Necrotizing Fasciitis of the Perineum and the Abdominal Wall-Surgical Approach

Abstract  Necrotizing fasciitis is a synergistic aerobical-anaerobical infection that rapidly spreads from its origin leading to foudroyant increasing soft tissue gangrene and systemic sepsis. In the perineal, perianal and genital regions it is referred to as Fournier's gangrene constituting a clinical entity with the gangrene of the abdominal wall. After a short presentation of the own experience with 17 patients the surgical approach to the life-threatening disease is presented reviewing the former and the recent literature. There is a worldwide consensus that immediate radical excision of the gangrene should be accompanied by intensive care measures. Functional and cosmetic defects are to be reconstructed in a second stage. However, morbidity and mortality remain high in spite of consequent treatment due to often associated significant co-morbidity of affected patients.     

Aluminum foil treatment combined with basic fibroblast growth factor (bFGF) for gangrene of the fingertip caused by collagen disease.

Although basic fibroblast growth factor (bFGF) is used for the treatment of various intractable ulcers, there have been no reports of using it for gangrene of the fingertips caused by collagen diseases. We successfully treated gangrene as a result of malignant rheumatoid arthritis with aluminum foil combined with bFGF.     

Warfarin-induced Venous Limb Gangrene

Warfarin is a commonly used anticoagulant that has been associated with several significant cutaneous side effects, most notably warfarin-induced skin necrosis. A lesser known adverse reaction to warfarin is warfarin-induced venous limb gangrene. Both cutaneous adverse effects share the same pathophysiology, but are clinically quite different. The majority of cases of warfarin-induced venous limb gangrene has been in patients with cancer or heparin-induced thrombocytopenia. However, other hypercoagulable disease states, such as the antiphospholipid antibody syndrome, can be associated with venous limb gangrene. In order to increase recognition of this important condition, the authors report a case of warfarin-induced venous limb gangrene in a patient with presumed antiphospholipid antibody syndrome and review the literature on warfarin-induced venous limb gangrene.Warfarin is a commonly used anticoagulant that has been associated with several significant cutaneous side effects. The authors report a case of warfarin-induced venous limb gangrene in a patient with presumed antiphospholipid antibody syndrome (APS). Warfarin-induced venous limb gangrene is a distinct entity from warfarin-induced skin necrosis. Due to its infrequency and the fact that it presents much differently than warfarin-induced skin necrosis, physicians may dismiss the fact that warfarin is the cause of a patient’s necrosis. For this reason, it is important to recognize this as a separate clinical disease from warfarin-induced skin necrosis with similar underlying pathophysiology. This report of warfarin-induced venous limb gangrene is intended to increase the index of suspicion for this rare drug reaction whose effective treatment requires early diagnosis.     

应用封闭式负压引流技术辅助治疗阴囊坏疽体会（附8例报告）

目的观察应用封闭负压引流技术辅助治疗阴囊坏疽的临床效果。方法对我科于2005年6月-2010年10月诊治的阴囊坏疽8例进行回顾性分析。本组患者局限于阴囊5例,并发双侧腹股沟区,阴茎皮下坏疽2例;并发肛周,左侧腹股沟区坏疽1例。8例均进行手术清创,并应用VSD持续负压吸引,同时给予抗感染对症治疗。拆除敷料创面干净后行二期手术。结果 6例使用VSD1次,行II期直接缝合后愈合;2例使用VSD2次,行腹股沟皮瓣转移后愈合。结论在清创后配合使用封闭式负压引流技术是治疗阴囊坏疽的一种有效方法,封闭式负压引流技术能够促进伤口的愈合,明显缩短治疗时间,减少换药次数,而且简单易行,值得推广。     

The early diagnosis of peripheral vascular disease

The time has long since passed when gangrene followed by amputation was the anticipated outcome of peripheral vascular disease of the extremities. Nevertheless, today in the United States it is estimated that there are more than half a million amputees. With preventive measures, early diagnosis, and adequate treatment, gangrene will be avoided and the patient will retain the use of his limbs.     

The prevention of traditional bone setter's gangrene

A two-year retrospective survey in southern Ethiopia revealed that 49 amputations had been performed, 25 of which were for gangrene following tight splintage applied by traditional bone setters. The aim of this study was to determine if it was possible to reduce this incidence of gangrene by offering one-day instructional courses to bone setters. In ten separate one-day courses 112 tradition healers attended. In addition, two-day courses were given to local health assistants, who also received written instructions for the safe care of fractures. A two-year prospective study revealed a marked reduction in amputations, from 49 to 25, with only seven rather than 25 being required for gangrene. We found that it is possible to educate traditional healers so that fewer gangrenous limbs require to be amputated.     

Experiences in the treatment of gas gangrene in accident surgery (author's transl)]

It is reported on 105 patients with gas gangrene. 68 cases were caused by accident, 7 of them died. Only the gas chromatographic identification of toxin in blood was needed to assure diagnosis. In 46 cases of gas gangrene localized in the lower limbs, amputation was necessary in 12 cases; in 5 cases gangrene in the lower leg, in 7 cases in the thigh. In ten cases of disease in the upper limbs three amputations were necessary. If OHP is implicated as soon as possible in the therapy of gas gangrene, in most cases local necrectomy with maintenance of the limb will be sufficient, if amputation was necessary, it was localized in the region of infection.     

Surgical management of multiple limb gangrene following dehydration in children

Multiple limb gangrene and auto-amputation without arterial vascular occlusive disease is uncommon. Seven such paediatric patients were managed at King Edward VIII Hospital, Durban, during the 6-year period ending in 1989. The spectrum and degree of limb gangrene ranged from phalangeal necrosis to distal limb mummification affecting one or more limbs. The most affected child had gangrene and mummification of all limbs as well as gangrene of the ear lobes and the tip of the nose. The main associated factor was severe fluid loss--2 children had received herbal enemas, with resultant hypotension, hypoperfusion, hypernatraemia and acidosis, which, it is postulated, led to peripheral thrombosis and the ensuing gangrene. It is suggested that aggressive fluid therapy, including low molecular weight dextran and correction of the metabolic derangement, should form the main thrust of the therapeutic endeavour. Once gangrene is established, surgical debridement and rehabilitation is all that is possible. Using this procedure only 2 patients died in the acute resuscitation phase.     

A Review of Consecutive Cases to Identify the Rate of Underlying Osteomyelitis in Patients Undergoing Surgical Treatment of Gangrene of the Forefoot and Impact of Acute Infection on Outcome Following Amputation

Medical literature offers no clear treatment guidelines when performing amputations for gangrene of the forefoot despite a high percentage that suffer poor outcome due to infection. Gas gangrene and wet gangrene are often preceded by dry stable gangrene. This is a retrospective review of consecutive patients who underwent forefoot amputation and bone biopsy as treatment of forefoot gangrene by a single surgeon. Procedures performed included digital, ray, or transmetatarsal amputation with bone biopsy sent for both culture and histopathologic evaluation. One hundred patients (35 females, 65 males) met inclusion criteria. Mean follow-up was 9.6 months. Mean age was 63.5 years old. Forty-six out of 100 (46%) had elective amputation while 54/100 (54%) were emergent for acute infection. Vascular intervention was performed in 52/100 (52%). Seventy-eight out of 100 (78%) had histopathologic diagnosis of acute osteomyelitis while 82/100 (82%) had positive bone culture. Patients with acute infection had worse outcomes, with higher rates of more proximal amputation and delayed wound healing. We found that 79.7% of patients who underwent forefoot amputation due to gangrene had underlying osteomyelitis. We also found that those with acute infection during the time of amputation had poorer postamputation outcomes such as delayed wound healing, revision surgery, and high rates of more proximal amputation. Therefore, it may imply that earlier amputation of stable gangrene prior to becoming acutely infected may decrease the occurrence of osteomyelitis and avoid some of the preventable postamputation complications. Further studies are warranted.     

Is penicillin G the drug of choice in gas gangrene? Results of a prospective documentation of clinical, microbiological and animal experiment data]

Between 1978 and 1990 98 patients with gas gangrene were treated in the departments of general surgery and traumatology of the University of Kiel. The microbiological results of tissue samples and results of animal infectious experiments were correlated to the clinical outcome. It could be shown, that gas gangrene due to C.perfringens alone had a higher mortality than gas gangrene due to polymicrobial infection. In trauma patients, however, the rate of amputations was lower in cases of clostridial monoinfections (25%), than in patients with mixed infections (48%). The results of animal experiments with guinea pigs which were infected by patients' infectious material showed a correlation to the clinical outcome. This correlation could not bee shown using isolated and cultured clostridia. Therefore and because of the quantity of mixed infections it is necessary to use broad spectrum antibiotics for treatment in cases of gas gangrene and for perioperative antibiotic prophylaxis. Penicillin-G alone can not more be recommended for this purpose.     

Fibrin sealant for the reconstruction of fournier's gangrene sequelae

PURPOSE: We describe the use of fibrin tissue adhesive as an adjunct for reconstructing genital skin loss due to Fournier's gangrene. MATERIALS AND METHODS: We treated 2 patients with Fournier's gangrene with repeat surgical débridement and antibiotics. Delayed primary closure was enhanced by using liquid fibrin sealant. In 1 case the sealant was used to obliterate a large testicular thigh pouch that had become infected. In the other case it was used to anchor the under surface of a thigh flap for scrotal reconstruction. RESULTS: In each patient the fibrin tissue adhesive prevented further complications of Fournier's disease. CONCLUSIONS: Fibrin sealant is an effective adjunct for managing extensive genital skin loss caused by Fournier's gangrene.     

Gangrene of the upper extremity following intra-arterial injection of drugs. A case report and review of the literature

A case of inadvertent intra-arterial self-injection of crushed codeine tablets in an 37-year-old man, resulting in gangrene of an upper extremity, is presented. The problem studied was whether the gangrene was caused by the codeine or by one of the excipients found in the tablets. The cause of the gangrene was investigated in an experimental study. Each of the components of the tablet (codeine, lactose, gelatin, carboxymethyl cellulose, calcium stearate, talc, and microcrystalline cellulose) was injected into the femoral arteries of dogs. The results of the study clearly demonstrate that the unique component producing the gangrene was the micro-crystalline cellulose, while the injection of pure codeine was harmless. To date, the only reported deleterious effects of intravascular injection of micro-crystalline cellulose have been pulmonary embolism and granulomatosis. Some examples of drugs that include microcrystalline cellulose are methadone, methaqualone, oxcycodone, acetaminophen, aspirin with codeine, propoxyphene napsylate, meprobamate, and phenobarbital. Recently, the vulnerability of drug addicts who habitually inject drugs into veins to the accidental injection of an artery has been noted, and it seems likely that in the future the problem of intra-arterial injection will increase in severity. The literature of the last 40 years is reviewed, and a list of drugs known to have produced gangrene when injected intra-arterially is cited.     

Treatment of gas gangrene. Results of a retro- and prospective analysis of a traumatologic patient sample over 20 years]

From 1970 to 1977 and from 1978 to 1990, the treatment and outcome in 136 patients with gas gangrene were investigated. The prognosis was better in patients with gas gangrene after trauma than in patients with gas gangrene resulting from vascular insufficiency or malignant tumours. In the first group the lethality of gas gangrene was 28.6%, in the second group, 7.1%. This difference is significant (P < 0.05). In 40.5% the infected extremities were saved. Patients with injuries without fractures did not lose limbs because of gas gangrene or die of it. When an operation was performed before or after the first session of oxygenation at high pressure (OHP) lethality was lower (20%) and the rate of saved limbs higher (80%) than with later operation (lethality, 50%; saved limbs, 45.5%). All patients who could not be treated by OHP, or only once or twice, died. From 1970 to 1977 patients who were treated surgically and received OHP for 5 days survived, and since 1978 this has applied to patients treated for 4 days. In general, the lives of patients with gas gangrene are no longer in danger by the 5th day of therapy. The use of checklists for diagnosis and therapy has been practised since 1978, and this is assumed to be one factor in the better outcome.     

Diagnosis of Meleney's synergistic gangrene

A retrospective and comparative study of 127 case reports of Meleney's postoperative progressive synergistic gangrene and of 62 examples of postoperative amoebic skin gangrene, showed that these two entities were clinically indistinguishable and that therefore a purely clinical diagnosis of Meleney's gangrene could not be made. Furthermore, a critical appraisal of the bacteriological data indicated that a certain diagnosis of Meleney's gangrene cannot be provided by the clinical bacteriologist. Finally, the histological features were entirely non-specific thus precluding a definitive diagnosis by the histopathologist. If Meleney's entity cannot be diagnosed its existence becomes debatable. The alternative diagnosis of cutaneous amoebiasis is advanced for consideration. Several of the outstanding features of Meleney's progressive gangrene, hitherto unexplained, are better understood if Entamoeba histolytica is accepted as the prime cause rather than bacteria.     

Fournier-gangrän

Fournier's gangrene is a relatively rare, mixed aerobic and anaerobic soft tissue infection in the perineoscrotal area. Although it is convenient to give it a separate name, it is really either necrotizing fasciitis or non-clostridial myonecrosis of the scrotal and perineal areas. The condition frequently develops from perianal diseases, including perianal abscess, anal fistulas, inflamed haemorrhoids and indwelling urethral catheter. In patients with Fournier's gangrene morbidity is extreme and mortality high. This article is based on a retrospective study of 15 cases of Fournier's gangrene, 13 in male and 2 in female patients. A combination of surgery and antibiotics was used to treat 9 patients. The last 6 cases were treated with a combination of surgery, antibiotics and hyperbaric oxygen. In 13 cases, the diagnosis was made on the basis of the fulminating progression of the infection to a scrotal gangrene, identification of multiple underlying pathogenic organisms and toxaemia. In the 2 female patients, a similar infection developed in the labia majora and perineum and extended to the buttocks and the anterior abdominal wall.     

Intramedullary nailing of the femur and the systemic activation of monocytes and neutrophils

Background

Breast gangrene is rare in surgical practice. Gangrene of breast can be idiopathic or secondary to some causative factor. Antibiotics and debridement are used for management. Acute inflammatory infiltrate, severe necrosis of breast tissue, necrotizing arteritis, and venous thrombosis is observed on histopathology. The aim of was to study patients who had breast gangrene.

Methods

A prospective study of 10 patients who had breast gangrene over a period of 6 years were analyzed

Results

All the patients in the study group were female. Total of 10 patients were encountered who had breast gangrene. Six patients presented with breast gangrene on the right breast whereas four had on left breast. Out of 10 patients, three had breast abscess after teeth bite followed by gangrene, one had iatrogenic trauma by needle aspiration of erythematous area of breast under septic conditions. Four had history of application of belladonna on cutaneous breast abscess and had then gangrene. All were lactating female. Amongst the rest two were elderly, one of which was a diabetic who had gangrene of breast and had no application of belladonna. All except one had debridement under cover of broad spectrum antibiotics. Three patients had grafting to cover the raw area.

Conclusion

Breast gangrene occurs rarely. Etiology is variable and mutifactorial. Teeth bite while lactation and the iatrogenic trauma by needle aspiration of breast abscess under unsterlised conditions could be causative. Uncontrolled diabetes can be one more causative factor for the breast gangrene. Belladonna application as a topical agent could be inciting factor. Sometimes gangrene of breast can be idiopathic. Treatment is antibiotics and debridement.     

Idiopathic purpura fulminans and varicella gangrenosa of both hands, toes and integument in a child.

Chicken pox is a common childhood illness and, though a vaccine is readily available, it is not routinely included in the vaccination schedule of most countries owing to its mild clinical nature. However, varicella gangrenosa is a rare complication of this disease, infrequently reported in the literature. We report the case of a child who developed purpura fulminans in the convalescent phase of chicken pox and subsequently presented with peripheral gangrene of both hands and the toes of the right foot, and skin gangrene. To our knowledge, bilateral gangrene of the hands has rarely been reported, and we present this case to highlight the serious nature of complications following varicella infection.     

Wet gangrene in hemodialysis patients with calciphylaxisis is associated with a poor prognosis

Calciphylaxis is a rare syndrome characterized by progressive vascular calcification and ischemic tissue loss in patients with chronic renal failure. We report our five-year experience with five patients who developed foot gangrene due to calciphylaxis. All five patients had characteristic clinical, laboratory, and radiologic findings of the disorder, but no diagnostic variable was uniformly present. All five had progressed to advanced gangrene at the time of surgical consultation. Despite aggressive local attempts to control infection, all five patients died of septic complications. Parathyroidectomy was performed in three patients but did not alter the course in any case. This small experience suggests that the outcome of foot gangrene associated with calciphylaxis is predicated on the degree of tissue loss. Aggressive local wound care does not appear to be adequate to control infection in patients who have already developed gangrene. Although parathyroidectomy may have important long-term advantages in patients with calciphylaxis, it does not appear to affect outcome in these advanced cases.     

Progressive postoperative gangrene of skin: Report of a case

A case of progressive postoperative gangrene of the abdominal wall has been presented. Hitherto some sixty cases have been reported.The process is a well outlined entity showing itself in the progressive necrosis of the skin and subcutaneous connective tissues, developing chiefly after operations on suppurating abdominal and thoracic lesions, and produced by symbiosis of specific streptococcus and nonspecific bacteria.Severe pain is characteristic. The gangrene does not extend to deeper layers and it is not contagious.Surgery is the only effective treatment. Postoperative treatment consists of sulfanilamide, zephyrolous dressings and blood transfusion. Early diagnosis is important and makes for a better prognosis.     

The role of hyperbaric oxygen in the management of Fournier's gangrene

Fournier's gangrene of the external genitals is a complex entity characterized by acute onset, rapid progress to gangrene, toxemia and high mortality rate. The disease may be primary as described by Fournier or secondary with a detectable cause in the colo-rectal area, the lower urogenital tract or in the perineum. The disease may affect healthy young males (originally described by Fournier) or elderly subjects especially with general ill health, cancer, diabetes, liver or renal failure, immunosuppression, etc. The microbiology is as complex as the etiology. The nosiology is likewise complex. Because the mortality is high, it is important to be aggressive in therapy. Triple attack is necessary, viz.: antibiotic coverage for aerobes and anaerobes, general supportive measures and adequate surgical debridement. We, recommend Hyperbaric Oxygen Therapy (HBO) treatment in specialized centers as an adjunctive measure since we had no mortality in the cases we treated. In expert centers, HBO has very few complications which are outweighed by the benefit the patient gets. The one-man chamber is the commonest in use, but for a compromised patient the multiplace may be more appropriate. In the very early stage, HBO may avert gangrene or reduce it. It is important to have a high index of awareness of this disease amongst the medical profession. More work is needed for the more precise definition, classification and management of the complex syndrome of Fournier.