CC BY
16
Rustamov Murodulla Isomiddinovich, candidate of medical sciences, assistant Department of General Surgery, Samarkand Medical Institute of the Republic of Uzbekistan
E-mail: [email protected] Sherbekov Ulugbek Axrorovich, candidate of medical sciences, Head of the Department of General Surgery, Samarkand Medical Institute of the Republic of Uzbekistan
E-mail: [email protected] Murtazaev Zafar Israfulovich, candidate of medical sciences, associate professor of the Department of General Surgery, Samarkand Medical Institute of the Republic of Uzbekistan E-mail: [email protected] Saydullaev Zayniddin Yakhshiboevich, assistant Department of General Surgery, Samarkand Medical Institute of the Republic of Uzbekistan
E-mail: [email protected]
THE ANALYSIS OF SURGICAL TREATMENT RESULTS IN PATIENTS WITH FOURNIER'S GANGRENE
Abstract: Results of surgical treatment of 13 patients with scrotum gangrene (Fournier's disease) admitted to the proctology department of the 1st SamMI Clinic are observed in the article. The early diagnostics and active management are used for radical surgical treatment of the purulent necrotic focus in combination with necrectomy in step-by-step maneuver. Complex system of the local treatment of the wound, purposeful and multiple component correction of systemic and metabolic disorders of the homeostasis are the real way to improve treatment results.
Keywords: gangrene, necrosis, necrectomy, antibiotic therapy, detox therapy.
Introduction: Clinical studies of the last years have of the subcutaneous fat and fascia (the iceberg phenomena) proved the increased frequency of the purulent-septic diseases [7-11]. Even though there is the extensive purulent-necrotic of soft tissues which were earlier considered casuistic. One of damage of the scrotum skin, testicle, as a rule, are not insuch diseases is Fournie's gangrene which represents a spe- volved in the process and remain healthy. This is the other cial type of surgical infection in soft tissues with the primary particularity of Fournie's gangrene. The viability of testicles necrosis of the superficial fascia of the external sexual organs is explained by autonomy of their blood supply indepen-and subcutaneous fat with further spreading of the purulent- dently from scrotum and penis, not only by hemodynamic necrotic process to the anterior abdominal wall, hips and particularities [3; 5; 7].
thighs as the morphological base. The clinical course of Fournie's gangrene as a form of sur-
In modern literature Fournie's gangrene is interpreted as gical sepsis is remarkable for the significant severity, and it is a specific form of progressing necrotising fasciitis, which is characterized by development of multiorgan failure and high characterized by extensive purulent-necrotic lesion of the su- mortality (from 50 to 75%) [10].
perficial fascia and spreading the process through the fascial The mortality forms 26.7-40% [1; 2; 8], in severe cases
spaces with typical symptoms of the systemic inflammatory it reaches 80% [6; 8; 10], in the group of unoperated patients response syndrome (SIRS) and manifestation of systemic en- it is close to 100% [9].
dotoxicosis and multiorgan failure [3; 4; 8]. In the opinion of M. V. Grineva and co-aurhors [4; 6; 11],
One of the most typical local signs of Fournie's gan- high mortality dictates imperative necessity to refer Fournie's grene is discrepancy between comparatively bordered local gangrene in category of diseases that require urgent surgical necrosis of the skin and extensive purulent-necrotic lesion intervention.
THE ANALYSIS OF SURGICAL TREATMENT RESULTS IN PATIENTS WITH FOURNIER'S GANGRENE
Purpose of the work: To produce the analysis of surgical treatment results in patients with Fournie's gangrene.
Materials and methods: During the last 15 years (from 2001 to 2016 years) 13 patients with gangrene of the scrotum (the Fournie's disease) have been treated at the Proctology department of the 1st SamMI clinics. Their age varied from 30 to 60 years old. Nosological reasons of Fournie's gangrene were diseases of colorectal area (13 patients).
Diabetes mellitus was revealed in 3 patients. 4 patients had been hospitalized in the period of the first 3 days of the disease onset, in the period from 4 to 7 dayd - 9 patients.
Slowly progressing (bordered) form of the diseases was noted in 4 patients, in which necrotic process was bordered within the scrotum. 9 patients had fulminant and fast progressing (wide-spread) forms of Fournie's gangrene. The local manifestations were characterized by the primary necrosis of the skin, subcutaneous fat of the scrotum and penis, purulent-necrotic lysis of the superficial as well as deep fascias with spreading of infectious-destructive process to the pubis, groin areas, hips and perineum.
The results and discussion: Treatment of the patients was concluded in more wide excision of necrotic tissues, opening and drainage of purulent leakage. The purposes of the surgical intervention were reconstruction of the scrotum and, by indications, reconstruction operations, directed on replacement of the lost covering tissues and correction of the defects on damaged areas.
Preoperative examination included the standard clinical, laboratory tests; ultrasound of the abdominal organs, EKG, and other specialists' examinations if necessary.
The surgical interventions were performed in condition of general, spinal or prolonged peridural anesthesia. Prolonged peridural blockade, as a method of optimal anesthesia was conducted even in the postoperative period during 3-5 days that has allowed to do the bandaging painlessly and to refuse the use of narcotic painkillers.
In 5 of 13 patients necrectomy was made 3 times in step-by-step maneur, in 4 patients - 4 times, in other 4 patients - 5 times. Microbiological observation of the wounds' discharges showed obligate anaerobic infection in 11 (92%) of 13 patients (Peptostreptococcus spp., Bacteroides spp.), as well as aerobic gram positive (Staphylococcus aureus, Staphylococ-cus epidermidis, Streptococcus viridans) and gram negative (Escherichia coli, Pseudomonas aeruginosa) microorganisms.
Complex of the treatment included combined antibacterial, infusion-transfusion, detoxic therapies, adequate correc-
tion of the metabolic disorders, stimulation of the immune-biological reactivity of the organism and healing processes in the wound.
Local treatment included antiseptic solutions (3% solution of hydrogen peroxide, 0.5% solution potassium permanganate, furacilin, 1% solution of dioxydine) with using moist drying bands. In this stage for the local sanitation a antiseptic decasan solution was broadly used. In order to speedup abruption of the purulent-necrotic debris and defoggings of the wounds in some cases proteolitic enzymes were used (trypsin, chymotrypsin).
In 8 of13 patients in complex of the local treatment of the wounds infrared ray exposure was used, in 5 patients - quartz irradiation of the wound surface. Also an ointment on hydro-philic base (Levomecol) was used which gives high dehydrating and sanitation effects. When exudative phase had changed to proliferative in order to stimulate metabolic and healing processes in the wound and the connective tissue to be formed ointment with topic action was used (Solcoseryl, Methyluracil)
The complex treatment has allowed to stabilize the condition of 9 from 13 patients gradually, to cure endotoxicosis, to border the purulent-necrotic process within damaged zones, to stimulate healing processes in the wound.
8 of 13 patients had the bordered form of Fournie's gangrene. In 3 of 8 patients the bordered wound defects of the scrotum has healed with secondary intention through scaring. In 5 cases when the scrotum defect was extensive with complete uncovering of the testicles and spermatic cord reconstruction of the scrotum using local tissues through immobilization of the wound edges and secondary stitching after defogging of the wound were performed.
4 of 13 patients died (24%). The mortality is explained by late hospitalization and tardy operation. All deceased patients had the wide-spread form Fournie's gangrene, which was characterized by fulminant and fast progressing course, extensive damage of the scrotum, penis with spreading of the purulent-necrotic process to the anterior abdominal wall, hips and perineum. The reasons of deaths were toxic shock (1 patient), progressing endotoxicosis (2 patients) and pulmonary embolism (1 patient).
The conclusions: thereby, early diagnostics and active management applicable for the purpose of radical surgical treatment of the purulent-necrotic focus in combination with sanitizing necrectomy, complex system of the local treatment, correction of the systemic and metabolic disorders of homeo-stasis are the real ways to improve the treatment results.
References:
1. Алиев С. А., Рафиев С. Ф., Рафиев Ф. С., Алиев Э. С. Болезнь Фурнье в практике хирурга. Хирургия 2008. - 11. -C. 58-63.
2. Бабажанов А. С., Худайназаров У Р., Ахмедов Г. К. Тактика хирургического лечения посттромбофлебитической язвы голени // Приоритетные направления развития науки и образования.- 2018.- С. 146-148.
3. Гринев М. В., Корольков А. Ю., Гринев К. М., Бейбалаев К. З. Некротизирующий фасциит-клиническая модель раздела здравоохранения: медицины критических состояний. Вестн хир 2013; 2: 32-38.
4. Рустамов М. И. и др. Обоснование хирургического метода лечения острого парапроктита // Национальная Ассоциация Ученых.- 2016.- № 1.- С. 9-10.
5. Рустамов М. И. и др. Методы лечения эпителиального копчикового хода // European Research.- 2018.- С. 136-140.
6. Черепанин А. И., Светлов К. В., Чернов А. Ф., Бармин Е. В. Другой взгляд на «болезнь Фурнье в практике хирурга». Хирургия 2009. - 10. - C. 47-50.
7. Шамсиев A. M. Атакулов Д. О., Юсупов Ш. А., Юлдашев Б. А. Влияние экологических факторов на частоту хирургических заболевании у детей / Проблемы опустынивания в Центральной Азии и их региональное стратегическое решение // Тезисы докладов. - Самарканд.2003.- С. 86-87.
8. Babajanov A. S. et al. Choices in surgical treatment of thermal burns // Science and world.2013.- P. 24.
9. Kasimov S. et al. haemosorption In Complex Management Of Hepatargia: o27 (l1-1) // The International Journal of Artificial Organs. 2013.- Т. 36.- No. 8.- 548 p.
10. Neary E. A. Case of Fournieris Gangrene. TSMJ 2004; 6: 68-73.
11. Shamsiyev A. M., Khusinova S. A. The Influence of Environmental Factors on Human Health in Uzbekistan // The SocioEconomic Causes and Consequences of Desertification in Central Asia.- Springer, Dordrecht, 2008.- P. 249-252.
