Management of adult patients with buttock and perineal burns

BACKGROUND: 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 > 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. LEVEL OF EVIDENCE: Epidemiologic study, level IV. Therapeutic study, level V.