Management of Fournier’s gangrene with skin grafting by bagging technique of testes: case report

iprs000128 10.3205/iprs000128 urn:nbn:de:0183-iprs0001287 Case Report Management of Fournier’s gangrene with skin grafting by bagging technique of testes: case report AlShehri AlShehri Yasir Ali YA

Department of Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, Phone: +966508033758Department of Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

Yasir-alshehri@hotmail.com author AlBurshaid AlBurshaid Hiba H

Department of Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

author AlBassam AlBassam Layan L

Department of Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

author AlMutairi AlMutairi Khalid K

Department of Plastic Surgery and Burn Unit, King Fahad Military Medical Complex, Dammam, Saudi Arabia

author German Medical Science GMS Publishing House

Düsseldorf

610 fournier bagging technique testes gangrene skin graft 20190204 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2193-8091 8 GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW GMS Interdiscip Plast Reconstr Surg DGPW 02 Aim: To share our experience with the management of Fournier gangrene (FG) using the bagging technique of the testes, and to highlight the importance of implementing a multidisciplinary approach in managing FG. Case presentation: A 58-year-old male with type 2 diabetes mellitus (DM) was brought to the emergency department (ED) with necrotizing fasciitis involving the genitalia; he was managed in the ED with Intravenous</PlainText></TextGroup> (IV) fluid resuscitation and IV antibiotics. The surgical team was consulted and multiple debridement procedures were done. Healthy granulation tissue was formed within one month of the serial debridement. A split-thickness skin graft using bagging technique of the testes and vacuum-assisted closure (VAC) were applied. The patient was reassessed one year following presentation, and a result with a near normal appearance was achieved with complete preservation of functional outcome.</Pgraph><Pgraph><Mark1>Conclusion:</Mark1> FG is a type of necrotizing fasciitis that could be managed either conservatively with IV antibiotics and/or hyperbaric oxygen, or surgically by debridement and applying VAC.</Pgraph><Pgraph>In our case, the testes were debrided and bagging technique of the testes was used. It’s believed that with this technique, the overall cosmetic and functional results are superior.</Pgraph></Abstract> <TextBlock linked="yes" name="Introduction"> <MainHeadline>Introduction</MainHeadline><Pgraph>Necrotizing fasciitis (NF) is a life-threatening condition that’s caused by toxin-producing bacteria and affects the fascia <TextLink reference="1"></TextLink>. One type of NF is Fournier gangrene, which mainly involves the inguinal and genital area <TextLink reference="2"></TextLink>. Jean Fournier, a dermatologist and venereologist, first described FG clinically in the late 1800s. He described it as an idiopathic fulminant gangrene of males’ inguinal and genital region that occurs rapidly and progressively <TextLink reference="3"></TextLink>. This rare and fatal infection, which mostly affects immunocompromised individuals, is a result of both aerobic and anaerobic bacteria <TextLink reference="2"></TextLink>, <TextLink reference="3"></TextLink>. Yilmazlar et al. found that Escherichia Coli was the most commonly identified microorganism in these cases <TextLink reference="4"></TextLink>. Early diagnosis, antibiotic treatment, surgical debridement and reconstruction of the affected area are the main aspects of managing this condition <TextLink reference="5"></TextLink>. In addition to these main steps, bagging technique of the testes was done, in which both testes were covered together with a split-thickness skin graft. With this technique, a near normal appearance and a complete functional outcome were achieved. </Pgraph></TextBlock> <TextBlock linked="yes" name="Case presentation"> <MainHeadline>Case presentation</MainHeadline><Pgraph>A 58-year-old male who is known to have type 2 diabetes mellitus (DM) presented to the emergency department (ED) with fever, vomiting, scrotal pain and swelling. After being thoroughly evaluated in the ED, the patient was clinically diagnosed with Fournier’s gangrene. Intravenous (IV) fluid resuscitation was initiated, IV antibiotics were given, and the surgical team (including urology and plastic surgery) was consulted.</Pgraph><Pgraph>The patient was shifted to the operating room (OR) where debridement was done by urology team (Figure 1 <ImgLink imgNo="1" imgType="figure"/>). The testes were temporarily relocated to the anteromedial side of the thighs in order to achieve an optimum scrotal wound closure (Figure 2 <ImgLink imgNo="2" imgType="figure"/>).</Pgraph><Pgraph>Following that, he underwent surgical debridement of the scrotum and penis four times, and vacuum-assisted closure (VAC) was applied to enhance wound healing (Figure 3 <ImgLink imgNo="3" imgType="figure"/>).</Pgraph><Pgraph>A healthy granulation tissue was formed over the wound within one month of serial debridement. Repositioning of the testes to their natural position was done and they were both sutured together by absorbable sutures. A split-thickness skin graft was used in three units to reconstruct the defect in the penis and inguinal area. The bagging technique was done by harvesting the skin from the back and was applied from the base of the penis and brought into the frontal part of it. The testes were approximated at the midline and were attached together with small sutures (Figure 4 <ImgLink imgNo="4" imgType="figure"/>).</Pgraph><Pgraph>After that, a mini abdominoplasty was done to the patient for a more enhanced shape and satisfactory result. A near normal appearance and satisfac<TextGroup><PlainText>tory</PlainText></TextGroup> result was achieved after two months and patient was discharged home with good urological and sexual function <TextGroup><PlainText>(Figure 5 </PlainText></TextGroup><ImgLink imgNo="5" imgType="figure"/>). The patient was reassessed one year following the surgery and was satisfied and with no complications.</Pgraph></TextBlock> <TextBlock linked="yes" name="Discussion"> <MainHeadline>Discussion</MainHeadline><Pgraph>FG is known to be a type of necrotizing fasciitis that affects the external genitalia, including the penis and scrotum of immunocompromised individuals <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>.</Pgraph><Pgraph>FG has many predisposing factors, the most common one being diabetes mellitus with an incidence of 46–76.9% <TextLink reference="7"></TextLink>. Other factors that may contribute to the condition include alcoholism, malignancy, obesity and extremes of age <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>.</Pgraph><Pgraph>Fournier’s gangrene is believed to be polymicrobial in origin, caused by both aerobic and anaerobic organisms that invade the area through skin abrasions caused by trauma or ulceration. This, along with the favorable environment for bacteria to grow that is found in high-risk individuals all contribute to the emergence of the disease <TextLink reference="8"></TextLink>.</Pgraph><Pgraph>In the majority of reported cases, there are underlying causes that may trigger FG including anal abscesses or trauma caused by a certain medical interventions to the scrotum or perineum <TextLink reference="9"></TextLink>. However, in our case no cause was found. </Pgraph><Pgraph>Despite advances in the medical field, the mortality rate of FG remains as high as 67%; thus, proper management steps should be carefully followed <TextLink reference="7"></TextLink>. Early recognition and diagnosis, aggressive antibiotic administration, fluid resuscitation, extensive surgical debridement are all important determinants of the outcome <TextLink reference="3"></TextLink>, <TextLink reference="7"></TextLink>. Today, the gold standard therapy for fournier’s gangrene is early and complete surgical debridement <TextLink reference="10"></TextLink>. Defects where large areas of tissue are lost necessitate reconstruction of the region by skin grafts or flaps <TextLink reference="5"></TextLink>. Other treatment modalities include hyperbaric oxygen (HBO) therapy <TextLink reference="11"></TextLink>, which is a widely accepted method that may help in the management of severe cases. Wound healing may be accelerated by using urinary and fecal diversion techniques <TextLink reference="12"></TextLink>.</Pgraph></TextBlock> <TextBlock linked="yes" name="Conclusion"> <MainHeadline>Conclusion</MainHeadline><Pgraph>Fournier’s gangrene is known to be a surgical emergency <TextLink reference="13"></TextLink>. One of the important risk factors leading to this condition is Diabetes Mellitus <TextLink reference="14"></TextLink>. Management of FG includes administration of IV antibiotics, fluid resuscitation and prompt surgical debridement and reconstruction by either skin flaps or grafts <TextLink reference="15"></TextLink>. Hyperbaric oxygen (HBO) therapy <TextLink reference="11"></TextLink> has proven beneficial in managing severe cases. Acceleration of wound healing may be achieved by diversion of urine and feces away from the affected area <TextLink reference="12"></TextLink>. In our case, skin grafts were applied using the bagging technique of the testes, which resulted in a satisfactory cosmetic and functional result.</Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph><SubHeadline>Ethical statement</SubHeadline><Pgraph><UnorderedList><ListItem level="1">Ethical approval: Ethical approval for this study was obtained from the responsible ethics committee.</ListItem><ListItem level="1">Informed consent: Informed consent was obtained from all individual participants included in the study.</ListItem></UnorderedList></Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Green RJ</RefAuthor> <RefAuthor>Dafoe DC</RefAuthor> <RefAuthor>Raffin TA</RefAuthor> <RefTitle>Necrotizing fasciitis</RefTitle> <RefYear>1996</RefYear> <RefJournal>Chest</RefJournal> <RefPage>219-29</RefPage> <RefTotal>Green RJ, Dafoe DC, Raffin TA. Necrotizing fasciitis. Chest. 1996 Jul;110(1):219-29. DOI: 10.1378/chest.110.1.219</RefTotal> <RefLink>http://dx.doi.org/10.1378/chest.110.1.219</RefLink> </Reference> <Reference refNo="2"> <RefAuthor>Thwaini A</RefAuthor> <RefAuthor>Khan A</RefAuthor> <RefAuthor>Malik A</RefAuthor> <RefAuthor>Cherian J</RefAuthor> <RefAuthor>Barua J</RefAuthor> <RefAuthor>Shergill I</RefAuthor> <RefAuthor>Mammen K</RefAuthor> <RefTitle>Fournier's gangrene and its emergency management</RefTitle> <RefYear>2006</RefYear> <RefJournal>Postgrad Med J</RefJournal> <RefPage>516-9</RefPage> <RefTotal>Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, Mammen K. Fournier's gangrene and its emergency management. Postgrad Med J. 2006 Aug;82(970):516-9. DOI: 10.1136/pgmj.2005.042069</RefTotal> <RefLink>http://dx.doi.org/10.1136/pgmj.2005.042069</RefLink> </Reference> <Reference refNo="3"> <RefAuthor>Heiner JD</RefAuthor> <RefAuthor>Eng KD</RefAuthor> <RefAuthor>Bialowas TA</RefAuthor> <RefAuthor>Devita D</RefAuthor> <RefTitle>Fournier's Gangrene due to Masturbation in an Otherwise Healthy Male</RefTitle> <RefYear>2012</RefYear> <RefJournal>Case Rep Emerg Med</RefJournal> <RefPage>154025</RefPage> <RefTotal>Heiner JD, Eng KD, Bialowas TA, Devita D. Fournier's Gangrene due to Masturbation in an Otherwise Healthy Male. Case Rep Emerg Med. 2012;2012:154025. DOI: 10.1155/2012/154025</RefTotal> <RefLink>http://dx.doi.org/10.1155/2012/154025</RefLink> </Reference> <Reference refNo="4"> <RefAuthor>Yilmazlar T</RefAuthor> <RefAuthor>Gulcu B</RefAuthor> <RefAuthor>Isik O</RefAuthor> <RefAuthor>Ozturk E</RefAuthor> <RefTitle>Microbiological aspects of Fournier's gangrene</RefTitle> <RefYear>2017</RefYear> <RefJournal>Int J Surg</RefJournal> <RefPage>135-8</RefPage> <RefTotal>Yilmazlar T, Gulcu B, Isik O, Ozturk E. Microbiological aspects of Fournier's gangrene. Int J Surg. 2017 Apr;40:135-8. DOI: 10.1016/j.ijsu.2017.02.067</RefTotal> <RefLink>http://dx.doi.org/10.1016/j.ijsu.2017.02.067</RefLink> </Reference> <Reference refNo="5"> <RefAuthor>Nickel JC</RefAuthor> <RefAuthor>Morales A</RefAuthor> <RefTitle>Necrotizing fasciitis of the male genitalia (Fournier's gangrene)</RefTitle> <RefYear>1983</RefYear> <RefJournal>Can Med Assoc J</RefJournal> <RefPage>445-8</RefPage> <RefTotal>Nickel JC, Morales A. Necrotizing fasciitis of the male genitalia (Fournier's gangrene). Can Med Assoc J. 1983 Sep 1;129(5):445-8. Available from: http://www.cmaj.ca/content/129/5/445</RefTotal> <RefLink>http://www.cmaj.ca/content/129/5/445</RefLink> </Reference> <Reference refNo="6"> <RefAuthor>Mallikarjuna MN</RefAuthor> <RefAuthor>Vijayakumar A</RefAuthor> <RefAuthor>Patil VS</RefAuthor> <RefAuthor>Shivswamy BS</RefAuthor> <RefTitle>Fournier's Gangrene: Current Practices</RefTitle> <RefYear>2012</RefYear> <RefJournal>ISRN Surg</RefJournal> <RefPage>942437</RefPage> <RefTotal>Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS. Fournier's Gangrene: Current Practices. ISRN Surg. 2012;2012:942437. DOI: 10.5402/2012/942437</RefTotal> <RefLink>http://dx.doi.org/10.5402/2012/942437</RefLink> </Reference> <Reference refNo="8"> <RefAuthor>Milović N</RefAuthor> <RefAuthor>Bancević V</RefAuthor> <RefAuthor>Campara Z</RefAuthor> <RefAuthor>Kosević B</RefAuthor> <RefAuthor>Zoranović U</RefAuthor> <RefTitle>Fournier's gangrene</RefTitle> <RefYear>2008</RefYear> <RefJournal>Vojnosanit Pregl</RefJournal> <RefPage>775-8</RefPage> <RefTotal>Milović N, Bancević V, Campara Z, Kosević B, Zoranović U. Fournier's gangrene. Vojnosanit Pregl. 2008 Oct;65(10):775-8. DOI: 10.2298/VSP0810775M</RefTotal> <RefLink>http://dx.doi.org/10.2298/VSP0810775M</RefLink> </Reference> <Reference refNo="9"> <RefAuthor>Chen Y</RefAuthor> <RefAuthor>Wang X</RefAuthor> <RefAuthor>Lin G</RefAuthor> <RefAuthor>Xiao R</RefAuthor> <RefTitle>Successful treatment following early recognition of a case of Fournier's scrotal gangrene after a perianal abscess debridement: a case report</RefTitle> <RefYear>2018</RefYear> <RefJournal>J Med Case Rep</RefJournal> <RefPage>193</RefPage> <RefTotal>Chen Y, Wang X, Lin G, Xiao R. Successful treatment following early recognition of a case of Fournier's scrotal gangrene after a perianal abscess debridement: a case report. J Med Case Rep. 2018 Jun 27;12(1):193. DOI: 10.1186/s13256-018-1697-9</RefTotal> <RefLink>http://dx.doi.org/10.1186/s13256-018-1697-9</RefLink> </Reference> <Reference refNo="7"> <RefAuthor>Norton KS</RefAuthor> <RefAuthor>Johnson LW</RefAuthor> <RefAuthor>Perry T</RefAuthor> <RefAuthor>Perry KH</RefAuthor> <RefAuthor>Sehon JK</RefAuthor> <RefAuthor>Zibari GB</RefAuthor> <RefTitle>Management of Fournier's gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment</RefTitle> <RefYear>2002</RefYear> <RefJournal>Am Surg</RefJournal> <RefPage>709-13</RefPage> <RefTotal>Norton KS, Johnson LW, Perry T, Perry KH, Sehon JK, Zibari GB. Management of Fournier's gangrene: an eleven year retrospective analysis of early recognition, diagnosis, and treatment. Am Surg. 2002 Aug;68(8):709-13.</RefTotal> </Reference> <Reference refNo="14"> <RefAuthor>Taken K</RefAuthor> <RefAuthor>Oncu MR</RefAuthor> <RefAuthor>Ergun M</RefAuthor> <RefAuthor>Eryilmaz R</RefAuthor> <RefAuthor>Demir CY</RefAuthor> <RefAuthor>Demir M</RefAuthor> <RefAuthor>Gunes M</RefAuthor> <RefTitle>Fournier's gangrene: Causes, presentation and survival of sixty-five patients</RefTitle> <RefYear>2016</RefYear> <RefJournal>Pak J Med Sci</RefJournal> <RefPage>746-50</RefPage> <RefTotal>Taken K, Oncu MR, Ergun M, Eryilmaz R, Demir CY, Demir M, Gunes M. Fournier's gangrene: Causes, presentation and survival of sixty-five patients. Pak J Med Sci. 2016 May-Jun;32(3):746-50. DOI: 10.12669/pjms.323.9798</RefTotal> <RefLink>http://dx.doi.org/10.12669/pjms.323.9798</RefLink> </Reference> <Reference refNo="10"> <RefAuthor>Pernetti R</RefAuthor> <RefAuthor>Palmieri F</RefAuthor> <RefAuthor>Sagrini E</RefAuthor> <RefAuthor>Negri M</RefAuthor> <RefAuthor>Morisi C</RefAuthor> <RefAuthor>Carbone A</RefAuthor> <RefAuthor>Bassi P</RefAuthor> <RefAuthor>Voce S</RefAuthor> <RefTitle>Fournier's gangrene: Clinical case and review of the literature</RefTitle> <RefYear>2016</RefYear> <RefJournal>Arch Ital Urol Androl</RefJournal> <RefPage>237-8</RefPage> <RefTotal>Pernetti R, Palmieri F, Sagrini E, Negri M, Morisi C, Carbone A, Bassi P, Voce S. Fournier's gangrene: Clinical case and review of the literature. Arch Ital Urol Androl. 2016 Oct;88(3):237-8. DOI: 10.4081/aiua.2016.3.237</RefTotal> <RefLink>http://dx.doi.org/10.4081/aiua.2016.3.237</RefLink> </Reference> <Reference refNo="16"> <RefAuthor>Rajan P</RefAuthor> <RefAuthor>Raza A</RefAuthor> <RefAuthor>Pemberton RJ</RefAuthor> <RefAuthor>Tolley DA</RefAuthor> <RefTitle>Testicular torsion following a skin graft for Fournier's gangrene</RefTitle> <RefYear>2009</RefYear> <RefJournal>Int J Clin Pract</RefJournal> <RefPage>176-7</RefPage> <RefTotal>Rajan P, Raza A, Pemberton RJ, Tolley DA. Testicular torsion following a skin graft for Fournier's gangrene. Int J Clin Pract. 2009 Jan;63(1):176-7. DOI: 10.1111/j.1742-1241.2005.00717.x</RefTotal> <RefLink>http://dx.doi.org/10.1111/j.1742-1241.2005.00717.x</RefLink> </Reference> <Reference refNo="13"> <RefAuthor>Hota PK</RefAuthor> <RefTitle>Fournier's Gangrene: Report of 2 Cases</RefTitle> <RefYear>2012</RefYear> <RefJournal>Case Rep Emerg Med</RefJournal> <RefPage>984195</RefPage> <RefTotal>Hota PK. Fournier's Gangrene: Report of 2 Cases. Case Rep Emerg Med. 2012;2012:984195. DOI: 10.1155/2012/984195</RefTotal> <RefLink>http://dx.doi.org/10.1155/2012/984195</RefLink> </Reference> <Reference refNo="15"> <RefAuthor>Karian LS</RefAuthor> <RefAuthor>Chung SY</RefAuthor> <RefAuthor>Lee ES</RefAuthor> <RefTitle>Reconstruction of Defects After Fournier Gangrene: A Systematic Review</RefTitle> <RefYear>2015</RefYear> <RefJournal>Eplasty</RefJournal> <RefPage>e18</RefPage> <RefTotal>Karian LS, Chung SY, Lee ES. Reconstruction of Defects After Fournier Gangrene: A Systematic Review. Eplasty. 2015 May 26;15:e18.</RefTotal> </Reference> <Reference refNo="11"> <RefAuthor>Sakalis V</RefAuthor> <RefAuthor>Giouris A</RefAuthor> <RefAuthor>Gkotsi A</RefAuthor> <RefAuthor>Papadopoulos A</RefAuthor> <RefAuthor>Kangas A</RefAuthor> <RefAuthor>Kipouros A</RefAuthor> <RefTitle>S112 is an early urinary and fecal diversion beneficial in patients presenting with fournier gangrene</RefTitle> <RefYear>2011</RefYear> <RefJournal>European Urology Supplements</RefJournal> <RefPage>601</RefPage> <RefTotal>Sakalis V, Giouris A, Gkotsi A, Papadopoulos A, Kangas A, Kipouros A. S112 is an early urinary and fecal diversion beneficial in patients presenting with fournier gangrene. European Urology Supplements. 2011 Okt;10(9):601. DOI: 10.1016/S1569-9056(11)61549-2</RefTotal> <RefLink>http://dx.doi.org/10.1016/S1569-9056(11)61549-2</RefLink> </Reference> <Reference refNo="12"> <RefAuthor>Milanese G</RefAuthor> <RefAuthor>Quaresima L</RefAuthor> <RefAuthor>Dellabella M</RefAuthor> <RefAuthor>Scalise A</RefAuthor> <RefAuthor>Di Benedetto GM</RefAuthor> <RefAuthor>Muzzonigro G</RefAuthor> <RefAuthor>Minardi D</RefAuthor> <RefTitle>A conservative approach to perineal Fournier's gangrene</RefTitle> <RefYear>2015</RefYear> <RefJournal>Arch Ital Urol Androl</RefJournal> <RefPage>28-32</RefPage> <RefTotal>Milanese G, Quaresima L, Dellabella M, Scalise A, Di Benedetto GM, Muzzonigro G, Minardi D. A conservative approach to perineal Fournier's gangrene. Arch Ital Urol Androl. 2015 Mar;87(1):28-32. DOI: 10.4081/aiua.2015.1.28</RefTotal> <RefLink>http://dx.doi.org/10.4081/aiua.2015.1.28</RefLink> </Reference> </References> <Media> <Tables> <NoOfTables>0</NoOfTables> </Tables> <Figures> <Figure format="png" height="263" width="356"> <MediaNo>3</MediaNo> <MediaID>3</MediaID> <Caption><Pgraph><Mark1>Figure 3: VAC was applied to aid formation of granulation tissue.</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="248" width="356"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Figure 1: Necrotic tissue of the genitalia was extensively debrided.</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="244" width="356"> <MediaNo>4</MediaNo> <MediaID>4</MediaID> <Caption><Pgraph><Mark1>Figure 4: Testes were approximated and the bagging technique was done using the skin graft.</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="239" width="356"> <MediaNo>2</MediaNo> <MediaID>2</MediaID> <Caption><Pgraph><Mark1>Figure 2: Testes were relocated in the anteromedial side of the thighs. Granulation tissue has been formed.</Mark1></Pgraph></Caption> </Figure> <Figure format="png" height="253" width="356"> <MediaNo>5</MediaNo> <MediaID>5</MediaID> <Caption><Pgraph><Mark1>Figure 5: Satisfactory healing and cosmetically near normal appearance was achieved after two months. </Mark1></Pgraph></Caption> </Figure> <NoOfPictures>5</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>