Minimal Debridement in the Treatment of Fournier's Gangrene

Abstract

Scrotal and perineal gangrene of the male genitalia was first described by Fournier in 1883. Treatment of the disease remains surgical despite the availability of modern antibiotics. Many authors advocate a wide debridement of all tissue superficial to the involved fascial layers. We have reviewed our experience of using wide and minimal debridement as the surgical technique of choice. In our retrospective study, nine patients were diagnosed and treated over a 2-year period for Fournier's gangrene. The mean age was 65+/-28 years. Two patients were admitted from chronic care facilities, four were diabetic, and two had taken oral steroids. Five of the nine patients were treated with the technique of minimal tissue debridement. In brief, the scrotum was bivalved along the median raphe, each scrotal sac was drained, and the testicles were exteriorized. Orchiectomy was performed if the testicles were grossly necrotic. Penrose drains were inserted from each scrotal sac to the counterincision at the level of the internal rings. All of the tissue involved was irrigated with betadine and peroxide, after debridement of the necrotic tissue. Broad-spectrum antibiotics along with daily packing were continued for 4 to 6 weeks; at the end of that time the testicles were returned to the scrotum and the skin was loosely reapproximated. Three of the nine patients were treated with wide debridement of all the soft tissue including the fascia. One of the patients displayed gangrene of the entire abdominal wall; he was not a surgical candidate and died 3 days later. The four patients treated with minimal debridement all obtained successful treatment of their fasciitis. However, one died of complications related to a duodenal ulcer. The mean hospital stay was 45+/-10 days. Two of the three patients treated with wide debridement required plastic reconstruction using a skin-muscle flap of the perineum. The remaining patient treated with wide debridement died of complications related to metastatic renal carcinoma. The mean hospital stay of this group was 62+/-12 days. The specific flora included: Bacteroidis fragilis in 87 per cent, Peptostreptococcus and Streptococcus in 75 per cent, Clostridia group, Escherichia coli, Enterobacter and Pseudomonas in 62 per cent, Klebsiella in 50 per cent, Staphylococcus in 37 per cent, and Proteus in 12 per cent of the patients. In the surgical management of Fournier's gangrene, wide drainage with minimal debridement resulted in similar morbidity and shorter hospital stay when compared with extensive debridement.