Low-intensity extracorporeal shock wave therapy in the postoperative management of Fournier`s gangrene - a case series of a new concept
Main Article Content
Abstract
Objectives: Fournier’s gangrene is an aggressive frequently fatal polymicrobial soft tissue infection of perineum and external genitalia requiring immediate radical surgery. Postoperative management includes mesh-graft and skin-flaps. We used low intensity shock wave therapy (Li-ESWT) in the management of wound healing following Fournier`s gangrene in three case series.
Materials and Methods: Li-ESWT was applied three times weekly with 2000-3000 shock waves at 3-4 Hz (Energy flux density: 0.25 mJ/mm2) using Duolith SD1 ultra without anesthesia. In one year, we treated 8 patients at two centers in Europe and Asia. Based on planimetric assessment of the wound area at respective times, we calculated the re-epithelization speed (cm2/d).
Results: Case series 1: Three patients after secondary healing of a skin flap. In all cases wound-healing was promoted within 6-7 weeks (re-epithelization speed 0.24-0.42 cm2/d). Case series 2: Two patients were primarily treated successfully over 6-7 weeks with significant closure of the wound (re-epithelization speed 0.65-0.79 cm2/d) followed by mesh-graft. Case series 3: Three patients exclusively treated by Li-ESWT showed complete restoration of penile and scrotal tissue within 4-5 months (i.e. re-epithelization speed of 0.47-0.70 cm2/d).
Conclusions: Li-ESWT could become an interesting non-invasive treatment modality for patients with secondary wound problems (i.e. Fournier`s gangrene).
Keywords:
Extracorporeal shock wave therapy, Fournier`s gangrene, wound healing, low-intensity ESWT, stem cell proliferation, re-epithelization, planimetric assessment
Article Details
How to Cite
JJ, Rassweiler et al.
Low-intensity extracorporeal shock wave therapy in the postoperative management of Fournier`s gangrene - a case series of a new concept.
Medical Research Archives, [S.l.], v. 12, n. 10, oct. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5801>. Date accessed: 22 dec. 2024.
doi: https://doi.org/10.18103/mra.v12i10.5801.
Section
Case Series
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000 Jun;87(6):718-28. doi: 10.1046/j.1365-2168.2000.01497.x. PMID: 10848848.
2. Jennifer Kranz, Riccardo Bartoletti, Franck Bruyère, et al. European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines. Eur Urol. In press.
https://doi.org/10.1016/j.eururo.2024.03.035
3. Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier's gangrene. A clinical review. Arch Ital Urol Androl. 2016 Oct 5;88(3):157-164. doi: 10.4081/aiua.2016.3.157. PMID: 27711086.
4. Suda S, Hayashida K. Crafting Contours: A Comprehensive Guide to Scrotal Reconstruction. Life (Basel). 2024 Feb 4;14(2):223. doi: 10.3390/life 14020223. PMID: 38398732; PMCID: PMC10890180.
5. Haidari M, Nazer MR, Ahmadinejad M, Almasi V, Khorramabadi MS, Pournia Y. Honey in the treatment of Fournier's gangrene as an adjuvant: a cross- sectional study. J Pak Med Assoc. 2014 May;64(5):571-3. PMID: 25272547.
6. Muñoz M, Del Sol M, Vásquez B. Antibacterial and wound-healing action of Ulmo honey (Eucryphia cordifolia) of differing degrees of purity. Front Vet Sci. 2023 May 12;10:1172025. doi: 10.3389/fvets.2023.1172025. PMID: 37252390; PMCID: PMC10213365.
7. Mladenov A, Diehl K, Müller O, von Heymann C, Kopp S, Peitsch WK. Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years. World J Emerg Surg. 2022 Aug 5;17(1):43.
8. Chaussy C, Brendel W, Schmiedt E. Extracorporeally induced destruction of kidney stones by shock waves. Lancet. 1980 Dec 13;2 (8207):1265-8. doi: 10.1016/s0140-6736(80)92335-1. PMID: 6108446.
9. Fuchs G, Miller K, Rassweiler J, Eisenberger F. Extracorporeal shock-wave lithotripsy: one-year experience with the Dornier lithotripter. Eur Urol. 1985;11(3):145-9. doi: 10.1159/000472479. PMID: 4029228.
10. Rompe JD, Hopf C, Nafe B, Burger R. Low-energy extracorporeal shock wave therapy for painful heel: a prospective controlled single-blind study. Arch Orthop Trauma Surg. 1996;115(2):75-9. doi: 10.1007/BF00573445. PMID: 9063856.
11. Haupt G, Chvapil M. Effect of shock waves on the healing of partial-thickness wounds in piglets. J Surg Res. 1990 Jul;49(1):45-8. doi: 10.1016/0022-4804(90)90109-f. PMID: 2359293.
12. Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M. Influence of shock waves on fracture healing. Urology. 1992 Jun;39(6):529-32. doi: 10.1016/0090-4295(92)90009-l. PMID: 1615601.
13. Schaden W, Thiele R, Kölpl C, Pusch M, Nissan A, Attinger CE, Maniscalco-Theberge ME, Peoples GE, Elster EA, Stojadinovic A. Shock wave therapy for acute and chronic soft tissue wounds: a feasibility study. J Surg Res 2007;143(1): 1-12.
14. Skov-Jeppesen SM, Petersen NA, Yderstraede KB, Jensen BL, Bistrup C, Lund L. Low-Intensity Extracorporeal Shockwave Therapy (LI-ESWT) in Renal Diseases: A Review of Animal and Human Studies. Int J Nephrol Renovasc Dis. 2023 Feb 6;16:31-42. doi: 10.2147/IJNRD.S389219. PMID: 36778197; PMCID: PMC9912820.
15. Mariotto SC, Amelio E, Ciampa AR, de Prati AC, Marlinghaus E, Russo S, Suzuki H. Extracorporeal shock waves: from lithotripsy to anti-inflammatory action by NO production. Nitric Oxide 2005; 12(2): 89-96.
16. Mittermayr R, Antonic V, Hartinger J, Kaufmann H, Redl H, Téot L, Stojadinovic A, Schaden W. Extracorporeal shock wave therapy (ESWT) for wound healing: technology, mechanisms, and clinical efficacy. Wound Repair Regen. 2012;20 (4):456-65.
17. Kisch T, Wuerfel W, Forstmeier V, Liodaki E, Stang FH, Knobloch K, Mailaender P, Kraemer R. Repetitive shock wave therapy improves muscular microcirculation. J Surg Res 2016; 201(2):440-445.
18. Serizawa F, Ito K, Matsubara M, Sato A, Shimokawa H, Satomi S. Extracorporeal shock wave therapy induces therapeutic lymphangiogenesis in a rat model of secondary lymphoedema. Eur J Vasc Endovasc Surg 2011; 42(2):254-260.
19. Frairia R, Berta L. Biological effects of extracorporeal shock waves on fibroblasts. A review. Muscles Ligaments Tendons J 2011 1(4): 138-147.
20. Holsapple JS, Cooper B, Berry SH, Staniszewska A, Dickson BM, Taylor JA, Bachoo P, Wilson HM. Low Intensity Shockwave Treatment Modulates Macrophage Functions Beneficial to Healing Chronic Wounds. International Journal of Molecular Sciences. 2021; 22(15):7844. https://doi.org/10.3390/ijms22157844
21. Basoli V, Chaudary S, Cruciani S, Santaniello S, Balzano F, Ventura C, Redl H, Dungel P, Maioli M. Mechanical Stimulation of Fibroblasts by Extracorporeal Shock Waves: Modulation of Cell Activation and Proliferation Through a Transient Proinflammatory Milieu. Cell Transplant. 2020 Jan-Dec;29:963689720916175. doi: 10.1177/0963689 720916175. PMID: 32326741; PMCID: PMC7586264.
22. Rassweiler JJ, Scheitlin W, Goezen AS, Rassweiler-Seyfried MC. Low-energy shockwave therapy in the management of wound healing following Fournier's gangrene. Eur Urol Open Sci 2022;45: 8-11.
23. Rassweiler J, Ringeisen M, Knobloch K, Schaden W. Efficacy and Theoretical Basis of Low-Intensity Shock Wave Therapy in the Management of Different Forms of Wound Healing: Own Experiences and a Review of the Literature, Medical Research Archives, [online] 2023; 11(8). https://doi.org/10.18103/mra.v 11i8.4394
24. Ottomann C, Hartmann B, Tyler J, Maier H, Thiele R, Schaden W, Stojadinovic A. Prospective randomized trial of accelerated re-epithelization of skin graft donor sites using extracorporeal shock wave therapy. J Amer Coll Surg 2010; 05.012; ISSN 1072-7515/10/; doi:10.1016
25. Wang CJ, Cheng JH, Kuo YR, Schaden W, Mittermayr R. Extracorporeal shockwave therapy in diabetic foot ulcers. Int J Surg. 2015 Dec;24(Pt B):207-9. doi: 10.1016/j.ijsu.2015.06.024. Epub 2015 Jun 12. PMID: 26079500.
26. Negm WA, El-Kadem AH, Elekhnawy E, Attallah NGM, Al-Hamoud GA, El-Masry TA, Zayed A. Wound-Healing Potential of Rhoifolin-Rich Fraction Isolated from Sanguisorba officinalis Roots Supported by Enhancing Re-Epithelization, Angiogenesis, Anti-Inflammatory, and Antimicrobial Effects. Pharmaceuticals (Basel). 2022 Jan 31;15(2):178. doi: 10.3390/ph15020178. PMID: 35215291; PMCID: PMC8874642.
27. Rowland MB, Moore PE, Bui C, Correll RN. Assessing wound closure in mice using skin-punch biopsy. STAR Protoc. 2023 Mar 17;4(1):101989. doi: 10.1016/j.xpro.2022.101989. Epub 2023 Jan 4. PMID: 36602903; PMCID: PMC9826969.
28. Kuai L, Zhang JT, Deng Y, Xu S, Xu XZ, Wu MF, Guo DJ, Chen Y, Wu RJ, Zhao XQ, Nian H, Li B, Li FL. Sheng-ji Hua-yu formula promotes diabetic wound healing of re-epithelization via Activin/ Follistatin regulation. BMC Complement Altern Med. 2018 Jan 29;18(1):32. doi: 10.1186/s12906-017-2074-8. PMID: 29378560; PMCID: PMC5789635.
29. Dymarek R, Kuberka I, Walewicz K, Taradaj J, Rosińczuk J, Sopel M. Is Shock Wave Application Effective on Various Chronic Wounds in the Geriatric Population? Preliminary Clinical Study. Clin Interv Aging. 2024 Apr 30;19:665-679. doi: 10.2147/CIA.S448298. PMID: 38706636; PMCID: PMC11069372.
30. Schuh CM, Heher P, Weihs AM, Banerjee A, Fuchs C, Gabriel C, Wolbank S, Mittermayr R, Redl H, Rünzler D, Teuschl AH. In vitro extracorporeal shock wave treatment enhances stemness and preserves multipotency of rat and human adipose-derived stem cells. Cytotherapy. 2014 Dec;16(12): 1666-78. doi: 10.1016/j.jcyt.2014.07.005. Epub 2014 Aug 28. PMID: 25174738.
31. Lin G, Van Kuiken M, Wang G, Banie L, Tan Y, Zhou F, Wang Z, Chen Y, Zhang Y, Lue TF. Microenergy acoustic pulse therapy restores function and structure of pelvic floor muscles after simulated birth injury. Transl Androl Urol 2022;11 (5): 595-605
32. Shin D, Jeon SH, Tian WJ, Kwon EB, Kim GE, Bae WJ, Cho HJ, Hong SH, Lee JY, Kim SW. Extracorporeal shock wave therapy combined with engineered mesenchymal stem cells expressing stromal cell-derived factor-1 can improve erectile dysfunction in streptozotocin-induced diabetic rats. Transl Androl Urol. 2021;10(6):2362-2372.
33. Kou D, Chen Q, Wang Y, Xu G, Lei M, Tang X, Ni H, Zhang F. The application of extracorporeal shock wave therapy on stem cells therapy to treat various diseases. Stem Cell Res Ther. 2024 Aug 26;15(1):271. doi: 10.1186/s13287-024-03888-w. PMID: 39183302; PMCID: PMC11346138.
2. Jennifer Kranz, Riccardo Bartoletti, Franck Bruyère, et al. European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines. Eur Urol. In press.
https://doi.org/10.1016/j.eururo.2024.03.035
3. Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier's gangrene. A clinical review. Arch Ital Urol Androl. 2016 Oct 5;88(3):157-164. doi: 10.4081/aiua.2016.3.157. PMID: 27711086.
4. Suda S, Hayashida K. Crafting Contours: A Comprehensive Guide to Scrotal Reconstruction. Life (Basel). 2024 Feb 4;14(2):223. doi: 10.3390/life 14020223. PMID: 38398732; PMCID: PMC10890180.
5. Haidari M, Nazer MR, Ahmadinejad M, Almasi V, Khorramabadi MS, Pournia Y. Honey in the treatment of Fournier's gangrene as an adjuvant: a cross- sectional study. J Pak Med Assoc. 2014 May;64(5):571-3. PMID: 25272547.
6. Muñoz M, Del Sol M, Vásquez B. Antibacterial and wound-healing action of Ulmo honey (Eucryphia cordifolia) of differing degrees of purity. Front Vet Sci. 2023 May 12;10:1172025. doi: 10.3389/fvets.2023.1172025. PMID: 37252390; PMCID: PMC10213365.
7. Mladenov A, Diehl K, Müller O, von Heymann C, Kopp S, Peitsch WK. Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years. World J Emerg Surg. 2022 Aug 5;17(1):43.
8. Chaussy C, Brendel W, Schmiedt E. Extracorporeally induced destruction of kidney stones by shock waves. Lancet. 1980 Dec 13;2 (8207):1265-8. doi: 10.1016/s0140-6736(80)92335-1. PMID: 6108446.
9. Fuchs G, Miller K, Rassweiler J, Eisenberger F. Extracorporeal shock-wave lithotripsy: one-year experience with the Dornier lithotripter. Eur Urol. 1985;11(3):145-9. doi: 10.1159/000472479. PMID: 4029228.
10. Rompe JD, Hopf C, Nafe B, Burger R. Low-energy extracorporeal shock wave therapy for painful heel: a prospective controlled single-blind study. Arch Orthop Trauma Surg. 1996;115(2):75-9. doi: 10.1007/BF00573445. PMID: 9063856.
11. Haupt G, Chvapil M. Effect of shock waves on the healing of partial-thickness wounds in piglets. J Surg Res. 1990 Jul;49(1):45-8. doi: 10.1016/0022-4804(90)90109-f. PMID: 2359293.
12. Haupt G, Haupt A, Ekkernkamp A, Gerety B, Chvapil M. Influence of shock waves on fracture healing. Urology. 1992 Jun;39(6):529-32. doi: 10.1016/0090-4295(92)90009-l. PMID: 1615601.
13. Schaden W, Thiele R, Kölpl C, Pusch M, Nissan A, Attinger CE, Maniscalco-Theberge ME, Peoples GE, Elster EA, Stojadinovic A. Shock wave therapy for acute and chronic soft tissue wounds: a feasibility study. J Surg Res 2007;143(1): 1-12.
14. Skov-Jeppesen SM, Petersen NA, Yderstraede KB, Jensen BL, Bistrup C, Lund L. Low-Intensity Extracorporeal Shockwave Therapy (LI-ESWT) in Renal Diseases: A Review of Animal and Human Studies. Int J Nephrol Renovasc Dis. 2023 Feb 6;16:31-42. doi: 10.2147/IJNRD.S389219. PMID: 36778197; PMCID: PMC9912820.
15. Mariotto SC, Amelio E, Ciampa AR, de Prati AC, Marlinghaus E, Russo S, Suzuki H. Extracorporeal shock waves: from lithotripsy to anti-inflammatory action by NO production. Nitric Oxide 2005; 12(2): 89-96.
16. Mittermayr R, Antonic V, Hartinger J, Kaufmann H, Redl H, Téot L, Stojadinovic A, Schaden W. Extracorporeal shock wave therapy (ESWT) for wound healing: technology, mechanisms, and clinical efficacy. Wound Repair Regen. 2012;20 (4):456-65.
17. Kisch T, Wuerfel W, Forstmeier V, Liodaki E, Stang FH, Knobloch K, Mailaender P, Kraemer R. Repetitive shock wave therapy improves muscular microcirculation. J Surg Res 2016; 201(2):440-445.
18. Serizawa F, Ito K, Matsubara M, Sato A, Shimokawa H, Satomi S. Extracorporeal shock wave therapy induces therapeutic lymphangiogenesis in a rat model of secondary lymphoedema. Eur J Vasc Endovasc Surg 2011; 42(2):254-260.
19. Frairia R, Berta L. Biological effects of extracorporeal shock waves on fibroblasts. A review. Muscles Ligaments Tendons J 2011 1(4): 138-147.
20. Holsapple JS, Cooper B, Berry SH, Staniszewska A, Dickson BM, Taylor JA, Bachoo P, Wilson HM. Low Intensity Shockwave Treatment Modulates Macrophage Functions Beneficial to Healing Chronic Wounds. International Journal of Molecular Sciences. 2021; 22(15):7844. https://doi.org/10.3390/ijms22157844
21. Basoli V, Chaudary S, Cruciani S, Santaniello S, Balzano F, Ventura C, Redl H, Dungel P, Maioli M. Mechanical Stimulation of Fibroblasts by Extracorporeal Shock Waves: Modulation of Cell Activation and Proliferation Through a Transient Proinflammatory Milieu. Cell Transplant. 2020 Jan-Dec;29:963689720916175. doi: 10.1177/0963689 720916175. PMID: 32326741; PMCID: PMC7586264.
22. Rassweiler JJ, Scheitlin W, Goezen AS, Rassweiler-Seyfried MC. Low-energy shockwave therapy in the management of wound healing following Fournier's gangrene. Eur Urol Open Sci 2022;45: 8-11.
23. Rassweiler J, Ringeisen M, Knobloch K, Schaden W. Efficacy and Theoretical Basis of Low-Intensity Shock Wave Therapy in the Management of Different Forms of Wound Healing: Own Experiences and a Review of the Literature, Medical Research Archives, [online] 2023; 11(8). https://doi.org/10.18103/mra.v 11i8.4394
24. Ottomann C, Hartmann B, Tyler J, Maier H, Thiele R, Schaden W, Stojadinovic A. Prospective randomized trial of accelerated re-epithelization of skin graft donor sites using extracorporeal shock wave therapy. J Amer Coll Surg 2010; 05.012; ISSN 1072-7515/10/; doi:10.1016
25. Wang CJ, Cheng JH, Kuo YR, Schaden W, Mittermayr R. Extracorporeal shockwave therapy in diabetic foot ulcers. Int J Surg. 2015 Dec;24(Pt B):207-9. doi: 10.1016/j.ijsu.2015.06.024. Epub 2015 Jun 12. PMID: 26079500.
26. Negm WA, El-Kadem AH, Elekhnawy E, Attallah NGM, Al-Hamoud GA, El-Masry TA, Zayed A. Wound-Healing Potential of Rhoifolin-Rich Fraction Isolated from Sanguisorba officinalis Roots Supported by Enhancing Re-Epithelization, Angiogenesis, Anti-Inflammatory, and Antimicrobial Effects. Pharmaceuticals (Basel). 2022 Jan 31;15(2):178. doi: 10.3390/ph15020178. PMID: 35215291; PMCID: PMC8874642.
27. Rowland MB, Moore PE, Bui C, Correll RN. Assessing wound closure in mice using skin-punch biopsy. STAR Protoc. 2023 Mar 17;4(1):101989. doi: 10.1016/j.xpro.2022.101989. Epub 2023 Jan 4. PMID: 36602903; PMCID: PMC9826969.
28. Kuai L, Zhang JT, Deng Y, Xu S, Xu XZ, Wu MF, Guo DJ, Chen Y, Wu RJ, Zhao XQ, Nian H, Li B, Li FL. Sheng-ji Hua-yu formula promotes diabetic wound healing of re-epithelization via Activin/ Follistatin regulation. BMC Complement Altern Med. 2018 Jan 29;18(1):32. doi: 10.1186/s12906-017-2074-8. PMID: 29378560; PMCID: PMC5789635.
29. Dymarek R, Kuberka I, Walewicz K, Taradaj J, Rosińczuk J, Sopel M. Is Shock Wave Application Effective on Various Chronic Wounds in the Geriatric Population? Preliminary Clinical Study. Clin Interv Aging. 2024 Apr 30;19:665-679. doi: 10.2147/CIA.S448298. PMID: 38706636; PMCID: PMC11069372.
30. Schuh CM, Heher P, Weihs AM, Banerjee A, Fuchs C, Gabriel C, Wolbank S, Mittermayr R, Redl H, Rünzler D, Teuschl AH. In vitro extracorporeal shock wave treatment enhances stemness and preserves multipotency of rat and human adipose-derived stem cells. Cytotherapy. 2014 Dec;16(12): 1666-78. doi: 10.1016/j.jcyt.2014.07.005. Epub 2014 Aug 28. PMID: 25174738.
31. Lin G, Van Kuiken M, Wang G, Banie L, Tan Y, Zhou F, Wang Z, Chen Y, Zhang Y, Lue TF. Microenergy acoustic pulse therapy restores function and structure of pelvic floor muscles after simulated birth injury. Transl Androl Urol 2022;11 (5): 595-605
32. Shin D, Jeon SH, Tian WJ, Kwon EB, Kim GE, Bae WJ, Cho HJ, Hong SH, Lee JY, Kim SW. Extracorporeal shock wave therapy combined with engineered mesenchymal stem cells expressing stromal cell-derived factor-1 can improve erectile dysfunction in streptozotocin-induced diabetic rats. Transl Androl Urol. 2021;10(6):2362-2372.
33. Kou D, Chen Q, Wang Y, Xu G, Lei M, Tang X, Ni H, Zhang F. The application of extracorporeal shock wave therapy on stem cells therapy to treat various diseases. Stem Cell Res Ther. 2024 Aug 26;15(1):271. doi: 10.1186/s13287-024-03888-w. PMID: 39183302; PMCID: PMC11346138.