The American Journal of Surgery (2009) 197, 660 665

Clinical Surgery-International

The use of vacuum assisted closure therapy in the management of Fourniers gangrene
Ersin Ozturk, M.D.*, Halil Ozguc, M.D., Tuncay Yilmazlar, M.D.
Department of General Surgery 16069, Uludag University Faculty of Medicine, Gorukle, Bursa, Turkey KEYWORDS:
Fourniers gangrene; VAC therapy; Negative pressure vacuuming; Wound care Abstract BACKGROUND: Vacuum Assisted Closure (VAC; Kinetic Concepts, Inc., San Antonio, TX) has been used to successfully treat a variety of complex wounds. This technique was investigated for use in managing Fourniers gangrene following initial debridement. METHODS: Ten patients with Fourniers gangrene were treated in this study. After initial surgical debridement, 5 were treated using conventional therapy and 5 were treated with VAC at each dressing change. The effectiveness and cost of VAC for this indication were assessed; patient and physician satisfaction were also determined. RESULTS: Conventional and VAC treatment were equally effective in healing the wounds. The total costs of each treatment were similar. With the use of VAC, patients had fewer dressing changes, less pain, fewer skipped meals, and greater mobility. Hands-on treatment time was decreased for physicians using VAC. CONCLUSIONS: VAC therapy is an effective and economical way to manage Fourniers gangrene. Patients and physicians were more satised with VAC therapy than with conventional treatment. 2009 Elsevier Inc. All rights reserved.

Fourniers gangrene is a potentially fatal disease characterized by necrotizing fasciitis of the perineal and genital regions.1 The typical therapeutic approach is prompt aggressive surgical debridement of the necrotic tissue.1,2 A single debridement is sometimes enough to treat Fourniers gangrene successfully; often, however, repeated debridements are necessary.3 Nevertheless, the Fourniers gangrene wound remains open, sometimes for an extended period of time, so that multiple regular wound dressing changes are needed. The localization and extent of the wounds associated with Fourniers gangrene usually necessitate analgesia or the use of operating rooms for changing the dressing. Since the dressing must sometimes be changed more than once per

day, this has a large negative impact on the patients quality of life as well as on the physicians quality of care. Vacuum Assisted Closure (VAC; Kinetic Concepts, Inc., San Antonio, TX) is a wound care system that works on the basis of negative pressure vacuuming; regulating the wound pressure reduces edema and promotes healing.4,5 Since it was rst introduced, VAC has been used successfully to treat many different types of wounds.6 24 Demaria et al reported using VAC on infected groin wounds following emergency femoral artery surgery,21 and Hallberg and Holmstrom reported its use on skin grafting perineal wounds.8 These 2 reports inspired us to compare the use of VAC therapy versus conventional therapy for treating patients with Fourniers gangrene following initial debridement.

* Corresponding author. Tel.: 0090 224 2952021; fax: 0090 224 4428398. E-mail address: drozturk@uludag.edu.tr Manuscript received October 17, 2007; revised manuscript April 7, 2008

Patients and Methods

Between January 2006 and August 2007, 10 patients (7 male, 3 female) with Fourniers gangrene were treated in the

0002-9610/$ - see front matter 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.04.018

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Department of General Surgery, Uludag University School of Medicine, Bursa, Turkey. Fourniers gangrene was dened as local if the lesions were conned to the perineum and/or pubic regions. If the lesions extended out of these regions, for example, to the abdomen, lumbar region, or legs, Fourniers gangrene was termed disseminated. Following initial debridement, the rst 5 consecutive patients were treated using wet-to-dry dressings with saline (conventional group), and the next 5 consecutive patients were managed with VAC therapy (VAC group). Topical antibiotics were not used. Written informed consent was obtained from all patients, and the study was approved by the ethical committee of the Uludag University Faculty of Medicine. After admission to the clinic, all patients were started on antibiotics (cephtriaxon, gentamicin, and metronidazol) and taken immediately to the operating room. All patients received an epidural catheter. Extensive surgical debridement was performed until healthy tissue was obtained. If the anal sphincter complex was damaged, a temporary colostomy was formed using a laparoscopic approach. Patients whose wounds were conventionally managed had the dressings on their wounds changed daily. Additional changes were performed if the dressings became wet due to blood or uid from the wounds. In addition, these patients were taken to the operating room every 48 hours, and dressing changes and jet lavage were performed with wound exploration. Dressing changes, both in the ward and in the operating room, were performed under epidural analgesia. Additionally, sedation was used for dressing changes in the operating room. For patients whose wounds were treated using VAC therapy, the VAC GranuFoam Large Dressing (Kinetic Concepts) was applied to the patients immediately following initial debridement (Fig. 1). Suction pressure of 125 mm Hg was applied to the wounds continuously, with 5 minutes of suction followed by 2 minutes of rest, until the next

Figure 2 (A) The wound of a patient with Fourniers gangrene after 1 round of VAC therapy. (B) The same wound after the completion of VAC therapy (4 applications of VAC).

Figure 1 Following debridement, the VAC system was applied to the perineum of a male patient with Fourniers gangrene who had a temporary stoma.

dressing change. Dressings were changed every 72 hours in the operating room under sedation plus epidural analgesia, and VAC was used at each change. Microbial cultures were taken from all patients before initial debridement and at every dressing change. After the wounds were clinically healed (Fig. 2) or the wound cultures were negative, tertiary wound closure was performed whenever possible (6 patients); otherwise, split thickness skin grafting was performed (4 patients). We assessed patients quality of life and physicians daily workload using VAC versus conventional treatment. Quality of life was assessed by evaluating patients pain and daily activities. Pain was scored using the visual analogue scale for pain (VAS),25 and by recording the patients need for analgesia, ie, how many times epidural analgesia was administered. Our hospital policy is to provide pain relief if the VAS score is greater than 5. The daily activities inuencing patients quality of life during their hospital stay were noted as follows: the number of times that the patient was mobile; the number of meals that were skipped due to

662 anticipation of general anesthesia for treatment in the operating room; the number of additional dressing changes at the patients request due to wet dressings; the number of additional bed sheet changes due to wet wounds (in addition to the customary daily changes); the number of baths; and the length of the hospital stay. Results are reported as median and range unless otherwise noted. A questionnaire was completed by 25 physicians in our hospital who are involved in the treatment of Fourniers gangrene patients (10 staff surgeons and 15 residency students) to determine their opinions of VAC versus conventional treatment. The questionnaire asked the physicians about the convenience of the 2 treatments, their impact on the physicians daily routine, the time needed to change conventional and VAC wound dressings, overall satisfaction with the 2 treatments, and which type of wound care system they preferred to use. For cost analysis, the expenses specically related to wound care for each patient were calculated, and then the total expenses for all 5 patients in each group were calculated. Expenses such as antibiotics and debridement-associated costs that were the same for all 10 patients regardless of treatment type were not included. For the conventional group, the following expenses were included in the total: the cost of wound dressing material ($60 per change); anesthesia-analgesia costs ($40 per treatment); operating room costs ($85 per each use); and hospital bed costs ($30 per day). For the VAC group, the following expenses were included in the total: the cost of the VAC GranuFoam Large Dressing Kit ($365 per kit); anesthesia-analgesia costs ($40 per treatment); operating room costs ($85 per each use); and hospital bed costs ($30 per day).

The American Journal of Surgery, Vol 197, No 5, May 2009

Table 2 Microbial culture results Conventional group VAC group (no. of patients) (no. of patients) 2 3 1 3 1 1 2 3 2 1 1 1

Micro-organism Citrobacter freundii Enterococcus Escherichia coli Klebsiella Proteus vulgaris Streptococcus agalactiae Streptococcus anginosus

Wounds were swabbed for culture prior to initial debridement.

Results
Patients characteristics and demographics are listed in Table 1. In the conventional group, lesions were conned to the perineum and pubic region in 3 patients. In 2 patients, lesions extended out of the pelvic region; in 1 patient, lesions extended to the navel and in the other patient, lesions extended to the interior region of the right upper leg.

In the VAC group, lesions were conned to the perineum and pubic region in 2 patients. One patient had Fourniers gangrene extending to the abdomen and lumbar regions. The other 2 patients, with anorectal abscesses as the origin of Fourniers gangrene, had lesions extending into presacral areas and over the sacral promontory. The anal sphincter complexes were damaged in 6 patients, 3 in each group, and these patients needed colostomies. Infections were polymicrobic in 4 of 5 patients in each group, and Escherichia coli was the most common micro-organism (Table 2). Three patients had 3 VAC therapy sequences, 1 patient had 4, and 1 patient needed 5 VAC treatments. VAC therapy was thus used 18 times total in this group. In the conventional group, 1 patient required 5 wound explorations, 10 routine wound dressing changes, and 3 additional changes; the other 4 patients required 3 wound explorations with 6 dressing changes. Of these 4 patients, 1 did not need additional changes, 1 needed 1 additional change, and 2 needed 2 additional changes. Patients in the VAC group reported less pain and less need for analgesics, had greater mobility, missed fewer meals, and needed fewer sheet and dressing changes than the patients in the conventional group. Moreover, patients in the VAC group could bathe, whereas patients in the conventional group could not. The length of the hospital stay was similar in both groups (Table 3).

Table 1 Variable

Patient characteristics Conventional group 56 (range 3164) 4 males, 1 female 4 (range 37) 3 anorectal, 2 urogenital 3 local, 2 disseminated 3 9 (range 715) 3 tertiary, 2 STGSs $8,800 VAC group 56 (range 3377) 3 males, 2 females 5 (range 36) 3 anorectal, 2 urogenital 3 local, 2 disseminated 3 10 (range 816) 3 tertiary, 2 STGSs $8,850

Age, mean (y) Sex Delay in initiation of treatment, median (d) Origin of Fourniers gangrene Dissemination Colostomy needed Time from initial surgical debridement to wound closure, median (d) Wound closure Cost (total)
STSG split thickness skin graft.

E. Ozturk et al.
Table 3 Variable

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Patient quality-of-life results Conventional group 6.8 14 times 0 6 2 2 0 13 days (range 67) (range 1421) (range 47) (range 14) (range 03) (range 1018) VAC group 2.4 4 times 2 2 0 0 3 14 days (range (range (range (range 23) 46) 23) 24)

VAS Need for analgesics No. of times per day a patient was mobile No. of skipped meals No. of additional sheet changes No. of additional dressing changes per day No. of baths LOS

(range 25) (range 1119)

VAS Visual analogue scale for pain; LOS length of hospital stay.

Of the 25 physicians surveyed, 92% (23) found using VAC treatment more convenient than using classic dressing changes, and 88% (22) thought that VAC was easier to use than classic wound care when dealing with Fourniers gangrene. Three physicians indicated no difference between the 2 wound care systems in terms of ease-of-use. About half of the physicians indicated that it took about the same amount of time to change the dressings regardless of which system was used. Twenty-three physicians (92%) indicated that they would prefer to use VAC to manage the wounds of patients with Fourniers gangrene in the future; 2 physicians did not indicate a preference. The total cost for treating 5 Fourniers gangrene patients with VAC therapy was calculated to be $8,850. The total cost for conventional treatment of 5 similar patients was $8,800. These data are summarized in Table 1.

Comments
In this study, VAC treatment was found to be effective in managing Fourniers gangrene, and this treatment was found to be similar in cost to conventional treatment. In addition, patients were more comfortable with VAC treatment and most physicians preferred it to conventional methods. VAC has been used with great success to care for a variety of wounds.6 VAC involves the application of open cell foam to a wound, adding a seal of adhesive drape, and then applying sub-atmospheric pressure to the wound in a controlled way.4 The technique effectively converts an open wound into a temporarily closed and controlled environment.8 Early laboratory and clinical studies demonstrated that VAC application promotes blood ow and creates a favorable environment for healing in wound beds.4,5 It has previously been reported that VAC expedites wound healing compared to conventional treatment for some types of wounds4,5; however, we did not nd this to be true in our study: the length of the hospital stay and the time from initial debridement to wound closure were similar in both VAC and conventional groups. However, VAC healed the wounds with fewer interventions than with conventional

wound care, which substantially increased the patients level of comfort. Because the VAC therapy system is portable, patients retained some degree of mobility rather than being conned to their beds. In addition, unlike patients treated conventionally, VAC patients could be bathed. Using VAC, there was no bad odor associated with the wound and no uncomfortable wet dressings. Since patients did not need signicant sedation and analgesia every day, oral intake was not limited. Thus, a marked increase in quality of life was observed when VAC was used compared to conventional treatment. Not only was VAC more comfortable for the patients, it was also preferred by the attending physicians. The number of interventions was decreased, so that treatment required less of the physicians time, and the patients had fewer complaints about pain and required less analgesia. These factors, along with the effectiveness of VAC treatment, contributed to the physicians satisfaction with VAC. In fact, the majority (92%) of the surveyed physicians supported the use, of VAC therapy in the management of Fourniers gangrene. The main criticism of VAC therapy has been its cost.9 Although we agree that it seems expensive, VAC therapy is actually quite cost-effective when a detailed analysis is performed. The suction unit is expensive, but after it is purchased it can be used for a long time. In this study, there was little to no difference between the cost of treating patients with VAC and treating patients conventionally. Philbeck et al looked at 1,032 patients and determined that there were lower costs associated with treating patients with VAC compared to conventional methods.26 Nevertheless, hospital and health costs vary in different countries, and this variation might make VAC or conventional treatment more or less economical, depending on the particular setting. The main adverse effect associated with VAC therapy has been that it is painful.9 However, the pain is more related to the nature of the wounds treated by VAC rather than to VAC itself. The patient is usually in pain when VAC is applied; however, all of our patients underwent dressing changes with VAC while sedated and with epidural analgesia, and they therefore did not report pain during the VAC procedure. In fact, in our study we found that the VAS

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The American Journal of Surgery, Vol 197, No 5, May 2009

Figure 3 dressing.

A temporary containment device was appliedthe anus priorVAC treatment. (A) The wound before dressing and (B) after

scores and the need for analgesia were signicantly higher in patients treated with conventional methods versus VAC. Applying a closed suction system to an anaerobic wound, which may encourage the growth of anaerobic microorganisms, is of some concern. However, VAC has been used to manage diabetic or venous ulcers, which are also anaerobic in nature. Hansson et al27 collected microbial samples from 58 patients with venous leg ulcers, all without clinical signs of infection. One or more obligate anaerobe species was found in 41% of the samples and in half of the ulcers, and constituted 62% of all bacterial species. VAC was successively used to treat such wounds.9,14 Applying a vacuuming using continuous, controlled pressure encourages angiogenesis; indeed, VAC therapy may increase oxygen and defender cells in the wound.4,5 VAC also reduces tissue edema and excess uid, which may prevent the wound from being a suitable environment for the micro-organisms. A potential problem in using VAC dressing on the anogenital region is that this region often includes the anus. If there is a temporary stoma, this is not a problem. However, a stoma is not always in place. In this scenario, gas passage is not a problem because gas can easily be absorbed by the VAC dressing, but stool passage may be problematic. One solution is to slow gastrointestinal motility by feeding the patient a diet of high-calorie, low-volume food. Then the patient can defecate after the VAC dressing is taken off and before the new dressing is placed. Enemas may also be helpful. Another solution is to soften the stool with oral laxatives so that liquid stool may be easily absorbed by the VAC system. It may also be helpful to use a temporary containment device that consists of a silicone catheter, syringe, and collection bag (Flexi-Seal FMS, Convatec, Princeton, NJ), which is indicated for bedridden or immobilized, incontinent patients with liquid or semi-liquid stool. At one end, the soft silicone catheter has a retention balloon that is inserted into the rectum. At the opposite end, the catheter has a connector for attaching the collection bag. The self-moisturizing retention balloon is inated with saline to help keep the system in place. Using this system, the

stool should be softened, as solid stool may obstruct the catheter. The main contraindication to this catheter is very weak sphincter muscles, which may not be able to hold the device in place. We chose to soften the stool in 1 patient, and in 1 other patient we used the temporary containment device (Fig. 3). In conclusion, VAC therapy shows promise for postoperative wound care of patients with Fourniers gangrene. It heals the lesions associated with Fourniers gangrene, is convenient for both patients and physicians, and reduces the physicians hands-on treatment time with costs that are similar to conventional methods.

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