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

Results

The authors evaluated a total of 17 cases of FG. An average of 5.5 operative interventions were performed, including simultaneous debridement and reconstruction. The average ICU and hospital LOS was 3.2 and 18.9 days, respectively. The average number of days from initial consult to wound closure was 24.3. Only 1 patient required an ostomy due to complete lack of viable perianal skin. Delayed primary closure was achieved in 100% of patients. Only 2 patients required a STSG as part of wound closure. Of those 2, the area of skin grafting required was well-below 15% of the total initial wound area. Nine of 17 patients were partially managed as an outpatient during wound closure; for these 9 patients, the mean number of outpatient management days was 16.0. There were no mortalities in this series of patients.

The following serve as exemplary cases of the 17 patients with FG treated with the reported surgical technique and wound healing course of treatment. eTable 2 documents all surgical and clinical outcome data for the 17 patients.

Case 2

A 42-year-old Caucasian man presented with a 5-day history of pain in the left buttock. The patient initially was seen at an outside hospital 5 days prior to presenting to the authors' institution and was treated for left thigh cellulitis with oral trimethoprim/sulfamethoxazole 800 mg to 160 mg twice daily for 10 days. His symptoms worsened prior to completion of this antibiotic course to include fever, malaise, and nausea. A computed tomography (CT) scan was consistent with extensive gas throughout the buttock, perineal region, and left hemiscrotum, with evidence of abscess in the left perianal region suggestive of FG.

On presentation, the patient received a 1-time dose of intravenous (IV) vancomycin 1000 mg, IV piperacillin/tazobactam 3.375 g, and IV clindamycin 300 mg. Infectious disease was consulted given this patient's status as a kidney transplant recipient. The IV clindamycin dosage was increased to 600 mg and continued for 3 additional doses. Intravenous daptomycin 750 mg was administered every 48 hours for 2 doses. The patient also was started on IV meropenem 1 g twice daily, which after 3 days was increased to 3 times daily for 11 additional days. This was later changed to IV ertapenem 1 g daily for 9 days (for a total 21-day course). In addition, he received recommended preventative antimicrobials, including oral trimethoprim/sulfamethoxazole 160 mg to 800 mg every Monday, Wednesday, and Friday (for Pneumocystis carinii pneumonia prevention) and oral valganciclovir 450 mg daily (for Cytomegalovirus disease prevention).

With an initial wound size of 400 cm2, the patient received the previously described operative management and wound care over the course of 32 in-hospital days and 0 outpatient days. The wound closed in 29 days (Figure 7).

Figure 7.

Case 2: Large (A) skin and (B) soft tissue flap preservation (black arrows); (C) staged delayed primary closure of preserved skin and soft tissue flaps from groin, scrotum, and perianal regions; and (D) outpatient 5-month follow-up after closure showed well-healed original exploratory incision (white arrows).

Case 3

A 52-year-old Caucasian man presented to an outside emergency department (ER) with perianal redness, swelling, and pain and was prescribed an oral 7-day course of levofloxacin 750 mg tablet daily and 10-day course of metronidazole 500 mg three times daily. His symptoms continued to worsen, and 3 days after initial presentation, he presented to the Miami Valley Hospital ER with a 6-day history of symptoms, including subjective fever, nausea, and vomiting. A CT scan of the pelvis demonstrated gas within the scrotum extending into the perineum concerning for FG.

On presentation, the patient received 1 dose of IV clindamycin 900 mg. He was placed immediately on IV piperacillin/tazobactam 3.375 g three times daily for 19 days and IV vancomycin 1 g twice daily for 18 days. He underwent initial debridement with emergency general surgery upon admission, but surgical care was later transferred to a burn and wound surgeon (TP). This patient also received 1 dose of IV cefazolin 2 g for surgical prophylaxis, which likely was administered in error without realizing the patient was on scheduled antibiotics. Wound cultures were positive for anaerobic gram-positive cocci and anaerobic gram-negative bacilli, beta-lactamase positive.

After receiving the above treatment protocol, the patient received a 35-cm2 STSG (initial wound size of 274 cm2), and the wound was closed on treatment day 19 after a hospital LOS of 21 days and no outpatient treatment (Figure 8).

Figure 8.

Case 3: (A) Wide perineum wound closed with (B) delayed primary closure (DPC) technique with a 35-cm2 split-thickness skin graft (STSG) (white arrow); and (C) outpatient follow-up 11 months after closure yielded acceptable outcomes of DPC and STSG.

Case 4

A 50-year-old Caucasian man presented to the Miami Valley Hospital ER with a 3- to 4-day history of swelling, redness, and increasing pain to the right buttock that was quickly spreading to the perineum and right testicle. A CT of the pelvis demonstrated subcutaneous edema and gas in the right perineum and scrotum with superficial abscess of the right buttock pathognomonic for FG. The patient underwent surgical debridement by emergency general surgery immediately upon admission. He received IV clindamycin 600 mg once then 900 mg 3 times daily for 3 days. Infectious disease was consulted early and managed the patient's antimicrobials, including IV vancomycin 1000 mg twice daily for 3 days and IV piperacillin/tazobactam 3.375 g three times daily for 30 days. Intravenous anidulafungin was added due to Candida growth on operative cultures, starting with a 200-mg loading dose followed by 100 mg daily for 20 days. Oral rifaximin 550 mg twice daily for 27 days was continued for treatment of hepatic encephalopathy.

With an initial wound size of 282 cm2, the patient's wound closed in 25 days with 29 in-hospital days following the aforementioned treatment (Figure 9).

Figure 9.

Case 4: Large preservation of (A) right scrotal skin and (B) soft tissue (black arrows); (C) partially closed wound and counter exploratory incision (white arrows) with contamination precautions implemented using fecal diversion device (black arrow); and (D) 9-month clinical follow-up with excellent cosmetic outcome of both the primary and counter exploratory incisions.

Case 5

A 37-year-old Caucasian man presented to a satellite ER of the authors' hospital with a complaint of right groin and testicular pain with associated fever and chills lasting 4 days. A CT of the pelvis showed subcutaneous gas within the anterior pelvis and medial thigh concerning for FG, so the patient was transferred to Miami Valley Hospital.

He was prescribed IV piperacillin/tazobactam 4.5 g loading dose followed by 3.375 g three times daily for 10 days. He also received IV clindamycin 900 mg loading dose followed by 600 mg three times daily; IV vancomycin 1250 mg twice daily also was administered for 2 days. The patient underwent surgical debridement with emergency general surgery immediately upon admission. Initial blood cultures were positive for gram-negative bacilli, and wound cultures were positive for multiple types of anaerobic gram-positive rods, anaerobic gram-negative bacilli, anaerobic gram-positive cocci, and Prevotella species. Aerobic cultures also grew gram-positive cocci and gram-negative bacilli.

Subsequently, the patient developed a rash that was attributed to piperacillin/tazobactam. He then was transitioned to IV vancomycin 1250 mg twice daily (later 1.5 g 2x/day), IV levofloxacin 750 mg daily, and IV metronidazole 500 mg three times daily for 9 additional days; IV fluconazole 400 mg daily also was added for 8 days.

The patient presented with a wound measuring 287 cm2, had a hospital LOS of 18 days and outpatient treatment of 10 days, and achieved wound closure following 28 days of this treatment (eFigure 10).

eFigure 10.

Case 5: (A) Skin and soft tissue sparing flap preservation technique with (B) delayed primary closure extending along the groin, scrotum, and perianal region; and (C) outpatient follow-up at 9.5 months shows great cosmetic and functional outcomes.

Case 6

A 56-year-old Caucasian woman presented to the Miami Valley Hospital ER with complaint of a right labial abscess that had been present for 3 days, with worsening swelling and redness. Previous treatment from the Miami Valley Hospital ER visit 3 days prior to presentation included oral cephalexin 500 mg 4 times per day for 7 days and trimethoprim-sulfamethoxazole 160 mg to 800 mg twice daily for 7 days (neither course was completed). A CT of the pelvis demonstrated a large area of inflammatory change and gas within the right labial soft tissues concerning for gas gangrene. She was treated empirically with IV vancomycin 1750 mg loading dose, then 1500 mg twice daily for 5 days and IV piperacillin/tazobactam 3.375 g three times daily for 13 days. The patient underwent emergent excisional debridement with the gynecology service on admission. Wound cultures were positive for microaerophilic streptococci. She was transitioned to oral amoxicillin-clavulanate 500 mg to 125 mg twice daily for 7 additional days. She also received 2 separate single doses of oral fluconazole 150 mg for urinary fungal infections.

With an initial wound measurement of 475 cm2 that took 27 days to close, she had a hospital LOS of 16 days and outpatient treatment of 6 days (Figure 11).

Figure 11.

Case 6: (A) Large, complex Fournier's gangrene treated with (B) skin and soft tissue sparing flap preservation surgery (black arrows); and (C) outpatient follow-up at 5.5 months demonstrated good cosmetic and functional outcomes.

Case 7

A 43-year-old Caucasian woman presented to the Miami Valley Hospital ER with primary complaints of weakness, nausea, and vomiting after experiencing a fall from a standing position. She was found to have an acute kidney injury secondary to dehydration and septic shock requiring pressor support. A right labial abscess present 2 days prior to admission was believed to be the source of sepsis. The gynecologic service was consulted on hospital day 1 and performed a bedside incision and drainage (I&D). The patient then was started on IV clindamycin 600 mg three times daily for 4 doses, then coverage was broadened to include IV vancomycin 1250 mg daily and IV piperacillin/tazobactam 3.375 g every 12 hours for 4 days. Oral fluconazole 50 mg also was administered once at the time of admission. The piperacillin/tazobactam then was discontinued and the patient was started on oral doxycycline 100 mg twice daily for 6 days.

Cultures grew methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, and coagulase-negative staphylococci (CoNS). On hospital day 12, she had worsening pain and swelling of the right labia. A CT scan showed evidence of persistent abscess; therefore, she was taken to the OR by the gynecologic service for I&D of the right vulvar abscess with vulvar debridement and partial vulvectomy. Operative cultures grew MRSA and E coli with 1 of 2 blood cultures growing CoNS. Intravenous vancomycin 1000 mg twice daily for 8 days and IV piperacillin/tazobactam 3.375 g every 12 hours were started for 11 days. The surgeon (TP) was consulted on hospital day 14 and performed subsequent debridements and complex closure.

As the vancomycin was discontinued, the oral doxycycline 100 mg twice daily was restarted for 6 additional days. When the piperacillin/tazobactam was discontinued, the patient was transitioned to oral amoxicillin-clavulanate 875 mg to 125 mg twice daily. Both the doxycycline 100 mg twice daily and oral amoxicillin-clavulanate 875 mg to 125 mg twice daily were continued 7 days after discharge.

With an initial wound size of 452 cm2, her wound closed in 24 days after an ICU LOS of 9 days, hospital LOS of 11 days, and outpatient treatment of 13 days (eFigure 12).

eFigure 12.

Case 7: (A) Fournier's gangrene treated with the (B) skin and soft tissue sparing flap preservation technique; and (C) outpatient follow-up 21 days after closure revealed a healed complex wound in the groin, labial, and perineum regions with good functional and cosmetic outcomes.

Case 8

A 53-year-old man, found to be unresponsive and hypothermic, was transferred directly from the authors' institution's satellite ER to the Miami Valley Hospital medical ICU with severe diabetic ketoacidosis, lactic acidosis, and acute kidney injury with erythema, pain, and swelling of the scrotum. The patient had noted the scrotal lesion 5 or 6 days prior to presentation. He reported trying to express the area himself but also admitted to active heroin abuse.

The patient was given piperacillin-tazobactam 3.375 g every 8 hours starting on the first hospital day and continued for 28 days. On hospital day 2, clindamycin 600 mg every 6 hours and vancomycin 1 g daily to 1.25 g twice daily were added and continued for 5 days. On hospital day 8, linezolid 600 mg twice daily was started and continued for 23 days. Wound cultures were positive for MRSA.

The patient had an initial wound size of 261 cm2 that took 26 days to close; he spent 22 days in the ICU, 38 in the hospital, and 0 in outpatient care (Figure 13).

Figure 13.

Case 8: (A) Perioperative Fournier's gangrene wound; (B) large skin and soft tissue flap preservation (black arrows) in a patient with a left groin burn scar contracture (white arrow in C); and (C) postoperative 3-month follow-up showing successful flap preservation and closure (black arrows) with good cosmetic and functional outcomes despite previous left groin burn scar contracture.

Case 12

A 46-year-old woman presented to the Miami Valley Hospital ER with a 6-day history of a "boil" on her left labia that had previously drained but had steadily worsening swelling, redness, and pain spreading to her mons pubis. A CT scan of the pelvis demonstrated gas within the left labia.

On the day of presentation, the patient was given vancomycin 1 g, which was increased to 2 g twice daily through hospital day 3. On hospital day 2, piperacillin/tazobactam 3.375 g three times per day was started and continued for 3 days. Piperacillin/tazobactam then was transitioned to oral amoxicillin-clavulanate 875 mg to 125 mg twice daily for 7 days. On hospital day 10, she was transitioned to clindamycin 600 mg every 8 hours and oral fluconazole 100 mg daily until discharge from the hospital. Wound cultures grew group C beta-hemolytic streptococci, microaerophilic streptococcus, and Corynebacterium.

Following the treatment reported, her initial wound size of 402 cm2 had received a 30-cm2 STSG and the wound closed in 56 days after 15 days in the hospital and 41 in outpatient treatment (eFigure 14).

eFigure 14.

Case 12: (A) Large, complex Fournier's gangrene wound; (B) successful delayed primary closure with a 30-cm2 split-thickness skin graft; and (C) postoperative clinical follow-up 15 days after closure.

Case 13

A 65-year-old woman presented to the Miami Valley Hospital ER with a 6-day history of an abscess to the right labia. She was treated by her family physician with ciprofloxacin 500 mg twice daily for 5 days with no improvement before the abscess spontaneously began to drain purulent fluid with worsening redness and pain spreading to the right buttock and thigh. A CT scan demonstrated right buttock and labial inflammation with fat stranding and no identifiable abscess.

On the day of presentation, the patient received a 1-time dose of vancomycin 1 g and was started on piperacillin/tazobactam 3.375 g three times daily for 8 days. On hospital day 2, she received a 1-time dose of metronidazole 500 mg and was started on linezolid 600 mg twice daily for 14 days. When piperacillin-tazobactam was discontinued, she was transitioned to oral amoxicillin-clavulanate 875 mg to 125 mg twice daily for 7 days. On hospital day 15, she was transitioned from amoxicillin-clavulanate to doxycycline 100 mg daily for 2 days prior to discharge. Wound cultures were positive for MRSA.

The patient's initial wound measuring 204 cm2 closed in 10 days with a hospital LOS of 15 days and no outpatient care following the aforementioned treatment (eFigure 15).

eFigure 15.

Case 13: (A) Large, complex Fournier's gangrene wound; (B) reproducible skin and soft tissue sparing flap preservation surgery yielding successful delayed primary closure; and (C) outpatient follow-up at 25 days revealed a healed complex wound in the labial and perianal regions with good cosmetic outcome.

Case 15

A 58-year-old man with a history of type 2 DM, hypertension, and anxiety presented to the Miami Valley Hospital ER with right buttock pain. Initial examination was concerning for perirectal abscess. The patient was admitted and taken to the OR by emergency general surgery for I&D of perirectal and right scrotal NSTI. Burn and wound service was consulted for further management.

On hospital day 2, he was given oral trimethoprim/sulfamethoxazole 500 mg twice daily for 1 day. On hospital day 3, he was started on clindamycin 900 mg every 8 hours, piperacillin-tazobactam 3.375 g twice daily, and vancomycin 1.75 g twice daily; this 3 antibiotic regimen was continued for 2 days. On hospital day 4, those 3 were discontinued, and he was transitioned to ampicillin/sulbactam 3 g every 6 hours and continued for 3 days. He then was transitioned to oral amoxicillin-clavulanate 500 mg to 125 mg twice daily for 3 days, and then an increased dose of 875 mg to 125 mg for the 6 remaining days of hospitalization.

After this course of treatment, his wound, initially measuring 201 cm2, closed in 5 days with a hospital LOS of 16 days (eFigure 16).

eFigure 16.

Case 15: (A) Preserved spared skin and soft tissue after 5 days of conservative wet-to-dry dressing changes by floor bedside nurse and primary team; (B) operative surgical excision with flap preservation; (C) delayed primary closure technique of spared skin and soft tissue flaps; and (D) outpatient follow-up at 40 days after closure with acceptable cosmetic outcome.

Case 16

A 53-year-old man, with a history of uncontrolled type 2 DM, presented with reports of 2 days of ongoing scrotal pain. A CT scan showed mild fat stranding within the perineum with features suggestive of cellulitis. The patient was taken to the OR by emergency general surgery for I&D.

On arrival, the patient was started on piperacillin-tazobactam 3.375 g three times daily, which was continued for 4 days until hospital day 5. He received a 1-time dose of clindamycin 900 mg on hospital day 2. On hospital day 3, he was started on daptomycin 500 mg twice daily, which was continued for 2 days. On hospital day 5 for 16 days, metronidazole 500 mg was administered 3 times daily and ceftriaxone 2 g daily. He then was transitioned to ampicillin/sulbactam 1.5 g three times daily for 5 days until discharge.

His wound measured 330 cm2 initially and healed in 16 days following 9 ICU days and 24 hospital days; no outpatient treatment was necessary (eFigure 17).

eFigure 17.

Case 16: (A) Perioperative wound after skin and soft tissue preservation surgery; (B) delayed primary closure technique of spared skin and soft tissue flaps; (C) residual spared scrotal skin after demarcation (white arrows); and (D) outpatient follow-up at 2 months with preserved scrotal skin and acceptable cosmetic outcome.

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