Selected Articles from the Journal Abdominal Surgery

This article originally appeared in the Spring, 2007 issue of the Journal.

Fournier's gangrene, rectal stapling-a lesson learnt

Jonathan Winehouse (MSc. FRCS Gen.Surg.),
Hassan Mukhtar (MD FRCS Gen.Surg.)
Department of Surgery Whittington (University)

Correspondence To:
Hospital NHS Trust, Highgate Hill, London N19 5NF,
England, United Kingdom. Tel No: 0044 207 272
3070 Fax no: 0044 208 349 9218
Email: Jonathan.Winehouse@whittington.nhs.uk

ABSTRACT
We report the first known case of Fournier's gangrene following difficult insertion of a rectal stapling device in an 88-year-old who underwent a high anterior resection for a rectal cancer. The patient developed full thickness skin necrosis of the perineal region and judicious debridement and a diverting ileostomy were required. We discuss various case reports showing an association between anorectal trauma, surgery and Fournier's gangrene.

SUMMARY
We report the first known case of Fournier's gangrene following difficult insertion of a rectal stapling device in an 88-year-old who underwent a high anterior resection for a rectal cancer. The patient developed full thickness skin necrosis of the perineal region. We discuss various case reports showing an association between anorectal trauma, surgery and Fournier's gangrene.

INTRODUCTION
Fournier's gangrene is named after French venereologist Jean Alfred Fournier (1832-1914) who first described fulminant gangrene of the penis and scrotum in 1883¹ and results in a highly lethal, rapidly progressive and often fatal, necrotizing infection of the perineal (Colles) and on occasion genital fascia². It is characterised by obliterative endarteritis of the subcutaneous arteries resulting in gangrene of the subcutaneous tissues and overlying skin³. The infection always requires an entry port and is usually associated with anorectal, genitourinary and gynecological polymicrobial infections that are probably synergistic in nature⁴.

We report the first known case of Fournier's gangrene following difficult insertion of a rectal stapling device in an 88-year-old who underwent a high anterior resection for colorectal carcinoma.

CASE REPORT
An retired 88 year old male, non-diabetic, ASA grade 2, complained of a short history of diahorrhea but no bleeding and at flexible sigmoidoscopy was noted to have an upper rectal mass, biopsy of which confirmed a poorly differentiated adenocarcinoma. The patient was admitted electively for a high anterior resection following further staging. Bowel resection and a high 5cm mesorectal excision were performed and the remaining rectal stump was cross-stapled with a TL60 (Ethicon Endo-Surgery Inc.). A high end-to-side tension- free CDH 29 (Ethicon Endo-Surgery Inc.) stapled rectal anastomosis was formed. The operating surgeon reported that instrumentation of the anus and rectum with the curved intraluminal stapler was initially difficult. No leak was apparent on testing the anastomosis at the time of operation. Histology confirmed clear proximal and distal bowel margins and a poorly differentiated upper rectal carcinoma T3 N0 M0 Duke's stage B. The patient made a slow but uneventful recovery but two weeks postoperatively became septic with a white cell count of 21.00 x 106/l and was noted to have an area of perineal necrosis anterior to the anus with associated scrotal swelling, surrounding skin erythema and odorous discharge of pus (Fig. 1). The patient also developed urinary retention requiring catheterisation. A provisional diagnosis of Fournier's necrotizing fasciitis was made and pus swabs grew a mixed growth of organisms. On examination under anaesthetic, the anastomosis was intact and the bowel wall immediately adjacent to the anastomosis appeared healthy but at the anorectal margin several centimetres below the anastomosis, superficial anterior rectal mucosal necrosis was noted. The area of necrosis extended in a superficial plane over the anus to involve the adjacent skin anteriorly over the perineal body (Fig.1). The involved anal and rectal mucosa and skin were locally debrided and a defunctioning loop ileostomy was formed and the patient made an uneventful recovery.

DISCUSSION
We suggest that the likely cause of Fournier's gangrene in our case was as a result of the shearing effects during anal instrumentation of the CD29 blunt ended staple housing (hammer) on the lower anorectal mucosa as the mucosal necrosis began well away from the anastomotic line. To our knowledge no authors have reported this complication with high rectal stapling devices although there has been a similar report of Fournier's following stapled rectal haemorrhoidectomy⁵ and also following perineal trauma⁶. In one case Fournier's resulted from the swallowing and subsequent rectal impaction of a chicken bone⁷. Fournier's gangrene has also been reported following transrectal prostate biopsy⁸, injection sclerotherapy⁹ , hemorrhoidal banding^10-12 and also as a result of anorectal examination and mucosal biopsy^13. The development of Fournier's gangrene after Milligan-Morgan hemorrhoidectomy in a previously healthy 76-year-old female patient has also been described¹⁴ which required an AP resection.

We therefore recommend the judicious use of lubricating jelly with the introduction of an appropriately sized stapler and we would also recommend that extreme care should be taken perhaps with initial gentle distraction of the anal sphincter prior to intubation so as to affect a more controlled and hence less traumatic entry. The authors also suggest that Glyceryl trinitrate or diltiazem ointment may also be useful as an adjunct to aid relaxation of the anal sphincter especially in patients with a preceding history of anal fissure^{15, 16}.

As in our case cutaneous manifestations of Fournier's gangrene should alert the clinician as to more extensive and deeper underlying disease as it is known that infection spreads aggressively along recognised fascial planes. Examination under anaesthesia with early aggressive surgical debridement remains a priority in the treatment of Fournier's gangrene. Diversion of the faecal and urinary streams may not always be necessary but should be considered on a case-by-case basis.We elected to divert our patient's faecal stream with an uneventful recovery. Despite optimal medical and surgical management however, the mortality rate in Fournier's gangrene still exceeds 40% in many series.

CONCLUSION
We report the first known case of Fournier's gangrene following difficult insertion of a rectal stapling device in a relatively fit 88-year-old who underwent a high anterior resection for colorectal carcinoma. Fournier's gangrene thankfully remains a relatively rare but lifethreatening complication of any form of perineal trauma including that following surgery. Early recognition and judicious aggressive debridement with diversion remains the mainstay of surgical treatment.

REFERENCES

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14. Lehnhardt M, Steinstraesser L, Druecke D, Muehlberger T, Steinau HU, Homann HH. Fournier's gangrene after Milligan-Morgan hemorrhoidectomy requiring subsequent abdominoperineal resection of the rectum: report of a case. Dis Colon Rectum. 2004;47:1729-1733.

15. Griffin N, Acheson AG, Jonas M, Scholefield JH. The role of topical diltiazem in the treatment of chronic anal fissures that have failed glyceryl trinitrate therapy. Colorectal Dis. 2002;4:430-435.

16. Cundall JD, Gunn J, Easterbrook JR, Tilsed JV.et al The dose response of the internal anal sphincter to topical application of glyceryl trinitrate ointment. Colorectal Dis. 2001;3:259-262.