Relationship between diversional stoma and mortality rate in Fournier's gangrene: a systematic review and meta-analysis

Purpose Fournier's gangrene (FG) is a rare potentially lethal necrotising infection of the perineum. While the gold standard management is early and aggressive surgical debridement, the evidence in the literature is unclear as to the role and outcomes of diversional stoma. Methods A systematic review was conducted to identify studies investigating the relationship between stoma formation and FG. Meta-analyses were performed using a random-effects model. Results Twenty-seven studies (n=1482) were included. There was no significant difference in disease severity scores between the stoma and no stoma groups. Mortality rate was significantly higher in patients who required diversional stoma (OR 1.71, 95% CI 1.13-2.59, p=0.01). Significantly more surgical procedures were performed on patients who underwent stoma formation, and the total hospital cost was also higher in this group. This study may have been limited by bias in patients with more fulminant course or sphincter damage requiring stoma as a medical necessity. Conclusion These findings suggest that the use of diversional stoma in FG is a predictor of poor outcomes. This study demonstrated that mortality rate remained high and a diversional stoma did not reduce risk of mortality as suggested by smaller case series. Its use should therefore be individualised based on disease severity and sphincter damage.