Fournier's Gangrene and fecal diversion. When, in which patients, and what type should I perform?

Fournier's Gangrene and fecal diversion. 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When, in which patients, and what type should I perform? Ana Ortega Ferrete, Enrique López, Luz Divina Juez Sáez, Juan Carlos García-Pérez, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2579452/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Fournier's gangrene (FG) is a necrotising fasciitis affecting the perineum and urogenital tissue. The mortality rate is high although early detection and aggressive debridement can reduce mortality by up to 16%. The prevalence of sequelae is very high and a colostomy is often necessary to control the perineal wound. Material and Methods A retrospective study was carried out to recruit all patients operated on by the General Surgery and Urology Departments with a diagnosis of GF at the University Hospital over 22 years. Mortality, The Fournier Gangrene Severity Index (FGSI) and fecal diversion (either surgical (colostomy) or straight (Flexi-seal)) are collected. Results A total of 149 patients met the inclusion criteria. FG´s most frequent cause was a perianal abscess (107 patients - 72%). 18 patients (12%) died of a specific cause of FG. Age (p=0,014) and patients with an oncological history (p=0,038), both were the only mortality risk factors for mortality according to logistic regression. 50 patients required some form of fecal diversion in the postoperative period (32 colostomies and 18 flexi-seal). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality. Conclusions One in eight patients died in the immediate postoperative period secondary to FG. Despite improved outcomes, 22% required a colostomy during admission. However, neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality. Non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible. gangrene Fournier colostomy FGSI Flexi-seal Figures Figure 1 Figure 2 Figure 3 Introduction Fournier's Gangrene (FG) is a necrotizing fascitis affecting the perineum and urogenital tissue. The most common cause is a perianal abscess, mainly if it is not drained early. Other origins have been described, as genitourinary infections, colorectal carcinoma, rectal perforation, acute diverticulitis, and hemorrhoid banding, among other routine surgical anal procedures ( 1 ). The extent of this necrosis usually goes further than the visual diagnosis; the bacteria spreads along fascial planes relatively quickly ( 2 ). Generally, the infection is polymicrobial, with mixed aerobes and anaerobes; the most frequently isolated microorganism is E. coli, followed by Streptococcus and Staphylococcus ( 3 ). Many predisposing factors have been associated with FG, such as Diabetes Mellitus, which has been described as up to 56%. ( 4 ). FG secondary to perforation of rectal cancer is rare and can be associated with neoadjuvant treatment such as Bevacizumab ( 5 ). Other risk factors include advanced age, ethanol abuse, steroid therapy, and immunosuppressive diseases such as AIDS, cirrhosis, or cancer ( 6 ). The incidence is 0.02% in hospitalized patients, with a rate of 1.6 per 100.000 males/year, more frequently in males (10:1) with 50–60 years old. ( 7 ). Mortality rates vary from 0 to 42% between studies, with a fulminant sepsis and subsequent multiple organ failure as the cause of the death. Early detection and aggressive debridement can reduce mortality by up to 16% ( 8 ). Outcome and mortality can be stratified using the Fournier's Gangrene Severity Index (FGSI) score. This score includes clinical and analytical parameters such as leucocytosis, glucose level, serum creatinine, temperature, heart, and respiratory rate. A score higher than 9 is a sensitive indicator of mortality with a 75% probability of death ( 9 ). Other studies, such as Lin et al., have tried simplifying the FGSI using three parameters: serum potassium, serum creatinine, and hematocrit. Their study showed that survivors had significantly lower serum creatinine and potassium and higher hematocrit level. Likewise, this score with three parameters showed a non-inferior to FGSI in their patients ( 10 ). FG can be fatal, so immediate resuscitation is basic. Initial management includes fluid resuscitation, correction of electrolyte imbalances, and broad-spectrum intravenous antibiotics. Aggressive and early surgical debridement is imperative. Non-viable tissue must be excised until viable and well-perfused tissue is reached. An average of 3.5 surgical debridements per patient can be necessary for proper infection control ( 6 ) ( 11 ). In extensive perianal infection, fecal diversion is performed to avoid wound contamination. Despite investigations, there is no consensus on using a colostomy or a fecal incontinence catheter (Flexi-seal) ( 12 ). The decision for a stoma is based on the surgeon's personal experience and the extension of the infection. Although the evidence is limited, and there are no recommendations in the clinical practice guidelines, the mortality risk has been associated with the stoma group patients (25%) more than in the non-stoma group (16%). However, the severity of the disease and the number of surgeries are more significant in the stoma group. Lower mortality has been reported with a primary colostomy (colostomy done during the first surgery- 16%) than with a secondary colostomy (40%) ( 13 ). The aim of this study was to evaluate the impact of fecal diversion on FG-associated mortality. Material And Methods Design A retrospective study was conducted to recruit all patients operated on, by the General Surgery and Urology Departments, with a FG diagnosis at University Hospital (Spain) from January 2000 to January 2022 from the analysis. Inclusion criteria were: patients over 18 years of age, clinical/radiological/pathological diagnosis of FG with at least 30 days of post-surgical follow-up. Patients with no clinical follow-up and no available medical records were excluded. Values Several categories of socio-demographic data were collected, such as: - Age (years), sex, comorbidities (diabetes mellitus, arterial hypertension, dyslipidemia), smoking or alcohol status, previous immunosuppression, history of urodigestive neoplasms and overweight (BMI > 24.9) - Clinical characteristics (pathophysiological origin) - Surgical considerations (first surgery, number of reoperations, derivative stoma, use of a temporary containment device, perineal reconstructive surgery, and postoperative complications on the Clavien-Dindo scale) - Others (follow-up time, causes of death, and Fournier Gangrene Severity Index). Definitions FG : clinical/radiological and anatomopathological diagnosis of the perineal necrotizing fascitis, regardless of its clinical origin. The Fournier Gangrene Severity Index (FGSI) is a validated scale that considers clinical and laboratory criteria, aiming to predict mortality from the time patients are received in the emergency room. It is a numerical scale that scores the following parameters: temperature (°C), heart rate, respiratory rate, blood sodium (mmol/l), blood potassium (mmol/l), blood creatinine (mg/100ml), hematocrit (%), and WBC, bicarbonate (mmol/l). Fecal diversion: either surgical (colostomy) or straight (Flexi-seal) during the first or other surgeries. Temporary containment device or Flexi-seal: A device indicated for incontinent, bedridden, or immobilized patients with liquid or semi-liquid feces. It is designed to safely and effectively contain and divert fecal matter, protect patient wounds from fecal contamination, and reduce the risk of skin breakdown and the spread of infection. Statistical analysis Continuous variables were tested for normality using the non-parametric Kolmogorov-Smirnov test. Quantitative variables are presented with mean and standard deviation values if the distribution is normal and with median and interquartile range (IQR) values otherwise. Categorical variables are expressed as absolute numbers and percentages. For the statistical analysis of quantitative variables, Student's t-test was used. For non-normal variables, non-parametric tests were used, and for categorical variables, Pearson's chi-square test was applied. Univariate logistic regression analysis was performed to identify risk factors associated with significant complications and postoperative death. To establish preoperative quantitative variables (including the severity index FG) as predictors of mortality and significant morbidity, a receiver operating characteristic (ROC) curve analysis was employed. The area under the curve (AUC) and its standard error were also calculated. A p-value <0.05 was considered statistically significant, and all ranges were calculated for a 95% confidence interval. The SPSS statistical package version 23.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Ethics committee All procedures performed with human participants followed the research committee's ethical standards, the 1964 Declaration of Helsinki, and its subsequent amendments or comparable ethical standards. Our Drug Research Ethics Committee approved the study. Results A total of 149 patients met the inclusion criteria. The mean age was 63.69 ±14.8 years, with a significant predominance of males (78%). Seventy-eight percent of the patients in the sample had some comorbidity. The most frequent being hypertension (59 patients - 37.8%), followed by diabetes mellitus (46 patients - 31%), and the median number of comorbidities was 1 (1-2). Analytically, patients had a median leukocyte count at diagnosis 18750 (13150-24550)/µL, mean CRP 271 ± 113 mg/L, and renal function (expressed as GFR) 73.7 ± 34 mL/min. FG´s most frequent cause was a perianal abscess (107 patients - 72%). Orchitis in 11% of the patients and gastrointestinal perforation in 7 patients (4%). The most frequent initial surgery was intensive debridement of the necrotic area (83%). However, an additional procedure was performed in 17% of the patients: a derivative stoma in 15 patients (17%) and an orchiectomy in 9 patients. More than half of the patients (55%) required more than one surgical intervention. The median number of procedures per patient performed in the operating theatre was 2 (1-2). In addition to curative surgery, almost one in five patients required reconstructive surgery by the plastic surgery department. Most patients were treated with a myocutaneous flap to cover the defect (22 patients). Some post-surgical complication was described in 88% of patients. Collected under the Clavien-Dindo classification, 56% (74 patients) were grade I-II (Table 1). Table 1. The sample’s baseline characteristics Values n=149 Death by FG N=18 No Death N=131 p Age (years) 63.69 ±14.8 71,95 ± 14,4 62,56 ± 14,6 0,011 Sex Male Female 116 (78) 33 (22) 13 (72,2) 5 (27,8) 103 (88,8) 28 (21,4) 0,550 Comorbidity Hypertension Diabetes mellitus Dyslipemia Inmunosuppression Toxics/drugs Personal history malignant neoplasm Obesity 59 (37.8) 46 (30.9) 26 (16.7) 25 (16.1) 24 (16.1) 18 (12.1) 16 (10.7) 8 (44,4) 8 (44,4) 4 (22,2) 5 (27,8) 3 (16,7) 5 (27,8) 2 (11,1) 8 (44,4) 38 (29) 22 (16,8) 20 (15,3) 21 (16) 13 (9,9) 14 (10,7) 0,798 0,187 0,521 0,188 1 0,045 1 Global comorbidity factor 1 (1-2) 2 (1-3) 1 (1-2) 0,083 WBCs (/µL) 18750 (13150-24550) 18600 (10750-23200) 18800 (13300-24500) 0,697 CRP ( mg/L) 271 ± 113 278 (171-331) 289 (173-347) 0,681 GFR (mL/min) 73.7 ± 34 53 (22-95) 77 (49-98) 0,218 Specific origin Perianal abscess Orchitis Gastrointestinal perforation Other 107 (72) 16 (11) 7 (4) 19 (13) 11 (61,1) 2 (11,1) 2 (11,1) 3 (16,7) 96 (73,3) 14 (10,7) 5 (3,8) 16 (12,2) 0,500 Initial surgery Debridement Debridement + colostomy Debridement + orchiectomy Other 124 (83) 15 (10) 9 (6) 1 (1) 16 (89) - 1 (5,6) 1 (5,6) 108 (82,4) 15 (11,5) 8 (6,1) - 0,024 Nº interventions (median) 2 (1-2) 1 (1-2) 2 (1-2) 0,122 FGSI 5 (3-7) 5 (4-9) 5 (3-7) 0,259 Postoperatory fecal derivation Flexi-seal rectal tube Colostomy 50 (33.6) 18 (36) 32 (64) 6 (33) 3 (50) 3 (50) 44 (33,6) 15 (34,1) 29 (65,9) 0,624 Colostomy at the end of the admission 33 (22) 3 (16,7) 30 (22,9) 0,796 Days after colostomy (median) 3 (0-7) 8 (0-20) 3 (3-5) 0,001 Definitive colostomy 22 (14.8) - - - Plastic surgery reconstruction Closure by primary intention Myocutaneous flap 29 (19.5) 7 (4.7) 22 (14.8) - - - Clavien-Dindo classification I II III IV 72 2 40 17 - 72 2 40 17 - Hospital admission (days) 25 (11-45) 7 (2-22) 27 (15-47) 0,348 WBC White Blood Cells count; CRP C Reactive Protein; GFR Glomerular Filtration Rate; FGSI Severity Index for Fournier`s Gangrene Fournier's gangrene and mortality During the postoperative hospital admission, 18 patients (12%) died of a specific cause of Fournier's gangrene. A comparison has been made between patients who died from FG and those who did not (Table 1). Patients who died during the hospitalization were found to be older (71.95 ± 14.4 vs. 62.56 ± 14.6; p=0.011) and with a personal history of oncological pathologies (p=0.045). Table 2 shows that both were the only mortality risk factors according to logistic regression. It is worth noting that patients with an oncological history had three times the risk of postoperative mortality (OR 3.49 (1.07-11.36; p=0.038). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality. In addition, a ROC curve has been performed to predict death after surgery. IGFS showed the best area under the curve as a predictor of mortality of the prognostic factors analyzed (AUC 0.661 (p=0.087)). The best cut-off point was 5 points (with a sensitivity of 77% and a specificity of 50%). For 9 points in our sample, IGFS presented a sensitivity of 23% and specificity of 87%, with a positive predictive value of 89% as a death factor. The global comorbidity index (AUC 0.593; p= 0.320) was the following parameter that showed adequate prediction (Figure 1). Fecal diversion Regarding postoperative faecal diversion: one-third of the patients (50) required some measure to isolate the perineal wound from faecal matter. In 32 patients, a surgical colostomy was performed at baseline. The median number of days to perform the stoma was 3 (0-7) days. As shown in figure 2, in 57.6% of the sample, the colostomy was performed within 72 hours. In the first week of diagnosis, 78.8% of patients had a stoma. In the second week, more than 90% of the sample had a colostomy. In only three patients, the stoma was delayed (20, 22, and 40 days respectively). In the remaining 18 patients, it was decided to use a temporary containment device (Flexi-seal) as a first step. All these devices were used from 2013 onwards Only one of these patients eventually required a colostomy during admission. Thus, at the end of admission, 22% of the sample (33 patients) had a stoma Figure 3. The risk factors associated with a post-surgical fecal diversion in the logistic regression were: diabetes mellitus (OR 0,43 (CI 95% 0,19-0,97); p=0,044), perianal origin (OR 3,94 (CI 95% 1,29-12.05); p=0,016) and a higher number of re-interventions (OR 3,09 (CI 95% 2,04-4,69); p<0,001). However, only diabetes and a higher number of surgical interventions were identified as risk factors associated with a surgical colostomy. Three of the 33 patients who underwent a colostomy at the time of admission died of FG. After the acute episode, one-third of the patients underwent intestinal transit reconstruction (10 patients). Table 2 used logistic regression to identify factors associated with a definitive ostomy. The only risk factors associated with a definitive stoma were a history of oncological disease and a higher number of re-interventions. In addition, colostomy within 24 hours or one week of the first operation raised tenfold the risk of permanent ostomy (OR 21.89 (5.7-82.9) vs. OR 34 (10-115.2)). Table 2. Logistic regression of the prognostic factors for postoperative consequences Fecal postoperatory diversion Colostomy during admision Definitive stoma ¹ Death OR (CI 95%) P value OR (CI 95%) P value OR (CI 95%) P value OR (CI 95%) P value Age (years) 0,99 (0,69-1,01) 0,446 0,66 (0,9-1,02) 0,994 1,02 (0,98-1,06) 0,188 1,05 (1,01-1,09) 0,014 Sex (male) 1,01 (0,44-2,3) 0,975 0,74 (0,3-2,13) 0,859 0,67 (0,26-2,4) 0,748 0,707 (0,23-2,15) 0,541 Comorbidity - Hypertension - Diabetes mellitus - Dyslipemia - Inmunosuppression - Toxics/drugs Malignant neoplasm Obesity 0,79 (0,39-1,61) 0,43 (0,19-0,97) 1,29 (0,54-3,11) 2,09 (0,87-5) 2,29 (0,94-5,55) 1,30 (0,47-3,59) 1,62 (0,57-4,66) 0,524 0,044 0,561 0,098 0,067 0,610 0,364 0,71 (0,3-1,6) 0,33 (0,12-0,9) 0,89 (0,3-2,6) 1,47 (0,6-3,8) 2,0 (0,7-5,2) 1,92 (0,7-5,6) 1,71 (0,5-5,3) 0,406 0,032 0,836 0,442 0,155 0,229 0,358 0,67 (0,26-1,77) 0,23 (0,05-1,05) 0,56 (0,1-2,6) 2,13 (0,67-6,73) 1,38 (0,41-4-64) 4,29 (1,24-14,85) 1,60 (0,41-8,35) 0,421 0,058 0,465 0,196 0,600 0,021 0,501 1,26 (0,46-3,39) 1,96 (0,71-5,34) 1,42 (0,43-4,71) 2,13 (0,68-6,45) 1,05 (0,28-3,94) 3,49 (1,07-11,36) 1,05 (0,21-5,02) 0,654 0,189 0,571 0,191 0,945 0,038 0,957 Comorbidity factor 1,1 (0,82-1,47) 0,532 0,99 (0,7-1,4) 0,946 0,98 (0,69-1,50) 0,943 1,49 (0,99-2,21) 0,052 WBCs (/µL) 1 0,883 1 0,573 1 0,515 1 0,805 CRP 1,01 (0,99-1,01) 0,291 1 0,649 1 0,966 0,99 (0,99-1,01) 0,727 GFR 1 0,943 1 0,756 1 0,611 0,99 (0,97-1,01) 0,240 Perianal abscess origin 3,94 (1,29-12.05) 0,016 1,07 (0,5-2,5) 0,895 0.63 (0.23-1,72) 0,366 1,25 (0,25-6,22) 0,788 Flexiseal fecal tube 0,18 (0-1,4) 0,104 0,37 (0-2,91) 0,344 1,54 (0,4-5,97) 0,527 FGSI 0,97 (0,85-1,11) 0,69 0,89 (0,7-1) 0,175 0,84 (0,69-1,04) 0,124 1,01 (0,92-1,31) 0,292 Nº reinterventions 3,09 (2,04-4,69) p<0,001 3,46 (2,2-5,4) p<0,001 2,56 (1,77-3,86) p<0,001 0,69 (0,41-1,17) 0,169 Colostomy during hospitalisation 0,67 (0,20-2,43) 0,552 Colostomy (days after) 1,07 (0,9-1,3) 0,394 1,05 (0,9-1,2) 0,373 Colostomy <24 hours 21,89 (5,7-82,9) p<0,001 0,53 (0,07-4,36) 0,553 Colostomy 1 week 34 (10-115,2) p<0,001 0,26 (0,03-2,07) 0,204 WBC White Blood Cells count; CRP C Reactive Protein; GFR Glomerular Filtration Rate; FGSI Severity Index for Fournier`s Gangrene; OR Odds ratio; CI Confidence Interval; Postoperative fecal diversion including flexi-fecal tube and colostomy (temporary or definitive); Death includes only patients who died of a specific cause of postoperative Fournier's Gangrene.¹Only in patients with fecal postoperatory derviation Discussion Our results showed a global mortality rate of 12%, identifying age and personal history of malignant neoplasia as independent risk factors for mortality. Traditionally, aggressive debridement and broad-spectrum antibiotic therapy have been shown to improve morbidity and decrease mortality. Despite improved diagnostic techniques and treatment, FG is often associated with signs of sepsis, rapid tissue destruction, and a mortality rate of 40% ( 14 , 15 ). FG can occur in healthy people; however, up to 70% of patients usually have risk factors such as diabetes, harmful use of alcohol, or an immunosuppressive disease. In the literature, the only factor unanimously associated with increased mortality is a delay in diagnosis and surgical treatment. There is some discrepancy about the prognostic factors for mortality, so attempts have been made to create mortality predictor scores. Laor E et al. in 1995 described Fournier's Gangrene Severity Index (FGSI) score to predict mortality using nine parameters. One of the best-known and most widely used scores in daily practice is the FGSI. This score sets the cut-off point to 9, with a 75% probability of death if the score is higher than this point. Likewise, Laor et al. establish a survival of 78% if the score is less than nine ( 9 ). Different studies widely support the validation of FGSI. However, the many parameters necessary make it a limited application at admission ( 6 , 16 ). This test has been applied in our population, and no statistically significant differences were found in the median FGSI concerning mortality. After constructing the ROC curve, the best cut-off point in our sample was 5 points (sensitivity 77%, specificity 50%). However, for the 9 points, the FGSI presented a specificity of 87% with a negative predictive value of 89%. In other words, below 9 points, the probability of dying from FG is about 10%. In addition to high mortality, post-surgical sequelae are one of the most characteristic features of FG, and all series agree on the high morbidity related to the pathology. In our sample, one out of four patients presented with significant long-term sequelae; more specifically, 22% required a derivative stoma during hospitalization. The factors associated with postoperative fecal diversion were immunosuppression or toxic and drug abuse, perianal origin, and greater reoperations. However, performing a stoma was not associated decreased postoperative mortality. Performing a derivative stoma has a role in reducing the wound's fecal contamination and helping control sepsis. Although the formation of the stoma reduces infection, mortality does not decrease with its formation because patients, who need it, usually have extensive necrosis and poor physiological status that mark their prognosis ( 13 , 17 ). In line with these results, we found a recent meta-analysis with the primary objective of evaluating the impact on mortality of performing a stoma in treating FG. Overall, the pooled mortality rate was significantly higher in patients who required a stoma (OR 1.71; 95% CI 1.13–2.59; p = 0.01). However, after subgroup analysis, the stoma was associated with significantly higher mortality in FG due to colorectal infection (p = 0.04) but not urogenital origin (p = 0.27) ( 18 ). Furthermore, it is noteworthy that the FGSI index showed an AUC of 0.455 (Fig. 3 ). Although this score was developed to quantify the severity of FG, several studies have found no relationship between the scores of patients with and without stoma ( 17 , 19 , 20 ). Our results, as well as the recent literature on the subject, support that performing a stoma does not decrease mortality associated with Fourier's Gangrene. On the other hand, on many occasions, although performing a stoma does not reduce mortality, it is necessary to perform a fecal diversion for local control of the wound. The question is when to perform the colostomy. Broder et al. propose delayed stoma formation a median of four days after the first intervention. They suggest that tissue edema regresses in the first 48h, allowing better evaluation of the sphincters and perianal tissues ( 17 , 21 ). Because most patients usually require a "second look" surgery within 48 h of initial debridement, some authors recommend that stoma formation be deferred at the first operation and performed later if needed. For our patients, the median of days to perform a colostomy after the first surgery was three days, and before the first week, nearly 80% of the sample had the stoma. Seven days after the first urgent drainage, only seven patients out of the total sample required a fecal diversion. In other words, after the initial "risk period" of the first week after the first surgery, the probability of needing a stoma decreases by 95% (Fig. 2 ). However, as seen in Table 2 , the timing of the stoma did not directly influence mortality. Another critical point is the probability of colostomy reversal. There are very few references in the literature on long-term outcomes after FG. In the study published by Czymek et al., the impact on quality of life after FG was evaluated. In their sample, some stoma was performed in 60% of patients. In patients with a long-term follow-up, this was permanent in 50% of them ( 22 ). Although these are different pathologies, these figures overlap those published on Hartmann's reversal surgery. In this recent study in which 228 Hartmann's procedures for multiple pathologies were analyzed, Hartmann's procedure is reversed less frequently than thought, and only 46% of Hartmann's procedures were stoma free at the end of the audit period ( 23 ). In our sample, of the total number of colostomies performed during hospital admission for FG, only one-third of the patients underwent intestinal transit reconstruction. In recent years, there has been some interest in using temporary fecal diversion devices such as Flexi-seal rectal tubes ( 24 ). This alternative method to surgical colostomy could provide economic benefits and patient comfort for short-term fecal diversion. Although initially designed for the management of fecal management of intensive care patients, in FG patients, it could be a practical and less invasive way to avoid fecal contamination of the perineal wound ( 25 , 26 ). However, this method of faecal diversion is relatively recent, and references in the literature only started to become popular in 2007. In fact, in our sample, the first patient to use this device was in 2013. After that, it was used in 18 patients (36% of postoperative fecal derivations), and only one patient underwent a final surgical colostomy. In summary, in our experience, surgical colostomy does not reduce mortality, and only one-third of patients have their intestinal transit reconstructed definitively. In addition, temporary fecal diversion devices have shown promising results. For these reasons, the decision to perform a surgical bowel diversion should be postponed as long as possible. In patients in whom fecal diversion is necessary for local control of the perineal wound, non-invasive methods should be used first. Thus, surgical colostomy should be reserved in cases of significant sphincter involvement and once the critical period of life has passed. Conclusions Although mortality due to FG has decreased, one in eight patients died in the immediate postoperative period. Despite improved outcomes, 22% required a colostomy during admission. Neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality, so non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible. Statements And Declarations Conflict of Interest: The authors declare that they have no conflict of interest. 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World J Surg Oncol. 2016;14(1):1–5. Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Archivio italiano di urologia e andrologia Arch ital urol androl = Archives of Italian urology and andrology. Arch Ital di Urol e Androl. 2016;88(3):157–64. Sorensen MD, Krieger JN, Rivara FP, Broghammer JA, Klein MB, Mack CD, et al. Fournier’s Gangrene: Population Based Epidemiology and Outcomes. J Urol. 2009;181(5):2120–6. Carvalho JP, Hazan A, Cavalcanti AG, Favorito LA. Relation between the area affected by Fournier’s gangrene and the type of reconstructive surgery used. A study with 80 patients. Int Braz J Urol. 2007;33(4):510–4. Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome Prediction in Patients with Fournier’s Gangrene. J Urol. 1995; Lin TY, Ou CH, Tzai TS, Tong YC, Chang CC, Cheng HL, et al. Validation and simplification of Fournier’s gangrene severity index. Int J Urol. 2014; Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, et al. 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What are the indications for a stoma in Fournier’s gangrene? Color Dis. 2011; 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. Langenbeck’s Arch Surg. 2021; Rosen DR, Brown ME, Cologne KG, Ault GT, Strumwasser AM. Long-term follow-up of Fournier’s Gangrene in a tertiary care center. J Surg Res. 2016 Nov;206(1):175–81. Li Y-D, Zhu W-F, Qiao J-J, Lin J-J. Enterostomy can decrease the mortality of patients with Fournier gangrene. World J Gastroenterol. 2014 Jun;20(24):7950–4. Bronder CS, Cowey A, Hill J. Delayed stoma formation in Fournier’s gangrene. Color Dis. 2004; Czymek R, Kujath P, Bruch HP, Pfeiffer D, Nebrig M, Seehofer D, et al. Treatment, outcome and quality of life after Fournier’s gangrene: A multicentre study. Color Dis. 2013;15(12):1529–36. Hallam S, Mothe BS, Tirumulaju RMR. Hartmann’s procedure, reversal and rate of stoma-free survival. Ann R Coll Surg Engl. 2018;100(4):301–7. Estrada O, Martinez I, Del Bas M, Salvans S, Hidalgo LA. Rectal diversion without colostomy in Fournier’s gangrene. Tech Coloproctol. 2009 Jun;13(2):157–9. Marín Vivó G, Calixto Rodríguez J, Rodríguez Martínez X. [Fecal control system Flexi-Seal FMS]. Rev Enferm. 2008 Oct;31(10):16–20. Ozkan OF, Koksal N, Altinli E, Celik A, Uzun MA, Cıkman O, et al. Fournier’s gangrene current approaches. Int Wound J. 2016 Oct;13(5):713–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Universitario Ramón y Cajal","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Enrique","middleName":"","lastName":"López","suffix":""},{"id":176746664,"identity":"c70facfc-8cd6-41e9-b58a-23801781a1ef","order_by":2,"name":"Luz Divina Juez Sáez","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYBACPhAhAcT8IEZCARFa2GBaJBtAWgyI1QICBgfAJDFaJNIfMFi22dgbn1+d+OGBAYM8v9gBQloSEhgk29KYzW683SwBdJjhzNkJBLUcAGo5zGZ24+wGkJYEg9sEtSQ2ALX85zGecXbzDyK1JANDq+2AhAF/7zYibeF5xnBA4lyygcQN3m0WCQYShP3Cz57+8LFEmZ09f//ZzTd/VNjI80sT0AICh0FRySABVilBWDkIMH4A23eAONWjYBSMglEw8gAAbP07SU1f5vQAAAAASUVORK5CYII=","orcid":"","institution":"Hospital Universitario Ramón y Cajal","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Luz","middleName":"Divina 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19:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2579452/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2579452/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":33192905,"identity":"e1d3db22-1418-4280-8402-6c9c93bc068d","added_by":"auto","created_at":"2023-02-20 18:24:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":59395,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curves for prediction of death and definitive stoma\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2579452/v1/75e701b9a044673599dc6179.png"},{"id":33192102,"identity":"7ba1302d-e0ba-4a06-bd4d-a23fd1271720","added_by":"auto","created_at":"2023-02-20 18:16:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":51189,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChronology of colostomy performance since diagnosis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2579452/v1/c98f59488d2d75ee2a703746.png"},{"id":33192101,"identity":"a4cab247-909c-46a6-8126-1a0f4fa9887c","added_by":"auto","created_at":"2023-02-20 18:16:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28785,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of fecal management in Fournier´s Gangrene\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2579452/v1/9200d63f07ccbab2dff585da.png"},{"id":33194817,"identity":"7b90f9e8-1638-45d4-9e57-b5264daaeac2","added_by":"auto","created_at":"2023-02-20 19:29:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":784072,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2579452/v1/4c52678f-a7a5-42b7-b141-5648b27ee050.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fournier's Gangrene and fecal diversion. When, in which patients, and what type should I perform?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFournier's Gangrene (FG) is a necrotizing fascitis affecting the perineum and urogenital tissue. The most common cause is a perianal abscess, mainly if it is not drained early. Other origins have been described, as genitourinary infections, colorectal carcinoma, rectal perforation, acute diverticulitis, and hemorrhoid banding, among other routine surgical anal procedures (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The extent of this necrosis usually goes further than the visual diagnosis; the bacteria spreads along fascial planes relatively quickly (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Generally, the infection is polymicrobial, with mixed aerobes and anaerobes; the most frequently isolated microorganism is E. coli, followed by Streptococcus and Staphylococcus (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMany predisposing factors have been associated with FG, such as Diabetes Mellitus, which has been described as up to 56%. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). FG secondary to perforation of rectal cancer is rare and can be associated with neoadjuvant treatment such as Bevacizumab (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Other risk factors include advanced age, ethanol abuse, steroid therapy, and immunosuppressive diseases such as AIDS, cirrhosis, or cancer (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe incidence is 0.02% in hospitalized patients, with a rate of 1.6 per 100.000 males/year, more frequently in males (10:1) with 50\u0026ndash;60 years old. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Mortality rates vary from 0 to 42% between studies, with a fulminant sepsis and subsequent multiple organ failure as the cause of the death. Early detection and aggressive debridement can reduce mortality by up to 16% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOutcome and mortality can be stratified using the Fournier's Gangrene Severity Index (FGSI) score. This score includes clinical and analytical parameters such as leucocytosis, glucose level, serum creatinine, temperature, heart, and respiratory rate. A score higher than 9 is a sensitive indicator of mortality with a 75% probability of death (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Other studies, such as Lin et al., have tried simplifying the FGSI using three parameters: serum potassium, serum creatinine, and hematocrit. Their study showed that survivors had significantly lower serum creatinine and potassium and higher hematocrit level. Likewise, this score with three parameters showed a non-inferior to FGSI in their patients (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFG can be fatal, so immediate resuscitation is basic. Initial management includes fluid resuscitation, correction of electrolyte imbalances, and broad-spectrum intravenous antibiotics. Aggressive and early surgical debridement is imperative. Non-viable tissue must be excised until viable and well-perfused tissue is reached. An average of 3.5 surgical debridements per patient can be necessary for proper infection control (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In extensive perianal infection, fecal diversion is performed to avoid wound contamination. Despite investigations, there is no consensus on using a colostomy or a fecal incontinence catheter (Flexi-seal) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The decision for a stoma is based on the surgeon's personal experience and the extension of the infection. Although the evidence is limited, and there are no recommendations in the clinical practice guidelines, the mortality risk has been associated with the stoma group patients (25%) more than in the non-stoma group (16%). However, the severity of the disease and the number of surgeries are more significant in the stoma group. Lower mortality has been reported with a primary colostomy (colostomy done during the first surgery- 16%) than with a secondary colostomy (40%) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of this study was to evaluate the impact of fecal diversion on FG-associated mortality.\u003c/p\u003e"},{"header":"Material And Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A retrospective study was conducted to recruit all patients operated on, by the General Surgery and Urology Departments, with a FG diagnosis at University Hospital (Spain) from January 2000 to January 2022 from the analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInclusion criteria were: patients over 18 years of age, clinical/radiological/pathological diagnosis of FG with at least 30 days of post-surgical follow-up. Patients with no clinical follow-up and no available medical records were excluded.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cu\u003eValues\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral categories of socio-demographic data were collected, such as:\u003c/p\u003e\n\u003cp\u003e- Age (years), sex, comorbidities (diabetes mellitus, arterial hypertension, dyslipidemia), smoking or alcohol status, previous immunosuppression, history of urodigestive neoplasms and overweight (BMI \u0026gt; 24.9)\u003c/p\u003e\n\u003cp\u003e- Clinical characteristics (pathophysiological origin)\u003c/p\u003e\n\u003cp\u003e- Surgical considerations (first surgery, number of reoperations, derivative stoma, use of a temporary containment device, perineal reconstructive surgery, and postoperative complications on the Clavien-Dindo scale)\u003c/p\u003e\n\u003cp\u003e- Others (follow-up time, causes of death, and Fournier Gangrene Severity Index).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eDefinitions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e: clinical/radiological and anatomopathological diagnosis of the perineal necrotizing fascitis, regardless of its clinical origin.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Fournier Gangrene Severity Index (FGSI)\u003c/strong\u003e is a validated scale that considers clinical and laboratory criteria, aiming to predict mortality from the time patients are received in the emergency room. It is a numerical scale that scores the following parameters: temperature (\u0026deg;C), heart rate, respiratory rate, blood sodium (mmol/l), blood potassium (mmol/l), blood creatinine (mg/100ml), hematocrit (%), and WBC, bicarbonate (mmol/l).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Fecal diversion:\u0026nbsp;\u003c/strong\u003eeither surgical (colostomy) or straight (Flexi-seal) during the first or other surgeries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTemporary containment device or Flexi-seal:\u003c/strong\u003e A device indicated for incontinent, bedridden, or immobilized patients with liquid or semi-liquid feces. It is designed to safely and effectively contain and divert fecal matter, protect patient wounds from fecal contamination, and reduce the risk of skin breakdown and the spread of infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables were tested for normality using the non-parametric Kolmogorov-Smirnov test. Quantitative variables are presented with mean and standard deviation values if the distribution is normal and with median and interquartile range (IQR) values otherwise. Categorical variables are expressed as absolute numbers and percentages.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;For the statistical analysis of quantitative variables, Student\u0026apos;s t-test was used. For non-normal variables, non-parametric tests were used, and for categorical variables, Pearson\u0026apos;s chi-square test was applied. Univariate logistic regression analysis was performed to identify risk factors associated with significant complications and postoperative death. To establish preoperative quantitative variables (including the severity index FG) as predictors of mortality and significant morbidity, a receiver operating characteristic (ROC) curve analysis was employed. The area under the curve (AUC) and its standard error were also calculated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA p-value \u0026lt;0.05 was considered statistically significant, and all ranges were calculated for a 95% confidence interval. The SPSS statistical package version 23.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics committee\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed with human participants followed the research committee\u0026apos;s ethical standards, the 1964 Declaration of Helsinki, and its subsequent amendments or comparable ethical standards. Our Drug Research Ethics Committee approved the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 149 patients met the inclusion criteria. The mean age was 63.69 \u0026plusmn;14.8 years, with a significant predominance of males (78%). Seventy-eight percent of the patients in the sample had some comorbidity. The most frequent being hypertension (59 patients - 37.8%), followed by diabetes mellitus (46 patients - 31%), and the median number of comorbidities was 1 (1-2). Analytically, patients had a median leukocyte count at diagnosis 18750 (13150-24550)/\u0026micro;L, mean CRP 271 \u0026plusmn; 113 mg/L, and renal function (expressed as GFR) 73.7 \u0026plusmn; 34 mL/min.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;FG\u0026acute;s most frequent cause was a perianal abscess (107 patients - 72%). Orchitis in 11% of the patients and gastrointestinal perforation in 7 patients (4%). The most frequent initial surgery was intensive debridement of the necrotic area (83%). However, an additional procedure was performed in 17% of the patients: a derivative stoma in 15 patients (17%) and an orchiectomy in 9 patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore than half of the patients (55%) required more than one surgical intervention. The median number of procedures per patient performed in the operating theatre was 2 (1-2). In addition to curative surgery, almost one in five patients required reconstructive surgery by the plastic surgery department. Most patients were treated with a myocutaneous flap to cover the defect (22 patients). Some post-surgical complication was described in 88% of patients. Collected under the Clavien-Dindo classification, 56% (74 patients) were grade I-II (Table 1).\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eThe sample\u0026rsquo;s baseline characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eValues\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en=149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003eDeath by FG\u003c/p\u003e\n \u003cp\u003eN=18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003eNo Death\u003c/p\u003e\n \u003cp\u003eN=131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e63.69 \u0026plusmn;14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e71,95 \u0026plusmn; 14,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e62,56 \u0026plusmn; 14,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e116 (78)\u003c/p\u003e\n \u003cp\u003e33 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (72,2)\u003c/p\u003e\n \u003cp\u003e5 (27,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e103 (88,8)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (21,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,550\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDiabetes mellitus\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDyslipemia\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eInmunosuppression\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eToxics/drugs\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePersonal history malignant neoplasm\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eObesity\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59 (37.8)\u003c/p\u003e\n \u003cp\u003e46 (30.9)\u003c/p\u003e\n \u003cp\u003e26 (16.7)\u003c/p\u003e\n \u003cp\u003e25 (16.1)\u003c/p\u003e\n \u003cp\u003e24 (16.1)\u003c/p\u003e\n \u003cp\u003e18 (12.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 \u0026nbsp;(10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (44,4)\u003c/p\u003e\n \u003cp\u003e8 (44,4)\u003c/p\u003e\n \u003cp\u003e4 (22,2)\u003c/p\u003e\n \u003cp\u003e5 (27,8)\u003c/p\u003e\n \u003cp\u003e3 (16,7)\u003c/p\u003e\n \u003cp\u003e5 (27,8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (11,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (44,4)\u003c/p\u003e\n \u003cp\u003e38 (29)\u003c/p\u003e\n \u003cp\u003e22 (16,8)\u003c/p\u003e\n \u003cp\u003e20 (15,3)\u003c/p\u003e\n \u003cp\u003e21 (16)\u003c/p\u003e\n \u003cp\u003e13 (9,9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (10,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,798\u003c/p\u003e\n \u003cp\u003e0,187\u003c/p\u003e\n \u003cp\u003e0,521\u003c/p\u003e\n \u003cp\u003e0,188\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0,045\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGlobal comorbidity factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e1 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e2 (1-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e1 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWBCs (/\u0026micro;L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e18750 (13150-24550)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e18600 (10750-23200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e18800 (13300-24500)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,697\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRP\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(\u003c/strong\u003e\u003cstrong\u003emg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e271\u0026nbsp;\u0026plusmn; 113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e278 (171-331)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e289 (173-347)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,681\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGFR (mL/min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e73.7 \u0026plusmn; 34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e53 (22-95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e77 (49-98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,218\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific origin\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003ePerianal abscess\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eOrchitis\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGastrointestinal perforation\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e107 (72)\u003c/p\u003e\n \u003cp\u003e16 (11)\u003c/p\u003e\n \u003cp\u003e7 (4)\u003c/p\u003e\n \u003cp\u003e19 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (61,1)\u003c/p\u003e\n \u003cp\u003e2 (11,1)\u003c/p\u003e\n \u003cp\u003e2 (11,1)\u003c/p\u003e\n \u003cp\u003e3 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e96 (73,3)\u003c/p\u003e\n \u003cp\u003e14 (10,7)\u003c/p\u003e\n \u003cp\u003e5 (3,8)\u003c/p\u003e\n \u003cp\u003e16 (12,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,500\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial surgery\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eDebridement\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDebridement + colostomy\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDebridement + orchiectomy\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e124 (83)\u003c/p\u003e\n \u003cp\u003e15 (10)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (89)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (5,6)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (5,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e108 (82,4)\u003c/p\u003e\n \u003cp\u003e15 (11,5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (6,1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026ordm; interventions (median)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e2 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e1 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e2 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGSI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e5 (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e5 (4-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e5 (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,259\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperatory fecal derivation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFlexi-seal rectal tube\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eColostomy\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e50 (33.6)\u003c/p\u003e\n \u003cp\u003e18 (36)\u003c/p\u003e\n \u003cp\u003e32 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e6 (33)\u003c/p\u003e\n \u003cp\u003e3 (50)\u003c/p\u003e\n \u003cp\u003e3 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e44 (33,6)\u003c/p\u003e\n \u003cp\u003e15 (34,1)\u003c/p\u003e\n \u003cp\u003e29 (65,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,624\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eColostomy at the end of the admission\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e33 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e3 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e30 (22,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,796\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDays after colostomy (median)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e3 (0-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e8 (0-20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e3 (3-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinitive colostomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e22 (14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlastic surgery reconstruction\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eClosure by primary intention\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMyocutaneous flap\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (19.5)\u003c/p\u003e\n \u003cp\u003e7 (4.7)\u003c/p\u003e\n \u003cp\u003e22 (14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eClavien-Dindo classification\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eI\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eII\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIII\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIV\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"34.92063492063492%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital admission (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e25 (11-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.57848324514991%\"\u003e\n \u003cp\u003e7 (2-22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.93121693121693%\"\u003e\n \u003cp\u003e27 (15-47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.638447971781305%\"\u003e\n \u003cp\u003e0,348\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cem\u003eWBC White Blood Cells count; CRP C Reactive Protein; GFR Glomerular Filtration Rate; FGSI Severity Index for Fournier`s Gangrene\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFournier\u0026apos;s gangrene and mortality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the postoperative hospital admission, 18 patients (12%) died of a specific cause of Fournier\u0026apos;s gangrene. A comparison has been made between patients who died from FG and those who did not (Table 1). Patients who died during the hospitalization were found to be older (71.95 \u0026plusmn; 14.4 vs. 62.56 \u0026plusmn; 14.6; p=0.011) and with a personal history of oncological pathologies (p=0.045). Table 2 shows that both were the only mortality risk factors according to logistic regression. It is worth noting that patients with an oncological history had three times the risk of postoperative mortality (OR 3.49 (1.07-11.36; p=0.038). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality.\u003c/p\u003e\n\u003cp\u003eIn addition, a ROC curve has been performed to predict death after surgery. IGFS showed the best area under the curve as a predictor of mortality of the prognostic factors analyzed (AUC 0.661 (p=0.087)). The best cut-off point was 5 points (with a sensitivity of 77% and a specificity of 50%). For 9 points in our sample, IGFS presented a sensitivity of 23% and specificity of 87%, with a positive predictive value of 89% as a death factor. The global comorbidity index (AUC 0.593; p= 0.320) was the following parameter that showed adequate prediction (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFecal diversion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding postoperative faecal diversion: one-third of the patients (50) required some measure to isolate the perineal wound from faecal matter.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 32 patients, a surgical colostomy was performed at baseline. The median number of days to perform the stoma was 3 (0-7) days. As shown in figure 2, in 57.6% of the sample, the colostomy was performed within 72 hours. In the first week of diagnosis, 78.8% of patients had a stoma. In the second week, more than 90% of the sample had a colostomy. In only three patients, the stoma was delayed (20, 22, and 40 days respectively).\u003c/p\u003e\n\u003cp\u003eIn the remaining 18 patients, it was decided to use a temporary containment device (Flexi-seal) as a first step. All these devices were used from 2013 onwards Only one of these patients eventually required a colostomy during admission. Thus, at the end of admission, 22% of the sample (33 patients) had a stoma Figure 3.\u003c/p\u003e\n\u003cp\u003eThe risk factors associated with a post-surgical fecal diversion in the logistic regression were: diabetes mellitus (OR 0,43 (CI 95% 0,19-0,97); p=0,044), perianal origin (OR\u0026nbsp;3,94 (CI 95% 1,29-12.05); p=0,016)\u0026nbsp;and a higher number of re-interventions (OR\u0026nbsp;3,09 (CI 95% 2,04-4,69); p\u0026lt;0,001). However, only diabetes and a higher number of surgical interventions were identified as risk factors associated with a surgical colostomy.\u003c/p\u003e\n\u003cp\u003eThree of the 33 patients who underwent a colostomy at the time of admission died of FG. After the acute episode, one-third of the patients underwent intestinal transit reconstruction (10 patients). Table 2 used logistic regression to identify factors associated with a definitive ostomy. The only risk factors associated with a definitive stoma were a history of oncological disease and a higher number of re-interventions. In addition, colostomy within 24 hours or one week of the first operation raised tenfold the risk of permanent ostomy (OR 21.89 (5.7-82.9) vs. OR 34 (10-115.2)).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"107%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Table 2.\u0026nbsp;\u003c/strong\u003eLogistic regression of the prognostic factors for postoperative consequences\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.587628865979383%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"21.649484536082475%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFecal \u0026nbsp;postoperatory diversion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"19.587628865979383%\"\u003e\n \u003cp\u003e\u003cstrong\u003eColostomy during admision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"19.587628865979383%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinitive stoma\u003c/strong\u003e\u003cstrong\u003e\u0026sup1;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"19.587628865979383%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeath\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (CI\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (CI\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (CI 95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (CI 95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,99 (0,69-1,01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e0,446\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,66 (0,9-1,02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,994\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1,02 (0,98-1,06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,05 (1,01-1,09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex (male)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,01 (0,44-2,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e0,975\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,74 (0,3-2,13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,859\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,67 (0,26-2,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,748\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,707 (0,23-2,15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,541\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cstrong\u003eDiabetes mellitus\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cstrong\u003eDyslipemia\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cstrong\u003eInmunosuppression\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cstrong\u003eToxics/drugs\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMalignant neoplasm\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eObesity\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,79 (0,39-1,61)\u003c/p\u003e\n \u003cp\u003e0,43 (0,19-0,97)\u003c/p\u003e\n \u003cp\u003e1,29 (0,54-3,11)\u003c/p\u003e\n \u003cp\u003e2,09 (0,87-5)\u003c/p\u003e\n \u003cp\u003e2,29 (0,94-5,55)\u003c/p\u003e\n \u003cp\u003e1,30 (0,47-3,59)\u003c/p\u003e\n \u003cp\u003e1,62 (0,57-4,66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,524\u003c/p\u003e\n \u003cp\u003e0,044\u003c/p\u003e\n \u003cp\u003e0,561\u003c/p\u003e\n \u003cp\u003e0,098\u003c/p\u003e\n \u003cp\u003e0,067\u003c/p\u003e\n \u003cp\u003e0,610\u003c/p\u003e\n \u003cp\u003e0,364\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,71 (0,3-1,6)\u003c/p\u003e\n \u003cp\u003e0,33 (0,12-0,9)\u003c/p\u003e\n \u003cp\u003e0,89 (0,3-2,6)\u003c/p\u003e\n \u003cp\u003e1,47 (0,6-3,8)\u003c/p\u003e\n \u003cp\u003e2,0 (0,7-5,2)\u003c/p\u003e\n \u003cp\u003e1,92 (0,7-5,6)\u003c/p\u003e\n \u003cp\u003e1,71 (0,5-5,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,406\u003c/p\u003e\n \u003cp\u003e0,032\u003c/p\u003e\n \u003cp\u003e0,836\u003c/p\u003e\n \u003cp\u003e0,442\u003c/p\u003e\n \u003cp\u003e0,155\u003c/p\u003e\n \u003cp\u003e0,229\u003c/p\u003e\n \u003cp\u003e0,358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,67 (0,26-1,77)\u003c/p\u003e\n \u003cp\u003e0,23 (0,05-1,05)\u003c/p\u003e\n \u003cp\u003e0,56 (0,1-2,6)\u003c/p\u003e\n \u003cp\u003e2,13 (0,67-6,73)\u003c/p\u003e\n \u003cp\u003e1,38 (0,41-4-64)\u003c/p\u003e\n \u003cp\u003e4,29 (1,24-14,85)\u003c/p\u003e\n \u003cp\u003e1,60 (0,41-8,35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,421\u003c/p\u003e\n \u003cp\u003e0,058\u003c/p\u003e\n \u003cp\u003e0,465\u003c/p\u003e\n \u003cp\u003e0,196\u003c/p\u003e\n \u003cp\u003e0,600\u003c/p\u003e\n \u003cp\u003e0,021\u003c/p\u003e\n \u003cp\u003e0,501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1,26 (0,46-3,39)\u003c/p\u003e\n \u003cp\u003e1,96 (0,71-5,34)\u003c/p\u003e\n \u003cp\u003e1,42 (0,43-4,71)\u003c/p\u003e\n \u003cp\u003e2,13 (0,68-6,45)\u003c/p\u003e\n \u003cp\u003e1,05 (0,28-3,94)\u003c/p\u003e\n \u003cp\u003e3,49 (1,07-11,36)\u003c/p\u003e\n \u003cp\u003e1,05 (0,21-5,02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,654\u003c/p\u003e\n \u003cp\u003e0,189\u003c/p\u003e\n \u003cp\u003e0,571\u003c/p\u003e\n \u003cp\u003e0,191\u003c/p\u003e\n \u003cp\u003e0,945\u003c/p\u003e\n \u003cp\u003e0,038\u003c/p\u003e\n \u003cp\u003e0,957\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity factor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,1 (0,82-1,47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e0,532\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,99 (0,7-1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,946\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,98 (0,69-1,50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,49 (0,99-2,21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWBCs (/\u0026micro;L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e0,883\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,573\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,515\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,805\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,01 (0,99-1,01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e0,291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,649\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,99 (0,99-1,01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,727\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGFR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e0,943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,756\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,611\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,99 (0,97-1,01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,240\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerianal abscess origin\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e3,94 (1,29-12.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e0,016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1,07 (0,5-2,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,895\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0.63 (0.23-1,72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,25 (0,25-6,22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,788\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlexiseal fecal tube\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,18 (0-1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,37 (0-2,91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,54 (0,4-5,97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,527\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGSI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,97 (0,85-1,11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e0,69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,89 (0,7-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e0,84 (0,69-1,04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,01 (0,92-1,31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,292\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026ordm; reinterventions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e3,09 (2,04-4,69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003ep\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e3,46 (2,2-5,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003ep\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e2,56 (1,77-3,86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003ep\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,69 (0,41-1,17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,169\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eColostomy during\u0026nbsp;\u003c/strong\u003e \u003cstrong\u003ehospitalisation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,67 (0,20-2,43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,552\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eColostomy (days after)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e1,07 (0,9-1,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,394\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e1,05 (0,9-1,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,373\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eColostomy \u0026lt;24 hours\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u003cstrong\u003e21,89 (5,7-82,9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,53 (0,07-4,36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"20%\"\u003e\n \u003cp\u003e\u003cstrong\u003eColostomy 1 week\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.421052631578947%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.631578947368421%\"\u003e\n \u003cp\u003e\u003cstrong\u003e34 (10-115,2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0,26 (0,03-2,07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.315789473684211%\"\u003e\n \u003cp\u003e0,204\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cem\u003eWBC White Blood Cells count; CRP C Reactive Protein; GFR Glomerular Filtration Rate; FGSI Severity Index for Fournier`s Gangrene; OR Odds ratio; CI Confidence Interval; Postoperative fecal diversion including flexi-fecal tube and colostomy (temporary or definitive); Death includes only patients who died of a specific cause of postoperative Fournier\u0026apos;s Gangrene.\u0026sup1;Only in patients with fecal postoperatory derviation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results showed a global mortality rate of 12%, identifying age and personal history of malignant neoplasia as independent risk factors for mortality. Traditionally, aggressive debridement and broad-spectrum antibiotic therapy have been shown to improve morbidity and decrease mortality. Despite improved diagnostic techniques and treatment, FG is often associated with signs of sepsis, rapid tissue destruction, and a mortality rate of 40% (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). FG can occur in healthy people; however, up to 70% of patients usually have risk factors such as diabetes, harmful use of alcohol, or an immunosuppressive disease. In the literature, the only factor unanimously associated with increased mortality is a delay in diagnosis and surgical treatment.\u003c/p\u003e \u003cp\u003eThere is some discrepancy about the prognostic factors for mortality, so attempts have been made to create mortality predictor scores. Laor E et al. in 1995 described Fournier's Gangrene Severity Index (FGSI) score to predict mortality using nine parameters. One of the best-known and most widely used scores in daily practice is the FGSI. This score sets the cut-off point to 9, with a 75% probability of death if the score is higher than this point. Likewise, Laor et al. establish a survival of 78% if the score is less than nine (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Different studies widely support the validation of FGSI. However, the many parameters necessary make it a limited application at admission (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This test has been applied in our population, and no statistically significant differences were found in the median FGSI concerning mortality. After constructing the ROC curve, the best cut-off point in our sample was 5 points (sensitivity 77%, specificity 50%). However, for the 9 points, the FGSI presented a specificity of 87% with a negative predictive value of 89%. In other words, below 9 points, the probability of dying from FG is about 10%.\u003c/p\u003e \u003cp\u003eIn addition to high mortality, post-surgical sequelae are one of the most characteristic features of FG, and all series agree on the high morbidity related to the pathology. In our sample, one out of four patients presented with significant long-term sequelae; more specifically, 22% required a derivative stoma during hospitalization. The factors associated with postoperative fecal diversion were immunosuppression or toxic and drug abuse, perianal origin, and greater reoperations. However, performing a stoma was not associated decreased postoperative mortality. Performing a derivative stoma has a role in reducing the wound's fecal contamination and helping control sepsis. Although the formation of the stoma reduces infection, mortality does not decrease with its formation because patients, who need it, usually have extensive necrosis and poor physiological status that mark their prognosis (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In line with these results, we found a recent meta-analysis with the primary objective of evaluating the impact on mortality of performing a stoma in treating FG. Overall, the pooled mortality rate was significantly higher in patients who required a stoma (OR 1.71; 95% CI 1.13\u0026ndash;2.59; p\u0026thinsp;=\u0026thinsp;0.01). However, after subgroup analysis, the stoma was associated with significantly higher mortality in FG due to colorectal infection (p\u0026thinsp;=\u0026thinsp;0.04) but not urogenital origin (p\u0026thinsp;=\u0026thinsp;0.27) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, it is noteworthy that the FGSI index showed an AUC of 0.455 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Although this score was developed to quantify the severity of FG, several studies have found no relationship between the scores of patients with and without stoma (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Our results, as well as the recent literature on the subject, support that performing a stoma does not decrease mortality associated with Fourier's Gangrene.\u003c/p\u003e \u003cp\u003eOn the other hand, on many occasions, although performing a stoma does not reduce mortality, it is necessary to perform a fecal diversion for local control of the wound. The question is when to perform the colostomy. Broder et al. propose delayed stoma formation a median of four days after the first intervention. They suggest that tissue edema regresses in the first 48h, allowing better evaluation of the sphincters and perianal tissues (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Because most patients usually require a \"second look\" surgery within 48 h of initial debridement, some authors recommend that stoma formation be deferred at the first operation and performed later if needed. For our patients, the median of days to perform a colostomy after the first surgery was three days, and before the first week, nearly 80% of the sample had the stoma. Seven days after the first urgent drainage, only seven patients out of the total sample required a fecal diversion. In other words, after the initial \"risk period\" of the first week after the first surgery, the probability of needing a stoma decreases by 95% (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, as seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the timing of the stoma did not directly influence mortality.\u003c/p\u003e \u003cp\u003eAnother critical point is the probability of colostomy reversal. There are very few references in the literature on long-term outcomes after FG. In the study published by Czymek et al., the impact on quality of life after FG was evaluated. In their sample, some stoma was performed in 60% of patients. In patients with a long-term follow-up, this was permanent in 50% of them (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Although these are different pathologies, these figures overlap those published on Hartmann's reversal surgery. In this recent study in which 228 Hartmann's procedures for multiple pathologies were analyzed, Hartmann's procedure is reversed less frequently than thought, and only 46% of Hartmann's procedures were stoma free at the end of the audit period (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In our sample, of the total number of colostomies performed during hospital admission for FG, only one-third of the patients underwent intestinal transit reconstruction.\u003c/p\u003e \u003cp\u003eIn recent years, there has been some interest in using temporary fecal diversion devices such as Flexi-seal rectal tubes (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This alternative method to surgical colostomy could provide economic benefits and patient comfort for short-term fecal diversion. Although initially designed for the management of fecal management of intensive care patients, in FG patients, it could be a practical and less invasive way to avoid fecal contamination of the perineal wound (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, this method of faecal diversion is relatively recent, and references in the literature only started to become popular in 2007. In fact, in our sample, the first patient to use this device was in 2013. After that, it was used in 18 patients (36% of postoperative fecal derivations), and only one patient underwent a final surgical colostomy.\u003c/p\u003e \u003cp\u003eIn summary, in our experience, surgical colostomy does not reduce mortality, and only one-third of patients have their intestinal transit reconstructed definitively. In addition, temporary fecal diversion devices have shown promising results. For these reasons, the decision to perform a surgical bowel diversion should be postponed as long as possible. In patients in whom fecal diversion is necessary for local control of the perineal wound, non-invasive methods should be used first. Thus, surgical colostomy should be reserved in cases of significant sphincter involvement and once the critical period of life has passed.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAlthough mortality due to FG has decreased, one in eight patients died in the immediate postoperative period. Despite improved outcomes, 22% required a colostomy during admission. Neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality, so non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible.\u003c/p\u003e"},{"header":"Statements And Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study has not received funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Ortega and E. L\u0026oacute;pez conducted the data search and drafted the main text of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLD Juez prepared the figures and tables\u003c/p\u003e\n\u003cp\u003eAll authors wrote, reviewed and approved the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eLaucks SS. Fournier\u0026rsquo;s gangrene. Surg Clin North Am. 1994;74(6):1339\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVick R, Carson CC. Fournier\u0026rsquo;s disease. Urol Clin North Am. 1999;26(4):841\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTang LM, Su YJ, Lai YC. The evaluation of microbiology and prognosis of fournier\u0026rsquo;s gangrene in past five years. Springerplus. 2015;4(1):2013\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eProvenzano D, Lo Bianco S, Zangh\u0026igrave; M, Campione A, Vecchio R, Zangh\u0026igrave; G. Fournier\u0026rsquo;s gangrene as a rare complication in patient with uncontrolled type 2 diabetes treated with surgical debridement: A case report and literature review. Int J Surg Case Rep. 2021;79:462\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYoshino Y, Funahashi K, Okada R, Miura Y, Suzuki T, Koda T, et al. Severe Fournier\u0026rsquo;s gangrene in a patient with rectal cancer: Case report and literature review. World J Surg Oncol. 2016;14(1):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSingh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Archivio italiano di urologia e andrologia Arch ital urol androl = Archives of Italian urology and andrology. Arch Ital di Urol e Androl. 2016;88(3):157\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSorensen MD, Krieger JN, Rivara FP, Broghammer JA, Klein MB, Mack CD, et al. Fournier\u0026rsquo;s Gangrene: Population Based Epidemiology and Outcomes. J Urol. 2009;181(5):2120\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCarvalho JP, Hazan A, Cavalcanti AG, Favorito LA. Relation between the area affected by Fournier\u0026rsquo;s gangrene and the type of reconstructive surgery used. A study with 80 patients. Int Braz J Urol. 2007;33(4):510\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLaor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome Prediction in Patients with Fournier\u0026rsquo;s Gangrene. J Urol. 1995;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLin TY, Ou CH, Tzai TS, Tong YC, Chang CC, Cheng HL, et al. Validation and simplification of Fournier\u0026rsquo;s gangrene severity index. Int J Urol. 2014;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eThwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, et al. Fournier\u0026rsquo;s gangrene and its emergency management. Postgraduate Medical Journal. 2006.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEray IC, Alabaz O, Akcam AT, Ulku A, Parsak CK, Sakman G, et al. Comparison of Diverting Colostomy and Bowel Management Catheter Applications in Fournier Gangrene Cases Requiring Fecal Diversion. Indian J Surg. 2015;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChen CS, Liu KL, Chen HW, Chou CC, Chuang CK, Chu SH. Prognostic factors and strategy of treatment in Fournier\u0026rsquo;s gangrene: a 12-year retrospective study. Changgeng Yi Xue Za Zhi. 1999;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTosun Y, Akıncı O, K\u0026uuml;\u0026ccedil;\u0026uuml;k HF. Risk factors for mortality in Fournier\u0026rsquo;s gangrene of anorectal origin. Ulus Travma ve Acil Cerrahi Derg. 2022;28(8):1128\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLeslie SW, Rad J, Foreman J. Fournier Gangrene. In Treasure Island (FL); 2022.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eŞahin E, Erşen O, Mercan \u0026Uuml;, Yılmaz S. The effect of Fournier gangrene severity index and microbial culture results on hospital length of stay, frequency of debridement, and mortality. Ulus Travma ve Acil Cerrahi Derg. 2022;28(2):155\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOzturk E, Sonmez Y, Yilmazlar T. What are the indications for a stoma in Fournier\u0026rsquo;s gangrene? Color Dis. 2011;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSarofim M, Di Re A, Descallar J, Toh JWT. Relationship between diversional stoma and mortality rate in Fournier\u0026rsquo;s gangrene: a systematic review and meta-analysis. Langenbeck\u0026rsquo;s Arch Surg. 2021;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRosen DR, Brown ME, Cologne KG, Ault GT, Strumwasser AM. Long-term follow-up of Fournier\u0026rsquo;s Gangrene in a tertiary care center. J Surg Res. 2016 Nov;206(1):175\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLi Y-D, Zhu W-F, Qiao J-J, Lin J-J. Enterostomy can decrease the mortality of patients with Fournier gangrene. World J Gastroenterol. 2014 Jun;20(24):7950\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBronder CS, Cowey A, Hill J. Delayed stoma formation in Fournier\u0026rsquo;s gangrene. Color Dis. 2004;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCzymek R, Kujath P, Bruch HP, Pfeiffer D, Nebrig M, Seehofer D, et al. Treatment, outcome and quality of life after Fournier\u0026rsquo;s gangrene: A multicentre study. Color Dis. 2013;15(12):1529\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHallam S, Mothe BS, Tirumulaju RMR. Hartmann\u0026rsquo;s procedure, reversal and rate of stoma-free survival. Ann R Coll Surg Engl. 2018;100(4):301\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEstrada O, Martinez I, Del Bas M, Salvans S, Hidalgo LA. Rectal diversion without colostomy in Fournier\u0026rsquo;s gangrene. Tech Coloproctol. 2009 Jun;13(2):157\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMar\u0026iacute;n Viv\u0026oacute; G, Calixto Rodr\u0026iacute;guez J, Rodr\u0026iacute;guez Mart\u0026iacute;nez X. [Fecal control system Flexi-Seal FMS]. Rev Enferm. 2008 Oct;31(10):16\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOzkan OF, Koksal N, Altinli E, Celik A, Uzun MA, Cıkman O, et al. Fournier\u0026rsquo;s gangrene current approaches. Int Wound J. 2016 Oct;13(5):713\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"gangrene, Fournier, colostomy, FGSI, Flexi-seal","lastPublishedDoi":"10.21203/rs.3.rs-2579452/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2579452/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFournier's gangrene (FG) is a necrotising fasciitis affecting the perineum and urogenital tissue. The mortality rate is high although early detection and aggressive debridement can reduce mortality by up to 16%. The prevalence of sequelae is very high and a colostomy is often necessary to control the perineal wound.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective study was carried out to recruit all patients operated on by the General Surgery and Urology Departments with a diagnosis of GF at the University Hospital over 22 years. Mortality, The Fournier Gangrene Severity Index (FGSI) and fecal diversion (either surgical (colostomy) or straight (Flexi-seal)) are collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 149 patients met the inclusion criteria. FG´s most frequent cause was a perianal abscess (107 patients - 72%). 18 patients (12%) died of a specific cause of FG. Age (p=0,014) and patients with an oncological history (p=0,038), both were the only mortality risk factors for mortality according to logistic regression. 50 patients required some form of fecal diversion in the postoperative period (32 colostomies and 18 flexi-seal). Neither the use of postoperative fecal diversion (surgical or Flexi-seal) nor the timing of its use had any effect on postoperative mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne in eight patients died in the immediate postoperative period secondary to FG. Despite improved outcomes, 22% required a colostomy during admission. However, neither the performance of a colostomy nor the timing was associated with decreased FG-associated mortality. Non-invasive methods should be used first and surgical bowel diversion should be postponed as long as possible.\u003c/p\u003e","manuscriptTitle":"Fournier's Gangrene and fecal diversion. When, in which patients, and what type should I perform?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-02-20 18:16:42","doi":"10.21203/rs.3.rs-2579452/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"357379b6-d254-49ac-826b-e8680a8550c9","owner":[],"postedDate":"February 20th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-02-24T03:59:11+00:00","versionOfRecord":[],"versionCreatedAt":"2023-02-20 18:16:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2579452","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2579452","identity":"rs-2579452","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}