SUMMARY. One of the critical sites of the thermal injuries is the region of the perineum. Burns of the perineum are relatively frequent, while affections of the anus and sphincters are rare. At the Prague Burns Centre, University Hospital KralOVSkG Vinohrady, two patients were treated with this kind of injury. The site of the burns proved in both instances decisive for treatment and for subsequent prognosis. The surgical procedures (necrectomy and autotransplantation) had to be prepared with regard to the case-histories: in the 11-year-old boy by colostomy and in the adult man suffering from muscular dystrophy by a synthetic low-residue diet.
Perineum- and Anusverbrennung
Musllovd A., Zajlcek R., Broz L., Konigova R.
Die Perineumregion ist eine den kritischen Stellen den Verb rennungsverletzungen. Die Perineumverbrennung kommt relativ haufig vor, den Anus and die Sphinktere werden aber nun selten befallen. Zwei Patienten mit solcher Verletzung wurden an den Klinik den Verb rennungsmedizin des Fakultatskrankenhauses in Prag behandelt. Die Lokalisation den Verbrennung zeigte sich in den beiden Falle fur die Therapie and weitere Prognose als entscheidend. Operative Eingriffe (Nekrektomie and Autotransplantation) erforderten angesichts den Patientenanamnese adaquate Vorbereitung. Beim elfjahrigen Jungen wurde eine Kolostomie durchgefiihrt. Beim Erwachsenen, den an Muskeldystrophie litt, wurde eine Diat ohne Gluten indiziert.
Key words: electrical injury of the perineum, electrical injury of the anus
The site of thermal injuries is one of the important factors that determines the severity of a burn injury, its prognosis and thus also the need for hospitalization.
One of the important sites (in addition to the face, neck, hands, soles and genitalia) is the area of the perineum and anus. Subjects with extensive thermal injuries affecting the buttocks frequently also have afflictions of the adjacent area of the genitals and perineum. The anus alone is affected only relatively rarely, because anatomically this area is protected by the buttocks and thus there remains a "sound strip of skin". Only in case of prolonged exposure to heat (impossibility of escape, severe injury impeding movement, etc.) or in the case of a local passage of electric current, does a deep and devastating injury to this whole part occur. Treatment of these patients is much more complicated and much more difficult as ensues from the site of injury:
At the Prague Burns Centre, University Hospital Vinohrady, two patients with burns of the perineum affecting also the anus were treated. Although the local injury was similar in both patients, the mechanism of injury, personal history and general course of the treatment was different.
The first patient was a 28-year-old man with full thickness skin loss 17 % BSA on the trunk, buttocks and perineum (Fig. 1). The injury occurred during a motor car crash when he landed under the exhaust pipe and could not escape because of a fracture of the right clavicle and severe muscular dystrophy (a progressive condition deteriorating since the age of two years). During the treatment in our department (after one week in hospital in the surgical ward of the catchment area), deep dry necrosis affecting the chest as well as both buttocks with burns of the m. sphincter ani externus and the posterior area of the scrotum was found. Necrectomy was possible (Fig. 2), but covering the areas with xenografts and later closure with autografts was impossible because of continual passage of faeces from the open anus. The method of choice in these cases is anus praeternaturalis, but the patient refused this method vehemently and the surgeons also hesitated because of the severe muscular dystrophy and muscular atonia of the abdominal wall.
After consultation with nutritionists, a special lowresidue diet was introduced, supplemented during the time of the surgical operations by parenteral nutrition. This special low-residue diet substantially reduced the amount and consistency of faeces; furthermore, intestinal microorganisms were limited to three types (coliform, enterococci, bacteroides), each at levels lower than 103/1 g faeces. Moreover, apparently due to the lack of substrate in the large bowel on the low-residue synthetic diet, no significant proliferation of yeasts occurred.
The burnt areas were autotransplanted only after an 8-day period when the passage of faeces was arrested (Fig. 3).
On the areas G neg. infection (Proteus, E. coli) predominated. Faeces were formed after introduction of the special diet only after 4 days, in very small amounts, and therefore tamponade of the ampulla with release of the contents was sufficient. Control bacteriological examination of faeces after termination of synthetic diet: E. coli, Proteus vulgaris, Proteus morgani.
The patient was discharged on the 48th day after admission with completely healed areas of the burns. He was recommended to attempt soft faeces and to ensure regular and careful dilatation of the internal portion of the anal sphincter and surrounding scars during hygienic procedures. The state of the anal opening was followed up at the out-patient department as stenosis of the circular scars was imminent; however, due to the care of the patient's wife, no further complications developed during the rehabilitation period.
The second similarly affected patient was a 11-yearold child with deep burns of the right upper extremity, left hand, both thighs, the right knee, buttocks and perineum (14 % BSA) (Fig. 4). This injury was caused by the passage of electric current: one contact was on the right upper extremity and the other contact on the inner surfaces of the buttocks and perineum. On the right upper extremity the musculature was completely destroyed; therefore on the third day after admission amputation at two-thirds of the arm was performed, and subsequently, after consultation with orthopaedists, on the 44th day exarticulation in the shoulder joint was made. In the area of the buttocks were deep crater-shaped defects with deep burns of the anus and the perianal region, with a tendency towards deepening. With regards to treatment and further surgery, already on the fourth day colostomy was indicated.
After necrectomy in the gluteal and perianal regions on the 7th and 18th day autografting was performed one week later (Fig. 5). After ATR, scarring and shrinking of the anal regions occurs (Fig. 6), and the anal opening is permeable only by a fingertip; therefore, to prevent further shrinking vaseline longette was inserted into the rectum and anus during "change of dressing". After complete healing a closure of the colostomy was indicated. Before this procedure, the pelvis minor was examined by magnetic resonance to evaluate the state of of the muscles of the pelvic floor and per rectum examination and EMG for functional evaluation of the anal sphincters.
<% createTable "Table I "," Comparison of two cases - histories with a similar site of injury","; Patient 1;Patient 2@;self-sufficiency;zero (severe muscular dystrophy);deteriorated (amputation of right upper extremity)@;year of injury;1975;2000@;age;28 years;11 years@;% affected;17 % BSA;14 % BSA@;treatment as regards perineum;special low residue diet;colostomy@;prognosis;very favourable;uncertain@;family support;wife;incomplete family","",4,300,true %>| <% immagine "Fig. 1","gr0000009.jpg","28-year-old man: severe muscular dystrophy.",230 %> | <% immagine "Fig. 2","gr0000010.jpg","28-year-old man: both buttocks, anus and posterior area of scrotum after necrectomy.",230 %> |
| <% immagine "Fig. 4A)","gr0000012.jpg","",230 %> | <% immagine "Fig. 4A)","gr0000013.jpg","11-year-old boy: A - right upper extremity, B buttocks, perzneal and perianal region.",230 %> |
| <% immagine "Fig. 5","gr0000014.jpg","11-year-old boy: the perineum and buttocks after closure with autografts.",230 %> | <% immagine "Fig. 6","gr0000015.jpg","11-yearold boy: shrinking of the perianal region.",230 %> |
Comparison of the two case histories reveals that at similar sites of injury, the method of treatment and prognosis differ considerably. Injury, despite its limited extent (less than 20 % BSA), led to severe mutilating damage that will call for long-term rehabilitation in both patients. The site of the damage is, in these cases, the main factor that determines the severity and prognosis of the injury.
For treatment in the acute stage, the case-history (associated diseases) is important, and during the rehabilitation period the family history is important, since in children close collaboration with the parents, their understanding and patience are significant. The first patient had a very dedicated wife and therefore the rehabilitation period developed without complications and after a one-year follow-up the patient no longer required dispensary care. The second patient a 11-year-old child - is from an incomplete socially underprivileged family. The mother looks after one-year-older twins in addition to the affected child. The course of rehabilitation and the incidence of further complications in this child is therefore difficult to predict (Tab. 1).