ORIGINAL ARTICLE
Management of adult patients with buttock and perineal burns: The Ross Tilley Burn Centre experience Nishant Merchant, MD, David Boudana, MD, L Willoughby, MD, JJ Lin, MS, Sarah Rehou, MS, Shahriar Shahrokhi, MD, and Marc G. Jeschke, MD, PhD, Toronto, Ontario, Canada
Perineal and buttock burns are challenging wounds to heal for several reasons because of the contamination risk and shear stress that is always present. Because of the nature of the wound bed, pathogens can have ready access to create systemic infections and complications. Prolonged healing times also delay the recovery for patients and add to their discomfort and psychological stress from the injury. The ideal treatment approach is not well defined, and the aims of this study were to conduct a literature review of current treatment suggestions and to look at our own patient population to determine how our center treated these challenging patients. METHODS: This is a retrospective review of all patients treated between 2010 and 2013 at our center. Patients that received care for burns to the perineum or buttocks were evaluated. Mortalities within 24 hours of admission and transfers before completion of their care were excluded. All patients older than 18 years were included in the study. The primary outcome studied was a cause for graft revision. Secondary outcomes included benefits and risks of fecal management devices, risk of infection, and mortality. RESULTS: The literature review did not show consensus on how to best manage this patient population. Our results however demonstrated that patients treated with the fecal management device Flexi-seal (Convatec, Skillman, NJ) were at increased risk of developing an infection involving an enteric pathogen and requiring revision procedures. The patient population that was treated with this device was also older and had larger burns. The patients within this group that were treated initially with allograft required fewer revisions when compared with patients that received autograft in this group (23% vs. 34%, p 9 0.05). CONCLUSION: After our data and the literature had been reviewed, the lack of evidence-based treatment protocols led us to create recommendations for burn surgeons with regard to the initial management of this complicated area. Certain key features include avoiding autograft at the primary excision if they have an increased revised Baux score and minimizing the amount of liquid stool contaminating the wound bed to increase success. (J Trauma Acute Care Surg. 2014;77: 640Y648. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level IV. Therapeutic study, level V. KEY WORDS: Burn; ileus; ostomy; morbidity; mortality. BACKGROUND:
B
urns to the perineum occur infrequently, with an incidence as low as 1.2% in the US pediatric population1 to 20% in Japanese adults;2Y6 however, they are quite difficult to manage. Perineal burns rarely occur in isolation1,7,8 and are typically caused by flame or scald injuries.1,4,5,8Y13 The perineum is fairly protected such that the total burns usually exceed this area. Studies have shown that nearly one third of patients with perineal injuries can die in the first 48 hours and that their overall mortality can be 25% to 50%,4Y6,14,15 which is why it is important to have a management plan to minimize complications and a protracted course.16 The management of burns to this region is complicated because of the contours of the surrounding tissue, constant bacterial contamination, and repetitive stress from activity.9Y11,13 Separate from the challenges faced by physicians in managing Submitted: November 15, 2013, Revised: May 28, 2014, Accepted: May 30, 2014. From the Division of Plastic Surgery, Departments of Surgery and Immunology, University of Toronto; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre; and Sunnybrook Research Institute, Toronto, Ontario, Canada. Address for reprints: Marc G. Jeschke, MD, PhD, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre; Division of Plastic Surgery, Department of Surgery, Department of Immunology, University of Toronto; Sunnybrook Research Institute, 2075 Bayview Ave, Rm D704, Toronto, ON, Canada, M4N 3 M5; email: [email protected]. DOI: 10.1097/TA.0000000000000405
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these wounds, they also decrease patients’ mobility, control over self, self-esteem, and self-image.14,17 Nearly 50 ago, Espinar18 suggested colostomy for deep wounds, especially when involving the anus.17 Ever since then, controversy remains regarding the need for diversion, with Weiler-Mithoff et al.15 stating little need for fecal diversion1 and Quarmby et al.19 describing the benefits of diversion.2Y6 To date, there is no consensus on a treatment regimen. Much of the difficulty is the scarcity and quality of the evidence (Class B and C at best). There is some agreement that severe anal burns benefit from surgical diversion and many of these wounds fared well with adequate wound care.1,2,15,16,19,20 A possible intermediary to surgical diversion is fecal management devices (FMDs), but the evidence is limited to small studies or surveys.6,9,16,21 Therefore, we retrospectively evaluated our experience to garner more information. At our institution, a mix of surgical and nonsurgical diversion methods as well as management without diversion was used. We combined the results of the literature review and our institutional experience to develop recommendations for the management of the perineal and buttock burns.
PATIENTS AND METHODS All adults consecutively admitted to our institution between 2010 and 2013 were retrospectively reviewed for buttock J Trauma Acute Care Surg Volume 77, Number 4
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and perineal burn wounds. They were stratified according to the initial method used to treat their wounds, total body surface area (TBS) involved, and diversion method to better understand the treatment options. Additional data were collected regarding their demographics, rate of infection, the day of the first bowel movement after admission, and rate of wound care failure (measured as failure of original treatment option). Patients that were transferred after the initiation of care or before completion of their care were excluded. The primary outcome was to identify patients that failed their initial treatment plan. Secondary outcomes were to understand the rate of infection, complications secondary to FMD, and mortality caused by enteric pathogen sepsis. Descriptive statistics were calculated for demographic variables. Statistical methods such as Student’s t test, W2 test, Fisher exact test (two-sided), Mann-Whitney U-test, and KruskalWallis test were used where appropriate. A Kaplan-Meier survival analysis and a log-rank test were also used. Normally distributed data are presented as mean T SEM. Nonnormally distributed data are presented as median and interquartile range (IQR). A twotailed p G 0.05 was accepted as significant.
treated without diversion (29 patients) or with the Flexi-seal system (Convatec, Skillman, NJ) (27 patients). The baseline patient and injury characteristics are presented in Table 1. The patients that were managed with a diversion method had significantly more severe burns overall and to the perineum.
Primary Procedure A total of 38 patients underwent a primary surgical procedure. Thirteen patients underwent primary excision and allograft placement, 6 patients received temporary coverage with Biobrane (Smith & Nephew, London, UK), 1 patient had excision only, and 18 patients were autografted at the first excision. Eleven patients (29%) required a revision procedure before discharge (Table 2). When comparing autograft versus allograft coverage after primary excision, there were no significant differences regarding the rate of revision or infection. A greater fraction of the patients receiving allograft were treated with an FMD, but the difference in the use rate was not significant. The device was placed earlier for allograft patients compared with the autograft group, without significant effects on outcomes (Table 3).
Revision Procedures
RESULTS Our institution admitted 74 patients that sustained a perineal or buttock burn. Thirteen patients were excluded; 1 was transferred before the completion of the treatment course, and 12 survived less than 24 hours. The patients’ mean age was 50.8 T 20.1 years. Median total TBS was 26.35% (IQR, 41.25%), of which 10.5% (IQR, 43.63%) was third-degree burns. Median buttock TBS was 2% (IQR, 4%), and 0% (IQR, 3.63%) was third degree. Median genital TBS was 0% (IQR, 1%), and coinciding portion was third degree. Average hospital stay for all patients was 21 days (IQR, 31) days.
Patients that received treatment with an FMD seem to be at greatest risk of requiring additional procedures. These data did not reach significance when compared with the patients treated for equal-size burns without Flexi-seal diversion, but the absolute values showed a tendency for failure in the diverted group. Only one patient that was managed without a Flexi-seal, TBS of greater than 40%, underwent a revision procedure. Patients receiving split-thickness grafts during the first procedure showed a risk of increased revision. The allograft group had fewer overall revisions, but also had half the patients compared with the autograft group (Table 2).
Diversion Method
Mortality
Of the remaining 61 patients, only 5 underwent ostomy procedures. Three patients received a diverting ostomy for wound care purposes; two (a loop colostomy and ileostomy) were preemptive, and another loop ileostomy was created after failed treatment. Two patients received ostomies (end-ileostomy and sigmoid colostomy) for intestinal perforation. Two ostomies were closed at 8 months and 14.5 months. At present, there are no known complications of the ostomy. The remaining patients were
There were 19 mortalities (25%) in the group. Of the 19 patients, 12 died within 24 hours of admission. Of the seven patients that survived greater than 24 hours, four underwent excision and Biobrane application, one underwent excision of wounds, and two patient were excised and autografted during the first operation. All of the late mortalities occurred in patients with greater than 21% TBS, and the majority of these patients were also much older. Neither the use of Flexi-seal nor
TABLE 1. Patient Demographics Excluding the 13 Patients That Either Died in Less Than 24 Hours or Were Transferred in the Middle of Their Treatment Course Variable
Diversion Method
Sex , male Age, y Third-degree TBS, % Total TBS, % Third-degree buttock TBS, % Total buttock TBS, % Third-degree genital TBS, % Total genital TBS, %
None (n = 29)
Flexi-seal (n = 27)
Ostomy (n = 5)
p
72% (21) 44.48 T 3.32 0 (4.5) 13.5 (20) 0 (0) 1 (2) 0 (0) 0 (0.5)
52% (14) 52.54 T 4.33 20 (34.5) 29.5 (32.25) 1.5 (3.25) 2.5 (3.75) 0 (0) 0 (0.75)
60% (3) 44.38 T 8.85 6 (15.75) 19 (12.5) 0 (1.25) 2.5 (2.25) 0 (0) 0 (0)
0.282 0.381 0.009 0.035 0.019 0.143 0.043 0.505
Data are presented as median and IQR. Age is presented as mean T SEM. p value calculated based on mean and SEM.
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641
642 67% (2) 54.6 T 18.1 3.5 (3.5) 3.5 (2.75) 2.5 (1.75) 3 (1.25) 0 (0) 0 (0.5) 30 (8.5) 100% (3) 2 (0.5) 1.5 (0.5) 1 (0) 0 33% (1) 0 0 0 67% (2) 2 (0.5) 3 (3.5) 0 (0.5) 67% (2) 67% (2)
Flexi-seal (n = 3)
TBS 0Y10%
0.19 0.68 0.16 0.36 0.09 0.03 N/A 0.77 0.006 0.006 0.003 0.09 0.12 N/A 0.71 N/A 0.05 N/A 0.19 0.86 N/A N/A N/A 0.05
p 20% (1) 59.8 T 10.2 5.5 (4.5) 12.5 (3) 0 (0) 4 (5) 0 (0) 0 (0) 26 (15) 60% (3) 2 (0.5) 1 (0) 1 (0) 0 40% (2) 0 0 0 60% (3) 2 (0) 4 (5) 0 (2) 40% (2) 20% (1)
Flexi-seal (n = 5)
TBS 11Y20%
0 35.4 T 5.8 0 (0.75) 16.5 (2.75) 0 (0) 4 (2.25) 0 (0) 0 (0) 23 (8.5) 50% (1) 1 (0) 0 (0) 1 (0) 0 0 0 100% (2) 0 0 1 (1) N/A N/A N/A 0
None (n = 2)
Age is presented as mean T SEM, and the remaining data points are presented as median (IQR). Significance p G 0.05 in bold. STSG, split-thickness skin graft; N/A, not applicable.
79% (11) 44.2 T 5.3 0 (0.75) 6.5 (3.75) 0 (0) 0 (0.75) 0 (0) 0.25 (0.5) 12 (8.5) 7% (1) 0 (0) 0 (0) 0 (0) 0 7% (1) 0 71% (10) 0 21% (3) 2 (2.5) N/A N/A N/A 0
None (n = 14)
Patient Demographics Based on Percent TBS Burned
Sex, male Age, y Third-degree TBS, % Total TBS, % Third-degree buttock TBS, % Total buttock TBS, % Third-degree genital TBS, % Total genital TBS, % Length of stay, d Organism present No. organisms Gram positive Gram negative Mortality (after 24 h) First operation Allograft Biobrane Daily wound care Excision only Meshed STSG Bowel movement (hospital day) Insertion (hospital day) Postoperative, d Reinserted Revision
Variable
TABLE 2.
1 0.38 0.19 0.57 1 0.57 N/A 1 0.57 0.81 0.57 0.38 0.38 N/A 0.89 N/A 0.07 N/A 0.55 1 N/A N/A N/A 0.50
p 56% (5) 67.8 T 5.6 20.5 (9.38) 26.75 (9.69) 2 (2.75) 2 (2.13) 0 (0) 0.13 (0.5) 41.5 (33.25) 89% (8) 3 (1.5) 1 (0) 1.5 (2) 22% (2) 44% (4) 11% (1) 11% (1) 0 33% (3) 2.5 (2.75) 7.5 (10.5) 4.5 (7.75) 22% (2) 38% (3)
Flexi-seal (n = 9)
TBS 21Y40%
78% (7) 49.0 T 6.1 4.5 (27) 26.75 (9.45) 0 (0.75) 1.75 (1.63) 0 (0) 0 (0) 19 (11.25) 45% (4) 1 (0.25) 1 (0) 1 (0.5) 33% (3) 0 33% (3) 33% (3) 11% (1) 22% (2) 4 (3) N/A N/A N/A 0
None (n = 9) 0.34 0.040 0.16 0.44 0.19 0.93 0.73 0.44 0.011 0.046 0.008 0.11 0.031 0.60 0.09 0.57 0.57 0.30 0.60 0.48 N/A N/A N/A 0.12
p
75% (3) 39.7 T 7.3 38.25 (20.63) 47.25 (6.88) 1.25 (1.38) 1.75 (2.13) 0 (0) 0 (0.25) 20.5 (8) 75% (3) 1 (1) 0 (0) 1 (1) 25% (1) 25% (1) 25% (1) 0 0 50% (2) 6.5 (1.5) N/A N/A N/A 25% (1)
None (n = 4)
80% (8) 34.6 T 3.9 47.25 (19.25) 59.75 (14.9) 1.75 (3.75) 2.5 (4.38) 0 (0) 0 (0.8) 72.5 (20.75) 90% (9) 2 (1) 1 (0) 2 (2) 0 40% (4) 10% (1) 10% (1) 0 40% (4) 3.5 (3.75) 7.5 (6.25) 5 (9) 44% (4) 44% (4)
Flexi-seal (n = 10)
TBS 9 40%
1 0.45 0.37 0.84 0.54 0.54 0.64 1 0.001 0.47 0.11 1 0.08 0.62 0.78 0.47 0.51 N/A 0.73 0.08 N/A N/A N/A 0.51
p
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TABLE 3. Patient Demographics Based on Comparison of Their Index Procedures and Outcomes Sex, male Age, mean T SEM Third-degree total TBS, median (IQR), % Total TBS, median (IQR), % Third-degree buttock TBS, median (IQR), % Total buttock TBS, median (IQR), % Third-degree genital TBS, median (IQR), % Total genital TBS, median (IQR), % Hospital stay, median (IQR), d Mortality (total) (Enteric organism) Blood Urine Sputum Wound Ostomy (patients) Revisions (patients) Flexi-seal use (patients) Hospital day insertion, median (IQR), d Inserted postoperatively (patients) Reinsertion (reason) (patients) First bowel movement, median (IQR), d
Allograft Patients (n = 13)
Autograft Patients (n = 23)
p G 0.05
7 52.6 T 19.5 20 (33.5) 31 (28) 1.5 (3) 2.5 (2.5) 0 (0) 0 (1) 41 (42) 0
12 45.9 T 21.7 10.5 (33.75) 21.88 (34.5) 0 (3.63) 1.5 (4) 0 (0) 0 (1) 34 (41.25) 2
0.92 0.31 0.90 0.72 0.85 0.58 0.40 0.87 0.84 0.53
Blood (5) Urine (3) Sputum (4) Wound (4) 2 3 11 4 (5) 6 4 (STSG protection) 2 (3)
Blood (4) Urine (6) Sputum (3) Wound (2) 3 8 13 3 (8.25) 8 5 (revision) 3 (3.25)
0.24 0.84 0.23 0.21 0.85 0.71 0.14 0.47 0.72 0.69 0.95
graft choice at the first operation significantly affected this outcome (Table 2). However, when comparing groups treated with an FMD versus no diversion, there was an absolute mortality difference but not significant at similar time points in the postburn period ( p = 0.065, Fig. 1).
Infections Infections with enteric organism identified in the bloodstream, urine, sputum, and wounds of the patients were noted to include Eschericha coli, Enterococcus, Enterobacter, Proteus mirabilis, and Klebsiella. Nearly half of the patients had an organism identified, but only four patients developed wound sepsis. When comparing groups with and without nonoperative diversion, there was an increased rate of infection with the use of a device ( p 9 0.05). However, this did not translate into a significantly greater rate of revision or mortality, but the relative rates of revision were greater in the device group (Table 2).
revisions or mortality. Rather, the size of their wounds and Pseudomonas septicaemia were the determinants of mortality. Compared with the wound management regimen that was used in the patients described earlier, most centers do not routinely treat patients with prophylactic antibiotics or provide daily whirlpool therapy that may further alter the flora around the perineum. Our patients did not receive empiric systemic antibiotics. We found a greater concentration of enteric pathogens growing from our wounds, although it did not seem to affect the revision or mortality rate significantly either.
Wound Shear Stress Shearing of the graft with activity and stool passage is of great concern postoperatively. To minimize this risk, some
DISCUSSION Difficulties With the Management of Perineal Burns Wound Contamination All burn wounds are at increased risk of developing an infection, secondary to a compromised barrier. Primarily, the organisms of concern, especially in the acute burn phase, are the gram-positive skin bacteria. However, given the proximity of the perineum to the gastrointestinal tract, gram-negative and anaerobic bacteria become increasingly more common. Rubis et al.10 were able to alter perineal flora, such that Pseudomonas aeruginosa and E. coli were the two most common organisms. They prophylactically treated wounds with antibiotics and daily whirlpool therapy. Interestingly, the organism did not impact
Figure 1. Kaplan-Meier curve of patients treated with a Flexi-seal for diversion versus no diversion (p = 0.065).
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authors significantly limit patient activity postoperatively. Weiler-Mithoff et al.15 placed patients on a 96-hour bed rest and severely limited activities for 4 weeks to 6 weeks. However, this poses its own consequences to the overall recovery and rehabilitation of the patient. Bowel movements are an essential part of maintaining physiologic functions, but stool passage deposits bacteria in the wound bed. Three options for stool passage are constipation, normal consistency, or liquid consistency. Constipation can increase the risk for perforation, sepsis, poor nutritional intake, or aspiration. Diarrhoea allows stool to permeate dressings and wounds more easily. Thus, soiling of the wound bed and mechanical stress from passing stool potentially destabilize a graft and its bed.
Management of Perineal Wounds Without Diversion For patients without diversion, wounds were protected from contamination and shear stress. Authors used rigorous cleansing/ dressing protocols, restricting bowel function, and/or prone positioning. Even the patients that required grafting tended to do well with appropriate wound care and critical care management.1 Thus, the authors recommended against the routine creation of a diverting ostomy.22 Simply having secure wound dressings can be adequate in a well-vascularized wound bed.15 Forced constipation and prone positioning are not frequently practiced at our center because patients and nurses often find it uncomfortable.11,14,23 Patients treated with an FMD were given cathartics; otherwise, they received stool softeners and promotility agents (Dulcolax) to maintain normal stool.
Wound Care for Nonoperative and Preoperative Wounds Fortunately, for patients who sustain superficial perineal burns, they can be managed nonoperatively with good results.5,12,24 In healthy individuals, these wounds heal within 3 weeks, assuming wound or systemic sepsis does not occur. To minimize this risk, patients receive aggressive wound care before excision. Multiple options are available for topical coverage, and many of the studies used various combinations along with whirlpool therapy to achieve their goal.8,10,19 As long as daily wound care is performed, the antimicrobial agent used has less importance as most combinations have been shown to be effective.
Wound Care in Postoperative Wounds Postoperative care varies primarily based on dressing management, positioning of the patient, and controlling bowel habits. Two general dressing concepts that improve postoperative wound care were effective barrier dressings and decreased contact time of the wound with stool. Bolster dressings better protected grafts and allowed for a secure but exchangeable method of wound care.11 Rubis et al.10 changed the dressing every 4 hours for 5 days to 7 days as opposed to using a bolster dressing in pediatric burn patients. This method used retention points with sutures and passing umbilical tape through them to secure a dressing and allow for easy exchange if they were soiledVsimilar to Montgomery straps for the abdomen. Frequent dressing changes are difficult to maintain because it consumes significant nursing resources, making it less feasible 644
in the current fiscal practice of medicine. If there was enough of a margin around the anus, we used negative pressure dressings with success. Once again, the main goal was to maintain secure dressings that left the graft immobile and clean and allowed for patient mobility. Further randomized studies are needed to see if the dressing choice makes a difference in treating this complicated area. Azmy et al.11 used constipation in the perioperative period to decrease stool exposure. Fecal passage was eliminated for 8 days to 10 days using Picolax/Neomycin/Flagyl/Phosphate Enema in the preoperative phase, with Imodium used postoperatively. Patients were kept on an elemental diet in the perioperative period. Good graft take was achieved without complication. Renz and Sherman25 evaluated 30 pediatric patients with an average burn size of 18.1%. The patients underwent bowel preparation, were given antibiotics, had an occlusive postoperative intrarectal catheter, were kept nil per os, or were positioned to minimize contamination of their wounds. Ten patients had complications secondary to diarrhoea. None of the above modalities effectively protected the autografts from stool, and eight patients developed an infection of their wounds. Four patients died of burn wound sepsis from a gram-positive bacteremia, which also had diarrheal stool consistency. Thus, the authors recommended early excision if the wounds were noted to have deep wound contamination. Another management method, as proposed by Potokar et al.,13 involved the administration of flucloxacillin or erythromycin to patients with isolated buttock burns. Patients with full-thickness burns underwent grafting between 1 week and 3 weeks after burn. All grafted patients were nursed prone or in the lateral decubitus position. They noted Pseudomonas and Methicillin-resistant Staphylococcus aureus infections in three of six patients, which caused significant graft compromise. There was no mention of enteric organisms creating complications. Thus, empiric antibiotics did not necessarily improve graft survival. With several options available to control fecal contamination of perineal burns, a simple option of maintaining normal stool is often overlooked. Rutan14 suggested several dietary modifications to maintain formed stool. The suggestions ranged from using soy or milk, less than 30% of daily calories from fat, supplementary vitamin A, early tube feed initiation, and recolonization of patients receiving antibiotics.
Management of Perineal Burns With Nonsurgical Diversion Fecal management systems were created to decrease contamination to the perineum by patients with limited mobility. These devices were adapted to facilitate healing in the burn population. Burn patients are faced with the challenge of maintaining bowel function and limited means of maintaining cleanliness secondary to pain, sedation, or restrictions on activity for wound healing purposes.7 Thus, the benefit of bypassing stool into a bag at bedside certainly has its benefits.6 Kement et al.6 avoided revision procedures in a population with an mean age of 43.1 years and mean TBS burn of 40.7%. One patient required a diverting colostomy due to delayed healing. Local infections were noted, but those three patients healed with conservative treatment. Anorectal complications * 2014 Lippincott Williams & Wilkins
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secondary to the Flexi-seal device were not mentioned. Keshava et al.21studied the Zassi bowel management system (Zassi, Fernandino Beach, FL), and the wounds remained clean because of the device. There was no mention of graft failure or sepsis. They also noted that none of the patients had mucosal injury from the tube being in place. Although FMD provides an alternative to diverting ostomies, they do not come without risk. For both bowel management devices, the recommended continuous indwelling position of the catheter is 29 days. Among the studies, the catheters remained in place from 1 day to 56 days. They would be removed once the wounds or grafts had demonstrated healing as per the surgeon evaluating the wound. In the studies that were evaluated, patients who exceeded this recommendation sustained mucosal injury, anal atony, and bowel occlusion.6,9,21 However, these complications may be attributed to the primary injury as well. Patients with electrical injury have shown dysfunction of the anal sphincter mechanism.6 Bordes et al.9did not show favorable results with the use of the fecal management systems in eight patients that were divided into Flexi-seal and Zassi groups. Three patients required an ostomy to complete their wound care. Four patients had additional complications: two patients had anal atony that led to fecal leakage, and one patient developed septic shock from obstruction. The last patient experienced bleeding from an anal ulcer. Fecal leakage rates with the use of bowel catheter systems have been reported to be between 40% and 75%. Local infection rates are also similarly as high and likely because of an increase in liquid stool.6,7,9,14,25 However, mortality rates are quite low.6,9 Our data showed a similarly lower mortality rate and increased infection rate (Fig. 1). The tendency at our institution was to manage patients with greater overall burn size/severity, burn size/severity of the perineum, or age with the Flexi-seal device as seen earlier. More of these patients underwent allograft after primary excision, which may have decreased their revision rate. However, the difference did not reach significance. Patients receiving allograft also had the Flexi-seal device nearly a week earlier into the hospital stay. Approximately half of the patients received the device before the first procedure in both groups. The patients that received the Flexiseal had significantly longer hospital stays in nearly all TBS groups. These results are skewed, as the patients that received them were more critically ill and/or older. Unfortunately, because these data were collected retrospectively, there is no information on the rate of complication from the use of the device. The majority of devices were used for less than the recommended 29 days, but it is not certain that there were no mucosal injury. None of the patients were noted to have gastrointestinal bleeding or workups for a documented gastrointestinal bleed.6,21 Contamination of the wounds was still present based on the number of revisions and enteric pathogens that grew out from various culture specimens from these patients. The rate of enteric pathogens causing an infection was significantly higher in certain body surface area groups but was not universally present. Thus, the trade-off seems to be lower mortality but greater risk of infection and revision.9 Although the conceptual advantages of an FMD seem promising, the results have been less supportive. Waste elimination that can be managed in the supine position is always
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helpful. Prone position, although helpful, is difficult to achieve in most patients. Yet, the placement of these devices can potentially decrease wound contamination and shear stress. However, several concerns arise with the use of bowel management systems. First, they may indirectly prolong immobilization of the patient so as to prevent the tube from falling out. This delays rehabilitation of the patient, interferes with graft healing because the wounds are always in a dependent position for edema and drainage to accumulate, and exposes patients to developing decubitus ulcers. Second, patients are forced to have liquid stool to avoid blockage of the devices. This can make administering certain medications and maintaining electrolyte balance difficult, and the diarrheal stool can leak around the tube, resulting in contamination of the surrounding wound. Finally, the application of pressure via the balloon may compromise blood flow to the perianal region, which is already affected by the burn injury. Many patients required ostomy diversion to complete their care, and other patients experience sepsis. Perhaps, better outcomes will result with a more judicious use of this device by placing it in the appropriate population.
Management of Perineal Burns with Surgical Diversion Surgical diversion to manage patients with perineal burns is least preferred based on the literature review. Only 5.4% of the nearly 800 patients in the review were treated with an ostomy. Of these 29 patients, half received an ostomy prophylactically. Although not clearly stated, many of these patients sustained severe burns directly to the anal region.7,18 For patients that undergo an ostomy procedure, several options are available. However, the preferred anatomic placement (ileostomy vs. colostomy) and the preferred surgical technique (laparoscopic26,27 vs. open2,19) are not fully defined. The advantage of an ileostomy includes mobility of the bowel to a location devoid of burns, which is greater than a colostomy (transverse and sigmoid colostomies being the main options). In turn, this frees donor sites for future grafts.27 The type of ostomy used could also vary to adjust for a nonburned location. The pros/ cons of an ileostomy versus colostomy with regard to fluid and electrolyte management are unchanged compared with the general population.27 Similarly, both groups are at risk of developing adhesions like the general population. Laparoscopic approaches are gaining favor, especially for diverting ileostomies,26 because they minimize the laparotomy scar, decrease intra-abdominal adhesions, and allow for increased donor sites. Beagley et al.27noted that another advantage included patient positioning postoperatively to allow for better graft ‘‘take.’’ They positioned their patients in the prone or decubitus position without worrying about a laparotomy scar dehiscence. An ostomy can be brought out in a superficial burn site or newly grafted site without significant risk.19 Bordes et al.9 recommended that the colostomy be placed in an unburned site. With major burns, this is often difficult for two reasons: (1) this limits available donor sites once the ostomy has been created, and (2) burns need to be excised and grafted before placement of the ostomy. To minimize postoperative wound infections, the incision should heal by secondary intention if involving a burn site. Patient selection and timing are also important. Elderly or unstable patients should avoid undergoing this procedure
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and be managed by alternative methods.3 Ostomy procedures should only be performed once a patient is stable to undergo general anesthesia procedure. Maturation of the ostomy can take place postoperatively in the intensive care unit as well to minimize duration of general anesthesia and allow for edema to decrease.2 Only five of our patients received an ostomy during their burn care. Two of these patients required an ostomy secondary to the development of a bowel perforation. The remaining three patients received an ostomy primarily for wound management due to burns involving the anus (two diverting loop ileostomies and one end colostomy).2,19 Both ileostomies were performed laparoscopically,26,27 with ports placed on nonburned/less deeply burned portions of the abdomen. These five patients did well. There were no mortalities within the group, but two patients required graft revision after the ostomies were created. Concerns for complications secondary to the creation of the ostomy are too early to be seen in our population. Except for one emergent ostomy creation, all four other patients had stabilized from the initial burn shock before diversion. Reversal was known to have occurred in only two patients at the time of publication, and they both maintained adequate bowel habits without intervention.
Timing of Ostomy Creation For patients with anal burns, there is some support for the use of a prophylactic ostomy to facilitate wound management and potentially mitigate infectious complications,4,7,18,19 especially when the burn directly involves the anus. Their use does not seem to affect mortality.20 These patients are at increased risk for delayed or problematic wound healing and compromised bowel function secondary scar contracture or anal stenosis. These patients often require dilation of their anus;4,26 otherwise, they risk constipation or obstruction. For patients that may have preexisting fecal incontinence, difficulties with wound healing or bowel function could be exacerbated. Fortunately, unless anal sphincter is injured because of the burn, fecal incontinence is unlikely as a result of the burn.4 For difficult wounds, the creation of a diverting ostomy can result in decreased purulent exudate, healthier granulation tissue, less graft loss, and fewer signs of infection systemically. Thus, if all other attempts have failed to heal a wound, ostomy creation is supported.7,27,28 Nearly half of the patients in the literature review received an ostomy for wound complications. The bacterial profile also can change from a gram-negative enteric organism to P. aeruginosa.19 Quarmby et al. noted that as they transitioned to early excision and grafting, failure of the grafts and infection rate increased until the addition of ostomies. Occasionally, an ostomy may be created in patients with neurologic issues that would limit care of the perineum.2,19 Although one would consider that diverting stool entirely from the region would decrease that rate of infection, mucosal sloughing from the rectum still seems to provide a source of bacteria.4,19,20
Timing of Ostomy Reversal Ostomy reversal follows recommendations similar for nonburn patients. Unfortunately, many of these patients have extensive injuries and a protracted course of months to years.2,26,27 The course is often extended secondary to repeated procedures for anal scar contractures that require anoplasty or dilation. Thus, 646
reversal should be performed after this has been treated completely so as to avoid complications.7,19 Patients with nonburned abdomens were more likely to be reversed promptly.2 Even if bacterial contamination is minimized and graft failure and sepsis are avoided, the subclinical infection may still pose a threat to healing and lead to increased scarring.3,15
Choice of Initial Graft Material It is unclear whether staging the reconstruction of the perineal wound has any benefits. Theoretically, there may be an advantage to perform early excision and allograft at a site affected by malperfusion from edema and compromised in-inflow in certain populations, that is, those with diabetes and peripheral vascular disease. This limits failed autografting and loss of donor tissue. Our patients that received allograft at the first operation required fewer revision procedures (23% vs. 34%). Although this difference was not significant when comparing both study groups, the allograft population was older, with more severe burns, and also more likely to have been treated with a Flexi-seal.
New Frontiers of Perianal Wound Care Reduced mechanical trauma and infectious exposure to this area will help with wound healing; an occlusive dressing would protect the grafts from both of these insults. Negativepressure wound therapy is gaining popularity and showing promise with improved healing of wounds and grafts. A second benefit would be early mobility. There are currently no studies using this device in the management of perianal burns.
CONCLUSION The literature review provided a foundation for developing recommendations in managing perineal and buttock burn wounds. First, the area is under mechanical and shear stress because of the patient’s movements and the passage of stool. Second, the contour of the tissue also makes it difficult to maintain a dressing to reinforce this area, minimize stress, and protect the graft. Third, with the natural skin barrier compromised from the injury, it is a haven for bacterial proliferating causing local and/or systemic infection. Lastly, the area is pressure dependent. In the postburn state, secondary to edema, shunting of blood flow, and inflammation, grafts to this area are at a greater risk compared with nondependent areas. This is magnified in the diabetic population because they already experience underlying microvascular disease. Recently, Bordes et al.16 published guidelines based on a survey and discussion by French Burn centers. Their results showed a fairly widespread use of an FMD. However, their recommendations showed restraint in using a diversion device as a first-line therapy similar to our recommendations detailed later. Their window to allow for wound healing and grafting is more prolonged than what we practice but also encourages the minimization of liquid stool exposure. Similar to most published studies, they retain the use of diverting ostomies for more complicated patients. For these reasons, we retrospectively reviewed our own patients to add to the paucity of published information. Our goal in managing these wounds is no different from elsewhere in the body. Excise the burn early, and graft/cover the wound to facilitate recovery and minimize risk of graft loss. There are * 2014 Lippincott Williams & Wilkins
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two main questions to consider when dealing with this problem. How extensive is the overall burn size? How close is the burn to the anus? (Fig. 2)
Recommendations for the Management of Perineal Burn Wounds 1. Determine injury to the anus/anal sphincter. What is the depth of the burn? Is there a concern for incontinence? If the burn involves the anus or is deep or if patient has developed incontinence secondary to the injury, then diverting ostomy should be performed. This allows adequate treatment (e.g., dilatation of anus) of the wound and minimizes complications of graft loss and from the anal burn before complications of obstruction secondary to stenosis or scar contracture (Grade C) occur. 2. Perianal and buttock wounds that are superficial should be treated with topical care and cleansing. Diarrhea should be avoided. Patients can be placed in the prone position or placed in the lateral decubitus position if tolerated (Grade C). 3. Perianal and buttock wounds that are deep should be excised and grafted at the time of the first prone procedure. Autograft is preferred so as to minimize placing the patient in the prone position multiple times in the operating room. However, patients with elevated revised Baux score29 should undergo initial treatment with allograft to minimize risk of autograft loss during the resuscitation state (Grade C).
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a. Diarrhea should be avoided. b. These patients can be managed in the prone position or in a decubitus position with solid stool. c. Nonsurgical fecal diversion is an option. d. Bolster dressing to the wounds with a ‘‘Montgomery strap’’ (suture placed in an interrupted fashion and tied to create an eyelet through which umbilical tape can be passed) and tie-over bolster would allow easier dressing changes after soiling. e. If there is adequate margin of the tissue surrounding the anus, negative-pressure wound dressings provide excellent stabilization and protection from contaminants to the graft. 4. If patient is intubated or has neurologic/psychological issues, then nonsurgical diversion should be performed after rectal examination is performed to evaluate mucosa, evacuate solid stool, and check for tone. The device should be removed within 29 days as recommended by the manufacturer or as soon as healing of the grafts are complete. Stool would need to be liquid while in place. This can be achieved with Lactulose. The stool should be solidified before tube removal so as to minimize liquid stool contaminating the wound once tube is out (Grade C). 5. The use of a diverting ostomy should be the last option for most patients after nonoperative interventions for fecal diversion have failed to allow wound healing (Grade C).
Figure 2. Algorithm for the management of buttock/perineal burns. * 2014 Lippincott Williams & Wilkins
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AUTHORSHIP N.M., and D.B., L.W., J.J.L., and S.R. collected and wrote part of the manuscript. M.G.J. and S.S. designed the study, reviewed and evaluated the data, and wrote and edited the manuscript.
DISCLOSURE This study was supported by Canadian Institutes of Health Research # 123336 and CFI Leader’s Opportunity Fund Project # 25407 (NIH RO1 GM087285-01).
REFERENCES 1. Alghanem AA, McCauley RL, Robson MC, Rutan RL, Herndon DN. Management of pediatric perineal and genital burns: twenty-year review. J Burn Care Rehabil. 1990;11:308Y311. 2. Nakazawa H, Ito H, Morioka K, Kikuchi Y, Honda T, Isago T. The use of temporary diverting colostomy to manage elderly individuals with extensive perineal burns. Burns. 2002;28:595Y599. 3. Bordes J, Gamelin A, Le Breton F, Perro G, Bourdais L, Lauwers M, Lefloch R. Faecal management in the perineal burns: the French experience. Burns. 2013;39:528Y529. 4. Bangma CH, Molen ABM, Boxma H. Burns to the perineum and genitals? Management, results and function of the thermally injured perineum in a 5-year-review. Eur J Plast Surg. 1995;18:111Y114. 5. Peck MD, Boileau MA, Grube BJ, Heimbach DM. The management of burns to the perineum and genitals. J Burn Care Rehabil. 2006;11:54Y56. 6. Kement M, Acar HA, Barlas IS, Aksakal N, Gezen C, Duzci U, Oncel M. Clinical evaluation of a temporary fecal containment device for non-surgical fecal diversion in perineal burns. Ulus Travma Acil Cerrahi Derg. 2011;17: 123Y127. 7. Kim KH, Tsuneda K. A case of perianal burn. Burns 1987;13:396Y397. 8. Angel C, Shu T, French D, Orihuela E, Lukefahr J, Herndon DN. Genital and perineal burns in children: 10 years of experience at a major burn center. J Pediatr Surg. 2002;37:99Y103. 9. Bordes J, Goutorbe P, Asencio Y, Meaudre E, Dantzer E. A non-surgical device for faecal diversion in the management of perineal burns. Burns. 2008;34:840Y844. 10. Rubis L, Law EJ, MacMillan BG. Management of burns of the perineum and buttocks. Burns. 1977;3:87Y92.
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11. Azmy AA, Raine PA, Gray G, Robertson L. Perianal burns in children: a plan of management. Burns. 1987;13:419Y420. 12. Michielsen D, Van Hee R, Neetens C, LaFaire C, Peeters R. Burns to the genitalia and the perineum. J Urol. 1998;159:418Y419. 13. Potokar T, Ramaswamy R, Dickson WA. Isolated buttock burns: epidemiology and management. Burns. 2001;27:629Y634. 14. Rutan RL. Management of perineal and genital burns. J ET Nurs. 1993;20: 169Y176. 15. Weiler-Mithoff EM, Hassall ME, Burd DA. Burns of the female genitalia and perineum. Burns. 1996;22:390Y395. 16. Bordes J, Le Floch R, Bourdais L, Gamelin A, Lebreton F, Perro G. Perineal burn care: French working group recommendations. Burns. Epub 2013;40:1Y9. 17. Taylor S, Manning S, Quarles J. A multidisciplinary approach to early mobilization of patients with burns. Crit Care Nurs Q. 2013;36:56Y62. 18. Espinar J. Serious perineal burns, surgical tactics, personal experience. Bol Soc Argent Cir. 1965;26:227. 19. Quarmby CJ, Millar AJ, Rode H. The use of diverting colostomies in paediatric peri-anal burns. Burns. 1999;25:645Y650. 20. Lam A, Wise L, Butcher H. Role of colostomy in perineal burns. Mo Med. 1974:71:538Y541. 21. Keshava A, Renwick A, Stewart P, Pilley A. A nonsurgical means of fecal diversion: the Zassi Bowel Management System. Dis Colon Rectum. 2007;50:1017Y1022. 22. Michielsen DP, Lafaire C. Management of genital burns: a review. Int J Urol. 2010;17:755Y758. 23. Peck MD, Heimbach DM. Does early excision of burn wounds change the pattern of mortality? J Burn Care Rehabil. 1989;10:7Y10. 24. Roberts DC, Whitaker IS, Drew PJ. Perineal scalds from drive through restaurants: a public health hazard. Burns. 2007;33:258Y260. 25. Renz BM, Sherman R. Exposure of buttock burn wounds to stool in scaldabused infants and children: stool-staining of eschar and burn wound sepsis. Am Surg. 1993;59:379Y383. 26. D’Souza BB, Heriot A, Bach S, Beer J. Severe perineal burns. ANZ J Surg. 2010;80:665Y666. 27. Beagley MJ, Poole G, Peat BG, Rees MJ. The use of temporary laparoscopic loop ileostomy in lumbosacral burns. Burns. 2000;26:298Y301. 28. Ameh EA. Perineal burns in children. Afr J Paediatr Surg. 2005;1:33Y35. 29. Osler T, Glance LG, Hosmer DW. Simplified estimates of the probability of death after burn injuries: extending and updating the baux score. J Trauma. 2010;68:690Y697.
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Management of adult patients with buttock and perineal burns: The Ross Tilley Burn Centre experience Nishant Merchant, MD, David Boudana, MD, L Willoughby, MD, JJ Lin, MS, Sarah Rehou, MS, Shahriar Shahrokhi, MD, and Marc G. Jeschke, MD, PhD, Toronto, Ontario, Canada
Perineal and buttock burns are challenging wounds to heal for several reasons because of the contamination risk and shear stress that is always present. Because of the nature of the wound bed, pathogens can have ready access to create systemic infections and complications. Prolonged healing times also delay the recovery for patients and add to their discomfort and psychological stress from the injury. The ideal treatment approach is not well defined, and the aims of this study were to conduct a literature review of current treatment suggestions and to look at our own patient population to determine how our center treated these challenging patients. METHODS: This is a retrospective review of all patients treated between 2010 and 2013 at our center. Patients that received care for burns to the perineum or buttocks were evaluated. Mortalities within 24 hours of admission and transfers before completion of their care were excluded. All patients older than 18 years were included in the study. The primary outcome studied was a cause for graft revision. Secondary outcomes included benefits and risks of fecal management devices, risk of infection, and mortality. RESULTS: The literature review did not show consensus on how to best manage this patient population. Our results however demonstrated that patients treated with the fecal management device Flexi-seal (Convatec, Skillman, NJ) were at increased risk of developing an infection involving an enteric pathogen and requiring revision procedures. The patient population that was treated with this device was also older and had larger burns. The patients within this group that were treated initially with allograft required fewer revisions when compared with patients that received autograft in this group (23% vs. 34%, p 9 0.05). CONCLUSION: After our data and the literature had been reviewed, the lack of evidence-based treatment protocols led us to create recommendations for burn surgeons with regard to the initial management of this complicated area. Certain key features include avoiding autograft at the primary excision if they have an increased revised Baux score and minimizing the amount of liquid stool contaminating the wound bed to increase success. (J Trauma Acute Care Surg. 2014;77: 640Y648. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level IV. Therapeutic study, level V. KEY WORDS: Burn; ileus; ostomy; morbidity; mortality. BACKGROUND:
B
urns to the perineum occur infrequently, with an incidence as low as 1.2% in the US pediatric population1 to 20% in Japanese adults;2Y6 however, they are quite difficult to manage. Perineal burns rarely occur in isolation1,7,8 and are typically caused by flame or scald injuries.1,4,5,8Y13 The perineum is fairly protected such that the total burns usually exceed this area. Studies have shown that nearly one third of patients with perineal injuries can die in the first 48 hours and that their overall mortality can be 25% to 50%,4Y6,14,15 which is why it is important to have a management plan to minimize complications and a protracted course.16 The management of burns to this region is complicated because of the contours of the surrounding tissue, constant bacterial contamination, and repetitive stress from activity.9Y11,13 Separate from the challenges faced by physicians in managing Submitted: November 15, 2013, Revised: May 28, 2014, Accepted: May 30, 2014. From the Division of Plastic Surgery, Departments of Surgery and Immunology, University of Toronto; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre; and Sunnybrook Research Institute, Toronto, Ontario, Canada. Address for reprints: Marc G. Jeschke, MD, PhD, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre; Division of Plastic Surgery, Department of Surgery, Department of Immunology, University of Toronto; Sunnybrook Research Institute, 2075 Bayview Ave, Rm D704, Toronto, ON, Canada, M4N 3 M5; email: [email protected]. DOI: 10.1097/TA.0000000000000405
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these wounds, they also decrease patients’ mobility, control over self, self-esteem, and self-image.14,17 Nearly 50 ago, Espinar18 suggested colostomy for deep wounds, especially when involving the anus.17 Ever since then, controversy remains regarding the need for diversion, with Weiler-Mithoff et al.15 stating little need for fecal diversion1 and Quarmby et al.19 describing the benefits of diversion.2Y6 To date, there is no consensus on a treatment regimen. Much of the difficulty is the scarcity and quality of the evidence (Class B and C at best). There is some agreement that severe anal burns benefit from surgical diversion and many of these wounds fared well with adequate wound care.1,2,15,16,19,20 A possible intermediary to surgical diversion is fecal management devices (FMDs), but the evidence is limited to small studies or surveys.6,9,16,21 Therefore, we retrospectively evaluated our experience to garner more information. At our institution, a mix of surgical and nonsurgical diversion methods as well as management without diversion was used. We combined the results of the literature review and our institutional experience to develop recommendations for the management of the perineal and buttock burns.
PATIENTS AND METHODS All adults consecutively admitted to our institution between 2010 and 2013 were retrospectively reviewed for buttock J Trauma Acute Care Surg Volume 77, Number 4
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and perineal burn wounds. They were stratified according to the initial method used to treat their wounds, total body surface area (TBS) involved, and diversion method to better understand the treatment options. Additional data were collected regarding their demographics, rate of infection, the day of the first bowel movement after admission, and rate of wound care failure (measured as failure of original treatment option). Patients that were transferred after the initiation of care or before completion of their care were excluded. The primary outcome was to identify patients that failed their initial treatment plan. Secondary outcomes were to understand the rate of infection, complications secondary to FMD, and mortality caused by enteric pathogen sepsis. Descriptive statistics were calculated for demographic variables. Statistical methods such as Student’s t test, W2 test, Fisher exact test (two-sided), Mann-Whitney U-test, and KruskalWallis test were used where appropriate. A Kaplan-Meier survival analysis and a log-rank test were also used. Normally distributed data are presented as mean T SEM. Nonnormally distributed data are presented as median and interquartile range (IQR). A twotailed p G 0.05 was accepted as significant.
treated without diversion (29 patients) or with the Flexi-seal system (Convatec, Skillman, NJ) (27 patients). The baseline patient and injury characteristics are presented in Table 1. The patients that were managed with a diversion method had significantly more severe burns overall and to the perineum.
Primary Procedure A total of 38 patients underwent a primary surgical procedure. Thirteen patients underwent primary excision and allograft placement, 6 patients received temporary coverage with Biobrane (Smith & Nephew, London, UK), 1 patient had excision only, and 18 patients were autografted at the first excision. Eleven patients (29%) required a revision procedure before discharge (Table 2). When comparing autograft versus allograft coverage after primary excision, there were no significant differences regarding the rate of revision or infection. A greater fraction of the patients receiving allograft were treated with an FMD, but the difference in the use rate was not significant. The device was placed earlier for allograft patients compared with the autograft group, without significant effects on outcomes (Table 3).
Revision Procedures
RESULTS Our institution admitted 74 patients that sustained a perineal or buttock burn. Thirteen patients were excluded; 1 was transferred before the completion of the treatment course, and 12 survived less than 24 hours. The patients’ mean age was 50.8 T 20.1 years. Median total TBS was 26.35% (IQR, 41.25%), of which 10.5% (IQR, 43.63%) was third-degree burns. Median buttock TBS was 2% (IQR, 4%), and 0% (IQR, 3.63%) was third degree. Median genital TBS was 0% (IQR, 1%), and coinciding portion was third degree. Average hospital stay for all patients was 21 days (IQR, 31) days.
Patients that received treatment with an FMD seem to be at greatest risk of requiring additional procedures. These data did not reach significance when compared with the patients treated for equal-size burns without Flexi-seal diversion, but the absolute values showed a tendency for failure in the diverted group. Only one patient that was managed without a Flexi-seal, TBS of greater than 40%, underwent a revision procedure. Patients receiving split-thickness grafts during the first procedure showed a risk of increased revision. The allograft group had fewer overall revisions, but also had half the patients compared with the autograft group (Table 2).
Diversion Method
Mortality
Of the remaining 61 patients, only 5 underwent ostomy procedures. Three patients received a diverting ostomy for wound care purposes; two (a loop colostomy and ileostomy) were preemptive, and another loop ileostomy was created after failed treatment. Two patients received ostomies (end-ileostomy and sigmoid colostomy) for intestinal perforation. Two ostomies were closed at 8 months and 14.5 months. At present, there are no known complications of the ostomy. The remaining patients were
There were 19 mortalities (25%) in the group. Of the 19 patients, 12 died within 24 hours of admission. Of the seven patients that survived greater than 24 hours, four underwent excision and Biobrane application, one underwent excision of wounds, and two patient were excised and autografted during the first operation. All of the late mortalities occurred in patients with greater than 21% TBS, and the majority of these patients were also much older. Neither the use of Flexi-seal nor
TABLE 1. Patient Demographics Excluding the 13 Patients That Either Died in Less Than 24 Hours or Were Transferred in the Middle of Their Treatment Course Variable
Diversion Method
Sex , male Age, y Third-degree TBS, % Total TBS, % Third-degree buttock TBS, % Total buttock TBS, % Third-degree genital TBS, % Total genital TBS, %
None (n = 29)
Flexi-seal (n = 27)
Ostomy (n = 5)
p
72% (21) 44.48 T 3.32 0 (4.5) 13.5 (20) 0 (0) 1 (2) 0 (0) 0 (0.5)
52% (14) 52.54 T 4.33 20 (34.5) 29.5 (32.25) 1.5 (3.25) 2.5 (3.75) 0 (0) 0 (0.75)
60% (3) 44.38 T 8.85 6 (15.75) 19 (12.5) 0 (1.25) 2.5 (2.25) 0 (0) 0 (0)
0.282 0.381 0.009 0.035 0.019 0.143 0.043 0.505
Data are presented as median and IQR. Age is presented as mean T SEM. p value calculated based on mean and SEM.
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642 67% (2) 54.6 T 18.1 3.5 (3.5) 3.5 (2.75) 2.5 (1.75) 3 (1.25) 0 (0) 0 (0.5) 30 (8.5) 100% (3) 2 (0.5) 1.5 (0.5) 1 (0) 0 33% (1) 0 0 0 67% (2) 2 (0.5) 3 (3.5) 0 (0.5) 67% (2) 67% (2)
Flexi-seal (n = 3)
TBS 0Y10%
0.19 0.68 0.16 0.36 0.09 0.03 N/A 0.77 0.006 0.006 0.003 0.09 0.12 N/A 0.71 N/A 0.05 N/A 0.19 0.86 N/A N/A N/A 0.05
p 20% (1) 59.8 T 10.2 5.5 (4.5) 12.5 (3) 0 (0) 4 (5) 0 (0) 0 (0) 26 (15) 60% (3) 2 (0.5) 1 (0) 1 (0) 0 40% (2) 0 0 0 60% (3) 2 (0) 4 (5) 0 (2) 40% (2) 20% (1)
Flexi-seal (n = 5)
TBS 11Y20%
0 35.4 T 5.8 0 (0.75) 16.5 (2.75) 0 (0) 4 (2.25) 0 (0) 0 (0) 23 (8.5) 50% (1) 1 (0) 0 (0) 1 (0) 0 0 0 100% (2) 0 0 1 (1) N/A N/A N/A 0
None (n = 2)
Age is presented as mean T SEM, and the remaining data points are presented as median (IQR). Significance p G 0.05 in bold. STSG, split-thickness skin graft; N/A, not applicable.
79% (11) 44.2 T 5.3 0 (0.75) 6.5 (3.75) 0 (0) 0 (0.75) 0 (0) 0.25 (0.5) 12 (8.5) 7% (1) 0 (0) 0 (0) 0 (0) 0 7% (1) 0 71% (10) 0 21% (3) 2 (2.5) N/A N/A N/A 0
None (n = 14)
Patient Demographics Based on Percent TBS Burned
Sex, male Age, y Third-degree TBS, % Total TBS, % Third-degree buttock TBS, % Total buttock TBS, % Third-degree genital TBS, % Total genital TBS, % Length of stay, d Organism present No. organisms Gram positive Gram negative Mortality (after 24 h) First operation Allograft Biobrane Daily wound care Excision only Meshed STSG Bowel movement (hospital day) Insertion (hospital day) Postoperative, d Reinserted Revision
Variable
TABLE 2.
1 0.38 0.19 0.57 1 0.57 N/A 1 0.57 0.81 0.57 0.38 0.38 N/A 0.89 N/A 0.07 N/A 0.55 1 N/A N/A N/A 0.50
p 56% (5) 67.8 T 5.6 20.5 (9.38) 26.75 (9.69) 2 (2.75) 2 (2.13) 0 (0) 0.13 (0.5) 41.5 (33.25) 89% (8) 3 (1.5) 1 (0) 1.5 (2) 22% (2) 44% (4) 11% (1) 11% (1) 0 33% (3) 2.5 (2.75) 7.5 (10.5) 4.5 (7.75) 22% (2) 38% (3)
Flexi-seal (n = 9)
TBS 21Y40%
78% (7) 49.0 T 6.1 4.5 (27) 26.75 (9.45) 0 (0.75) 1.75 (1.63) 0 (0) 0 (0) 19 (11.25) 45% (4) 1 (0.25) 1 (0) 1 (0.5) 33% (3) 0 33% (3) 33% (3) 11% (1) 22% (2) 4 (3) N/A N/A N/A 0
None (n = 9) 0.34 0.040 0.16 0.44 0.19 0.93 0.73 0.44 0.011 0.046 0.008 0.11 0.031 0.60 0.09 0.57 0.57 0.30 0.60 0.48 N/A N/A N/A 0.12
p
75% (3) 39.7 T 7.3 38.25 (20.63) 47.25 (6.88) 1.25 (1.38) 1.75 (2.13) 0 (0) 0 (0.25) 20.5 (8) 75% (3) 1 (1) 0 (0) 1 (1) 25% (1) 25% (1) 25% (1) 0 0 50% (2) 6.5 (1.5) N/A N/A N/A 25% (1)
None (n = 4)
80% (8) 34.6 T 3.9 47.25 (19.25) 59.75 (14.9) 1.75 (3.75) 2.5 (4.38) 0 (0) 0 (0.8) 72.5 (20.75) 90% (9) 2 (1) 1 (0) 2 (2) 0 40% (4) 10% (1) 10% (1) 0 40% (4) 3.5 (3.75) 7.5 (6.25) 5 (9) 44% (4) 44% (4)
Flexi-seal (n = 10)
TBS 9 40%
1 0.45 0.37 0.84 0.54 0.54 0.64 1 0.001 0.47 0.11 1 0.08 0.62 0.78 0.47 0.51 N/A 0.73 0.08 N/A N/A N/A 0.51
p
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TABLE 3. Patient Demographics Based on Comparison of Their Index Procedures and Outcomes Sex, male Age, mean T SEM Third-degree total TBS, median (IQR), % Total TBS, median (IQR), % Third-degree buttock TBS, median (IQR), % Total buttock TBS, median (IQR), % Third-degree genital TBS, median (IQR), % Total genital TBS, median (IQR), % Hospital stay, median (IQR), d Mortality (total) (Enteric organism) Blood Urine Sputum Wound Ostomy (patients) Revisions (patients) Flexi-seal use (patients) Hospital day insertion, median (IQR), d Inserted postoperatively (patients) Reinsertion (reason) (patients) First bowel movement, median (IQR), d
Allograft Patients (n = 13)
Autograft Patients (n = 23)
p G 0.05
7 52.6 T 19.5 20 (33.5) 31 (28) 1.5 (3) 2.5 (2.5) 0 (0) 0 (1) 41 (42) 0
12 45.9 T 21.7 10.5 (33.75) 21.88 (34.5) 0 (3.63) 1.5 (4) 0 (0) 0 (1) 34 (41.25) 2
0.92 0.31 0.90 0.72 0.85 0.58 0.40 0.87 0.84 0.53
Blood (5) Urine (3) Sputum (4) Wound (4) 2 3 11 4 (5) 6 4 (STSG protection) 2 (3)
Blood (4) Urine (6) Sputum (3) Wound (2) 3 8 13 3 (8.25) 8 5 (revision) 3 (3.25)
0.24 0.84 0.23 0.21 0.85 0.71 0.14 0.47 0.72 0.69 0.95
graft choice at the first operation significantly affected this outcome (Table 2). However, when comparing groups treated with an FMD versus no diversion, there was an absolute mortality difference but not significant at similar time points in the postburn period ( p = 0.065, Fig. 1).
Infections Infections with enteric organism identified in the bloodstream, urine, sputum, and wounds of the patients were noted to include Eschericha coli, Enterococcus, Enterobacter, Proteus mirabilis, and Klebsiella. Nearly half of the patients had an organism identified, but only four patients developed wound sepsis. When comparing groups with and without nonoperative diversion, there was an increased rate of infection with the use of a device ( p 9 0.05). However, this did not translate into a significantly greater rate of revision or mortality, but the relative rates of revision were greater in the device group (Table 2).
revisions or mortality. Rather, the size of their wounds and Pseudomonas septicaemia were the determinants of mortality. Compared with the wound management regimen that was used in the patients described earlier, most centers do not routinely treat patients with prophylactic antibiotics or provide daily whirlpool therapy that may further alter the flora around the perineum. Our patients did not receive empiric systemic antibiotics. We found a greater concentration of enteric pathogens growing from our wounds, although it did not seem to affect the revision or mortality rate significantly either.
Wound Shear Stress Shearing of the graft with activity and stool passage is of great concern postoperatively. To minimize this risk, some
DISCUSSION Difficulties With the Management of Perineal Burns Wound Contamination All burn wounds are at increased risk of developing an infection, secondary to a compromised barrier. Primarily, the organisms of concern, especially in the acute burn phase, are the gram-positive skin bacteria. However, given the proximity of the perineum to the gastrointestinal tract, gram-negative and anaerobic bacteria become increasingly more common. Rubis et al.10 were able to alter perineal flora, such that Pseudomonas aeruginosa and E. coli were the two most common organisms. They prophylactically treated wounds with antibiotics and daily whirlpool therapy. Interestingly, the organism did not impact
Figure 1. Kaplan-Meier curve of patients treated with a Flexi-seal for diversion versus no diversion (p = 0.065).
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authors significantly limit patient activity postoperatively. Weiler-Mithoff et al.15 placed patients on a 96-hour bed rest and severely limited activities for 4 weeks to 6 weeks. However, this poses its own consequences to the overall recovery and rehabilitation of the patient. Bowel movements are an essential part of maintaining physiologic functions, but stool passage deposits bacteria in the wound bed. Three options for stool passage are constipation, normal consistency, or liquid consistency. Constipation can increase the risk for perforation, sepsis, poor nutritional intake, or aspiration. Diarrhoea allows stool to permeate dressings and wounds more easily. Thus, soiling of the wound bed and mechanical stress from passing stool potentially destabilize a graft and its bed.
Management of Perineal Wounds Without Diversion For patients without diversion, wounds were protected from contamination and shear stress. Authors used rigorous cleansing/ dressing protocols, restricting bowel function, and/or prone positioning. Even the patients that required grafting tended to do well with appropriate wound care and critical care management.1 Thus, the authors recommended against the routine creation of a diverting ostomy.22 Simply having secure wound dressings can be adequate in a well-vascularized wound bed.15 Forced constipation and prone positioning are not frequently practiced at our center because patients and nurses often find it uncomfortable.11,14,23 Patients treated with an FMD were given cathartics; otherwise, they received stool softeners and promotility agents (Dulcolax) to maintain normal stool.
Wound Care for Nonoperative and Preoperative Wounds Fortunately, for patients who sustain superficial perineal burns, they can be managed nonoperatively with good results.5,12,24 In healthy individuals, these wounds heal within 3 weeks, assuming wound or systemic sepsis does not occur. To minimize this risk, patients receive aggressive wound care before excision. Multiple options are available for topical coverage, and many of the studies used various combinations along with whirlpool therapy to achieve their goal.8,10,19 As long as daily wound care is performed, the antimicrobial agent used has less importance as most combinations have been shown to be effective.
Wound Care in Postoperative Wounds Postoperative care varies primarily based on dressing management, positioning of the patient, and controlling bowel habits. Two general dressing concepts that improve postoperative wound care were effective barrier dressings and decreased contact time of the wound with stool. Bolster dressings better protected grafts and allowed for a secure but exchangeable method of wound care.11 Rubis et al.10 changed the dressing every 4 hours for 5 days to 7 days as opposed to using a bolster dressing in pediatric burn patients. This method used retention points with sutures and passing umbilical tape through them to secure a dressing and allow for easy exchange if they were soiledVsimilar to Montgomery straps for the abdomen. Frequent dressing changes are difficult to maintain because it consumes significant nursing resources, making it less feasible 644
in the current fiscal practice of medicine. If there was enough of a margin around the anus, we used negative pressure dressings with success. Once again, the main goal was to maintain secure dressings that left the graft immobile and clean and allowed for patient mobility. Further randomized studies are needed to see if the dressing choice makes a difference in treating this complicated area. Azmy et al.11 used constipation in the perioperative period to decrease stool exposure. Fecal passage was eliminated for 8 days to 10 days using Picolax/Neomycin/Flagyl/Phosphate Enema in the preoperative phase, with Imodium used postoperatively. Patients were kept on an elemental diet in the perioperative period. Good graft take was achieved without complication. Renz and Sherman25 evaluated 30 pediatric patients with an average burn size of 18.1%. The patients underwent bowel preparation, were given antibiotics, had an occlusive postoperative intrarectal catheter, were kept nil per os, or were positioned to minimize contamination of their wounds. Ten patients had complications secondary to diarrhoea. None of the above modalities effectively protected the autografts from stool, and eight patients developed an infection of their wounds. Four patients died of burn wound sepsis from a gram-positive bacteremia, which also had diarrheal stool consistency. Thus, the authors recommended early excision if the wounds were noted to have deep wound contamination. Another management method, as proposed by Potokar et al.,13 involved the administration of flucloxacillin or erythromycin to patients with isolated buttock burns. Patients with full-thickness burns underwent grafting between 1 week and 3 weeks after burn. All grafted patients were nursed prone or in the lateral decubitus position. They noted Pseudomonas and Methicillin-resistant Staphylococcus aureus infections in three of six patients, which caused significant graft compromise. There was no mention of enteric organisms creating complications. Thus, empiric antibiotics did not necessarily improve graft survival. With several options available to control fecal contamination of perineal burns, a simple option of maintaining normal stool is often overlooked. Rutan14 suggested several dietary modifications to maintain formed stool. The suggestions ranged from using soy or milk, less than 30% of daily calories from fat, supplementary vitamin A, early tube feed initiation, and recolonization of patients receiving antibiotics.
Management of Perineal Burns With Nonsurgical Diversion Fecal management systems were created to decrease contamination to the perineum by patients with limited mobility. These devices were adapted to facilitate healing in the burn population. Burn patients are faced with the challenge of maintaining bowel function and limited means of maintaining cleanliness secondary to pain, sedation, or restrictions on activity for wound healing purposes.7 Thus, the benefit of bypassing stool into a bag at bedside certainly has its benefits.6 Kement et al.6 avoided revision procedures in a population with an mean age of 43.1 years and mean TBS burn of 40.7%. One patient required a diverting colostomy due to delayed healing. Local infections were noted, but those three patients healed with conservative treatment. Anorectal complications * 2014 Lippincott Williams & Wilkins
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secondary to the Flexi-seal device were not mentioned. Keshava et al.21studied the Zassi bowel management system (Zassi, Fernandino Beach, FL), and the wounds remained clean because of the device. There was no mention of graft failure or sepsis. They also noted that none of the patients had mucosal injury from the tube being in place. Although FMD provides an alternative to diverting ostomies, they do not come without risk. For both bowel management devices, the recommended continuous indwelling position of the catheter is 29 days. Among the studies, the catheters remained in place from 1 day to 56 days. They would be removed once the wounds or grafts had demonstrated healing as per the surgeon evaluating the wound. In the studies that were evaluated, patients who exceeded this recommendation sustained mucosal injury, anal atony, and bowel occlusion.6,9,21 However, these complications may be attributed to the primary injury as well. Patients with electrical injury have shown dysfunction of the anal sphincter mechanism.6 Bordes et al.9did not show favorable results with the use of the fecal management systems in eight patients that were divided into Flexi-seal and Zassi groups. Three patients required an ostomy to complete their wound care. Four patients had additional complications: two patients had anal atony that led to fecal leakage, and one patient developed septic shock from obstruction. The last patient experienced bleeding from an anal ulcer. Fecal leakage rates with the use of bowel catheter systems have been reported to be between 40% and 75%. Local infection rates are also similarly as high and likely because of an increase in liquid stool.6,7,9,14,25 However, mortality rates are quite low.6,9 Our data showed a similarly lower mortality rate and increased infection rate (Fig. 1). The tendency at our institution was to manage patients with greater overall burn size/severity, burn size/severity of the perineum, or age with the Flexi-seal device as seen earlier. More of these patients underwent allograft after primary excision, which may have decreased their revision rate. However, the difference did not reach significance. Patients receiving allograft also had the Flexi-seal device nearly a week earlier into the hospital stay. Approximately half of the patients received the device before the first procedure in both groups. The patients that received the Flexiseal had significantly longer hospital stays in nearly all TBS groups. These results are skewed, as the patients that received them were more critically ill and/or older. Unfortunately, because these data were collected retrospectively, there is no information on the rate of complication from the use of the device. The majority of devices were used for less than the recommended 29 days, but it is not certain that there were no mucosal injury. None of the patients were noted to have gastrointestinal bleeding or workups for a documented gastrointestinal bleed.6,21 Contamination of the wounds was still present based on the number of revisions and enteric pathogens that grew out from various culture specimens from these patients. The rate of enteric pathogens causing an infection was significantly higher in certain body surface area groups but was not universally present. Thus, the trade-off seems to be lower mortality but greater risk of infection and revision.9 Although the conceptual advantages of an FMD seem promising, the results have been less supportive. Waste elimination that can be managed in the supine position is always
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helpful. Prone position, although helpful, is difficult to achieve in most patients. Yet, the placement of these devices can potentially decrease wound contamination and shear stress. However, several concerns arise with the use of bowel management systems. First, they may indirectly prolong immobilization of the patient so as to prevent the tube from falling out. This delays rehabilitation of the patient, interferes with graft healing because the wounds are always in a dependent position for edema and drainage to accumulate, and exposes patients to developing decubitus ulcers. Second, patients are forced to have liquid stool to avoid blockage of the devices. This can make administering certain medications and maintaining electrolyte balance difficult, and the diarrheal stool can leak around the tube, resulting in contamination of the surrounding wound. Finally, the application of pressure via the balloon may compromise blood flow to the perianal region, which is already affected by the burn injury. Many patients required ostomy diversion to complete their care, and other patients experience sepsis. Perhaps, better outcomes will result with a more judicious use of this device by placing it in the appropriate population.
Management of Perineal Burns with Surgical Diversion Surgical diversion to manage patients with perineal burns is least preferred based on the literature review. Only 5.4% of the nearly 800 patients in the review were treated with an ostomy. Of these 29 patients, half received an ostomy prophylactically. Although not clearly stated, many of these patients sustained severe burns directly to the anal region.7,18 For patients that undergo an ostomy procedure, several options are available. However, the preferred anatomic placement (ileostomy vs. colostomy) and the preferred surgical technique (laparoscopic26,27 vs. open2,19) are not fully defined. The advantage of an ileostomy includes mobility of the bowel to a location devoid of burns, which is greater than a colostomy (transverse and sigmoid colostomies being the main options). In turn, this frees donor sites for future grafts.27 The type of ostomy used could also vary to adjust for a nonburned location. The pros/ cons of an ileostomy versus colostomy with regard to fluid and electrolyte management are unchanged compared with the general population.27 Similarly, both groups are at risk of developing adhesions like the general population. Laparoscopic approaches are gaining favor, especially for diverting ileostomies,26 because they minimize the laparotomy scar, decrease intra-abdominal adhesions, and allow for increased donor sites. Beagley et al.27noted that another advantage included patient positioning postoperatively to allow for better graft ‘‘take.’’ They positioned their patients in the prone or decubitus position without worrying about a laparotomy scar dehiscence. An ostomy can be brought out in a superficial burn site or newly grafted site without significant risk.19 Bordes et al.9 recommended that the colostomy be placed in an unburned site. With major burns, this is often difficult for two reasons: (1) this limits available donor sites once the ostomy has been created, and (2) burns need to be excised and grafted before placement of the ostomy. To minimize postoperative wound infections, the incision should heal by secondary intention if involving a burn site. Patient selection and timing are also important. Elderly or unstable patients should avoid undergoing this procedure
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and be managed by alternative methods.3 Ostomy procedures should only be performed once a patient is stable to undergo general anesthesia procedure. Maturation of the ostomy can take place postoperatively in the intensive care unit as well to minimize duration of general anesthesia and allow for edema to decrease.2 Only five of our patients received an ostomy during their burn care. Two of these patients required an ostomy secondary to the development of a bowel perforation. The remaining three patients received an ostomy primarily for wound management due to burns involving the anus (two diverting loop ileostomies and one end colostomy).2,19 Both ileostomies were performed laparoscopically,26,27 with ports placed on nonburned/less deeply burned portions of the abdomen. These five patients did well. There were no mortalities within the group, but two patients required graft revision after the ostomies were created. Concerns for complications secondary to the creation of the ostomy are too early to be seen in our population. Except for one emergent ostomy creation, all four other patients had stabilized from the initial burn shock before diversion. Reversal was known to have occurred in only two patients at the time of publication, and they both maintained adequate bowel habits without intervention.
Timing of Ostomy Creation For patients with anal burns, there is some support for the use of a prophylactic ostomy to facilitate wound management and potentially mitigate infectious complications,4,7,18,19 especially when the burn directly involves the anus. Their use does not seem to affect mortality.20 These patients are at increased risk for delayed or problematic wound healing and compromised bowel function secondary scar contracture or anal stenosis. These patients often require dilation of their anus;4,26 otherwise, they risk constipation or obstruction. For patients that may have preexisting fecal incontinence, difficulties with wound healing or bowel function could be exacerbated. Fortunately, unless anal sphincter is injured because of the burn, fecal incontinence is unlikely as a result of the burn.4 For difficult wounds, the creation of a diverting ostomy can result in decreased purulent exudate, healthier granulation tissue, less graft loss, and fewer signs of infection systemically. Thus, if all other attempts have failed to heal a wound, ostomy creation is supported.7,27,28 Nearly half of the patients in the literature review received an ostomy for wound complications. The bacterial profile also can change from a gram-negative enteric organism to P. aeruginosa.19 Quarmby et al. noted that as they transitioned to early excision and grafting, failure of the grafts and infection rate increased until the addition of ostomies. Occasionally, an ostomy may be created in patients with neurologic issues that would limit care of the perineum.2,19 Although one would consider that diverting stool entirely from the region would decrease that rate of infection, mucosal sloughing from the rectum still seems to provide a source of bacteria.4,19,20
Timing of Ostomy Reversal Ostomy reversal follows recommendations similar for nonburn patients. Unfortunately, many of these patients have extensive injuries and a protracted course of months to years.2,26,27 The course is often extended secondary to repeated procedures for anal scar contractures that require anoplasty or dilation. Thus, 646
reversal should be performed after this has been treated completely so as to avoid complications.7,19 Patients with nonburned abdomens were more likely to be reversed promptly.2 Even if bacterial contamination is minimized and graft failure and sepsis are avoided, the subclinical infection may still pose a threat to healing and lead to increased scarring.3,15
Choice of Initial Graft Material It is unclear whether staging the reconstruction of the perineal wound has any benefits. Theoretically, there may be an advantage to perform early excision and allograft at a site affected by malperfusion from edema and compromised in-inflow in certain populations, that is, those with diabetes and peripheral vascular disease. This limits failed autografting and loss of donor tissue. Our patients that received allograft at the first operation required fewer revision procedures (23% vs. 34%). Although this difference was not significant when comparing both study groups, the allograft population was older, with more severe burns, and also more likely to have been treated with a Flexi-seal.
New Frontiers of Perianal Wound Care Reduced mechanical trauma and infectious exposure to this area will help with wound healing; an occlusive dressing would protect the grafts from both of these insults. Negativepressure wound therapy is gaining popularity and showing promise with improved healing of wounds and grafts. A second benefit would be early mobility. There are currently no studies using this device in the management of perianal burns.
CONCLUSION The literature review provided a foundation for developing recommendations in managing perineal and buttock burn wounds. First, the area is under mechanical and shear stress because of the patient’s movements and the passage of stool. Second, the contour of the tissue also makes it difficult to maintain a dressing to reinforce this area, minimize stress, and protect the graft. Third, with the natural skin barrier compromised from the injury, it is a haven for bacterial proliferating causing local and/or systemic infection. Lastly, the area is pressure dependent. In the postburn state, secondary to edema, shunting of blood flow, and inflammation, grafts to this area are at a greater risk compared with nondependent areas. This is magnified in the diabetic population because they already experience underlying microvascular disease. Recently, Bordes et al.16 published guidelines based on a survey and discussion by French Burn centers. Their results showed a fairly widespread use of an FMD. However, their recommendations showed restraint in using a diversion device as a first-line therapy similar to our recommendations detailed later. Their window to allow for wound healing and grafting is more prolonged than what we practice but also encourages the minimization of liquid stool exposure. Similar to most published studies, they retain the use of diverting ostomies for more complicated patients. For these reasons, we retrospectively reviewed our own patients to add to the paucity of published information. Our goal in managing these wounds is no different from elsewhere in the body. Excise the burn early, and graft/cover the wound to facilitate recovery and minimize risk of graft loss. There are * 2014 Lippincott Williams & Wilkins
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two main questions to consider when dealing with this problem. How extensive is the overall burn size? How close is the burn to the anus? (Fig. 2)
Recommendations for the Management of Perineal Burn Wounds 1. Determine injury to the anus/anal sphincter. What is the depth of the burn? Is there a concern for incontinence? If the burn involves the anus or is deep or if patient has developed incontinence secondary to the injury, then diverting ostomy should be performed. This allows adequate treatment (e.g., dilatation of anus) of the wound and minimizes complications of graft loss and from the anal burn before complications of obstruction secondary to stenosis or scar contracture (Grade C) occur. 2. Perianal and buttock wounds that are superficial should be treated with topical care and cleansing. Diarrhea should be avoided. Patients can be placed in the prone position or placed in the lateral decubitus position if tolerated (Grade C). 3. Perianal and buttock wounds that are deep should be excised and grafted at the time of the first prone procedure. Autograft is preferred so as to minimize placing the patient in the prone position multiple times in the operating room. However, patients with elevated revised Baux score29 should undergo initial treatment with allograft to minimize risk of autograft loss during the resuscitation state (Grade C).
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a. Diarrhea should be avoided. b. These patients can be managed in the prone position or in a decubitus position with solid stool. c. Nonsurgical fecal diversion is an option. d. Bolster dressing to the wounds with a ‘‘Montgomery strap’’ (suture placed in an interrupted fashion and tied to create an eyelet through which umbilical tape can be passed) and tie-over bolster would allow easier dressing changes after soiling. e. If there is adequate margin of the tissue surrounding the anus, negative-pressure wound dressings provide excellent stabilization and protection from contaminants to the graft. 4. If patient is intubated or has neurologic/psychological issues, then nonsurgical diversion should be performed after rectal examination is performed to evaluate mucosa, evacuate solid stool, and check for tone. The device should be removed within 29 days as recommended by the manufacturer or as soon as healing of the grafts are complete. Stool would need to be liquid while in place. This can be achieved with Lactulose. The stool should be solidified before tube removal so as to minimize liquid stool contaminating the wound once tube is out (Grade C). 5. The use of a diverting ostomy should be the last option for most patients after nonoperative interventions for fecal diversion have failed to allow wound healing (Grade C).
Figure 2. Algorithm for the management of buttock/perineal burns. * 2014 Lippincott Williams & Wilkins
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AUTHORSHIP N.M., and D.B., L.W., J.J.L., and S.R. collected and wrote part of the manuscript. M.G.J. and S.S. designed the study, reviewed and evaluated the data, and wrote and edited the manuscript.
DISCLOSURE This study was supported by Canadian Institutes of Health Research # 123336 and CFI Leader’s Opportunity Fund Project # 25407 (NIH RO1 GM087285-01).
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