Perry Travis L, Kranker Lindsay M, Mobley Erin E, Curry Eileen E, Johnson R Michael
Miami Valley Hospital Regional Adult Burn and Wound Center, Dayton, OH; Wright State University, Boonshoft School of Medicine, Department of Surgery, Dayton, OH.
Wright State University, Boonshoft School of Medicine, Department of Surgery, Dayton, OH.
Wounds. 2018 Oct;30(10):290-299.
Fournier's gangrene (FG) remains a forbidding necrotizing soft tissue infection (NSTI) that necessitates early recognition, prompt surgical excision, and goal-directed antibiotic therapy. Traditionally, surgical management has included wide radical excision for sepsis control, but this management often leaves large, morbid wounds that require complex wound coverage, prolonged hospitalizations, and/or delayed healing.
The purpose of this case series is to report the outcomes of FG using a surrogate approach of concurrent debridement of spared skin and soft tissue, negative pressure wound therapy (NPWT), and serial delayed primary closure (DPC).
A retrospective review of 17 consecutive patients with FG treated with concurrent skin and soft tissue sparing surgery, NPWT, and serial DPC at Miami Valley Hospital Regional Adult Burn and Wound Center (Dayton, OH) between 2008 and 2018 was conducted. Patients were included if the following were noted: clinical suspicion of FG based on genital and perineal cellulitis, fever, leukocytosis, and confirmation of tissue necrosis upon surgical exploration. Patients not treated with skin sparing surgical debridement or wounds with an inability to maintain a NPWT dressing seal were excluded.
The mean number of total surgeries including simultaneous debridement and reconstruction was 5.5. The average intensive care unit and hospital length of stay was 3.2 and 18.9 days, respectively. The average number of days from initial consult to wound closure was 24.3. The need for colostomy and skin grafts were nearly eliminated with this surrogate approach. Using this reproducible technique, DPC was achieved in 100% of patients. Only 11.8% (2/17) required split-thickness skin grafting as part of wound closure. The majority (9/17; 52.9%) were partially managed as an outpatient during wound closure. During staged DPC, the mean number of outpatient management days was 16.0. There were no mortalities in this series of patients.
To the best of the authors' knowledge, this is the largest case series reported in the literature using skin and soft tissue sparing surgery for wound closure of a FG NSTI.
福尼尔坏疽（FG）仍然是一种严重的坏死性软组织感染（NSTI），需要早期识别、及时手术切除以及目标导向性抗生素治疗。传统上，手术治疗包括广泛的根治性切除以控制败血症，但这种治疗方式常常会留下大的、病态的伤口，需要复杂的伤口覆盖、延长住院时间和/或延迟愈合。
本病例系列的目的是报告采用保留皮肤和软组织同步清创、负压伤口治疗（NPWT）以及系列延迟一期缝合（DPC）的替代方法治疗FG的结果。
对2008年至2018年期间在迈阿密谷医院区域成人烧伤与伤口中心（俄亥俄州代顿）接受保留皮肤和软组织同步手术、NPWT以及系列DPC治疗的17例连续性FG患者进行回顾性研究。如果出现以下情况则纳入患者：基于生殖器和会阴蜂窝织炎、发热、白细胞增多症临床怀疑FG，以及手术探查时确认组织坏死。未接受保留皮肤手术清创治疗的患者或无法维持NPWT敷料密封的伤口患者被排除。
包括同步清创和重建在内的总手术平均次数为5.5次。重症监护病房和住院的平均时长分别为3.2天和18.9天。从初次就诊到伤口闭合的平均天数为24.3天。采用这种替代方法几乎消除了结肠造口术和皮肤移植的需求。使用这种可重复的技术，100%的患者实现了DPC。仅11.8%（2/17）的患者在伤口闭合时需要进行中厚皮片移植。大多数患者（9/17；52.9%）在伤口闭合期间部分作为门诊患者进行处理。在分期DPC期间，门诊处理的平均天数为16.0天。该系列患者中无死亡病例。
据作者所知，这是文献中报道的使用保留皮肤和软组织手术闭合FG NSTI伤口的最大病例系列。
