In a patient with extensive, refractory hidradenitis suppurativa involving the perineal/perianal region who is a surgical candidate, should fecal diversion (temporary loop colostomy) be performed prior to definitive surgery?

Fecal Diversion in Extensive Perineal/Perianal Hidradenitis Suppurativa

Fecal diversion via temporary colostomy should be considered selectively rather than routinely in patients with extensive perineal/perianal hidradenitis suppurativa, reserved primarily for cases where fecal contamination would significantly compromise wound healing after wide excision.

Evidence-Based Approach to Decision-Making

The major North American and British guidelines 1, 2 do not specifically address fecal diversion for perineal HS, but they emphasize multidisciplinary surgical planning for extensive disease. The surgical literature provides clearer guidance on when colostomy is actually necessary.

When Fecal Diversion Is NOT Routinely Required

The best available surgical evidence demonstrates that colostomy is needed in only a minority of cases:

• In a 56-patient series of extensive gluteal/perineal HS, only 41% required diverting colostomy 3
• In a 15-patient series, only 1 patient (6.7%) needed diverting colostomy 4
• A 43-patient retrospective analysis found colostomy was "rarely necessary" 5

Most patients with extensive perineal/perianal HS can undergo wide excision without fecal diversion and achieve successful healing through secondary intention or delayed skin grafting 4, 3.

Specific Indications for Temporary Colostomy

Consider fecal diversion when:

• Wound location: Lesions directly involving or immediately adjacent to the anal verge where fecal contamination is unavoidable
• Wound size: Massive excisions extending circumferentially around the anus
• Delayed skin grafting planned: When you intend to leave wounds open initially then graft (colostomy facilitates graft take) 3
• Severe infection: Extensive necrotic tissue requiring aggressive debridement with high contamination risk
• Patient factors: Inability to maintain adequate wound hygiene or diarrheal conditions

Surgical Strategy Without Colostomy

For most patients, the preferred approach is 4, 3:

1. Wide surgical excision to disease-free margins (this is non-negotiable for cure)
2. Wound management options:
   • Secondary intention healing: 10-12 weeks to complete healing 4, 3
   • Delayed skin grafting: 6-8 weeks total healing time (superior to secondary intention) 4, 3
   • Primary closure with flaps: ~2 weeks healing (limited applicability in extensive disease) 4

Critical Pitfalls to Avoid

• Do not perform skin grafting without adequate wound bed preparation - partial graft loss occurred in 37.5% of cases even with optimal management 3
• Screen for squamous cell carcinoma in long-standing disease (>20-30 years) - this is a life-threatening complication requiring more aggressive surgery including possible abdominoperineal resection 4, 6
• Avoid inadequate excision - conservative approaches and limited excisions lead to near-inevitable recurrence 4, 5

Alternative to Formal Colostomy

For borderline cases, a temporary anal tube sutured into the anorectum can divert feces for 10-14 days during the critical early healing phase, avoiding the morbidity of formal colostomy 7. This technique was successfully used in one HS patient and may represent a middle-ground option.

Perioperative Considerations

• Continue medical therapy (biologics, antibiotics) through the perioperative period 1
• Multidisciplinary team involvement is essential for wound management decisions 2
• Plan for prolonged hospitalization - these patients require extended inpatient wound care regardless of diversion status 4

The decision for fecal diversion should be made jointly by colorectal surgery and dermatology based on specific wound characteristics, not as a routine prophylactic measure. The evidence clearly shows that the majority of patients achieve cure without colostomy when wide excision is performed properly 4, 3, 5.