Original Paper

Urologia Internationalis

Received: April 25, 2014 Accepted after revision: July 24, 2014 Published online: February 7, 2015

Urol Int DOI: 10.1159/000366137

Hyperbaric Oxygen Therapy as an Adjuvant Therapy for Comprehensive Treatment of Fournier’s Gangrene Chao Li Xu Zhou Long-Fei Liu Fan Qi Jin-Bo Chen Xiong-Bing Zu Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, China

Abstract Objectives: To compare simple conventional treatment with the addition of hyperbaric oxygen therapy (HBOT) to conventional therapies in the treatment of Fournier’s gangrene (FG). Methods: A retrospective study of clinical data was performed by reviewing 28 cases of FG from January 2004 to December 2013 at Xiangya Hospital, Central South University. Among them, 12 patients were treated with the conventional therapy (non-HBOT group) and the other 16 cases were combined with hyperbaric oxygen therapy besides conventional therapy (HBOT group). All patients were followed up for 2 months to assess the therapeutic effect. The analyzed data included age, Fournier gangrene severity index (FGSI) score, number of surgical debridement, indwelling drainage tube time, length of stay (LOS), effective time, and curative time. Results: The mortality rate was lower in the HBOT group at 12.5% (2/16) compared to the non-HBOT group, which was 33.3% (4/12). The difference in the number of surgical debridement, indwelling drainage tube time, and curative time between were significantly lower in the HBOT group compared to the non-HBOT group. Conclusions: Our preliminary research suggests that the effect of combining hyperbaric oxygen therapy with conventional therapy of-

© 2015 S. Karger AG, Basel 0042–1138/15/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin

fers considerable advantage in the management of Fournier’s gangrene. Multicenter studies with a larger sample size are required to confirm these observations. © 2015 S. Karger AG, Basel

Introduction

Fournier’s gangrene (FG) is a potentially life-threatening progressive infection necrotizing fasciitis of the perineal, genital, or perianal regions, which commonly affects men despite aggressive modern management; it is associated with high morbidity and mortality, and the mortality of FG may be as high as 3 to 67% [1]. Treatment and disease management include broad spectrum antibiotics, radical surgical debridement, fecal and urinary diversion, and vacuum-assisted closure (VAC) treatment, all of which have resulted in a decrease in the mortality rate and length of stay (LOS) [2–4]. Hyperbaric oxygen therapy implies placing the patient in an environment of increased ambient pressure while breathing 100% oxygen, resulting in enhanced oxygenation of the arterial blood and tissues. Hyperbaric oxygen is widely believed to be an effective adjunctive therapy in the treatment of FG, even though there is no conclusive evidence regarding its effectiveness. Putative benefits of hyperbaric oxygen therapy include neutralization of anaerobic organisms, improvement in neutrophil function, increased fibroblast proliferation, and angiogenesis. However, the use of hyperbaric oxygen therapy Jin-Bo Chen and Xiong-Bing Zu Department of Urology, Xiangya Hospital Central South University Changsha, Hunan 410008 (China) E-Mail chenjinbo1989 @ yahoo.com and whzuxb @ 163.com

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Key Words Fournier’s gangrene · Comprehensive treatment · Hyperbaric oxygen therapy · Early debridement · Length of stay

Table 2. The pathogens of the 28 cases

Predisposing factors

Patients, n

p, %

Pathogens

Patients, n

p, %

Diabetes mellitus Scrotal dermatitis Hemorrhoids combined perianal abscess Long term oral glucocorticoid treatment history Rectal perforation Unknown

10 4 3

35.71 14.29 10.71

17 3 3

60.71 10.71 10.71

2 2 3

7.14 7.14 10.71

E. coli Streptococcus Staphylococcus aureus E. coli combined with gas production capsular bacteria Pseudomonas aeruginosa Unknown

1 2 2

3.57 7.14 7.14

is still under debate, as no prospective controlled trials have been published for its effectiveness in FG. The purpose of this study was to evaluate the value of HBOT as an effective and efficient adjunct therapy for FG management.

Materials and Methods Clinical Samples This study retrospectively analyzed the data collected from 28 cases of FG from January 2004 to December 2013 at Xiangya Hospital, Central South University, because of low incidence of FG and relatively small sample size. Diagnostic criteria included erythema or swelling of the scrotum, perineum or perianal areas, fluctuation, crepitus, or purulence of the subcutaneous tissue (demonstrated by physical examination and laboratory data or radiologic imaging), surgical findings of necrotic tissue, debridement, and histopathology with proven necrotizing fasciitis [5]. All male cases fitting the diagnostic criteria were included in the study. All the patients stayed in the hospital in wards with good ventilation. A small number of patients suffered from a large area of infection, which led to sepsis, septic shock, acute renal failure, or other dangerous situations; they needed long-term treatment in the intensive care unit (ICU). However, due to financial constraints, most of the patients and their families did not agree to enter the ICU. Patients with incomplete clinical data, debridement histopathology data that did not support necrotizing infection, and those patients who did not complete the treatment procedures were excluded from the analysis. Informed consent was obtained from all the patients, and the study was approved by the ethics committee of Xiangya Hospital. Among the 28 cases, 12 were treated with the conventional therapy, which included early debridement, use of broad-spectrum antibiotics, aggressive resuscitation, multiple debridement, and nutritional support [6]. The remaining 16 patients were given HBOT, in addition to conventional therapy. Predisposing factors, pathogens, and Fournier’s gangrene severity index (FGSI) scores were recorded at the time of admission. Clinical Characteristics of Patients All the 28 patients were male, with a mean age of 47 (ranging from 24 to 75 years). Mortality rate was 21.43% (6/28), which was slightly different from what was reported previously. For example,

2

Urol Int DOI: 10.1159/000366137

Altarac et al. reviewed that the mortality rate was 36.6%, but those recorded in Aridogan et al. were reduced to 29.6% [7, 8]. Among the participating patients, 10 (35.71%) had a history of diabetes mellitus, 4 (14.29%) had scrotal dermatitis, and 3 (10.71%) had hemorrhoids combined with perianal abscess as predisposing factors. Patients who had long-term oral glucocorticoid treatment and a history of rectal perforation were 2 (7.14%) in both groups (table  1). There were 25 (89.29%) scrotal gangrene and 3 (10.71%) penile skin gangrene patients. Most patients showed scrotum, perineum skin irritation, and pain, accompanied by chills, fever, with body temperature ranging from 38.5–40.0 ° C. In a short time, the patients showed blisters, ulceration pus, and eventually necrosis. In 20 (71.43%) patients, soft tissue had crepitus, including 15 (53.57%) patients whose gas within the scrotum was detected by ultrasonography or computed tomography. Bacterial culture and drug sensitivity tests were performed with patients’ wound exudates. All 26 (92.86%) cases were culture positive, including 17 (60.71%) cases of E. coli, 3 (10.71%) cases of streptococcus, 3 (10.71%) cases of staphylococcus aureus, 2 (7.14%) cases of pseudomonas aeruginosa, and 1 (3.57%) case of E. coli combined with gas producing capsular bacteria (table 2).  

 

Treatment Methods With the increasing number of antibiotics coming into use, drug resistance had become a large problem, so the broad-spectrum antibiotics could fully cover all pathogens. The recommended antibiotics included ceftriaxone, gentamicin, and clindamycin [9]. According to the actual situation of our hospital, all the patients used 2 or 3 kinds of antibiotics: Penicillin 2,000,000 U, 3 times per day, Clindamycin 600 mg, 4 times per day, combined with Metronidazole 500 mg, 3 times per day, and adjusted the kinds or dosages according to the results of bacterial culture and drug-sensitive tests. The dosages were adjusted according to the results of bacterial culture and drug-sensitive tests. From the isolates that have been grown in the patients, many were enterobacteria, which were sensitive to Gentamicin (80,000 U, 3 times per day). In addition, Fluconazole was added for those with diabetes or other immunological disorders. The antibiotics were changed to Imipenem-Cilastatin or Piperacillin-Tazobactam if the patient was not sensitive to empiric antimicrobial treatment. All the 28 patients were treated with the early debridement and incisiondrainage after admission. Wound dressings were changed twice a day, by cutting off the necrotic devitalized tissue, down to the deep fascia, and washed repeatedly with 3% hydrogen peroxide. Scrotoplasty was performed for 7 of the cases, scrotal skin grafting for 11,

Li/Zhou/Liu/Qi/Chen/Zu

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Table 1. The predisposing factors of the 28 cases

Table 3. The clinical features of the 28 cases

Age, years

FGSI score

Number of debridement

The clinical features of the HBOT group 1 37 5 2 2 42 8 1 3 50 12 2 4 45 9 1 5 75 14 1 6 36 4 1 7 55 10 2 8 53 8 1 9 26 6 1 10 62 6 1 11 58 3 2 12 52 5 1 13 44 7 1 14 28 3 1 15 31 7 1 16 44 11 2 The clinical features of the non-HBOT group 1 53 8 3 2 29 4 2 3 34 4 2 4 24 3 2 5 45 6 1 6 51 9 2 7 59 11 2 8 33 7 1 9 69 14 3 10 66 10 3 11 54 6 2 12 64 7 3

Indwelling drainage tube time, days

LOS, days

Effective time, days

Curative time, days

Ending

5 6 5 4 4 3 6 4 4 4 3 4 4 3 5 7

32 29 38 42 7 40 8 31 11 39 37 36 47 28 33 45

6 7 8 4 – 4 – 5 5 4 4 6 4 3 5 7

11 15 18 14 – 13 – 17 15 13 11 16 17 11 14 30

S S S S D S D S S S S S S S S S

7 6 7 3 6 11 8 6 10 4 5 4

12 38 40 25 42 14 16 52 13 48 39 36

– 7 5 3 7 – – 6 – 9 4 5

– 19 21 27 29 – – 35 – 42 17 14

D S S S S D D S D S S S

and urethral fistulation and scrotal skin grafting after the penile amputation for 2 cases, when the wound had grown into fresh granulated tissue. All the 12 cases in the group without HBOT treatment had scrotal gangrene. Multiple areas of postoperative incision were drained by iodoform gauze, and washed with 3% hydrogen peroxide, saline, and metronidazole solution. Among the 16 patients who were given HBOT, 13 (81.25%) cases had scrotal gangrene and 3 (18.75%) cases had penile gangrene of the skin. HBOT was commonly initiated as soon as patients stabilized and continued until the wound healed. After the initial debridement, HBOT was given twice a day for 5–7 days (2.5 units of absolute atmosphere oxygen, 90–120 min each time, interval for 10 h). The other treatments were the same as the conventional therapy group. Fournier’s gangrene severity index (FGSI) was used to judge the severity degree of FG as described by Laor et al. It comprises 9 parameters, including temperature, pulse, respiratory rate, levels of sodium, potassium and creatinine, hematocrit, leukocytosis, and bicarbonate levels. Each parameter is given a 0 to 4 score [10]. Apart from this, FG confined to the urogenital or anorectal region

was given a score of 1; confined to the pelvic region was given 2; extending beyond the pelvic region was given 6; and age over 60 was given 1 [11]. All the scores were added up to calculate the total score. Higher FGSI score stands for worse prognosis [10]. All patients were followed up for 2 months to assess the therapeutic effect. During follow-up, effective improvement of symptoms and time for complete cure were measured. Family members of the patients were advised by the physician to report these two variables. Complete cure was defined as disappearance of clinical symptoms, reduced wound inflammation, and no requirement for repeated debridement. Effective improvement was defined as decrease in wound secretions, reduced inflammation, and improved clinical symptoms. No obvious improvements of clinical symptoms and signs, or deterioration were considered invalid. Basic medical data, including age, FGSI, number of debridement, indwelling drainage tube time, LOS, effective time, and curative time were collected for all the participants. The clinical data of 28 cases are described in table 3.

Hyperbaric Oxygen Therapy as an Adjuvant Therapy

Urol Int DOI: 10.1159/000366137

3

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S = Surviving; D = dead.

tional treatment and combined with HBOT

Mean age, years Mean FGSI score Mean number of debridement Mean indwelling drainage tube time Mean LOS, days Mean effective time Mean curative time

Non-HBOT (n = 12)

HBOT (n = 16)

p

48.42±15.31 7.42±3.20

46.13±13.11 7.38±3.20

>0.05 >0.05

2.17±0.72

1.32±0.48

0.05

Hyperbaric Oxygen Therapy as an Adjuvant Therapy for Comprehensive Treatment of Fournier's Gangrene.

To compare simple conventional treatment with the addition of hyperbaric oxygen therapy (HBOT) to conventional therapies in the treatment of Fournier'...
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