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Journal of Postgraduate Medicine, Vol. 54, No. 2, April-June, 2008, pp. 83-84 Guest Editorial Fournier's gangrene, still an enigma Eke N University of Port Harcourt Teaching Hospital, Port Harcourt 500001 Code Number: jp08035 First documented in 1883 by Professor Jean-Alfred Fournier (1832-1914), Fournier′s gangrene (FG) has continued to be of interest to physicians, especially now urologists. Women and children, not mentioned in the original report, are now known to suffer from it. However, reports on women remain scanty. It is suspected that involvement of women is underreported. [1] New reports, even if not offering much new, will continue to be relevant for continuing medical education because of continued late diagnosis by unsuspecting physicians. Each generation of doctors will first address issues in contemporary literature before recourse to past literature. The diagnosis of FG is largely based on the clinical features, most importantly the anatomical area of the perineum and external genitalia. Thus both males and females are prone, as found by Unalp et al. , [2] in this issue. Radiological investigations as well as histopathology may assist in defining the extent of the disease and in monitoring response to treatment. In spite of efforts to determine prognostic factors, it has been difficult to significantly reduce the mortality and consequently morbidity also. The Fournier′s gangrene severity index (FGSI) was proposed by Laor et al. in 1995 [3] to prognosticate on the outcome of the disease but does not seem to have impacted on the management universally. A part of the problem with universal application of the index lies in the low incidence of the disease, such that any one unit cannot recruit more than a limited number of patients in a period of practice. The two papers in this issue rank among the top 10 largest series on FG since 1990. Both are retrospective studies and one applied the index. In view of the low incidence of FG, it is necessary to design some prospective studies on the subject, conscious of the long period required for such a study to yield reliable and useful results. Collaborative multi-center studies are necessary. It has been observed that FGSI can be a useful basis to compare outcomes of management of FG. [4] Without recourse to the index, every patient should be treated on the basis of individual merit and considerations. Although in this issue of the journal, the authors did not find that anorectal source of sepsis had a worse prognosis, there could be an explanation for the findings of many authors [1],[5],[6] that anorectal or colonic source of sepsis worsened prognosis. The anatomical area is awash with different types of organisms of varying virulence as well as synergism. The tissue planes permit organisms to spread. Testicular necrosis in FG is another indicator of severe disease as this points to retroperitoneal sepsis which causes thrombosis of the testicular blood vessels. [7] The retroperitoneal sepsis limits adequate drainage unless drainage is instituted through a laparotomy. Ultimately, sepsis and its complications account for the majority of deaths in FG. [7],[8] The role of diabetes mellitus is reemphasized by the two authors in this issue with figures of 35.3% [2] and 51.3%. [9] In a previous review of 1726 cases published in the literature, [10] diabetes mellitus was a factor in 20% of the patients. However, it is yet to be settled by authors universally whether diabetes mellitus in FG is an etiological factor, a predisposing factor or merely a co-morbid factor. All may find application in specific instances. The ultimate goal in the management of FG is to eliminate mortality. Mortality rates in FG vary from center to center and from region to region. In an unpublished study by this author, mortality rates are lowest in Africa and highest in NorthAmerica. This is in spite of advances in the management of afflicted persons. It is wise to treat every patient aggressively with available resources to prevent severe sepsis or stem the effects of sepsis. As stressed by the authors in this issue and others, aggressive treatment involves resuscitation with fluids and multiple parenteral antimicrobial agents and unrelenting excision of all necrotic tissues as they present. Many patients will be cured without the need for colostomy, grafts or hyperbaric oxygen treatment. References
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