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Volume: 3 Issue: 2 June 2023

FULL TEXT

ARTICLE
Are Perianal Burns Really that Dangerous?

ABSTRACT

OBJECTIVES: This study aimed to evaluate burns involving the genitals, perineum, and buttocks of pediatric patients and to compare mortality-related factors with the existing literature.
MATERIALS AND METHODS: We retrospectively investigated 67 pediatric patients admitted for emergency surgery at the Burn Center of Gazi Yaşargil Training and Research Hospital, Turkey, between January 2019 and June 2022.
RESULTS: Mean age of the 67 patients was 3.37 ± 3.73 years. The patients mostly resided in the city, and 17 patients were admitted to the hospital within 1 or more days of the injury. Patients in the 0- to 4-year age group ranked highest in occurrence of perineal burns; the incidence gradually decreased after 4 years of age. Scalding occurred in 59 patients, flame burns in 4 patients, and perineal injuries from electrical burns in 4 patients. Perineal wound culture results were positive for 40.9% patients, with Staphylococcus epidermis being the most common bacteria (37.9%). No patient underwent colostomy as a result of a perianal burn; 2 patients (3.0%) developed sepsis, and 1 patient (1.5%) died.
CONCLUSIONS: The risk of temporary colostomy or ileostomy is reduced in perineal burns when there is adequate early, aggressive, and extensive debridement, in addition to antimicrobial therapy.


KEY WORDS: Morbidity, Mortality, Pediatrics, Perineal burns

INTRODUCTION

Every year, about 1 million people in Turkey are affected by burns, of which only 12 000 to 13 000 receive hospital treatment and approximately 2000 patients die annually.1 In the United States, the total number of burn injuries requiring medical treatment is approximately 450 000 annually, of which 40 000 are hospitalized.2 The lower extremity is the most common body part affected by burn injuries. The perineum is a vital part of the body, both anatomically and functionally, and wound care in the perineum is technically challenging owing to its anatomic location, 3-dimensionality of the region, its proximity to the anus, and the consequent difficulty in controlling fecal contamination. Pediatric patients are often prone to fecal contamination, especially infants and children who have yet to be toilet trained. Therefore, inadequate management of burn wounds in the perineum may result in increased invasive wound sepsis, graft loss, scar contracture, and anal and urinary dysfunction, as well as delayed hospital discharge and greater complications and cost of care.3 In this study, we aimed to evaluate burns involving the genitals, perineum, and buttocks of pediatric patients and compare the mortality-related factors with the existing literature.

MATERIALS AND METHODS

We retrospectively analyzed the hospital records of 67 pediatric patients with perineal burns who were seen at the Burn Center of Gazi Yaşargil Training and Research Hospital, Turkey, between January 2019 and June 2022. All patients admitted to the department were accepted based on American Burn Association criteria. A urinary catheter was inserted in all patients. Patients were hydrated with Ringer lactate following the Galveston formula. Fluid therapy was adjusted to 1 to 2 mL/kg/hour urine output. Nasoenteric feeding were started in patients with severe major burns (total body surface area [TBSA] of >20%) and in patients who could not tolerate oral food. In patients with hemoglobin <8 g/dL, erythrocyte suspension was given to keep hemoglobin above 10 g/dL. We reviewed medical records of each patient to ascertain the etiology of the hot body contacted leading to burn, the demographic characteristics, depth and TBSA of the burn, length of hospital stay, treatment modalities, and morbidity and mortality data.

Statistical analyses

Collected data were entered in MS Excel 2007 worksheets (Microsoft Corp). We used SPSS version 20.0 (IBM Corp) to perform analysis of variance. We calculated significant difference, mean and standard deviation, or median and interquartile range and used the between-group Fisher minimally different post hoc test and the chi-square test to explain the distribution of variables between different groups across statistical data. We used the Mann-Whitney U test to compare 2 or more categorical variable groups (age, sex, burn type, outcome) and multivariate logistic regression analysis to screen for risk factors in burn patients. P < .05 indicated statistical significance.

RESULTS

Of the 67 patients, 44 were male and 23 were female patients. Most patients resided in the city, and 17 patients were admitted to the hospital within 1 day or more Table 1. With regard to perianal burns, the right upper extremity was affected in 5 patients (7.4%), whereas the left upper extremity was affected in 14 patients (20.9%). Abdominal and chest burns were seen in 27 patients (40.3%). Ten patients (14.9%) had burns on their back, and 59 patients (88.1%) had burns on right and left lower extremities each. The 0- to 4-year age group had the most burn injuries, with number of patients with injuries decreasing after the age of 4 years. When we compared the distribution of pediatric perineal burns across different age groups, no significant differences were found (P = .031) Figure 1. Scalding was observed in 59 patients, flame burns in 4 patients, and perineal injuries from electrical burns in 4 patients. We observed that perineal burns were most common in the summer months Figure 2. Perineal burn wound culture results were positive for 40.9% patients, with Staphylococcus epidermis as the most common bacteria (37.9%) Table 2. No patient underwent colostomy due to perianal burn; a urinary catheter was placed during hospitalization to prevent possible bacterial infection in all perineal and genital burns. Most patients were treated with silver sulfadiazine cream 1% dressing daily, and escharectomy was done as required Figure 3. Only 15 patients (22.5%) required graft application for perineal burns. Two patients (3.0%) developed sepsis, and 1 patient (1.5%) died. The average hospital stay for all patients was 5.04 ± 4.17 days. When we compared hospital stay duration for perineal burns versus hospitalization for burns in other body parts, no significant difference was observed (P = .852).

DISCUSSION

Scald burns are reportedly the most common cause of perineal burns,2,3 as also observed in our study. Burn wounds in the gluteal, perineal, and upper thigh areas are associated with numerous complications and are often prone to deep and fecal contamination, especially in pediatric patients who are not yet toilet trained. Antiseptic application is also difficult because of the 3-dimensional contours in the perineal area.3 In our study, patients in the 0- to 4-year age group had the most perineal burns, of which 46.2% were second-degree superficial burns. The high prevalence in the 0- to 4-year age group is probably because these children are unable to realize the danger and their protective reflexes are not well developed, resulting in severe burns. Generally, wound cultures are mixed, with polymicrobial consisting of both aerobic and anaerobic bacteria, as observed in our study Table 2. Whereas the most common bacteria in the literature is Escherichia coli, present in 43% to 80% of cases,4 Staphylococcus epidermidis was the most frequently occurring bacteria in our study. The negative results for perineal wound culture in 40.9% of our patients can be explained by the regular silver sulfadiazine dressing started from the first day of hospitalization, as well as use of a urinary catheter to prevent contamination. Jabir and colleagues5 reported that scalding burns are encountered mostly in winter and least in summer. Turkey, as a country, connects Asia, the Middle East, and Europe, not only geographically, but also culturally. Drinking tea is an everyday practice in Turkey, and brewing tea is the most common tea-making method used by Turkish people. Unfortunately, the preparation procedure is a high-risk situation for children, as it is reported that spillage or food preparation is a common reason for scald burns among children.6 Furthermore, the reported incidence of perineal burns peaks during the spring and summer. In Turkey, scalding burns are also common during this season, especially in children, since yogurt is made from milk in the spring and the highest temperatures are observed in summer. Yogurt is made by first boiling the milk and then cooling it by adding yeast to the milk. Rate of scald was especially shown in the 0- to 4-year age group. In this age group, children are less likely to perceive dangers, have less control over their environment, and react more slowly to situations that could lead to injury, making injury inevitable in young children.7,8 Bordes and colleagues9 suggested a residue-free diet for isolated, deep, and partial perineal burns. Most of our patients had second-degree superficial and deep burns. We fed most of our patients according to this diet. Postoperative fecal diversion is recommended for patients with extensive burns, those with isolated deep perineal burns when there is potential for long-term healing, for patients with comorbidities (American Society of Anesthesiologists score >2), and for patients with wound graft failures.9 Sigmoid end-colostomy with Hartmann closure of the distal end operation is usually performed in patients.10 None of the patients in our study required a fecal diversion operation. Jabir and colleagues5 described the mean healing time for burn wounds in their study as 24.06 days (range, 20-41 days) for children and 32.34 days (range, 15-52 days) for adults. In our study, 75.6% of patients were younger than aged 14 years, and the mean healing time was 23.9 ± 50.0 days. Our findings also support the results of Jabir and colleagues5 and Viljanto and colleagues11that showed that perineal burn wounds heal faster in children than in adults. The reported incidence of sepsis in perineal burns varies between 1% and 13%. Temporary colostomy has been traditionally used to prevent fecal contamination of the burned area in perianal burns.3,12,13 It is noteworthy that none of our patients required a temporary colostomy or ileostomy. For the perianal area, silver dressing was applied after each defecation and cleaning of the area, and a urinary catheter was placed in the genital area. Daily sulfadiazine cream 1% dressing and escharectomy, as required, were administered. Consequently, only 2 patients (3.0%) in our study developed sepsis. Empirical oral or intravenous antibiotic therapy regimen was started in patients who showed signs of sepsis. Antibiotic was thus changed according to the antibiotic susceptibility of the bacterial agent isolated as a result of the culture. Although the patient improved clinically more slowly with empirical treatment, a rapid recovery was observed in the patient when the antibiotic was started according to the culture results. In perianal burns, traditional partial thickness skin grafting is not as successful as with other body parts. The reason for this is mechanical stress and enormous bacterial colonization.14 In our patients, we performed grafting in deep and extensive burns, isolated full-thickness patients, and patients who did not heal despite dressing. Only 22.5% of the patients required graft application for perineal burns. We did meticulous local care after surgery. Close follow-up is necessary to obtain a satisfactory surgical result. Kement and colleagues13 reported a mortality rate of 33.3%, and the TBSA of the patients who died in their study was >50%. Jabir and colleagues5 reported a mortality rate of 0, with a mean TBSA of 3.07% (0.10%-25.50%). In our study, the mortality rate was 1.5%, and our mean TBSA was 9.18 ± 9.13% (range, 4%-35%). Our institution is the only burn center in our region. There are also burn units at the Dicle University Medical Faculty and at Şanlıurfa Mehmet Akif İnan Training and Research Hospital. Injured children are transferred to our burn center by local health centers after primary health care services. Because children with minor burns were omitted from our analysis, investigation of follow-up results for patients without major burns at Dicle University and in the burn units of the Mehmet Akif İnan Training and Research Hospital was a study limitation. Another limitation is the lack of strict follow-up findings because of the retrospective nature of our study.

CONCLUSIONS

Aggressive and extensive debridement should be performed within 48 to 72 hours after burn trauma, in addition to adequate antimicrobial therapy for the treatment of perianal burns. These methods can result in reduced risk of temporary colostomy or ileostomy, especially in pediatric patients. Age-related intrinsic factors accelerate the recovery time of burns in pediatric patients.

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Volume : 3
Issue : 2
Pages : 39 - 43


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From the Gazi Yasargil Training and Research Hospital Department of General Surgery, Diyarbakır, Turkey
Acknowledgements: We thank Gazi Yasargil Teaching and the workers at the Research Hospital General Surgery Clinic. The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Ebral Yiğit, Gazi Yasargil Training and Research Hospital Department of General Surgery, Diyarbakır, Turkey 21090
PHONE: +90 5334889334
E-MAIL:ebralyigit@gmail.com