Fournier’sgangrenebyperianalabscess Coloproctology Journalof

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w w w . j c o l . o r g . b r

Journal of

Coloproctology

Original Article

Fournier’s gangrene by perianal abscess

Natiele Santos de Souza

^a,∗

, Djoney Rafael dos Santos

^b

,

André Pereira Westphalen

^c

, Fernando Antonio Campelo Spencer Netto

^d

aHospital Norte Paranaense, Cirurgia Geral, Maringá, PR, Brazil

bHospital do Câncer de Cascavel, União Oeste Paranaense de Estudos e Combate ao Câncer, Cancerologia Cirúrgica, Casvavel, PR, Brazil

cUniversidade Estadual do Oeste do Paraná, Cascavel, PR, Brazil

dRoyal College of Physicians and Surgeons of Canada, Canada

a r t i c l e i n f o

Article history:

Received 31 March 2020 Accepted 5 July 2020

Available online 13 September 2020

Keywords:

Fournier’s gangrene Necrotizing fasciitis Abscess

Colorectal surgery Debridement

a b s t r a c t

Objective:To describe and analyze the cases of Fournier’s Gangrene caused by perianal abscess treated in a tertiary hospital in western Paraná, correlating possible factors that inﬂuence mortality, with emphasis on late diagnosis and therapy.

Methods:A retrospective and descriptive case series was carried out based on the analysis of medical records of patients with Fournier’s Gangrene due to perianal abscess from January 2012 to December 2017.

Results:Thirty-one patients with Fournier’s Gangrene due to perianal abscess were treated in the period: 26 men and 5 women. Mean age was 53.51±14.5 years. The most prevalent comorbidity in this group was type 2 diabetes mellitus, showing a strong correlation with mortality. The mean time from disease progression, from the initial symptom to the admission at the service, was 9.6±6.81 days. All patients were submitted to antibiotic therapy and surgical treatment, with a mean of 3.25±2.89 procedures/patient. Seven (22.58%) patients died and all of them showed signs of sepsis on admission; only 2 patients with sepsis did not die.

Conclusion:The presence of sepsis on admission and type 2 diabetes mellitus were strongly correlated with mortality.

creativecommons.org/licenses/by-nc-nd/4.0/).

Gangrena de Fournier por abscesso perianal

Palavras-chave:

Gangrena de fournier Fasciite necrosante Abscesso

Cirurgia colorretal Desbridamento

r e s u m o

Objetivo:Descrever e analisar os casos de gangrena de Fournier por abscesso perianal atendidos em hospital terciário do oeste do Paraná, correlacionando possíveis fatores que inﬂuenciem a mortalidade, com ênfase ao diagnóstico e terapêuticas tardias.

Métodos:Realizou-se um estudo de série de casos, retrospectivo e descritivo baseado na análise de prontuários de pacientes portadores de gangrena de Fournier devido a abscesso perianal no período de Janeiro de 2012 à Dezembro de 2017.

∗Corresponding author.

E-mail:natielesantossouza@outlook.com(N.S. de Souza).

https://doi.org/10.1016/j.jcol.2020.07.004

2237-9363/© 2020 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Coloproctologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Cascavel,

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Resultados: Foramtratados31pacientescomgangrenadeFournierporabscessoperianal noperíodo,sendo26homense5mulheres.Amédiadeidadefoide53,51±14,5anos.A comorbidadedemaiorprevalêncianestegrupofoidiabetemelitustipo2,demonstrando fortecorrelaçãocommortalidade.Amédiadotempodeevoluçãodadoença,dosintoma inicialatéentradanoserviço,foide9,6±6,81dias.Todosospacientesforamsubmetidosà antibioticoterapiaetratamentocirúrgicocommédiade3,25±2,89procedimentos/paciente.

Sete(22,58%)pacientesevoluíramparaóbitoetodosestesapresentavamsinaisdesepsena admissão;apenas2pacientescomsepsenãoevoluíramaóbito.

Conclusão: Presenc¸adesepseaadmissãoediabetemelitustipo2foramfortementecorrela- cionadascommortalidade.

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Theperianalabscessisanacuteinﬂammatoryevent,which hasseveraletiologies,withthemainonebeingnon-speciﬁc cryptoglandularinfection.^1,2 Thispathologymanifestsitself mainlyaslocaledema, feverand pain.^1–3 Whendiagnosed early,thetreatmentconsistsofsimpledrainage,^2,3whichcan beperformedinprimaryhealthcare.Thelackoftreatment or ineffective management allows the spread of infection fromtheperineumtosofttissues,withthesubsequentdevel- opment of necrotizing fasciitis, also known as Fournier’s Gangrene (FG),^1–3 thus requiring a surgical approach for debridement,performedintertiarycare.^2–4

Fournier’sgangrene is apolymicrobialinfection^3,5–8 and has various causes, and its main cause is the perianal abscess.Thiscondition canlead tosepsisand death, with this evolution being closely correlated with late diagnosis andmanagement,virulenceoftheinvolvedmicroorganism, perianalabscessand underlyingcomorbidities.^1,2,6–8 There- fore,itsearlydiagnosisisextremelyimportant,allowingthe implementation of adequate and efﬁcient treatment, thus improvingthepatient’schancesofsurvival.^1–3

ThetreatmentofFGconsistsofvigoroushydration,hydro- electrolyticbalancerestoration,drainageandbroad-spectrum empiricalantibiotictherapy.²Thesurgicaltreatmentisper- formedthroughbroadandradicaldebridementuntilhealthy tissueisfound.^1–3 Toreducefecalcontaminationandfacili- tatehealingoftheperinealwound,intestinaltransitdiversion throughanostomycanbeperformed.Moreover,severalrecon- structiveprocedurescanbeusedtocorrectthetissuedefect.² Despitetheaggressivemultidisciplinaryandsurgicaltreat- ment,mortalityratesvarybetween20%and40%inmostcases butcan varyfrom 4%to88%.^8,9 Thishigh mortalityrate is partlyattributabletothe aggressivenatureofthe infection andtheunderlyingcomorbidities.Themortalityratesare2to 3-foldhigherindiabetics,elderlypatientsandinpatientswith delayedtreatment.¹

Giventheseverityoftheevolutionofperianalabscessdue toFGwithahighmortalityrate,theaimofthisstudyisto describeand analyze the casesof Fournier’sgangrene due toperianal abscesstreatedinatertiaryhospitalinwestern Paraná,correlatingpossiblefactorsthatcaninﬂuencemortal- ity,withemphasisonlatediagnosisandtherapies.

Methods

Thisisaretrospectiveand descriptivestudy ofcaseseries, based on the analysis of physical and electronic medical recordsofpatientswithFournier’sgangreneduetoperianal abscesstreatedatHospitalUniversitáriodoOestedoParaná- HUOPinthemunicipalityofCascavel,stateofParaná,Brazil, fromJanuary2012toDecember2017.

Thepatientswereselectedaccordingtotheinclusioncri- teria:a)PatientsdiagnosedwithFGduetoprobableperianal abscessadmittedtoHUOPbetweenJanuary2012andDecem- ber2017;b)Over18yearsofage.Theexclusioncriteriawere:

a)Patientswithotherdiagnoses;b)Patientsunder18yearsof age.

Thedatafromthephysicalandelectronicmedicalrecords wererecordedonadatacollectionformcontaininginforma- tion on demography, comorbidities,clinical and laboratory presentation, implemented treatment, evolution, complica- tionsandmortality(Table1).

Additionally,theqSOFAscore¹⁰wasusedtoscreenforsep- sisonhospitaladmission,consideringaspositivecasesthe patientswithsuspected/documentedinfectionplusascore of2or3ontheqSOFA.Withthehelpofcomplementaryexams onhospitaladmission,thediagnosisofsepsiswassupported byaSOFAscore¹⁰≥2.Moreover,amortalitypredictorscore, theCharlsonComorbidityIndex(CCI),^11,12 wasalsoused,as showninTable1.

Effortsweremadetomaintaintheconﬁdentialityofthe information collected and the anonymity of the patients involvedinthestudy.Thisresearchprojectwasapprovedby theResearchEthicsCommitteeofUniversidadeEstadualdo OestedoParaná(UNIOESTE)atitsCampusinCascavel/PR, undern.56997516.1.0000.0107.

Statisticalanalysis

Thenumericalvariablesweretestedaccordingtothedistri- butionofnormalitybytheShapiro-Wilktestand,astheyhad anormaldistribution,theyareshownasmeansandstandard deviations.Fisher’s exacttestwasusedforthecorrelations proposedaccordingtothestudyaim.Forthequalitativevari- ables,frequencydistributionswereperformedandshownas

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Table1–Datacollectioninstrument.

Gender Age(years) Comorbidities CCI Pre-diagnosis evolution(days)

Hospitallengthof stay(days)

Totalprocedures performed

Presenceofsepsis onadmission

Death

M 50 DM2 3 7 11 3 − −

M 47 Absent 0 6 8 1 − −

M 23 ParaplegiaandCKD 4 4 41 14 − −

F 77 DM2andSAH 4 10 13 6 YES YES

M 74 Smoking 4 14 20 1 − −

M 51 DM2 2 14 14 2 − −

M 62 SAH,

cardiopathyand smoking

4 15 27 4 − −

M 68 2 7 15 3 − −

M 53 SAH,DM2,

dyslipidemiaand cardiopathy

4 6 35 7 YES YES

F 61 DM2andSAH 4 30 10 1 − −

M 47 Smoking 1 15 31 4 − −

M 69 DM2andSAH 3 5 17 3 − −

M 73 SAH 3 15 20 1 − −

M 40 0 7 9 2 − −

F 51 DM2,SAH,

smokingandobesity

4 10 26 5 YES YES

M 78 SAHand

smoking

4 30 17 1 − −

M 63 DM2and

smoking

5 7 55 5 YES YES

F 54 DM2 2 4 24 4 − −

M 73 DM2andCKD 7 2 2 1 YES YES

M 35 Smoking 1 5 3 1 − −

M 38 Smoking 1 15 5 1 YES −

F 31 0 16 8 1 − −

M 41 0 7 10 2 − −

M 46 0 8 2 1 YES YES

M 48 DM2andSAH 1 9 16 4 − −

M 58 SAHand

chronicliverdisease

4 5 12 3 − −

M 56 DM2and

obesity

2 1 42 6 YES −

M 31 Smoking 1 7 3 1 − −

M 44 DM2and

cardiopathy

2 5 2 1 − −

M 50 Obesity 1 7 129 9 − −

M 67 DM2andSAH 4 7 29 3 YES YES

Source:Theauthors.

CCI,CharlsonComorbidityIndex;M,Male;F,Female;DM2,Type2DiabetesMellitus;CKD,ChronicKidneyDisease;SAH,SystemicArterial Hypertension.

absolutenumbersandpercentage.Theinformationobtained frommedicalrecordswasshownintables.

Results

Thesampleconsistedof31 individualstreated duringa6- yearinterval,andmostweremales(Table2).Allpatientshad Fournier’sgangreneonadmission.Therefore,allofthemwere startedonbroad-spectrumantibiotictherapy,associatedwith surgicaltreatmentforinfectioncontrol,inadditiontocon- comitanttreatmentoftheassociatedconditions.

Ofthecomorbiditiesseeninthesample,type2diabetes mellitus(DM2)wasthemostfrequent(45%),followedbysys-

temicarterialhypertension(35%).Othercomorbiditiessuch as chronic kidney disease, heart disease, obesity, dyslipi- demia and chronic liver disease were also present, but at lowerfrequencies(<10%).Nine(29%)patientsweresepticon admission. TheCharlsonComorbidityIndex(CCI)mortality predictorscorewascalculated,andtheresultsrangedfrom0 to7,withthemeanofsurvivorsbeing2.04andthemeanof non-survivors,4.

Atotal of101surgical procedureswere performed,with an average of 3.25±2.89 procedures / patient. The patient withthehighestnumberofinterventionsunderwent14proce- dures.Colostomywasperformedin5patients(16%)tocontrol fecalcontaminationandcystostomyin2(6.45%),sincesurgi-

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Table2–ClinicalproﬁleofpatientswithFGdueto perianalabscess,HUOP2012−2017.

Variables Results

Male 26(83.87%)

Female 5(16.13%)

Age 53.51±14.56years

Type2DiabetesMellitus 14(45.16%) SystemicArterialHypertension 11(35.48%)

Smoking 9(29.03%)

Alcoholuse 6(19.35%)

Pre-diagnosisevolution 9.6±6.81days

Sepsisonadmission 9(29%)

Source:Theauthors.

Table3–SurgicalproceduresinpatientswithFGdueto perianalabscess,HUOP2012−2017.

Typeofsurgicalprocedure Numberof procedures performed

Debridement 85

Colostomy 5

Anorectalabscessdrainage 3

Cystostomy 2

Flaps 2

Reconstructions 1

Otherprocedures^a 3

Total 101

Source:Theauthors

a Lowerlimbfasciotomy,scrotalabscessdrainageandexploratory laparotomy.

caldebridementand/orinfection-relatededemaaffectedthe penileregion,causingobstruction.Nineteen(61.29%)patients requiredfurthersurgicaldebridementduringthesamehospi- talization(Table3).

Inoursampleof31patients,themeanhospitallengthof staywas21.16±23.93days.Five(29.7%)patientsremainedin theIntensiveCareUnit(ICU).Seven(22.58%)patientsdied,all ofwhichhadsignsandsymptomsofsepsisonadmission,with p=0.00001.Othervariables,suchasDM2andhospitallength ofstay,werealsotestedinrelationtomortality(Table4).The survivingpatientsweredischargedandfollowedattheHUOP woundoutpatientclinic.

Discussion

Fournier’sgangreneisarelativelyuncommoncondition,with anestimatedincidenceof1.6casesper100,000men,¹³with apeakincidencebetweentheﬁfthandsixthdecadesoflife;

however,the incidenceisincreasingduetotheincrease in thepopulation’slifeexpectancy.⁹Inoursampleof31patients withFGduetoperianalabscessseenovera6-yearperiod,the vastmajorityofpatients,83.87%,consistedofmalepatients andthe mean agewas53.51±14.56years,inlinewiththe epidemiologicalproﬁleofthereviewedstudies.4,6,7,9,13,14

Comorbiditiescompriseanimportantriskfactor forthe occurrenceofFG,withDM2beingtheconditionwiththegreat-

estassociationintheliterature.^3,4,7,15WhencorrelatingDM2 tothe mortalityinFGdue toperianal abscess,wedemon- strated a p=0.01941. Of the patients in our study, 45.16%

werediabeticsand35.48%werehypertensiveindividuals.Five patientsdidnotreportanycomorbidities.However,afterthe statisticalanalysis,therewasnocorrelationbetweenDM2and thepresenceofperianal abscessasaprobablecauseofFG.

Patients who died hada two-foldincreaseinthe Charlson ComorbidityIndexscore,thusshowingthatcomorbiditiesare apositivepredictorofmortality.

ThemortalityraterelatedtoFGreportedintheliterature, fromancienttimestothepresentday,isabout20%.^4,8,9Inour study,thisratewas22.58%.AccordingtoTenorioetal.,⁸late diagnosisandinterventionhaveahighcorrelationwithmor- tality.ForAzolasetal.,¹⁶thisassociationisnotasigniﬁcant riskfactoratthestatisticalanalysis.Inourresearch,ittook patients4–30daystoaccesstertiarycare;whenanalyzingit innumbers,thereisanaverageof9.6daysbetweensymptom onsetanddiagnosis,whichisconsideredalongtime.

When correlating mortality with a period ≥7 days of pre-diagnostic evolution, we demonstrated ap-value=0.34, demonstratingthelittlerelevanceofthisvariableinoursam- ple.Theabsenceofdifferencecanbejustiﬁedbytherelatively small sample,leadingtoaBetaerror.Moreover,the hospital length ofstayis amajor riskfactor for mortality,with p=0.055.¹⁶Thisconditionoccursmainlyduetothepatient’s septicdisorderandthenumberofsurgicalinterventionsthe patienthasundergone.¹⁵

Inoursample,thesepsisonadmissionfactorwasasso- ciatedtoall casesofdeath, p=0.00001.Ofthe 31assessed patients, 9had signs and symptoms of sepsison hospital admission,ofwhich7died.Noneofthesepatientshadthe opportunitytohavetheperianalabscessdrainedpriortothe FGcomplication.Also,notallsepticpatientswereadmitted totheIntensiveCareUnit (ICU),since,ofatotalof9septic patients, only5remained inthe ICU.Thissituation isdue tothescarcityofICUbedsontheadmissionday;therefore, thesepatientsendedupreceivingintensivecareintheemer- gencyroomorinﬁrmarybed,untilavacancywasavailableor untiltheyshowedclinicalimprovement.Ofthe4patientsin thiscondition,twodiedontheseconddayofhospitalization, evenbeforethechangeofsectorcouldbeattained,andthe othertwoshowedclinicalimprovementanddidnotrequire ICUadmission.

Moreover,101surgicalprocedures were performed,with an average of 3.25±2.89 procedures/patient. When divid- ing the surgical interventions into two groups, survivors andnon-survivors,theaverageofinterventionsamongnon- survivorswas4/patient,whiletheaverageamongsurvivors was3/patient.Thisfactreinforcesthattheﬁrstsurgeryper- formed must be of ample resection, debriding all necrotic tissueuntilhealthytissueisfound.^1,2,6,15^,16

Conclusions

Consideringtheabove,wecanconcludethatthecorrelation betweenthepre-diagnostic timeofevolutionandmortality didnotshowasigniﬁcantassociation.Thissituationcanbe justiﬁedbythefactthat oursampleincludesonlypatients

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Table4–FGmortalityduetoperianalabscessrelatedtovariables,HUOP2012−2017.

Mortality p

Yes(total7) No(total24)

Pre-diagnosisevolution≥7days 5 16 0.34823

Presenceofsepsisonadmission 7 2 0.00001

PatientwithType2DiabetesMellitus 6 8 0.01941

Hospitallengthofstay≥20days 4 8 0.18240

Source:Theauthors

intertiaryhealthcare;therefore,wedidnotobtainstatistical parameterstomakecomparisonsbetweenpatientsthatwere treatedearlyandthosetreatedlate.

Also, we can afﬁrm that there was a strong correlation between mortality and signs of sepsis at admission, withp=0.00001and,also,betweenmortalityandDM2,with p=0.01941. Moreover, we realized that even with current therapeuticadvancesand amultidisciplinary approach,FG continuestoshowprolongedhospitallengthofstayandhigh mortalityrates.^8,9,15

Thesedataindicatetheneedforimprovementinprimary healthcareservices,withtraining inthediagnosis ofperi- analabscesses,optimizationoftreatmentandearlyreferral ofthesepatientstoaspecialist.Thus,therewillbeareduc- tioninthemorbidityandmortalityofthisdisease,sincethese arepotentiallypreventableissueswithanearlyintervention, eitherbyidentifyinganddrainingoftheabscessintheBasic HealthUnitorthroughtreatmentatthetertiarylevel.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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