Fournier’s gangrene (FG) is a rare, rapidly progressing necrotizing fasciitis that affects the perineum and external genitalia [1]. This severe polymicrobial infection spreads along the fascial plane, impacting adjacent soft tissues and leading to significant morbidity. FG is characterized by obliterative endarteritis and subcutaneous arterial thrombosis, resulting in gangrene of the subcutaneous tissue and overlying skin [2,3].

Despite its rarity, with a prevalence of less than 0.02% of all inpatient cases, FG is a critical condition that requires immediate medical attention [4]. It predominantly affects males at a ratio of 10:1 and is usually associated with immunocompromised states or other comorbidities, although it can also occur in healthy individuals [5]. Common symptoms include scrotal swelling, tachycardia, purulent drainage, crepitus, and fever, with additional clinical features such as palpable crepitus, purpura, bullae, and tissue discoloration [6,7].

Effective management of FG involves prompt surgical debridement to remove all dead, infected, and necrotic tissue, which is crucial for improving prognosis. Preparation of the wound bed is essential to promote proper healing, which includes managing non-vital tissue, controlling bacterial load, and managing exudate [8]. Vacuum-assisted closure (VAC) therapy has been shown to optimize wound healing by reducing inflammatory exudate, promoting granulation tissue, stimulating angiogenesis, and improving overall tissue formation. VAC therapy also offers practical benefits such as fewer dressing changes, reduced pain, greater mobility, decreased management time, and potentially shorter hospital stays [9,10].

Currently, research on the relationship between different types of wound care for FG patients and the length of hospital stay is limited [11]. Understanding these factors is vital as they directly influence patient outcomes, including mortality and overall recovery. Therefore, this study aims to compare the types of VAC and non-VAC wound care with the length of stay in FG patients treated at a tertiary hospital in Surabaya, Indonesia.

This was a cross-sectional study with a descriptive analytic design utilizing a retrospective design using secondary data. The study population consisted of patients with FG treated by the plastic reconstructive and aesthetic surgery department at a tertiary hospital in Surabaya, Indonesia from May 2017 to April 2021.

Inclusion criteria encompassed patients diagnosed with FG, regardless of comorbidities, who received either VAC or non-VAC wound care methods. Patients not meeting these criteria were excluded. FG was defined as necrotizing fasciitis affecting both deep and superficial tissues, characterized by clinical symptoms such as numbness, redness, swelling of the perineum, scrotum, and genitals, along with systemic symptoms such as fever, chills, urinary retention, and weakness.

The treatment protocols involved a systematic assessment of each patient’s wound using the TIMERS framework (tissue management, infection and inflammation control, moisture balance, edge of wound advancement, regeneration, and social factors). This method ensured that the chosen wound care approach—whether VAC or non-VAC—was tailored to the specific needs of the wound at that time. VAC treatment applied intermittent or continuous negative pressure to create an optimal moist environment for healing, while non-VAC treatment involved the use of hydrogel, absorbent dressings, or tulle, depending on the wound’s characteristics (Fig. 1). Data collected included patient age, comorbidities, microbiology results, type of reconstructive surgery performed, wound care method (VAC or non-VAC), and length of hospital stay. The length of stay was evaluated from the time of admission until discharge, whether the patient survived or not. These data were analyzed to assess the outcomes of different wound care methods, focusing particularly on the length of hospital stay. In this study, all participants provided written informed consent. The study protocol was approved by the Ethics Committee of Soetomo General Hospital (2357/108/VIII/2023).

Secondary data obtained from medical records covering the period from May 2017 to April 2021 were analyzed. Based on these findings, it was found that 12 patients had been admitted with FG who were treated by the plastic reconstructive and aesthetic surgery department. Total sampling was done on these 12 patients. During admission, the patients’ wound conditions were assessed first, then wound care was provided according to each patient’s wound condition. The length of hospital stay was evaluated from the time the patient was admitted until discharge from the hospital, whether in a living or deceased condition.

The majority of the patients (66.7%) were in the 16- to 60-year age group, while the remaining patients were over 60 years old. The mean age of the patients was 50.25 years. In terms of comorbidities, diabetes mellitus was the most prevalent, affecting 83.2% of the patients. Other significant comorbidities included hypertension and hepatitis. These underlying conditions likely contributed to the severity and management complexity of FG in these patients (Table 1).

Wound care methods varied among the patients. A total of 83.2% of the patients received VAC therapy, which is known for its benefits in promoting wound healing through negative pressure. The remaining patients were treated with non-VAC methods, including hydrogel, absorbent dressings, or tulle. When analyzing the types of surgical interventions performed, we found that 50.0% of the patients underwent flap advancement, 33.3% underwent bilateral medial thigh flap procedures, and the remaining patients received skin grafts. These surgical approaches were chosen based on the extent of the tissue damage and the overall condition of the patients.

Regarding the length of hospital stay, the data showed a mean hospitalization period of 40.5 days. Statistical analysis indicated that the data were not normally distributed (P=0.03). As a result, we used the Mann-Whitney U test to analyze the correlation between the type of wound treatment and the length of hospital stay. The analysis revealed that there was no significant relationship between the type of wound treatment (VAC or non-VAC) and the length of hospital stay for patients with FG (P=0.283) (Table 2).

Our study offers observations on the demographic and clinical characteristics, as well as treatment approaches, in a small cohort of patients diagnosed with FG at a single tertiary hospital in Surabaya, Indonesia. The majority of our patients were aged between 16 and 60 years, with diabetes mellitus identified as the most common comorbidity, affecting 83.2% of the cohort. The high incidence of diabetes among FG patients aligns with existing literature, which identifies diabetes as a major risk factor due to its impact on immune function and wound healing capacity. This emphasizes the importance of managing underlying comorbidities in patients with FG to improve their overall prognosis [12,13].

The wound care methods employed in this study included both VAC therapy and non-VAC treatments such as hydrogel, absorbent dressings, or tulle. VAC therapy is recognized for its ability to accelerate wound healing through negative pressure, with 83.2% of our patients receiving this treatment. The remaining patients were managed with non-VAC methods, highlighting the variability in clinical practice and resource availability. Surgical interventions also varied, with half of the patients undergoing flap advancement procedures, followed by bilateral medial thigh flap and skin grafts, chosen based on the extent of tissue damage and patient condition. These findings underscore the necessity for individualized treatment plans tailored to the specific needs and conditions of each patient [14].

One of the key findings of our study was the lack of a significant correlation between the type of wound treatment (VAC or non-VAC) and the length of hospital stay, which averaged 40.5 days. The statistical analysis using the Mann-Whitney U test indicated that factors other than wound care method might play a more critical role in determining the duration of hospitalization. These could include the severity of the infection at presentation, the presence of comorbidities, and the timing of surgical intervention. This finding suggests that while wound care is crucial, a multifaceted approach addressing all aspects of patient health is necessary for improving outcomes in FG patients [15].

Our results are consistent with previous studies that have also failed to find a significant difference in hospital stay duration based on wound care methods. For instance, a study by Vuruskan et al. [16] found that while VAC therapy offered some advantages in wound healing efficiency, it did not significantly reduce the length of hospital stay compared to traditional wound care methods. This could be due to the complex and multifactorial nature of FG, where factors such as early diagnosis, prompt surgical intervention, and comprehensive management of comorbid conditions are critical determinants of patient outcomes [17,18].

In cases of FG, applying VAC therapy can indeed be challenging due to the presence of active infections and the anatomical complexities involved. Despite these challenges, we employed the TIMERS framework to guide our wound care management, which provided a structured approach to addressing these difficulties. Managing infection and inflammation (the “I” in TIMERS) is particularly critical in FG. We acknowledged the need for controlling bioburden through appropriate antimicrobial treatments and regular debridement before initiating VAC therapy. While systemic antibiotics were often necessary, posing additional challenges such as resistance, we managed to integrate VAC therapy effectively when feasible. When VAC was not appropriate, non-VAC methods were employed, ensuring adherence to the TIMERS principles of wound care. This approach allowed us to optimize wound healing outcomes even in the face of significant clinical challenges.

Our study has several limitations, including the small sample size from a single tertiary hospital, which limits statistical power and limits generalizability. The retrospective design and lack of detailed recovery data may not fully capture treatment efficacy. Additionally, challenges associated with the use of VAC therapy—such as active infection and anatomic constraints—were not fully addressed. Despite these limitations, we hope to provide additional insights into the management of FG. Future research should include larger, multicenter studies to increase generalizability and include comprehensive data on patient recovery and complications. Examination of infection management practices, timing of intervention, and the impact of multidrug-resistant organisms would provide a more nuanced understanding of factors influencing hospitalization and patient outcomes.

In conclusion, there was no correlation found between VAC wound care and the length of hospital stay in FG patients treated at a tertiary hospital in Surabaya, Indonesia. Similarly, there was also no correlation observed between non-VAC wound care and the length of hospital stay. These results suggest that factors beyond wound care methods, such as comorbidities and infection severity, play crucial roles in determining patient outcomes. Further research with larger cohorts is needed to explore these additional factors.