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Fournier Jean Alfred Gangrene foudroyante de la verge Sem Med

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Fournier Jean Alfred Gangrene foudroyante de la verge Sem Med Powered By Docstoc
					Fournier, Jean-Alfred. Gangrene foudroyante de la verge. Sem Med 1883; 3:
345-8. Translated by Corman AS. Dis Col Rect 1988; 31(12):984-88.
             The article is difficult to sort out because it is broken up into
      many anecdotal experiences. Fournier recognizes diabetes, malaria
      and typhoid as predisposing conditions for perineal gangrene. He
      describes four cases of idiopathic genital gangrene and adds a fifth
      from a colleague. The distinguishing feature is the idiopathic nature
      of the disease, as he elucidates many other cases of genital gangrene
      with known causes (consistent with a venereologist’s experience in
      Paris of the 1880’s: “I will add that if it is possible to cause gangrene
      of the penis by excessive sexual intercourse, then we would see a
      great deal of this problem in our clinics…”).
             “In analyzing this story, we could not find any possible
      explanation for this gangrene…It was truly amazing to see a man lose
      his penis without really understanding why.”
             “…I want to state in the name of our Clinic, that there exists a
      different gangrene of the penis from the other types involving the
      same organ, and different in these respects: 1. By the absence of any
      predetermined cause 2. By special symptoms of which the principal
      ones follow:
             A gangrenous and sudden beginning; astonishingly rapid
      extension; always considerable extension; the frequent coexistence of
      purple discoloration; and finally an excessive morbidity.
             It is this type of gangrene which, it is no exaggeration to say,
      should be given the name, fulminant, and it is this description which I
      propose to dedicate in our next discussion.”

Ledingham IM and Tehranis MA. Diagnosis, clinical course and treatment of
acute dermal gangrene. Br J Surg 1975; 62: 364-372.
      Twenty patients with acute dermal gangrene folowing surgery, trauma
      or sepsis are described. In 12 the skin became gangrenous secondary
      to a necrotizing process affecting the subdermal fascia, and in 8 the
      condition arose primarily in the skin. In the first group mortality was
      high unless radical excision of the necrotic fascia was performed at an
      early stage; in 3 of the recent patients the overlying skin was removed,
      defatted and stored for later grafting. In the second group, incision
      and adequate drainage combined with antibiotics seems to suffice.
      Hyperbaric oxygen was of dubious value in the first group but
      appeared to contribute to arrest of the lesion in the second group.”
“The multiplicity of terms used to describe variants of the condition
further      complicates       understanding      of     the      clinical
problem…[prompting] the authors to simplify the classification of
these conditions into two categories…”
1)Necotizing fasciitis (Wilson 1952): “a progressive, usually rapid,
necrotizing process affecting the subcutaneous fat, the superficial
fascia and the superior surface to the deep fascia. The skin is initially
intact but becomes gangrenous secondary to interruption of its deep
blood supply.”
2)Progressive bacterial gangrene: “a more slowly progressive lesion
affecting the total thickness of skin but not involving deep fascia; pus
formation is variable.”
Predominantly clostridial infections were excluded.
Necotizing fasciitis developed after drainage of ischiorectal sepsis in 6
(50%). Five of the patients had preexisting systemic disease: DM (2),
actinomycosis, rheumatoid arthtritis/steroids, and carcinomatosis.
Arose as cellulitis progressing to duskiness then blue with blisters.
“The fascial involvement was much more extensive than that of the
related skin.” Time between initiating factor and the first signs
involving skin was 11 days (range 6-31). Most frequent organisms
were coliforms, enterococci and strep. Only one instance of hemolytic
strep occurred. The authors attribute a shift in isolates (from
Meleney’s time) to early use of antibiotics and rapid overgrowth of
coliforms (associated with a shift in site from extremities). In three of
four cases of radical debridement, skin was banked (4 degrees) for
grafting. Mortality 67% (8 of 12) due to PE and toxemia. “On the
basis of present experience the best results appear to follow early,
multiple and extensive incisions into the affected area with complete
excision of the underlying necrotic fascia. Whether the large flaps of
skin thus created should simply be reflected or excised and stored is
debatable, but if there is any doubt about the adequacy of drainage the
latter alternative is preferable and is best done at one operation…The
role of hyperbaric oxygen in the treatment of this condition is
uncertain…”
In progressive bacterial gangrene, no lag time (quiescent period) was
noted. Incision and drainage along with hyperbaric oxygen appeared
to halt the progression of disease (as opposed to necrotizing fasciitis).
Fournier’s gangrene is included in this group. “Recently, the
justification for these separate subgroups has been questioned since
they are almost certainly at most variants of a single process.”
Riseman JA, Zamboni WA, Curtis A. Hyperbaric oxygen therapy for necrotizing
fasciitis reduces mortality and the need for debridements. Surgery 1990; 108(5);
847-850.
       Group 1 (n=12) patients received standard therapy of debridement and
       antibiotics while group 2 (n=17) received HBO (90 min at 2.5 atm,
       every 8 hours the first day then twice daily, average 7.4 treatments
       total) in addition to surgery and antibiotics. Affected surface areas
       were similar in size but group 2 had more perineal involvement and
       shock (27% vs 8%). All group 2 patients had their first dive within 24
       hours of admission, five before surgery. Mortality was significantly
       lower in the HBO group (23% vs 67%, p < 0.02). Group 2 also
       required less debridements to control the infection (1.2 vs 3.3,
       p < 0.03). “The addition of HBO therapy to the surgical and
       antimicrobial treatment of necrotizing fasciitis significantly reduced
       mortality and wound morbidity (number of debridements) in this
       study, especially among nonclostridial infections. We conclude that
       HBO should be used routinely in the treatment of necrotizing
       fasciitis.”
       Inclusion of clostridial infections may skew the results.

Stephens BJ, Lathrop JC, Rice WT. Fournier’s gagnrene: Historic (1764-1978)
versus contemporary (1979-1988) differences in etiology and clinical importance.
Am Surgeon 1993; 59: 149-54.
      In the decade 1979-1988, 449 cases were reported. In the historical
      period (1764-1978), 386 cases were reported. During the modern
      period studied, the average age of the patients was 49.8 years; with 14
      per cent occurring in females. The most commonly reported
      etiologies were colorectal (33%), idiopathic (26%), and genitourinary
      (21%). Mortality associated with colorectal etiology was highest
      (33%). Female mortality was not significantly greater than male
      mortality when obstetrical etiology was excluded. Overall mortality
      was 22%. Compared with the historical figures, the authors
      concluded that “neither the introduction of antibiotics nor the
      development of newer ones has reduced mortality significantly. In
      spite of newer diagnostic techniques, the etiology remains unclear in
      over one-fourth of cases.”

Efem SE. Recent advances in the management of Fournier’s gangrene: preliminary
observations. Surgery 1993;113(2): 201-4.
      Twenty cases were managed with systemic antibiotics and
      unprocessed honey were compared to 21 cases managed with
      orthodox (excision, debridement) methods. No deaths and no
      (excisional) operations occurred in the honey group as opposed to
      three deaths in the orthodox group. Th authors felt that honey
      alleviated morbidity faster. The “orthodox” and the honey groups
      were not managed by the same consultant. The orthodox group was
      studied retrospectively. “Honey combine all these actions (i.e.,
      wound debridement, topical antibacterial activity, and local generation
      of oxygen). The action of unprocessed honey on Fourier’s gangrene
      is simply remarkable. When it is applied on the ulcer, it immediately
      halts the advancing necrosis. It debrides, sterilized, deodorized, and
      dehydrates the wound, and it stimulates actual regeneration of scrotal
      skin by rapid epithelialization. All these changes can be observed
      within 1 week of topical application of honey.”

Laucks SS. Fournier’s Gangrene. Surg Clin North Am 1994; 74 (6): 1339-54
     A good, brief description of anatomy is included. “Several named
     fascial planes, including dartos fascia, Buck’s fascia, and Colles’
     fascia, are present in the genital and perineal areas. They are all
     related by either intermingling of their fibers or immediate physical
     proximity. The fascial planes of the genitalia continue up onto the
     anterior abdominal wall as Scarpa’s fascia. Because Fournier’s
     gangrene begins as a necrotizing infection of the fascia, its direction
     of spread is determined by these anatomic fascial planes. The outlet
     of the pelvis is divided into anterior and posterior triangles. Infections
     of the anterior (urogenital) triangle generally arise in the lower urinary
     tract, spread to the corpora spongiosum, penetrate the tunica
     albuginea, and spread to Buck’s fascia. One this plane is readhed, the
     infection can spread along the fascial planes to the dartos, Colles’, and
     Scarpa’s fasciae. Infections arising in the posterior (anorectal)
     triangle penetrate Colles’fascia, then progress anteriorly along the
     Buck’s, dartos, and Scarpa’s fasciae.”
     Necrosis of the testicles implies thrombosis of the testicular artery and
     suggests an intra-abdominal or retroperitoneal nidus of infection.
     Consider imaging and laparotomy.
     Fecal and urinary diversion are controversial. Some propose
     colostomy in the face of massive perirectal wound, infected sphincter,
     rectal/colon perforation, or immunocompromise.                 Suprapubic
     catheterization may be advocated in known stricture disease with
     extravasation and phlegmon.

Kaiser RE, Cerra FB. Progressive necrotizing surgical infections—a unified
approach. J Trauma 1981; 21(5): 349-55.
             “A number of authors have described various forms of
      aggressive necrotizing surgical infections. Included in this group are:
      necrotizing fasciitis, clostridial cellulitis and myonecrosis, and
      synergistic necrotizing cellulitis.
             A great deal of effort has been placed in attempts to classify
      these infectious entities on the basis of the layers of soft tissue
      involved, the types of organisms involved, and the necessary surgical
      treatment required. The entities, however, all seem to be variations of
      the same disease process. Such classification systems only seem to
      have produced a pseudoclassification that has provided a great deal of
      confusion for practicing clinical surgeons who deal with this
      uncommon set of surgical infections.”
             Twenty “progressive necrotizing surgical infections” were
      studied. Group I was treated with a “unified treatment protocol:”
      early diagnosis, antibiotics and early aggressive excision of all
      necrotic tissue with control of the source if possible. Mortality was
      8.3%. Group II was treated with antibiotics and delayed (1-3 days)
      surgery (mortality 75%). Group III was treated with antibiotics and
      incision and drainage (100% mortality). No topical antibiotics were
      used as the series evolved as the authors felt it obscured exam. The
      authors concluded “there seems to be no need to classify necrotizing
      infections into different types. Recognizing them as the same disease
      process treating them with a unified approach resulted in a significant
      reduction in mortality.”
             Discussion by Lewis Flint: “Descriptions based upon
      bacteriologic data are of necessity after the fact, while a definition
      based upon the type of tissue involved (subcutaneous tissue, fascia, or
      muscle) may be misleading, since localization of the infection to a
      single tissue plane is dependent on the point at which diagnostic and
      therapeutic intervention takes place. For example, necrotizing
      fasciitis, allowed to progress, will spread to involve underlying
      muscle and overlying skin and subcutaneous tissue. As surgeons we
      continuously seek to refine knowledge, but it is obvious that in
      classifying soft-tissue infections we have been somewhat like the
      blind men trying to describe an elephant.
             Several years ago President-elect Baxter suggested we define
      soft-tissue infections based on the most satisfactory treatment
      modality.”

Plamer LS, Winter HI, Tolia BM. The limited impact of involved surgace area
and surgical debridement on survival in Fournier’s gagnrene. Brit J Urol 1995; 76:
208-212.
      The authors reviewed the records of 30 patients. The mortality rate
      was 43%. The mean surface area involved in survivors was 4.3%
      (range 1-16.5%) which did not differ significantly from nonsurvivors,
      7.2% (range 5-20.5%). “Although no linear correlation exited, the
      quantified extent of disease may affect outcome as patients with 5%
      of body surface area involved were more likely to succumb to the
      disease. Finally, the number of surgical debridements, even if first
      performed within 24 hr of presentation, had no impact on outcome in
      patients with Fournier’s gangrene.”

Kirby RS. Improving outcomes in fournier’s gangrene. BJU 2004; 691-692.
     A very brief review. The title is a little misleading as nothing new in
     the way of improving outcomes is offered and the majority of the
     article is simply a review of the entity.

Edlich RF, Winters KL, Britt LD. Massive soft tissue infections: Necrotizing
fasciitis and Purpura Fulminans. Journal of Long-term Effects of Medical Implants
2005; 15(1); 57-65.
              The authors are of the opinion that massive soft tissue
       infections can be best taken care of at burn centers, particularly those
       with hyperbaric facilities. The authors emphasize EARLY aggressive
       debridement and resuscitation. Rapid diagnosis should be made on
       clinical exam. A gram stain of needle aspirate and the “finger test”
       can support the diagnosis. The authors also discuss frozen section
       biopsies of fascia. MRI is recommended. Delay in diagnosis and
       treatment are correlated with mortality. Early enteral feeding is
       appropriately stressed.

				
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