Fournier Gangrene Medical Slides

Present the time-critical nature: every hour delay in surgical debridement increases mortality. Czymek (2009) showed mortality increased from 24% to 37% when surgery was delayed >24 hours. Debridement principles: (1) Wide excision of ALL necrotic tissue — skin, subcutaneous fat, and fascia until reaching healthy, bleeding tissue edges. (2) Do not close the wound — leave open for repeated inspection. (3) Plan for repeat debridement every 24-48 hours (average 3-5 debridements per patient). (4) The "dishwater gray" fascia and lack of bleeding tissue are pathognomonic — excise until healthy tissue encountered. (5) Testicular involvement is rare (testes have independent blood supply from aorta) — preserve if viable. Consider fecal diversion (loop colostomy) if perineal involvement is extensive to reduce wound contamination.

Present the empiric broad-spectrum regimen targeting polymicrobial infection (average 4 organisms: E. coli, Bacteroides, Streptococcus, Staphylococcus, Clostridium, Klebsiella): Triple therapy — (1) Carbapenem (meropenem 1g q8h) or piperacillin-tazobactam 4.5g q6h (covers gram-negatives + anaerobes), (2) Vancomycin 15-20 mg/kg q8-12h (covers MRSA), (3) Clindamycin 900 mg q8h (anti-toxin effect — suppresses bacterial toxin production, similar rationale as in group A strep necrotizing fasciitis). Some centers use metronidazole instead of clindamycin. Culture-guided narrowing once operative cultures and sensitivities available. Antifungal (fluconazole or caspofungin) if Candida species isolated, which occurs in up to 20% of cases. Duration: continue until debridements complete and patient clinically improving.

Present the staged approach: Phase 1 (debridement, days 1-7+): serial debridements every 24-48 hours until wound bed is clean with granulation tissue. Negative pressure wound therapy (VAC) between debridements (promotes granulation, reduces wound size, manages exudate). Phase 2 (wound bed preparation, weeks 1-3): continue VAC therapy, nutritional optimization (protein 1.5-2 g/kg/day, caloric supplementation), control diabetes. Diverting colostomy reversal planned for later. Phase 3 (reconstruction): small defects may heal by secondary intention with VAC. Moderate defects: split-thickness skin graft (most common reconstructive technique). Large defects: local flaps (gracilis, pudendal-thigh, lotus petal) or regional flaps. Scrotal reconstruction: residual scrotal skin is remarkably regenerative; primary closure often possible after initial retraction. Functional outcomes (urinary, sexual, fecal continence) are acceptable in 60-80% of survivors despite extensive initial debridement.