Fournier’s gangrene: our experience with 38 patients and analysis of factors affecting mortality

Abstract

Objectives: Despite increased developments in treatment modalities,mortality rates for Fournier’s gangrene (FG) are still high. High mortality rates necessiate the analysis of predisposing factors, laboratory parameters and development of scoring systems for FG. The aim of the present study was to evaluate parameters and scoring systems which may predict mortality and morbidity. Besides,the effect of comorbid conditions on outcomes of FG patients were investigated. Material-methods: A total of 38 patients admitted to our clinic between 2010 and 2015 with diagnosis of FG were included in the study. Surgical and medical treatments were performed for each patient.Medical records such as age, symptom duration, presence of comorbidites and colostomy application, vital signs, extent of the disease and preoperative laboratory parameters were recorded.All those parameters were analysed for their effects on mortality and morbidity. Results: Of 38 patients,7 were died and 31 were survived. Overall mortality rate was 18.4%. Mean age of deceased patients were significantly higher than that of survivors (71.14±12.5 vs. 53.25±16.07, p=0.006).Preoperative laboratory parameters were similar among groups. Diabetes mellitus (DM) was the most common comorbidity in patients (n=17, 45%). Groups were similar in terms of the presence of DM.Mortality and intensive care unit admission was not related to DM. Fournier’s Gangrene Severity Index (FGSI) and neutrophil to lymphocyte ratio (NLR),scoring systems which were thought the reflect severity of FG, were correlated with each other. However, those scores were not different between survivor and deceased patients. Conclusion: Advanced age was found to be related to mortality. However, FGSI and NLR was not associated with the worse prognosis. Also, DM was not associated with length of hospital stay and mortality.

Keywords

• Fournier’s gangrene,mortality,Fournier Gangrene Severity Index,neutrophil lymphocyte ratio,diabetes mellitus

Fournier gangreninde mortaliteyi etkileyen faktörlerin değerlendirilmesi: 38 hastalık deneyimimiz

Abstract

Amaç: Fournier gangreni (FG) tedavi yöntemlerindeki ilerlemelere rağmen yüksek mortalite ile sonuçlanan bir hastalıktır. Tedavi ve bakım hizmetlerindeki iyileşmeye rağmen mortalite oranlarının yüksek olması FG gelişimi için risk faktörlerinin ve mortaliteyi öngörecek parametre ve skorlama sistemlerinin belirlenmesi fikrini gündeme getirmiştir. Bu çalışmada FG hastalarında mortalite ve morbiditeyi öngörecek parametrelerin belirlenmesi ve ek hastalık varlığının prognozla ilişkisinin incelenmesi amaçlanmaktadır. Gereç ve Yöntemler: Çalışmaya 2010- 2015 yılları arasında kliniğimizde FG tanısı ile cerrahi ve medikal tedavi uygulanmış 38 hasta dahil edilmiştir.Hastaların yaş,başvuru süresi, komorbidite ve kolostomi varlığı gibi parametrelerinin yanı sıra vital bulguları,hastalığın yayılımı ve preoperatif kan değerleri retrospektif olarak kaydedildi. Bu değerlerin mortalite, yoğun bakım yatışı ve hospitalizasyon süreleri ile ilişkileri değerlendirildi. Bulgular: Toplam 38 hastanın 7’si ölmüş, 31 tanesi hayatta kalmıştır.Genel mortalite oranı %18.4’tür. Ölenlerin ortalama yaşı hayatta kalanlardan anlamlı olarak daha yüksekti (71.14±12.5 vs. 53.25±16.07, p=0.006).Ölen ve hayatta kalan hastalar arasında preoperatif laboratuar parametreleri açısından anlamlı farklılık izlenmedi.Diyabetes mellitus (DM), en sık karşılaşılan komorbid hastalıktı (n=17, %45). Gruplar arasında DM varlığı açısından anlamlı fark yoktu.Mortalite ve yoğun bakım yatış oranları ile DM varlığı arasında ilişki bulunamadı.Hastalığın şiddetini gösterdiği düşünülen Fournier Gangreni Şiddet İndeksi (FGSI) ile nötrofil lenfosit oranı (NLR) parametreleri arasında anlamlı ilişki bulunsa da (r:0.424, p:0.008), ölen ve hayatta kalan hastalar arasında her iki parametre açısından anlamlı farklılık izlenmedi. Sonuç: Çalışmamızda ileri yaş FG hastalarında mortaliteyi etkileyen bir faktör olarak belirlenmiştir.Buna karşın FGSI ve NLR gibi FG şiddeti ile ilişkili parametrelerle kötü prognoz arasında bir ilişki saptanamamıştır.Yine DM varlığı ile hastanede yatış süresi ve mortalite arasında anlamlı ilişki bulunamamıştır.

Keywords

• Fournier gangreni,mortalite,fournier gangreni şiddet indeksi,nötrofil lenfosit oranı,diyabetes mellitus

References

1. 1. Fournier JA. Jean-Alfred Fournier 1832-1914. Gangrene foudroyante de la verge (overwhelming gangrene). Sem Med 1883. Dis Colon Rectum 1988;31:984-8.
2. 2. Sorensen MD, Krieger JN, Rivara FP, Klein MB, Wessells H. Fournier’s gangrene: management and mortality predictors in a population based study.J Urol 2009;182:2742-7.
3. 3. Benjelloun el B, Souiki T, Yakla N, Ousadden A, Mazaz K, Louchi A, Kanjaa N, Taleb KA. Fournier’s gangrene: our experience with 50 patients and analysis of factors affecting mortality. World J Emerg Surg 2013:1;8-13
4. 4. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg 2000; 87: 718-28.
5. 5. Clayton MD, Fowler JE Jr, Sharifi R, Pearl RK. Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. Surg Gynecol Obstet 1990;170:49-55.
6. 6. Sen H, Bayrak O, Erturhan S, Borazan E, Koc MN. Is hemoglobin A1c level effective in predicting the prognosis of Fournier gangrene? Urol Ann 2016;8:343-7.
7. 7. Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier’s gangrene. J Urol 1995;154:89-92.
8. 8. Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier’s gangrene: an analysis of 80 patients and a novel scoring system. Tech Coloproctol 2010;14:217-23.

9. 9. Bozkurt O, Sen V, Demir O, Esen A. Evaluation of the utility of different scoring systems (FGSI, LRINEC and NLR) in the management of Fournier’s gangrene. Int Urol Nephrol 2015;47:243-8.
10. 10. Tarchouli M, Bounaim A, Essarghini M, Ratbi MB, Belhamidi MS, Bensal A, et al. Analysis of prognostic factors affecting mortality in Fournier’s gangrene: A study of 72 cases. Can Urol Assoc J 2015;9:E800-4
11. 11. Dahm P, Roland FH, Vaslef SN, Moon RE, Price DT, Georgiade GS, Vieweg J. Outcome analysis in patients with primary necrotizing fasciitis of the male genitalia. Urology 2000;56:31-5.
12. 12. Erol B, Tuncel A, Hanci V, Tokgoz H, Yildiz A, Akduman B, Kargi E, Mungan A. Fournier’s gangrene: overview of prognostic factors and definition of new prognostic parameter. Urology 2010;75:1193-8.
13. 13. Tuncel A, Aydin O, Tekdogan U, Nalcacioglu V, Capar Y, Atan A. Fournier’s gangrene: Three years of experience with 20 patients and validity of the Fournier’s Gangrene Severity Index Score. Eur Urol 2006;50:838-43.
14. 14. Janane A, Hajji F, Ismail TO, Chafiqui J, Ghadouane M, Ameur A, et al. [Hyperbaric oxygen therapy adjunctive to surgical debridement in management of Fournier’s gangrene: usefulness of a severity index score in predicting disease gravity and patient survival]. Actas Urol Esp 2011;35:332-8.
15. 15. Zahorec R. Ratio of neutrophil to lymphocyte counts--rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy 2001;102:5-14. 16. Yim SU, Kim SW, Ahn JH, Cho YH, Chung H, Hwang EC, et al. Neutrophil to Lymphocyte and Platelet to Lymphocyte Ratios Are More Effective than the Fournier’s Gangrene Severity Index for Predicting Poor Prognosis in Fournier’s Gangrene. Surg Infect (Larchmt) 2016;17:217-23. 17. Paty R, Smith AD. Gangrene and Fournier’s gangrene. Urol Clin North Am 1992;19:149-62.
16. 18. Corcoran AT, Smaldone MC, Gibbons EP, Walsh TJ, Davies BJ. Validation of the Fournier’s gangrene severity index in a large contemporary series. J Urol 2008;180:944-8.
17. 19. Nisbet AA, Thompson IM. Impact of diabetes mellitus on the presentation and outcomes of Fournier’s gangrene. Urology 2002;60:775-9.
18. 20. Oymacı E, Coşkun A, Yakan S, Erkan N, Uçar AD, Yıldırım M. Evaluation of factors affecting mortality in Fournier’s Gangrene: Retrospective clinical study of sixteen cases. Ulus Cerrahi Derg 2014;30:85-9.
19. 21. McCormack M, Valiquette AS, Ismail S. Fournier’s gangrene: A retrospective analysis of 26 cases in a Canadian hospital and literature review. Can Urol Assoc J 015;9:E407-10.