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Management of Fournier's gangrene: experience of a university
hospital of Curitiba
Manejo da gangrena de Fournier: experiência de um hospital universitário
de Curitiba
Apriano Antonio Met"; Dorvam CeLso Nogueira FitHo ACBC-PR?; Lucas Marques MANTOVANÊ; MicHeLE MaMpRiM GRiPPAZ,
Rair Bencer 2, Denise Krauss, Denise Rigas*
ABSTRACT
Objective: To analyze the results obtained in the Department of General Surgery, Cajuru University Hospital - PUCPR, with the
treatment of Fournier's gangrene. Methods: We reviewed the charts of 40 patients diagnosed with Fournier's gangrene
admitted to the Cajuru University Hospital from November 1999 to April 2006, analyzing gender, age, predisposing factors,
etiology, lesion location, laboratory tests, surgical procedures, antibiotic use and hyperbaric oxygen therapy. Results: The most
common etiology was the anorectal origin. The most prevalent etiological agent was E. coli The predominant predisposing factor
was diabetes mellitus. The majority of patients were male. The location and extent of injury was usually in the perineum. All
undenwent surgical debridement, 17 with associated colostomy and two with combined cystostomy. All patients received antibiotics,
the most used being metronidazole and gentamicin. Twenty-six patients underwent hyperbaric therapy. The overall mortality
was 20%. Conclusion: Fournier's syndrome, despite all the advances in treatment today, continues to show high mortality
rates. Early recognition of infection associated with invasive and aggressive treatment are essential for attempting to reduce
these prognostic indices
Key words: Fournier's gangrene. Hyperbaric Oxygenationvutilization. Therapy.
INTRODUCTION
ean Alfred Fournier, a French virologist (venerologist),
described, in 1883, five cases of gangrene of the scrotum
in young healthy patients without an apparent
cause!2, Fournier's Syndrome or Gangreneis a rare condition
characterized by acute onset and progression to fulminant
sepsis with high levels of morbidity and mortality.
Fournier's Syndrome (FS) was classified as primary
when a cause was not identified and secondary when
causing factors were discovered?. The disease is not
exclusive to men, as there have been cases of vulvar
necrosis*s.
Contemporary series indicate that FS tends to
affect patients between the third and sixth decade of life,
with predisposing comorbidities, and in most cases, a
present etiologic factor”.
Despite the controversy in the description of the
syndrome, it is characterized by a polymicrobial infection
(aerobic and anaerobic bacteria) with an identifiable cause
in 95% of cases, beginning in the genital or perineal
regions*. It is characterized by an obliterative endarteritis,
followed by ischemia and thrombosis of subcutaneous
vessels, resulting in necrosis of the skin and adjacent
subcutaneous tissue?º, even before evidence of erythema,
crepitus and blistering formation.
Microbial factors can activate the coagulation
cascade directly or indirectly by inducing production of
proinflammatory cytokines and subsequent tissue factor
expression in endothelial cells and monocytes, which
activate the clotting cascade"!, evolving to thrombosis
of blood vessels, the main characteristic of this
syndrome.
Predisposing factors include: diabetes mellitus,
local trauma, urine leakage, perirectal or perineal surgery",
extention of a periuretral/anal infection'?"3, anorectal
abscess, genitourinary infection!41s, alcoholism,
immunosuppression and renal or hepatic disease's'º.
The male gender has a high prevalence (10:1)
of Fournier's Gangrene.
Work done at the General Surgery Service and at the Hyperbaric Oxygen Therapy Service, Hospital Universitário Cajuru — PUCPR — Curitiba,
Paraná, Brazil
1. Head, Hyperbaric Oxygen Therapy Service, Hospital Universitário Cajuru - PUCPR - Curitiba, Paraná, Brazil; 2. Former Resident, General
Surgery Service, Hospital Universitário Cajuru - Curitiba, Paraná, Brazil; 3. Resident, Otorhinolaryngology, HSCM — Paraná, Brazil; 4. Resident,
Gynecology and Obstetrics, HSCM — Paraná, Brazil
Rev. Col. Bras. Cir. 2010; 376): 435-441