaka P, Młynarczyk G, Radziszewski P. Med Sci Monit. 2018;24:548–555. [PMC free article] [PubMed] [Google Scholar] [Ref list]
13. Vick R, Carson CC., III Fournier’s disease. Urologic Clinics of North America. 1999;26(4):841–849. [PubMed] [Google Scholar]
14. Cihan, A., Menteş, B. B., Sucak, G., Karamercan, A., Naznedar, R., & Ferahköşe, Z. (1999). Fournier's gangrene after hemorrhoidectomy: association with drug-induced agranulocytosis. Report of a case. Diseases of the colon and rectum, 42(12), 1644–1648. https://doi.org/10.1007/BF02236224
15. Prohorov AV. Furnier's gangrene. Kazan Med J. 2016; 97: 256–261.
16. Chernyadyev SA, Ufimtseva MA, Vishnevskaya IF, Bochkarev YM, Ushakov AA, Beresneva TA, Galimzyanov FV, Khodakov VV. Fournier's Gangrene: Literature Review and Clinical Cases. Urol Int. 2018;101(1):91-97. doi: 10.1159/000490108. Epub 2018 Jun 27. PMID: 29949811; PMCID: PMC6106138.
17. Kincius M, Telksnys T, Trumbeckas D, Jievaltas M, Milonas D. Evaluation of LRINEC scale feasibility for predicting outcomes of Fournier gangrene. Surg Infect (Larchmt) 2016; 17:448–453.
18. 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 literature review. World J Surg Oncol. 2016;14:34. [PMC free article] [PubMed] [Google Scholar]
19. Kaya C, Bozkurt E, Ömero?lu S, Yazici P, Mihmanli M (2017) Fournier’s Gangrene after Hemorrhoidectomy: Case Report and Review of Literature. Gastroenterol Hepatol Open Access 7(2): 00238. DOI: 10.15406/ghoa.2017.07.00238
20. Jeong, H. J., Park, S. C., Seo, I. Y., & Rim, J. S. (2005). Prognostic factors in Fournier gangrene. International journal of urology: official journal of the Japanese Urological Association, 12(12), 1041–1044. https://doi.org/10.1111/j.1442-2042.2005.01204.x
21. Yanar H, Taviloglu K, Ertekin C, et al. Fournier’s gangrene: risk factors and strategies for management. World J Surg. 2006;30(9):1750–1754.
22. Kilic A, Aksoy Y, Kilic L. Fournier’s gangrene: etiology, treatment, and complications. Ann Plast Surg. 2001;47(5):523–527.
23. Gutmann H, Gonen P, Deutsch AA. Complications of anal dilatation for acute anal fissure (letter). Dis Colon Rectum. 1989;32(6):545.
24. Cakmak GK, Irkorucu O, Ucan BH, et al. Fournier’s gangrene after open hemorrhoidectomy without a predisposing factor: report of a case and review of the literature. Case Rep Gastroenterol. 2009;3(2):147–155.
25. Wang YS, Wong CH, Tay YK. Staging of necrotizing fasciitis based on the evolving cutaneous features. Int J Dermatol. 2007;46(10):1036–1041.
26. Wall DB, de Virgilio C, Black S, et al. Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection. Am J Surg. 2000;179(1):17–19.
27. Korkut M, Içöz G, Dayangaç M, Akgün E, et al. Outcome analysis in patients with Fournier’s gangrene: report of 45 cases. Dis Colon Rectum. 2003;46(5):649–652.
28. El Ammari JE, Ahssaini M, El Fassi MJ, et al. Retroperitoneal-necrotizing fasciitis due to chronic pyelonephritis. J Emerg Trauma Shock. 2010;3(4):419–420.
29. Czymek, R., Hildebrand, P., Kleemann, M., Roblick, U., Hoffmann, M., Jungbluth, T., Bürk, C., Bruch, H. P., & Kujath, P. (2009). New insights into the epidemiology and etiology of Fournier's gangrene: a review of 33 patients. Infection, 37(4), 306–312. https://doi.org/10.1007/s15010-008-8169-x
30. Fajdic J, Bukovic D, Hrgovic Z, et al. Management of Fournier’s gangrene - report of 7 cases and review of the literature. Eur J Med Res. 2007;12(4):169–172.
31. Sugihara, T., Yasunaga, H., Horiguchi, H., Fujimura, T., Ohe, K., Matsuda, S., Fushimi, K., & Homma, Y. (2012). Impact of surgical intervention timing on the case fatality rate for Fournier's gangrene: an analysis of 379 cases. BJU international, 110(11 Pt C), E1096–E1100. https://doi.org/10.1111/j.1464-410X.2012.11291.x
32. Bonkat G., Bartoletti R., Bruyère F., Cai T., Geerlings S.E., Köves B., Schubert S., Wagenlehner F. EAU Guidelines on Urological Infections, European Association of Urology. 2021. [(accessed on 12 July 2021)]. Available online: https://uroweb.org/guideline/urological-infections/ [Ref list]
33. Park SJ, Kim DH, Choi CI, Yun SP, Kim JH, Seo HI, et al. Necrotizing soft tissue infection: analysis of the factors related to mortality in 30 cases of a single institution for 5 years. Ann Surg Treat Res. 2016;91:45–50. [PMC free article] [PubMed] [Google Scholar] [Ref list]
34. Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014 Aug;51(8):344-62. [PMC free article] [PubMed] [Reference list]
35. Park SJ, Kim DH, Choi CI, Yun SP, Kim JH, Seo HI, et al. Necrotizing soft tissue infection: analysis of the factors related to mortality in 30 cases of a single institution for 5 years. Ann Surg Treat Res. 2016;91:45–50. [PMC free article] [PubMed] [Google Scholar] [Ref list]
36. Erol B, Tuncel A, Hanci V, Tokgoz H, Yildiz A, Akduman B, Kargi E, Mungan A: Fournier’s gangrene: overview of prognostic factors and definition of new prognostic parameter. Urology 2010; 75:1193–1198. https://doi.org/10.1016%2Fj.urology.2009.08.090
37. Ersay, A., Yilmaz, G., Akgun, Y., & Celik, Y. (2007). Factors affecting mortality of Fournier's gangrene: review of 70 patients. ANZ journal of surgery, 77(1-2), 43–48. https://doi.org/10.1111/j.1445-2197.2006.03975.x
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.