When is fecal diversion for sacral wounds indicated?

Fecal Diversion for Sacral Wounds: Indications and Management

Fecal diversion via colostomy for sacral wounds is indicated in cases of anal sphincter involvement, fecal incontinence, and continued fecal contamination of the wound that impedes healing. 1

Primary Indications for Fecal Diversion

• Anal sphincter involvement - When the wound affects or is in close proximity to the anal sphincter, diversion prevents further tissue damage 1
• Fecal incontinence - Patients unable to control bowel movements leading to repeated wound contamination 1
• Continued fecal contamination - Persistent soiling of the wound despite standard wound care measures 1
• Deep tissue involvement - Extensive sacral wounds with significant depth that are repeatedly contaminated 1
• Pelvic osteomyelitis - Particularly in patients with paraplegia who have pressure injuries complicated by bone infection 1

Decision-Making Algorithm

1. Initial assessment (first 48 hours):

   • Evaluate extent of wound, proximity to anal sphincter, and degree of contamination 1
   • Assess patient's continence status and ability to maintain wound hygiene 1
   • Postpone definitive decision regarding stoma creation for at least 48 hours to allow acute inflammation and edema regression 1

2. Try non-surgical alternatives first:

   • Temporary fecal management systems (rectal tubes) for short-term diversion 1, 2
   • Negative pressure wound therapy (NPWT) combined with fecal management systems 2, 3
   • Regular wound care with frequent dressing changes after bowel movements 1

3. Proceed to surgical diversion if:

   • Non-surgical methods fail to prevent contamination 1
   • Wound healing is significantly impaired by continued fecal contamination 4
   • Patient has paraplegia with recurrent wound infections despite conservative measures 1

Considerations Before Proceeding with Colostomy

• Nutritional status assessment - Hypoalbuminemia (<2.5 g/dL) is associated with significantly higher mortality (11.4% vs 3.5%) following diverting colostomy 5
• Comorbidity evaluation - High ASA class (3-4) patients have increased surgical risk 5
• Risk-benefit analysis - Colostomy carries a potential burden of morbidity and requires subsequent surgical procedure for closure 1
• Cost implications - Temporary stoma formation significantly increases healthcare costs without affecting mortality rates 1

Alternatives to Surgical Colostomy

• Temporary fecal management systems - Rectal tubes can effectively divert fecal matter away from sacral wounds 2, 3
• Combined approach - NPWT with fecal management systems provides protection from contamination while promoting wound healing 2
• Limitations - Temporary devices should be used for limited periods (10-14 days) to avoid intra-rectal damage 1, 6

Multidisciplinary Approach

• Involve general/emergency surgeons, urologists, intensivists, and plastic surgeons early 1
• Consult wound and ostomy nurses for specialized wound care expertise 2
• Consider plastic surgery for complex wound closure once infection is controlled 1

Potential Complications of Colostomy

• Overall 30-day mortality rate of 6.7% for diverting colostomy in pressure ulcer patients 5
• Higher complication rates in colostomy group (55%) compared to primary repair (27%) 7
• Stoma-related complications including parastomal hernias, prolapse, and skin irritation 5
• Need for subsequent surgical procedure for stoma closure 1

Conclusion

While fecal diversion via colostomy is beneficial for wound healing in specific circumstances, it should be reserved for cases where non-surgical alternatives have failed and when the benefits clearly outweigh the risks. The decision should be made after a 48-hour observation period by a multidisciplinary team, with careful consideration of the patient's nutritional status and comorbidities 1, 5.