Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Table 1 Anorectal causes of Fournier’s gangrene - incidence, colostomy rate, duration of hospitalization and survival

Ref.	Anorectal cause	Male:female ratio	Rectal cancer in all-cause group	Rectal cancer in anorectal cause group	Colostomy (all-cause/rectal cause)	Survival (all-cause/rectal cause)	The most common region	Duration of hospitalization (d)
Benjelloun el et al[12], 2013	70.00%	44:6	0%		10%/no data	76%/no data	scrotum	21.00
Bhatnagar et al[13], 2008	7.30%	Male only (110)	0%		4%/no data	92.7%/no data	Scrotum	19.30
Cakmak et al[14], 2008	63.10%	45:20:00	0%		23.1%/no data	70.3%/no data		24.40
Carroll et al[15], 1986	50.00%	13:1			28.57%/no data	79%/no data		48.00
Czymek et al[16], 2009	57.60%	23:10	3%	5.26%		81.9%/no data
Efem[17], 1994	0.00%	Male only (20)	0%				Scrotum
Eke[9], 2000	21.00%	10:1				84%/no data		2-278
Eskitaşcıoğlu et al[18], 2014	20.00%	19:1	2.50%	50.00%	15%/no dana		Scrotum	34.78
Fajdic et al[19], 2007	42.85%	Male only (7)	0%		14.3%/no data	85.7%/no data	Perianal	25.80
Ghnnam et al[20], 2008	54.05%	Male only (74)	0%		1.4%/no data	78.4%/no data		9.20
Rodríguez Hermosa et al[21], 2001	30.00%	Male only (10)	0%		30%/50%	60%/75%	Scrotum	27.00
Jiménez-Pacheco et al[22], 2012	29.70%	Male only (37)	0%			95%/no data		27.54
Kahramanca et al[23], 2014	22.06%	48:20	1.47%	6.67%	22.06%/no data	92.65%/no data		15.37
Kara et al[24], 2009	33.30%	10:5	0%		53.3%/no data	80%/no data	Scrotum and perineum
Karbhari et al[25], 2014	20.00%		0%			80%/no data	Scrotum
Khan[26], 2009	21.00%	Male only (19)	0%		5.3%/no data			26.00
Khandelwal[27], 2013	24.60%	Male only (57)	0%		20.3%/no data	68.5%/no data		19.60
Korkut et al[28], 2003	58.00%	37:8	2.22%	3.85%	40%/no data	80%/no data		12.00
Liang et al[29], 2008	87.50%	Female only (8)	0%		87.5%/85.7%	75%/85.7%		32.20
Morua et al[30], 2009		48:2			10%/no data	88%/no data	Scrotum	23.76

Table 2 Anorectal causes of Fournier’s gangrene

Ref.	Abscess	Hemorrhoidectomy	Hemorrhoids	Intestinal obstruction	Perianal fistula	RT for rectal carcinoma	Rectal carcinoma	Artificial sphincter	Anal fissure	Rectal injury
Benjelloun el et al[12], 2013	88.50%		11.50%
Bhatnagar et al[13], 2008		75.00%		25.00%
Cakmak et al[14], 2008	43.90%	43.90%			12.20%
Czymek et al[16], 2009	68.42%				3.00%	15.79%	3.00%	3.00%
Eskitaşcıoğlu et al[18], 2014	56.25%				12.50%		12.50%		18.75%
Fajdic et al[19], 2007	33.30%		33.30%		33.30%
Ghnnam et al[20], 2008	90.00%	10.00%
Rodríguez Hermosa et al[21], 2001	75.00%									25.00%
Kahramanca et al[23], 2014	66.66%						6.66%			26.66%
Kara et al[24], 2009	60.00%									40.00%
Khan[26], 2009	75.00%	25.00%
Khandelwal[27], 2013	75.00%	25.00%
Korkut et al[28], 2003	92.30%				4.16%		4.16%
Liang et al[29], 2008	100.00%
Oymacı et al[31], 2014	100.00%
Ozkan et al[32], 2014	62.50%						25.00%			12.50%
Singh et al[33], 2004	100.00%
Tan et al[34], 2006	40.00%	40.00%					20.00%
Unalp et al[35], 2008	100.00%
Villanueva-Sáenz et al[36], 2002	88.00%				8.00%		4.00%
Walker et al[37], 1983							100.00%
Wang et al[38], 2012	91.00%						9.00%

RT: Radiotherapy.

Table 3 Case reports of Fournier’s gangrene as associated with perforated rectal cancer

Ref.	Age/Sex	Risk factors	Duration of symptoms/hospitalization	L/CRP	Starting point	DRE	MSCT (tumor, air)	Rectoscopy	Distance from AC border	Microbiology	Operation	Day of operation	Outcome/survival
Ash et al[41], 2005	33/m		2/nd	10/nd	Scrotum		Yes (tumor, air)	No			Colostomy	1
Carr[42], 2010	54/m	Alcoholism	nd/23	nd	Scrotum, perineum, gluteus		Yes (tumor, no air)				APR	1	Alive
Chan et al[43], 2013	78/m	Smoker, hypertension, cerebrovascular accident, dyslipidemia	5/nd	36.8/nd	Perineum, scrotum	Neg	Yes (tumor, air)	Yes	10 cm	E. coli	Colostomy	5	Alive
Eke et al[44], 1999	65/m	Diabetes	nd/nd	nd	Penis					S. aureus	Sigmoid colostomy		Alive
Gamagami et al[45], 1998	45/m	Diabetes	4/nd	nd	Perianal	Pos		Yes		E. coli, Enterococi	Loop colostomy/APR	1/28	Alive/1 yr df
Gupta[46], 2010	55/m		7/nd	14.4/149		Pos		Yes		E. coli, Bacteroides	Colostomy		Died
Highton et al[47], 2009	79/m		2/nd	nd	Right thigh	Neg		Yes	Upper	E. coli, anaerobes	End colostomy and mucosus fistula	1	Alive
Katusić et al[48], 2010	65/m		nd/23	nd	Scrotum, perianal, right groin	Pos				E. coli, Pseudomonas	No colostomy		Alive
Khalil et al[49], 2010	71/m	No	10/nd	20/424	Right thigh	Neg	Yes (tumor, air)				Hartmann procedure		Alive/6 yr Survival
Kojima et al[50], 2007	56/m	Diabetes	nd/nd	23/196	Scrotum	Pos	Yes (tumor, air)		4 cm	E. coli, M. morganii, Enterococcus spp., Microaerophilic streptococcus, B. fragillis	Colostomy/APR	1/121	Alive
Lamy et al[51], 2003	71/f	Diabetes	14/nd	33/270	Gluteal, left thigh	Pos	Yes (tumor, air)	Yes	10 cm	Bacteroides spp.	Colostomy/APR	1/60	Alive/1 mo suvival
Lawrentschuk et al[52], 2003	55/m	No	6/43	n/nd	Perineum, scrotum	Neg	Yes (air, no tumor)	Yes	5 cm	E. coli, Enterococcus species mixed, anaerobes, S. epidermidis	End colostomy/APR	1/16	Alive
Liu et al[53], 2006	56/m	Alcoholic cirrhosis, diabetes, renal insufficiency	nd/nd	nd		Pos		Yes	8 cm	group G streptococcus	No colostomy		Died
Mcmullin et al[54], 2006	70/m		nd/26	33/nd	Scrotum	No	Yes (tumor, air)		3 cm	E. coli, Enterococcus, Bacteroides spp.	Colectomy + APR		Alive/2 yr survival
Moslemi et al[55], 2009	48/m		nd/nd	18/nd	Penis, perianal	Pos	Yes (tumor, no air)	Yes			Loop colostomy		Alive/1 yr df
Mulholland et al[56], 1990	73/m		nd/nd	nd	Scrotum, penis	Pos			AC border	Streptococcus viridans, E. coli, Bacteroides spp. and diphtheroids	Hartmann procedure	4	alive
O'Connor et al[57], 2009	80/m		nd/nd	ml/nd	Scrotum	Pos	Yes (tumor, no air)	Yes	Low		Loop colostomy		Alive
Öner et al[58], 2013	57/m	No	nd/25	22/nd	Scrotum	Pos	Yes	Yes			End colostomy/APR	1/11	Alive/1 yr df
Rajendran et al[59], 2011	73/f		nd/nd	nd	Perianal		Yes (tumor, air)				Colostomy
Villa Sánchez et al[60], 2014	43/m		nd/nd	2.7/270	Thigh, groin					E. coli, Streptoccous spp.	Colostomy	4	Died
Scott et al[61], 1988	63/m		nd/130	nd	Perianal	Pos		Yes			APR		Alive
Tai et al[62], 2012	28/m		nd/nd	13/195	Right leg		Yes (tumor, air)			E. coli	Colostomy
Woodcock et al[63], 2006	66		nd/59	nd	Perineum, scrotum perianal, ingvinal	Pos		Yes	Low	β-haemolytic streptococci, coliforms, mixed anaerobes	Loop colostomy/APR	1/180+	Alive

Table 4 Classification, clinical aspects, anatomopathology and microbiology of necrotizing soft tissue infections[96,113-116]

	Necrotizing fasciitis	Necrotizing fasciitis	Clostridium myonecrosis (gas gangrene)	Fungal necrotizing fasciitis	Clostridium fasciitis	Progressive bacterial synergistic gangrene	Synergistic necrotizing cellulitis	Pseudomonas gangrenous cellulitis	Streptococcal myonecrosis (necrotizing myositis)
	Type 1	Type 2	Type 3	Type 4
Pain	+/++	++/+++	+++	+++	+	+++	++/+++	+/++	++/+++
Anaesthesia of lesions	In advanced stages	In advanced stages	-	-	-	-	-	-/+	-
Cutaneous signs	Edema, erythema, bullae, necrotic and ulcerated lesions	Edema, erythema, necrotic bullae	Pale, Yellow-brown discoloration of skin, Necrotico-hemorragic (brown) bullae	Edema, erythema	Minor edema, pale skin	Necrotic ulcer dusky margin and erythematous periphery at the margins of the wound	Cellulitis with foul-smelling, thick discharge from necrotic skin	Black/gray eschar.Dark discharge with surrounding erythema, hemorrhagic bullae	Edema, copper colored, blisters in advanced stage
Subcutaneous appearance of infection	Subcutaneous tissue and fascial necrosis	Subcutaneous tissue and fascial necrosis	Necrotic area composed of green-black patches.	Subcutaneous tissue, fascial and muscle necrosis		Subcutaneous tissue necrosis and gangrene	Dark pus or 'dishwasher' fliud		Seropurulent discharge
			Serosanguinous. "mousy"-smelling discharge, bluish muscles
Systemic toxicity	+ to +++	+ to +++ (Toxic shock syndrome)	+++	+++	+	+	++ to +++	+++	+ to +++ (Streptococcal Toxic Shock Syndrome)
Fever	High	High	Moderate to high	High		Minimal or absent	Moderate	High
Progression	Moderate (3-14 d)	Very fast (1-3 d)	Very fast (1-3 d)	Very fast (1-3 d)	Moderate (> 3 d)	Moderate (3-14 d)	Moderate (3-14 d)	Moderate (3-14 d)	Fast (1-4 d)
Crepitus (gas)	-/+	-	+++	++/+++	++	-	+	-	-/+
Deep fascias infection	- to ++	+ to +++	+++		+	-	- to ++	-	-/+
Muscular infection	-/+ (secondary)	-/+ (secondary)	+++		-	-	+ to +++	-	+++
Site of entry, initiating factor	Wound, vascular lesion, surgery, local infection	Trauma, surgery, cutaneous lesion, burn, erysipelas, varicella	Non penetrating trauma, limb crushing, im. injection, sepsis	Trauma, surgery	Wound, surgery	Surgery	Prior local lesions, perirectal lesions	Trauma, surgery	Trauma, surgery, muscle strain
Risk factors	Diabetes mellitus	Vascular disease	Immunosuppression	Immunosupression	Diabetes mellitus		Diabetes mellitus	Immunosupresson	Immunosupression
Miocrobiology	Enterobacteraceae, Anaerobes, Streptococcus, Staphyloccocus	Group A Streptococcus, methicillin-resistant S. aureus (MRSA)	C. perfingens	C. albicans	C. perfingens, C. septicum	Staphylococcus aureus, microaerophilic streptococci, Enterobacteriaceae	Mixed aerobes and anaerobes	Pseudomonas aeruginosa	Group A Streptococcus
			C. septicum/Vibrio spp.	C. neoformans