Treatment and Reconstruction in Necrotizing Fasciitis: Our Clinical Approach
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Abstract
Background: Necrotizing fasciitis is a rare but serious soft tissue infection that is often life-threatening. This infection is caused by various bacteria and spreads rapidly into deeper tissues. It usually starts with a small wound or cut in the skin and can progress very rapidly, leading to extensive tissue destruction, systemic toxicity and ultimately very high mortality rates.
Aims: This article will focus on the strategies we apply in clinical practice to prevent and manage necrotizing fasciitis.
Methods: Patients admitted to our clinic between January 2014 and December 2023 were retrospectively reviewed. Individuals whose initial diagnosis and treatment were from an external center and those with a follow-up period of less than six months after treatment were excluded from the study. This article included 127 patients. They were evaluated in terms of epidemiology, demographic characteristics, treatment timing, reconstruction options, return to daily life and complications.
Results: Necrotizing fasciitis was observed in the perineum in 92 cases, in the lower extremities in 22 cases, in the upper extremities in 7 cases and in the inguinal region in 6 cases out of 127 patients. The average laboratory risk indicator for necrotising fasciitis (LRINEC) score was 6.7. All patients underwent debridement after diagnosis. Reconstruction was not started until the LRINEC score was below 4 and culture negativity was achieved. As a reconstruction method, skin graft was used in 48 patients, local fasciocutaneous flap in 29 patients, medial circumflex femoral artery flap in 27 patients, free anterolateral thigh flap in 7 patients, singapore flap in 6 patients, scrotal advancement flap in 6 patients and pedicled anterolateral thigh flap in 4 patients. Partial flap loss occurred in 4 patients and surgical site infection occurred in 21 patients. There were no major complications. After reconstruction, the mean time to return to daily life was 14.3 days.
Conclusion: These results show that the need for surgical intervention in the treatment of necrotizing fasciitis varies according to the site of infection and the type of microorganism. Demographic factors had no significant effect on the number of surgical debridements. These findings may provide important clues to guide clinical practice and optimize treatment protocols.
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References
2. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis. 2007;44(5):705-710. Doi:10.1086/511638.
3. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003;85(8):1454-1460.
4. Misiakos E.P., Bagias G., Patapis P., Sotiropoulos D., Kanavidis P., Machairas A. Current concepts in the management of necrotizing fasciitis. Front. Surg. 2014:1. Doi: 10.3389/fsurg.2014.00036.
5. Oppegaard O, Rath E. Treatment of Necrotizing Soft Tissue Infections: Antibiotics. Adv Exp Med Biol. 2020;1294:87-103. Doi:10.1007/978-3-030-57616-5_7.
6. Gelbard RB, Ferrada P, Yeh DD, et al. Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018;85(1):208-214. Doi:10.1097/TA.0000000000001857.
7. Cheng NC, Yu YC, Tai HC, et al. Recent trend of necrotizing fasciitis in Taiwan: focus on monomicrobial Klebsiella pneumoniae necrotizing fasciitis. Clin Infect Dis. 2012;55(7):930-939. Doi:10.1093/cid/cis565.
8. Bellapianta JM, Ljungquist K, Tobin E, Uhl R. Necrotizing fasciitis. J Am Acad Orthop Surg. 2009;17(3):174-182. Doi:10.5435/00124635-200903000-00006.
9. Wang JM, Lim HK. Necrotizing fasciitis: eight-year experience and literature review. Braz J Infect Dis. 2014;18(2):137-143. Doi:10.1016/j.bjid.2013.08.003.
10. Goh T, Goh LG, Ang CH, Wong CH. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):e119-e125. Doi:10.1002/bjs.9371.
11. Misiakos EP, Bagias G, Papadopoulos I, et al. Early Diagnosis and Surgical Treatment for Necrotizing Fasciitis: A Multicenter Study. Front Surg. 2017;4:5. Published 2017 Feb 7. Doi:10.3389/fsurg.2017.00005.
12. Vayvada H, Demirdover C, Menderes A, Karaca C. Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature. Int Wound J. 2013;10(4):466-472. Doi:10.1111/j.1742-481X.2012.01006.x.
13. Lewis GD, Majeed M, Olang CA, et al. Fournier's Gangrene Diagnosis and Treatment: A Systematic Review. Cureus. 2021;13(10):e18948. Published 2021 Oct 21. Doi:10.7759/cureus.18948.
14. Sarofim M, Di Re A, Descallar J, Toh JWT. Relationship between diversional stoma and mortality rate in Fournier's gangrene: a systematic review and meta-analysis. Langenbecks Arch Surg. 2021;406(8):2581-2590. Doi:10.1007/s00423-021-02175-z.
15. Murakami M, Okamura K, Hayashi M, Minoh S, Morishige I, Hamano K. Fournier's gangrene treated by simultaneously using colostomy and open drainage. J Infect. 2006;53(1):e15-e18. Doi:10.1016/j.jinf.2005.09.018.
16. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541. Doi:10.1097/01.ccm.0000129486.35458.7d.
17. Chao WN, Tsai SJ, Tsai CF, et al. The Laboratory Risk Indicator for Necrotizing Fasciitis score for discernment of necrotizing fasciitis originated from Vibrio vulnificus infections. J Trauma Acute Care Surg. 2012;73(6):1576-1582. Doi:10.1097/TA.0b013e318270d761.
18. El-Menyar A, Asim M, Mudali IN, Mekkodathil A, Latifi R, Al-Thani H. The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic role. Scand J Trauma Resusc Emerg Med. 2017;25(1):28. Published 2017 Mar 7. Doi:10.1186/s13049-017-0359-z.
19. Irmak F, Sirvan SS, Sizmaz M, Yazar SK, Akcal A, Karsidag S. Perineoscrotal Reconstruction Following Fournier's Gangrene using The Upper Medial Thigh Perforator Flap. Turkish Journal of Plastic Surgery 27(3):p 127-131, Jul–Sep 2019. | DOI: 10.4103/tjps.tjps_82_18.
20. Kim T, Park SY, Kwak YG, et al. Etiology, characteristics, and outcomes of community-onset necrotizing fasciitis in Korea: A multicenter study. PLoS One. 2019;14(6):e0218668. Published 2019 Jun 20. Doi:10.1371/journal.pone.0218668.
21. Gawaziuk JP, Liu T, Sigurdson L, et al. Free tissue transfer for necrotizing fasciitis reconstruction: A case series. Burns. 2017;43(7):1561-1566. Doi:10.1016/j.burns.2017.04.007.
22. Michael P, Peiris B, Ralph D, Johnson M, Lee WG. Genital Reconstruction following Fournier's Gangrene. Sex Med Rev. 2022;10(4):800-812. Doi:10.1016/j.sxmr.2022.05.002.
23. Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene. Burns. 2003;29(8):857-862. Doi:10.1016/j.burns.2003.07.001.
24. Hsu H, Lin CM, Sun TB, Cheng LF, Chien SH. Unilateral gracilis myofasciocutaneous Reconstr Aesthet Surg. 2007;60(9):1055-1059. Doi:10.1016/j.bjps.2006.09.005.
25. Chen SY, Fu JP, Chen TM, Chen SG. Reconstruction of scrotal and perineal defects in Fournier's gangrene. J Plast Reconstr Aesthet Surg. 2011;64(4):528-534. Doi:10.1016/j.bjps.2010.07.018.
26. Narayan N, McCoubrey G. Necrotizing fasciitis: a plastic surgeon's perspective. Surgery. 2019;37(1):33-37 Doi:10.1016/j.mpsur.2018.11.009.