Treatment of Fournier's Gangrene With a Novel Negative Pressure Wound Therapy System

Jozef Verbelen, RN, MN; Henk Hoeksema, PT; Alexander Heyneman, RN, MN; Ali Pirayesh, MD; Stan Monstrey, MD, FRCS, PhD

Disclosures

Wounds. 2011;23(11):342-349. 

In This Article

Abstract and Introduction

Abstract

Fournier's gangrene (FG) is a complex condition that requires surgical debridement, hemodynamic support, antibiotics, and appropriate wound management. This study is the first to assess the use of a low-vacuum negative pressure wound therapy (LV-NPWT) system with low-adherent contact surface in two cases of FG. Methods. The protocol-of-care included twice weekly dressing changes and irrigation with a povidone-iodine-water mixture. Assessments included wound progression (% granulation tissue), ratings of dressing ingrowth, pain during treatment and at dressing changes, patient comfort, and ease-of- use. Results. A 51-year-old man (Patient A) developed FG after surgical removal of a perianal abscess. He received 16 days of LV-NPWT with five dressing changes. A 64-year-old man (Patient B) with multiple comorbidities, developed FG after traumatic injury. He received 20 days of LV-NPWT with six dressing changes. In both patients, LV-NPWT promoted rapid granulation tissue formation. Pain scores averaged low-to-moderate during treatment and dressing changes, and tissue ingrowth was minimal. Conclusion. Overall, ratings were favorable for LV-NPWT ease-of-use and patient comfort. Despite the complexity of these wounds, with the use of LV-NPWT, both wounds progressed to a point where they were able to successfully receive surgical closure with skin grafts and/or flaps. These cases may suggest that LV-NPWT may have a potential role in complex wound management.

Introduction

Fournier's gangrene (FG) is a life threatening condition characterized by an acute, often polymicrobial, necrotizing soft tissue infection of the perineal and genital region, possibly extending into the abdominal wall.[1–7] Fournier's disease can occur in both males and females.[2] Diabetes mellitus, vascular disease of the pelvis, morbid obesity, alcoholism, and intravenous drug abuse are found to be frequently cited predisposing comorbidities for FG.[1] Microorganisms often involved include Streptococci, Staphylococci, Enterobacteriaceae, anaerobic organisms, and/or fungi.[1]

Standard multidisciplinary management of FG consists of urgent and aggressive surgical debridement, intensive hemodynamic support, and stabilization combined with broad-spectrum antibiotics.[1–7] Surgical debridement, repeated if necessary, will result in large volume deficit wound(s) requiring further wound bed preparation before surgical reconstruction with skin grafts and/or muscle flaps can be performed.

Besides daily dressing changes and/or hyperbaric oxygen therapy, one documented option for wound bed preparation is the application of negative pressure wound therapy (NPWT) also referred to as topical negative pressure (TNP).[4–10] NPWT involves the application of a controlled subatmospheric pressure to a wound bed. The vacuum is generated by a pump and subsequently conducted and diffused to the vacuum-sealed wound bed by a specialized NPWT dressing.

Mechanisms of action attributed to NPWT include an increase in blood flow, promotion of angiogenesis, reduction in wound surface area, positive modulation of the inhibitory contents of wound fluid, induction of cell proliferation, reduction of edema, and bacterial clearance.[11]

The first commercially available system for NPWT, V.A.C® Therapy (KCI, Inc, San Antonio, TX), was developed in the 1990s.[12–14] Since then, several other NPWT systems have been commercialized. Two dressings are commonly used in NPWT: foam (polyurethane foam, polyvinylalcohol foam) and gauze (fluff dried 100% woven gauze with a crinkle-weave pattern). Generally, -125 mmHg is considered as standard negative pressure during NPWT, but the most efficacious level of negative pressure remains a subject of debate with opinions ranging from -40 mmHg to -150 mmHg.[11,15–17]

Another option for applying NPWT is the Engenex® Advanced NPWT System using the Engenex® NPWT pump with Bio-Dome™ Wound Interface Dressing ([LV-NPWT], ConvaTec, Inc, Skillman, NJ—Engenex and Bio-Dome are registered trademarks of Boehringer Technologies, LP). The dressing is composed of nonwoven polyester layers joined by a silicone elastomer with a low adherent contact surface containing numerous void spaces. Due to the unique properties of the dressing negative pressure is applied at lower vacuum ranging from -30 mmHg to -75 mmHg.

The objective of these case studies was to assess the use of LV-NPWT in the preparation of FG wounds for surgical closure. To date, there are no published studies on the use of LV-NPWT in these types of wounds.

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