The limited impact of involved surface area and surgical debridement on survival in Fournier's gangrene

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Abstract
To evaluate the influence of involved surface area (extent of disease) and the number and timing of surgical débridements on survival in patients with Fournier's gangrene. The medical records of 30 patients with Fournier's gangrene treated over a 15-year period were reviewed. The extent of disease was quantified and expressed as a percentage of the body surface area by applying a modified diagram used to assess burn injuries. The number of surgical débridements and their timing with respect to initial presentation and to each other were also analysed. Patients were stratified by outcome (survival or death) and the data evaluated by Student's t-test, Fisher's exact test and regression analysis. Of 30 patients treated 13 died (43%) and 17 survived (57%). The mean surface area involved by disease among survivors was 4.3% (range 1-16.5%) and 7.2% (range 5-20.5%) for non-survivors (P = 0.10). Whilst no direct correlation between death rate and extent of disease existed, patients with < 5% surface area involvement were more likely to survive (P = 0.014). Every patient underwent surgical débridement of the involved area (mean 1.72 procedures per patient). Survivors underwent from one to four débridements (mean 1.79) and non-survivors one to three débridements (mean 1.63); the mean number of débridements did not influence outcome (P = 0.68). The performance of more than one débridement did not affect survival (P = 1.00). The initial débridement was performed within 24 h of presentation in 10 of 13 patients who died and 11 of 17 survivors and had no effect on outcome (P = 0.69). A second débridement was performed after a mean of 6.8 days (range 1-12) among the six survivors and 5.4 days (range 2-16) among the five non-survivors; this difference was not statistically significant (P = 0.65). Four survivors required a third débridement, one required a fourth and one patient who succumbed underwent a third débridement. The mortality rate from Fournier's gangrene continues to be substantial (43% in our series). Although no linear correlation existed, 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 débridements, even if first performed within 24 h of presentation, had no impact on outcome in patients with Fournier's gangrene.