Malattia di Fournier: caso clinico e revisione della letteratura

Abstract

OBJECTIVE: The authors report their experience in diagnosis and treatment of one case of Fournier's gangrene; recent international literature review. EXPERIMENTAL DESIGN: Complete clinical report. Diagnostic, clinical and prognostic indication, evaluation of effectiveness of surgical treatment (debridement and necrosectomy) and follow-up; comparison between indications and multidisciplinary approach proposed by international literature. SETTING: Operative Unit of General and Thoracic Surgery. University "Paolo Giaccone" of Palermo. INTERVENTION: Repeated surgical treatment previous multimodal approach, according to international guide-lines. RESULTS: Complete recovery with "restitutio ad integrum". No relapse were recorded at follow up. CONCLUSIONS: Fournier's gangrene is an uncommon and aggressive synergistic fasciitis of the perineum and genital organs, which may bring the patient to death; it is a true surgical emergency. The disease can no longer be considered to be idiopathic; in most cases a urologic, colorectal or cutaneous source can be identified. Despite antibiotics and aggressive debridement, the mortality rate remains high, particularly in the elderly, in patients with renal failure, and in patients with extensive disease. The presentation is highly variable, necessitating a high index of suspicion. High risk patients include diabetics, alcoholics and debilitated and immunosuppressed individuals. As the AIDS population increases, the incidence of Fournier's gangrene may increase as well. In questionable cases, imaging modalities should be performed to allow early diagnosis and to reduce misses diagnosis. Broad spectrum antibiotics (while waiting for the results of culture and antibiogram effectuated on tissue specimens obtained during necrosectomy) and aggressive debridement remain the hallmarks of treatment. Hyperbaric oxygen therapy and improved local wound care may decrease the extent of tissue destruction. The surgical operation has to be performed in emergency to avoid a rapid spread of tissue necrosis and a possible development towards septic shock. Reconstructive techniques afford better cosmetic results. With early recognition, prompt treatment, improved wound care and reconstructive efforts, the mortality rates and cosmetic results should continue to improve.