- Email: [email protected]
A call for evidence: Timing of surgery in burns
617
burns 38 (2012) 614–618
Rejection delay (day)
18 16 14 12 10 8 6 4 2 0 0,0
0,5
1,0
1,5
2,0
OD (570 nm)
Fig. 1 – Evaluation of the rejection delay and the viability of the cryopreserved skin (optical density at 570 nm adjusted for weight). Statistical analyses were performed by Spearman test (Rho = S0.22, p = 0.46).
unstable overall health status of the patients, the administration of vasopressors, the local infectious processes within the skin, and the quality of surgical excision are also factors that directly influence whether skin grafts take. Lastly, what is the relevance of the MTT assay relative to the viability in clinical settings?
1.
Conflict of interest
*Corresponding author at: Service de chirurgie ge´ne´rale, plastique et ambulatoire, AP-HP Hoˆtel-Dieu, 1 place parvis Notre Dame, 75004 Paris, France. Tel.: +33 1 42 34 80 63; fax: +33 1 42 34 82 21 E-mail addresses: [email protected] [email protected] (S. Gaucher) 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.12.025
None.
references
Letter to the Editor [1] Klein MB, Shaw D, Barese S, Chapo GA, Cuono CB. A reliable and cost-effective in vitro assay of skin viability for skin banks and burn centers. J Burn Care Rehabil 1996;17:565–70. [2] Bravo D, Rigley TH, Gibran N, Strong DM, Newman-Gage. Effect of storage and preservation methods on viability in transplantable human skin allografts. Burns 2000;26: 367–78. [3] Castagnoli C, Alotto D, Cambieri I, Casimiri R, Aluffi M, Stella M, et al. Evaluation of donor skin viability: fresh and cryopreserved skin using tetrazolium assay. Burns 2003;29:759–67. [4] Gaucher S, Elie C, Ve´rola O, Jarraya M. Viability of cryopreserved human skin allografts: effects of transport media and cryoprotectant. Cell Tissue Bank February 2011 [Epub ahead of print]. [5] Kearney JN, Wheldon LA, Gowland G. Cryopreservation of skin using a murine model: validation of prognostic viability assay. Cryobiology 1990;27:24–30.
Sonia Gauchera,b,c,* Universite´ Paris Descartes, Paris Sorbonne Cite´, 75006 Paris, France b Service de chirurgie ge´ne´rale, plastique et ambulatoire, AP-HP Hoˆtel-Dieu, 75004 Paris, France c Service des bruˆle´s, AP-HP Hoˆpital Cochin, 75014 Paris, France
a
Mohamed Jarraya Banque des Tissus Humains, AP-HP Hoˆpital Saint Louis, 75010 Paris, France
A call for evidence: Timing of surgery in burns Dear Editor, Despite the progress in burn care, there is still no worldwide consensus on the best timing of surgery in burns. In some countries, for example the United Kingdom (UK), early excision and grafting is well accepted, while in other countries, like the Netherlands, delayed excision and grafting is the usual approach. This difference was the topic of a ‘‘battle’’ between two burn surgeons: A. Kay, Royal Centre for Defence Medicine (UK) and G.I.J.M. Beerthuizen, Martini Hospital Groningen (The Netherlands), organised at the European Burn Association Congress in The Hague on September 24th, 2011. Kay presented his vision: early excision and grafting, why not? In his opinion, early excision in massive deep burns should be performed at admission when the burns are scrubbed for proper assessment and escharotomies might be performed. Kay stated that it would be illogical to stop at this point and not remove the dead tissue that stimulates the ongoing inflammatory response. He referred to a metaanalysis [1] in which several studies, published since the introduction of early excision and grafting in the 1970s, are combined. The authors of this review concluded that early excision and grafting is beneficial in reducing mortality and
618
burns 38 (2012) 614–618
length of hospital stay, but has the drawback of a greater volume of blood loss. Beerthuizen on the other hand, had an opposite opinion: he prefers delayed excision and grafting in burns. He doubted whether the studies that presented a lower mortality in patients treated with early excision and grafting are still valid at this moment. He stated that the improved total burn care has decreased the mortality rates in burns, in both early and delayed excision, and shifted the attention to morbidity (e.g. scarring). Especially early excision and grafting might exacerbate morbidity because clinical assessment of burn wounds (size and depth) in the first days post injury often leads to overestimation [2], and consequently could lead to overzealous excision. Another reason to be reluctant to early excision and grafting is that this warrants surgery in an unstable patient. An operation while the patient is still in its resuscitation phase, will cause an additional loss of blood [1] and might worsen the condition and prognosis of the patient. To conclude, the results of previous research on early excision and grafting have not led to convincing evidence on the best timing of surgery in burns. In addition, recent guidelines (EBA, ABA, ANZBA) leave this decision to the burn care specialist [3–5]. Early excision might reduce mortality and length of hospital stay but has the drawback of performing surgery on an unstable patient and the risk of unnecessary surgery. All things considered, there is a need for more evidence on this topic. With this letter we would encourage burn care specialists to publish their experience with early vs. delayed grafting or even conduct a randomised controlled trial in order to settle this ‘battle’.
Conflict of interest statement There are no financial or personal relationships which have biased our letter. We did not receive any grants or funding to write this letter.
The authors are preparing a Cochrane systematic review about ‘early excision and grafting in burns’.
references
[1] Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns 2006;32(March (2)):145–50. [2] Monstrey S, Hoeksema H, Verbelen J, Pirayesh A, Blondeel P. Assessment of burn depth and burn wound healing potential. Burns 2008;34(September (6)):761–9. [3] http://www.euroburn.org/userfiles/users/36/pdf/guidelines/ EBAGuidelinesBurnCareVersion1.pdf. [4] http://www.ameriburn.org/Chapter14.pdf. [5] http://anzba.org.au/phocadownload/ahp%20guidelines%20 edition%202%20%20final%20copy%20october%202007.pdf.
M.J. Hop* C.J. Hoogewerf M.E. van Baar Association of Dutch Burn Centres (ADBC), Maasstad Hospital Rotterdam, Netherlands C.H. van der Vlies Maasstad Hospital Rotterdam, Netherlands E. Middelkoop Association of Dutch Burn Centres (ADBC), Red Cross Hospital Beverwijk, Netherlands *Corresponding author. Tel.: +31 6 489 256 10 E-mail address: [email protected] (M.J. Hop) 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2012.01.013
burns 38 (2012) 614–618
Rejection delay (day)
18 16 14 12 10 8 6 4 2 0 0,0
0,5
1,0
1,5
2,0
OD (570 nm)
Fig. 1 – Evaluation of the rejection delay and the viability of the cryopreserved skin (optical density at 570 nm adjusted for weight). Statistical analyses were performed by Spearman test (Rho = S0.22, p = 0.46).
unstable overall health status of the patients, the administration of vasopressors, the local infectious processes within the skin, and the quality of surgical excision are also factors that directly influence whether skin grafts take. Lastly, what is the relevance of the MTT assay relative to the viability in clinical settings?
1.
Conflict of interest
*Corresponding author at: Service de chirurgie ge´ne´rale, plastique et ambulatoire, AP-HP Hoˆtel-Dieu, 1 place parvis Notre Dame, 75004 Paris, France. Tel.: +33 1 42 34 80 63; fax: +33 1 42 34 82 21 E-mail addresses: [email protected] [email protected] (S. Gaucher) 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.12.025
None.
references
Letter to the Editor [1] Klein MB, Shaw D, Barese S, Chapo GA, Cuono CB. A reliable and cost-effective in vitro assay of skin viability for skin banks and burn centers. J Burn Care Rehabil 1996;17:565–70. [2] Bravo D, Rigley TH, Gibran N, Strong DM, Newman-Gage. Effect of storage and preservation methods on viability in transplantable human skin allografts. Burns 2000;26: 367–78. [3] Castagnoli C, Alotto D, Cambieri I, Casimiri R, Aluffi M, Stella M, et al. Evaluation of donor skin viability: fresh and cryopreserved skin using tetrazolium assay. Burns 2003;29:759–67. [4] Gaucher S, Elie C, Ve´rola O, Jarraya M. Viability of cryopreserved human skin allografts: effects of transport media and cryoprotectant. Cell Tissue Bank February 2011 [Epub ahead of print]. [5] Kearney JN, Wheldon LA, Gowland G. Cryopreservation of skin using a murine model: validation of prognostic viability assay. Cryobiology 1990;27:24–30.
Sonia Gauchera,b,c,* Universite´ Paris Descartes, Paris Sorbonne Cite´, 75006 Paris, France b Service de chirurgie ge´ne´rale, plastique et ambulatoire, AP-HP Hoˆtel-Dieu, 75004 Paris, France c Service des bruˆle´s, AP-HP Hoˆpital Cochin, 75014 Paris, France
a
Mohamed Jarraya Banque des Tissus Humains, AP-HP Hoˆpital Saint Louis, 75010 Paris, France
A call for evidence: Timing of surgery in burns Dear Editor, Despite the progress in burn care, there is still no worldwide consensus on the best timing of surgery in burns. In some countries, for example the United Kingdom (UK), early excision and grafting is well accepted, while in other countries, like the Netherlands, delayed excision and grafting is the usual approach. This difference was the topic of a ‘‘battle’’ between two burn surgeons: A. Kay, Royal Centre for Defence Medicine (UK) and G.I.J.M. Beerthuizen, Martini Hospital Groningen (The Netherlands), organised at the European Burn Association Congress in The Hague on September 24th, 2011. Kay presented his vision: early excision and grafting, why not? In his opinion, early excision in massive deep burns should be performed at admission when the burns are scrubbed for proper assessment and escharotomies might be performed. Kay stated that it would be illogical to stop at this point and not remove the dead tissue that stimulates the ongoing inflammatory response. He referred to a metaanalysis [1] in which several studies, published since the introduction of early excision and grafting in the 1970s, are combined. The authors of this review concluded that early excision and grafting is beneficial in reducing mortality and
618
burns 38 (2012) 614–618
length of hospital stay, but has the drawback of a greater volume of blood loss. Beerthuizen on the other hand, had an opposite opinion: he prefers delayed excision and grafting in burns. He doubted whether the studies that presented a lower mortality in patients treated with early excision and grafting are still valid at this moment. He stated that the improved total burn care has decreased the mortality rates in burns, in both early and delayed excision, and shifted the attention to morbidity (e.g. scarring). Especially early excision and grafting might exacerbate morbidity because clinical assessment of burn wounds (size and depth) in the first days post injury often leads to overestimation [2], and consequently could lead to overzealous excision. Another reason to be reluctant to early excision and grafting is that this warrants surgery in an unstable patient. An operation while the patient is still in its resuscitation phase, will cause an additional loss of blood [1] and might worsen the condition and prognosis of the patient. To conclude, the results of previous research on early excision and grafting have not led to convincing evidence on the best timing of surgery in burns. In addition, recent guidelines (EBA, ABA, ANZBA) leave this decision to the burn care specialist [3–5]. Early excision might reduce mortality and length of hospital stay but has the drawback of performing surgery on an unstable patient and the risk of unnecessary surgery. All things considered, there is a need for more evidence on this topic. With this letter we would encourage burn care specialists to publish their experience with early vs. delayed grafting or even conduct a randomised controlled trial in order to settle this ‘battle’.
Conflict of interest statement There are no financial or personal relationships which have biased our letter. We did not receive any grants or funding to write this letter.
The authors are preparing a Cochrane systematic review about ‘early excision and grafting in burns’.
references
[1] Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns 2006;32(March (2)):145–50. [2] Monstrey S, Hoeksema H, Verbelen J, Pirayesh A, Blondeel P. Assessment of burn depth and burn wound healing potential. Burns 2008;34(September (6)):761–9. [3] http://www.euroburn.org/userfiles/users/36/pdf/guidelines/ EBAGuidelinesBurnCareVersion1.pdf. [4] http://www.ameriburn.org/Chapter14.pdf. [5] http://anzba.org.au/phocadownload/ahp%20guidelines%20 edition%202%20%20final%20copy%20october%202007.pdf.
M.J. Hop* C.J. Hoogewerf M.E. van Baar Association of Dutch Burn Centres (ADBC), Maasstad Hospital Rotterdam, Netherlands C.H. van der Vlies Maasstad Hospital Rotterdam, Netherlands E. Middelkoop Association of Dutch Burn Centres (ADBC), Red Cross Hospital Beverwijk, Netherlands *Corresponding author. Tel.: +31 6 489 256 10 E-mail address: [email protected] (M.J. Hop) 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2012.01.013