CASE REPORT Colostomy-Sparing Fecal Diversion in a Child After Extensive Perianal Trauma Nathaniel E. Uecker, MD, Patrick J. O’Neill, PhD, MD, FACS, Salvatore C. Lettieri, MD, FACS, Tammy R. Kopelman, MD, FACS, Kevin N. Foster, MD, MBA, FACS, Marc R. Matthews, MD, FACS, and Daniel M. Caruso, MD, FACS U ncomplicated and expeditious regional wound healing after anorectal, perianal, and perineal trauma can be challenging. Although most wounds in this area will heal with aggressive local dressing care, historical practice had dictated the need for surgical fecal diversion (i.e., colos- tomy) in patients who fail conservative measures or in those that subjectively have extensive, initial soft tissue disease. A recent study in adult burn and debilitated patients has demonstrated regional wound care successes with the use of temporary, nonsurgical fecal diversion (i.e., bowel management systems [BMS] 1 ). However, because of the lack of evidence for nonsurgical diversion tech- niques in children, colostomy remains standard despite the need for future surgery and all the associated physical, psychologic, and emotional liabilities. We report an exam- ple of BMS use (i.e., nonsurgical fecal diversion) in a pediatric patient with extensive back, buttock, and thigh trauma. This new, nonsurgical methodology permitted suc- cessful clinical outcome without colostomy placement and its related morbidities in a child. Case Presentation A helmeted 13-year-old boy (54 kg) was riding a bicycle when he was struck by and pulled under a full- sized city bus. The bus dragged him along the asphalt 25 feet after impact. After a prolonged extrication, he was transported to our level I Adult and Pediatric Trauma Center. On admission, he was tachycardic (110 beats per minute) but had otherwise normal vital signs. He had a nonfocal primary survey and a visibly deformed right femur with an intact lower leg and foot. After completion of the secondary survey, the patient underwent full diag- nostic imaging which revealed pubic rami, sacral, and iliac crest fractures along with closed right tibial and left humeral fractures. A urethral injury was noted by cysto- gram for which a suprapubic cystostomy tube was placed. No other cranial, cervical, thoracic, abdominal, or pelvic internal injuries were diagnosed. A substantial degloving injury was noted to the patient’s posterior torso, bilateral posterolateral thighs, and buttocks approximating 25% total body surface area. The overlying skin was devitalized, minimally bleeding, and grossly contaminated. The patient was taken to the operating room that day for sharp debridement, wound lavage, and orthopedic reduction of the extremity fractures (Fig. 1). Postoperatively, the patient received our standard Burn Center tube feeding diet with a goal intake of 2.0 –3.0 g protein/kg and 50 –55 kcal/kg each day. A stool softener was added to lessen the impact of narcotic-induced constipation often seen in this patient population with a goal of one bowel movement daily or every other day. Standard oral doses of vitamin C, vitamin A, and zinc were also supplemented. During the next 2 weeks, the patient returned to the operating room multiple times for debridement and pulse lavage irrigation of the slowly healing wounds as well as completion of the remaining orthopedic procedures. Initial wound care included multiple daily dressing changes. It was our belief that with such aggressive, local wound care, we might be able to avoid a colostomy and its potential morbidity in this child. Once stooling began, external reservoir systems as well as negative pressure dressings were used in an attempt to keep the surrounding tissue free from fecal contamination. Although largely free of ne- crotic or devitalized tissue by this time, complete wound healing was jeopardized by the proximity to the patient’s anus and the almost daily regional soilage because of stooling despite these labor- and time-intensive efforts (Fig. 2). By 3 weeks postinjury, it was clear that fecal diversion would be necessary to avoid wound infection and subsequent graft failure. Traditional surgical methods for fecal diversion were discussed at length with the family who were justifiably concerned over the potential adverse sequelae of this option in their child. The family then consented to the off-label use of the BMS product (ActiFlo Indwelling Bowel Catheter, Submitted for publication June 11, 2007. Accepted for publication August 15, 2007. Copyright © 2010 by Lippincott Williams & Wilkins From the Division of Burns, Trauma Surgery, and Surgical Critical Care, Mari- copa Medical Center and the Arizona Burn Center, Phoenix, Arizona; and Division of Plastic Surgery, Maricopa Medical Center, Phoenix, Arizona. Presented at the 59th Annual Southwestern Surgical Congress Meeting, Rancho Mirage, CA, March 25–28, 2007. Address for reprints: Patrick J. O’Neill, PhD, MD, FACS, Division of Burns, Trauma Surgery, and Surgical Critical Care, Department of Surgery, Mari- copa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008; email: patrick_oneill@dmgaz.org. DOI: 10.1097/TA.0b013e3181588811 The Journal of TRAUMA ® Injury, Infection, and Critical Care • Volume 68, Number 2, February 2010 E49