Predicting Mortality in Fournier Gangrene and Validating the Fournier Gangrene Severity Index: Our Experience with 50 Patients in a Tertiary Care Center in India.

OBJECTIVE: To identify factors that dictate morbidity and mortality in patients with Fournier's Gangrene and validate the Fournier gangrene severity index (FGSI). MATERIALS AND METHODS: We prospectively studied 50 patients with FG from January 2016 to December 2016 pertaining to their presenting signs, intraoperative findings, and postoperative wound management and outcome. We also checked the power of the FGSI to predict the outcome of the patients in terms of mortality. Receiver operating characteristic curve was used to determine the optimum cutoff of FGSI score to predict mortality. Principle component analysis was performed to check for the possibility of reduction in the number of factors included in the FGSI. RESULTS: The mean age at presentation was 53 ± 16 years with a mortality rate of 24%. Factors associated with mortality were increasing age (p = 0.0001), presence of diabetes (p = 0.002), bed-ridden status (p = 0.001), alcoholic liver disease (p = 0.005), altered international normalized ratio (p > 0.005), late presentation (p = 0.001), and a FGSI score of > 9 at admission (p = 0.004). The mean FGSI score among survivors was 4.39 ± 3.80 compared to 14.22 ± 3.93 among those who died. The area under the curve FGSI score to predict mortality at a cutoff of 9 was 0.961 (95% CI 0.910-1.000). CONCLUSION: Increasing age, diabetes, alcoholic liver disease, bed-ridden status, delayed hospital presentation, and an altered international normalized ratio at presentation are associated with higher mortality in FG. The FGSI at admission should be used to identify patients with serious prognosis requiring intensive care.

Laparoscopic parastomal hernia repair: A modified technique of mesh placement in Sugarbaker procedure.

INTRODUCTION: Conventional surgery for parastomal hernia entails primary suture repair or stoma relocation. Laparoscopic surgery has advantages of less pain, faster post-operative recovery and better cosmesis. While the Sugarbaker technique has been valued for least recurrences, however, it exposes the stomal loop to the parietal surface of the mesh exposing it to complications. We report a modification of mesh placement after primary defect repair to improvise the safety of meshplasty and to minimise mesh erosions into the stomal loop of bowel. PATIENTS AND METHODS: Patients with permanent stoma presenting with a parastomal bulge leading to difficulty with stoma care or abdominal distention or pain were included in the study. A pre-operative computed tomography scan was performed in all patients to rule out any recurrence of primary pathology for which stoma was created and to study the abdominal musculature and defects. RESULTS: Of 14 patients, 12 patients had end-sigmoid stoma, one had end ileostomy following surgery for ulcerative colitis and one had urinary conduit. The size of the defect varied from 4.5 cm to 6 cm in diameter, and the average duration of surgery was 125 min. Pain assessed on VAS score was higher in the first 12 h, and all were started on orals on the next day, and average hospital stay was 4.2 days. The longest follow-up of 7 years and shortest of 15 months did not reveal any complications as recurrence, seroma, mesh infections or erosions into the stoma. CONCLUSION: Modified placement of composite mesh is safe and helps in minimising mesh-related complications of the Sugarbaker technique for parastomal hernias.