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Early excision and grafting (EE&G): Opportunity or threat?
JBUR 5231 No. of Pages 3
burns xxx (2017) xxx –xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Letter to the Editor
Early excision and grafting (EE&G): Opportunity or threat? In the past, burn patients used to be treated with dressings and topical antimicrobial agents until the eschar separated spontaneously. If the patient survived, the granulating wound would then be covered with skin graft, a process that could take 3–5 weeks. Patients with severe burns treated in this way, were more likely to die due to sepsis. Furthermore, with this approach, patients’ hospital stay was prolonged, and patients were more talented to develop hypertrophic scarring and contractures due to delayed wound healing. Cope et al. pioneered the concept of early excision and grafting of burn wounds in 1942. Janzekovic in 1970 reintroduced the concept of tangential excision and immediate resurfacing with skin grafting [1]. The goal is to excise all devitalized tissue and render the wound suitable for skin grafting. Early excision and grafting is now the standard surgical management of deep burns and it gradually popularized in our country during last decade. By this technique, an open wound is primarily closed, and thus circumvents the possibility of infection. There is less discomfort, more rapid restoration of function, quicker discharge from hospital, earlier rehabilitation and the decrease of hospital costs [1,2]. Metabolic needs are decreased and with less scar, the cosmetic result is improved. And most importantly, it reduces burn mortality rate. Excision is made between the third and fifth day postburn if possible, but more delay may be necessary to determine which burns are superficial and able to spontaneously heal. Early wound closure also reduces duration of illness, septic complications, and the need for major reconstruction, while decreasing hospital costs [2,3]. Most articles concentrate mostly on EEG advantages rather than its disadvantages. The most important mentioned disadvantages are copious bleeding and severe hemodynamic disturbance. But, very little has been written about human faults and unnecessary excision of superficial burns. I am in a position that many acute burn patients are consulted with me by telemedicine and also direct visit every day. Also I see a significant number of burn patients referred to our clinic for reconstructive surgeries. Unfortunately, acute superficial burn wounds scheduling for EE&G
are not uncommon. On the other hand, in the patients with history of EE&G referred for reconstructive surgeries, there are many patients which spontaneous epithelialization was happened underneath the skin graft and only few remnants of skin graft are seen (Fig. 1). It is due to burn depth misdiagnosis [4]. The important question is why this happens? I think the answer is: 1. Evaluation by an experienced surgeon as to whether a partial-thickness burn will heal in 3 weeks is about 70% accurate [2]. So, more delay may be necessary to determine which burns are superficial and able to spontaneously heal. In the delayed skin grafting era, burn wounds were continuously followed by burn surgeons. So, at the end of the treatment period, their judgment about the burn depth was self evaluated and this was resulted in gradual and persistent increased experience about the course of burn wound healing and increased accuracy of their judgement. But after the popularization of EE&G, these inexpensive and invaluable learning materials have been largely lost. 2. As we know, three zones of a burn were described by Jackson in 1947. Zone of coagulation, at the point of maximum damage with irreversible tissue loss. The surrounding zone of stasis with decreased perfusion but potentially salvageable tissue. And the main aim of burn resuscitation is to increase tissue perfusion of this zone and any additional insults such as prolonged hypotension or infection can convert this zone into an area of complete tissue loss. Zone of hyperemia, the outermost zone with increased tissue perfusion. It will invariably recover unless there is severe sepsis or prolonged hypoperfusion. According to the above mentioned information, majority of burned areas is heterogenous and usually both superficial and deep burns are inseparable neighbors. In the operating room, despite various techniques such as donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and
Please cite this article in press as: A.A. Mohammadi, S. Mohammadi, Early excision and grafting (EE&G): Opportunity or threat?, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.03.021
JBUR 5231 No. of Pages 3
2
burns xxx (2017) xxx –xxx
Fig. 1 – Overestimation of burn depth and unnecessary excision of superficial 2nd degree burn. Spontaneous epithelialization underneath the skin grafted area in a 13 y/o boy, only few remnants of skin graft are being seen.
limb tourniquets, significant blood loss continues to plague early tangential excision of the burn wound [5,6], especially between 2 and 16 days after burn [7]. The surgeon is struggling on two problems. First, fast termination of the surgery to prevent severe hemodynamic disturbance due to copious bleeding and second, accurate differentiation of deep burned areas in a severely bleeding environment to excise them and save the superficial parts. Deciding on which parts should be excised in a severely bleeding area in a very short time is a difficult job and may lead to over or under excision of burned tissues and unfortunately accuracy of depth estimation is sometimes sacrificed in favor of decreased operative time. And according to our investigations on burn registry data, the percentage of mean grafted area per mean burned area has increased significantly (32.35% in the EE&G era compared to 21.72% in the delayed grafting era) in the last few years which EE&G has become the standard method in our burn center and unfortunately this simply means increasing the severity of injury in a severely injured patient which seeks our help. To overcome these unwanted catastrophic faults, we recommend: 1. Preoperative clinical and Laser Doppler (if available) assessment and marking of burned areas as superficial and suspicious zone (not to be excised) and deep zone (to be excised) by experienced senior burn surgeons rather than intra-operative hasty inaccurate decision. The suspicious area should never be excised. It should be followed and managed based on next few days findings. 2. Planning staged EE&G and limit each operative session to excise 20% TBSA as far as possible, for better concentration on accuracy rather than speed of operation, especially in
the low experienced (EE&G) centers, despite adoption of all efforts at decreasing blood loss. 3. EE&G is not the only method of burn management and delayed grafting method is still worthy in many burn patients. Since the most important advantage of EE&G is decreasing mortality rate in extensive burns, it is rational for low experienced burn surgeons to be more conservative in less extensive burns with mostly partial thickness or unidentifiable burn depth to avoid harming the patient with over-excision of burned areas and also imposing more donor site deformity. REFERENCES
[1] Saaiq M, Zaib S, Ahmad S. Early excision and grafting versus delayed excision and grafting of deep thermal burns up to 40% total body surface area: a comparison of outcome. Age (yr) 201229(14.3) 28.8–14.4. [2] Mohammadi AA, Bakhshaeekia AR, Marzban S, Abbasi S, Ashraf AR, Mohammadi MK, et al. Early excision and skin grafting versus delayed skin grafting in deep hand burns (a randomised clinical controlled trial). Burns 2011;37(1):36–41. [3] Anzarut A, Chen M, Shankowsky H, Tredget EE. Quality-of-life and outcome predictors following massive burn injury. Plast Reconstr Surg 2005;116(3):791–7. [4] Mohammadi AA, Bakhshaeekia AR. Epithelial bridge: a cosmetic problem associated with early excision and grafting of burned hands, that indicates burn depth misdiagnosis. Burns 2009;35(7):1049–50. [5] Cartotto R, Musgrave MA, Beveridge M, Fish J, Gomez M. Minimizing blood loss in burn surgery. J Trauma 2000;49 (6):1034–9. [6] Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns 2006;32(2):145–50.
Please cite this article in press as: A.A. Mohammadi, S. Mohammadi, Early excision and grafting (EE&G): Opportunity or threat?, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.03.021
JBUR 5231 No. of Pages 3
3
burns xxx (2017) xxx –xxx
[7] Desai MH, Herndon DN, Broemeling L, Barrow RE, Nichols Jr. RJ, Rutan RL. Early burn wound excision significantly reduces blood loss. Ann Surg 1990;211(6)753–9 discussion 9–62.
Ali Akbar Mohammadi* Burn and Wound Healing Research Center, Plastic and Reconstructive Surgery Ward, Shiraz University of Medical Sciences, Shiraz, Iran
* Corresponding author. E-mail address: [email protected] (Aa. Mohammadi). Available online xxx http://dx.doi.org/10.1016/j.burns.2017.03.021 © 2017 Elsevier Ltd and ISBI. All rights reserved.
Soheil Mohammadi Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
Please cite this article in press as: A.A. Mohammadi, S. Mohammadi, Early excision and grafting (EE&G): Opportunity or threat?, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.03.021
burns xxx (2017) xxx –xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Letter to the Editor
Early excision and grafting (EE&G): Opportunity or threat? In the past, burn patients used to be treated with dressings and topical antimicrobial agents until the eschar separated spontaneously. If the patient survived, the granulating wound would then be covered with skin graft, a process that could take 3–5 weeks. Patients with severe burns treated in this way, were more likely to die due to sepsis. Furthermore, with this approach, patients’ hospital stay was prolonged, and patients were more talented to develop hypertrophic scarring and contractures due to delayed wound healing. Cope et al. pioneered the concept of early excision and grafting of burn wounds in 1942. Janzekovic in 1970 reintroduced the concept of tangential excision and immediate resurfacing with skin grafting [1]. The goal is to excise all devitalized tissue and render the wound suitable for skin grafting. Early excision and grafting is now the standard surgical management of deep burns and it gradually popularized in our country during last decade. By this technique, an open wound is primarily closed, and thus circumvents the possibility of infection. There is less discomfort, more rapid restoration of function, quicker discharge from hospital, earlier rehabilitation and the decrease of hospital costs [1,2]. Metabolic needs are decreased and with less scar, the cosmetic result is improved. And most importantly, it reduces burn mortality rate. Excision is made between the third and fifth day postburn if possible, but more delay may be necessary to determine which burns are superficial and able to spontaneously heal. Early wound closure also reduces duration of illness, septic complications, and the need for major reconstruction, while decreasing hospital costs [2,3]. Most articles concentrate mostly on EEG advantages rather than its disadvantages. The most important mentioned disadvantages are copious bleeding and severe hemodynamic disturbance. But, very little has been written about human faults and unnecessary excision of superficial burns. I am in a position that many acute burn patients are consulted with me by telemedicine and also direct visit every day. Also I see a significant number of burn patients referred to our clinic for reconstructive surgeries. Unfortunately, acute superficial burn wounds scheduling for EE&G
are not uncommon. On the other hand, in the patients with history of EE&G referred for reconstructive surgeries, there are many patients which spontaneous epithelialization was happened underneath the skin graft and only few remnants of skin graft are seen (Fig. 1). It is due to burn depth misdiagnosis [4]. The important question is why this happens? I think the answer is: 1. Evaluation by an experienced surgeon as to whether a partial-thickness burn will heal in 3 weeks is about 70% accurate [2]. So, more delay may be necessary to determine which burns are superficial and able to spontaneously heal. In the delayed skin grafting era, burn wounds were continuously followed by burn surgeons. So, at the end of the treatment period, their judgment about the burn depth was self evaluated and this was resulted in gradual and persistent increased experience about the course of burn wound healing and increased accuracy of their judgement. But after the popularization of EE&G, these inexpensive and invaluable learning materials have been largely lost. 2. As we know, three zones of a burn were described by Jackson in 1947. Zone of coagulation, at the point of maximum damage with irreversible tissue loss. The surrounding zone of stasis with decreased perfusion but potentially salvageable tissue. And the main aim of burn resuscitation is to increase tissue perfusion of this zone and any additional insults such as prolonged hypotension or infection can convert this zone into an area of complete tissue loss. Zone of hyperemia, the outermost zone with increased tissue perfusion. It will invariably recover unless there is severe sepsis or prolonged hypoperfusion. According to the above mentioned information, majority of burned areas is heterogenous and usually both superficial and deep burns are inseparable neighbors. In the operating room, despite various techniques such as donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and
Please cite this article in press as: A.A. Mohammadi, S. Mohammadi, Early excision and grafting (EE&G): Opportunity or threat?, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.03.021
JBUR 5231 No. of Pages 3
2
burns xxx (2017) xxx –xxx
Fig. 1 – Overestimation of burn depth and unnecessary excision of superficial 2nd degree burn. Spontaneous epithelialization underneath the skin grafted area in a 13 y/o boy, only few remnants of skin graft are being seen.
limb tourniquets, significant blood loss continues to plague early tangential excision of the burn wound [5,6], especially between 2 and 16 days after burn [7]. The surgeon is struggling on two problems. First, fast termination of the surgery to prevent severe hemodynamic disturbance due to copious bleeding and second, accurate differentiation of deep burned areas in a severely bleeding environment to excise them and save the superficial parts. Deciding on which parts should be excised in a severely bleeding area in a very short time is a difficult job and may lead to over or under excision of burned tissues and unfortunately accuracy of depth estimation is sometimes sacrificed in favor of decreased operative time. And according to our investigations on burn registry data, the percentage of mean grafted area per mean burned area has increased significantly (32.35% in the EE&G era compared to 21.72% in the delayed grafting era) in the last few years which EE&G has become the standard method in our burn center and unfortunately this simply means increasing the severity of injury in a severely injured patient which seeks our help. To overcome these unwanted catastrophic faults, we recommend: 1. Preoperative clinical and Laser Doppler (if available) assessment and marking of burned areas as superficial and suspicious zone (not to be excised) and deep zone (to be excised) by experienced senior burn surgeons rather than intra-operative hasty inaccurate decision. The suspicious area should never be excised. It should be followed and managed based on next few days findings. 2. Planning staged EE&G and limit each operative session to excise 20% TBSA as far as possible, for better concentration on accuracy rather than speed of operation, especially in
the low experienced (EE&G) centers, despite adoption of all efforts at decreasing blood loss. 3. EE&G is not the only method of burn management and delayed grafting method is still worthy in many burn patients. Since the most important advantage of EE&G is decreasing mortality rate in extensive burns, it is rational for low experienced burn surgeons to be more conservative in less extensive burns with mostly partial thickness or unidentifiable burn depth to avoid harming the patient with over-excision of burned areas and also imposing more donor site deformity. REFERENCES
[1] Saaiq M, Zaib S, Ahmad S. Early excision and grafting versus delayed excision and grafting of deep thermal burns up to 40% total body surface area: a comparison of outcome. Age (yr) 201229(14.3) 28.8–14.4. [2] Mohammadi AA, Bakhshaeekia AR, Marzban S, Abbasi S, Ashraf AR, Mohammadi MK, et al. Early excision and skin grafting versus delayed skin grafting in deep hand burns (a randomised clinical controlled trial). Burns 2011;37(1):36–41. [3] Anzarut A, Chen M, Shankowsky H, Tredget EE. Quality-of-life and outcome predictors following massive burn injury. Plast Reconstr Surg 2005;116(3):791–7. [4] Mohammadi AA, Bakhshaeekia AR. Epithelial bridge: a cosmetic problem associated with early excision and grafting of burned hands, that indicates burn depth misdiagnosis. Burns 2009;35(7):1049–50. [5] Cartotto R, Musgrave MA, Beveridge M, Fish J, Gomez M. Minimizing blood loss in burn surgery. J Trauma 2000;49 (6):1034–9. [6] Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns 2006;32(2):145–50.
Please cite this article in press as: A.A. Mohammadi, S. Mohammadi, Early excision and grafting (EE&G): Opportunity or threat?, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.03.021
JBUR 5231 No. of Pages 3
3
burns xxx (2017) xxx –xxx
[7] Desai MH, Herndon DN, Broemeling L, Barrow RE, Nichols Jr. RJ, Rutan RL. Early burn wound excision significantly reduces blood loss. Ann Surg 1990;211(6)753–9 discussion 9–62.
Ali Akbar Mohammadi* Burn and Wound Healing Research Center, Plastic and Reconstructive Surgery Ward, Shiraz University of Medical Sciences, Shiraz, Iran
* Corresponding author. E-mail address: [email protected] (Aa. Mohammadi). Available online xxx http://dx.doi.org/10.1016/j.burns.2017.03.021 © 2017 Elsevier Ltd and ISBI. All rights reserved.
Soheil Mohammadi Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
Please cite this article in press as: A.A. Mohammadi, S. Mohammadi, Early excision and grafting (EE&G): Opportunity or threat?, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.03.021