Outcomes in Fournier's Gangrene Using Skin and Soft Tissue Sparing Flap Preservation Surgery for Wound Closure

An Alternative Approach to Wide Radical Debridement

Travis L. Perry, MD; Lindsay M. Kranker, MD; Erin E. Mobley, PA; Eileen E. Curry, MD; R. Michael Johnson, MD, MPH

Disclosures

Wounds. 2018;30(10):290-299. 

In This Article

Abstract and Introduction

Abstract

Introduction: Fournier's gangrene (FG) remains a forbidding necrotizing soft tissue infection (NSTI) that necessitates early recognition, prompt surgical excision, and goal-directed antibiotic therapy. Traditionally, surgical management has included wide radical excision for sepsis control, but this management often leaves large, morbid wounds that require complex wound coverage, prolonged hospitalizations, and/or delayed healing.

Objective: The purpose of this case series is to report the outcomes of FG using a surrogate approach of concurrent debridement of spared skin and soft tissue, negative pressure wound therapy (NPWT), and serial delayed primary closure (DPC).

Materials and Methods: A retrospective review of 17 consecutive patients with FG treated with concurrent skin and soft tissue sparing surgery, NPWT, and serial DPC at Miami Valley Hospital Regional Adult Burn and Wound Center (Dayton, OH) between 2008 and 2018 was conducted. Patients were included if the following were noted: clinical suspicion of FG based on genital and perineal cellulitis, fever, leukocytosis, and confirmation of tissue necrosis upon surgical exploration. Patients not treated with skin sparing surgical debridement or wounds with an inability to maintain a NPWT dressing seal were excluded.

Results: The mean number of total surgeries including simultaneous debridement and reconstruction was 5.5. The average intensive care unit and hospital length of stay was 3.2 and 18.9 days, respectively. The average number of days from initial consult to wound closure was 24.3. The need for colostomy and skin grafts were nearly eliminated with this surrogate approach. Using this reproducible technique, DPC was achieved in 100% of patients. Only 11.8% (2/17) required split-thickness skin grafting as part of wound closure. The majority (9/17; 52.9%) were partially managed as an outpatient during wound closure. During staged DPC, the mean number of outpatient management days was 16.0. There were no mortalities in this series of patients.

Conclusions: To the best of the authors' knowledge, this is the largest case series reported in the literature using skin and soft tissue sparing surgery for wound closure of a FG NSTI.

Introduction

Fournier's gangrene (FG) is an infrequent yet rapidly advancing, life-threatening necrotizing soft tissue infection (NSTI). Even Hippocrates, in the earliest known written description of NSTIs, singles out FG's particularly devastating effects, writing "But the most dangerous cases of all cases were when the pubes and genital organs were attacked."[1] The eponym is assigned to Jean-Alfred Fournier, a Parisian dermatologist and venereologist, who published a case series in 1883 describing "fulminant gangrene" of the penis and scrotum in 5 otherwise healthy young men.[2] There are only 1000 NSTI cases in the United States annually,[3] but the incidence appears to be increasing.[4–6] Conclusive diagnosis is established upon surgical exploration. The fundamental surgical goals are immediate abolishment of purulent and necrotic tissue to eliminate further vertical and centrifugal transmission of infection during the primary exploration.[7,8]

The mortality rate of NSTI has decreased over the last 10 years due to increased emphasis on high degree of suspicion, early diagnosis, sepsis protocols with early broad-spectrum antibiotics, and surgical intervention. Traditionally reported mortality rates range from 3.6% to 40%,[3,4,9–18] with even higher rates reported,[19,20] but recent National Surgical Quality Improvement Program data suggest a modern mortality of about 10%.[5] Historically, surgical management of FG, which includes wide radical excision of the sentinel area of necrosis as well as potentially viable surrounding skin and soft tissue, has remained relatively unchanged. Patients are left with large, morbid perioperative wounds that often necessitate multiple surgical debridements prior to reconstruction; other centers report 2.64,[12] 5.02,[4] and 5.55[21] debridements. Increased length of stay (LOS) is inextricably linked to these large, complex wounds. Studies report LOS consistent with 69.3 days,[4] 41 days,[22] 36 days,[9] 19.7 days,[23] 18 days,[5] and 12 days.[12] These large, complex wounds also create formidable challenges in regards to postoperative wound care, quality of life, functionality, and acceptable cosmetic outcomes. Many of these wounds are still allowed to close by secondary intention wound healing; even with superior care, 18% remain partially open at 6-month follow-up.[12] Patients experience long-term decreases in quality of life even after the physical wounds have healed.[24]

Previous studies have characterized the degrees of skin and soft tissue viability in a similar manner to thermal wound theory, which describes injury zones of coagulation, stasis, and hyperemia.[7] As described by Wong et al,[7] zone 1 is the area of nonviable skin at the epicenter of infection and exhibits hemorrhagic bullae, dermal hemorrhage, and frank dermal gangrene. Zone 2 surrounds zone 1 and is marked by exquisite tenderness, erythema, and warmth. Zone 3 is normal skin not yet infected. Although necrosis within zone 1 must be resected in its entirety, zones 2 and 3 depict potentially salvageable skin and soft tissue to be used for future reconstruction (Figures 1, 2).[7] These observations closely evaluate the somatic clues of skin and soft tissue viability. They also promote recognition of collateral blood flow from the dermal and subdermal plexus to viable skin and soft tissue. This insight afforded the authors the opportunity to develop a technique that promotes complete surgical excision with safe skin and soft tissue flap preservation.

Figure 1.

Zone 1 depicts the sentinel area of infection that is completely excised via an exploratory incision (arrows). Zone 2 depicts the outer extent of undermining by infection; note the skin in zone 2 is cellulitic, not necrotic, and is potentially salvageable through intact dermal and subdermal collateral blood flow preservation. Zone 3 illustrates normal skin.

Figure 2.

Zone 1 depicts the sentinel area of infection, which has the greatest vertical transmission. Zone 2 depicts the outer extent of undermining and the centrifugal spread of infection. Note that zone 2 houses potentially salvageable intact dermal and subdermal collateral microvasculature. Figure created by Lindsay Kranker, MD.

This 17-patient case series reports the outcomes of FG using a surrogate approach of concurrent debridement of spared skin and soft tissue, negative pressure wound therapy (NPWT), and serial delayed primary closure (DPC). The treatment in these cases serves to contrast the traditional surgical management team approach. The authors approached each case through exploratory incisions that allowed full access to the underlying infection and necrosis while considering future reconstruction using spared skin and soft tissue. This illustrates the Miami Valley Hospital Regional Adult Burn and Wound Center (Dayton, OH) approach of meticulous serial debridement with simultaneous DPC of spared skin and soft tissue flaps in FG.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....