Annals of the M.B.C. - vol. 1° - n° 2 - September 1988 IS EARLY SURGICAL TREATMENT STILL THE BEST SOLUTION FOR DEEP BURNS? Mahler D., Ben-Meir R, Ben-Yakar 1, Hauben D., Greber B., Sagi A.
SUMMARY. Early surgical excision with immediate autografting has long become an alternative treatment to the more conventional procedure of autografting after spontaneous separation and bedside debridement of deep bum eschars. In the Soroka Medical Center the year 1975 was a crossroad date, for prior to that year all bums were treated by the conservative method while since then early tangential excision and early skin grafting has been applied as the treatment of choice. Between the years 1964-1974 1100 bum patients were hospitalized in our Dept. 255 of them suffered from deep bums and were treated conservatively by bathing with various solutions and dressings with occlusive bandages with various antibiotic powder or ointment. After a good granulation tissue was obtained a sj~in grafting was performed. Between the years 1975-1985, 4734 bum patients were admitted to the same Dept. 934 of them suffered from deep bums and were treated by early tangential excision and early skin grafting in the first instance and with Jobst pressure garment, occupational therapy and physiotherapy afterwards. This early surgical treatment by comparison with the conservative treatment shortened morbidity, reduced the hospital stay, minimized the need for secondary operations, lowered the mortality from 33% to 2.71% and led to good functional and cosmetic results, enabling the affected patients to quickly return to normal routine life and activity. Early Surgical Excision with immediate autografting has long become an alternative treatment to the more conventional procedure of grafting after spontaneous sloughing and long bedside treatment of deep bum eschars. One must not forget, on the other hand, that resuscitation of burns and knowledge of fluid-electrolytes balance have made outstanding progress since the time of the "conservative period". These two parameters, together with early excision and grafting, as well as other factors (such as Jobst pressure garments), share the responsibility for the improvement in the treatment of burns.Yet, "improvement" is a subjective evaluative description, and most comparative studies of burns fail to prove objectively the exact parameters of this improvement. In the presented study it seems that due to technical reasons we can achieve some "objective" results, although we cannot ignore the above mentioned accessory parameters. In the Soroka University Hospital the year 1975 was a crossroad date, for prior to that year all bums were treated by the Conservative method, while since then the Early Tangential Excision with Early Grafting has been applied as the treatment of choice. The distribution of burned patients in this study is as follows:
The treatment in the Surgical period was based on as early as possible tangential excision of the bum eschar and early grafting, together with early physiotherapy, occupational therapy and Jobst pressure garments. One can judge the improvement in 3 different categories: A. Mortality B. Duration of hospitalisation C. Number of secondary operations needed A. Mortality: Although many
factors play their role in the mortality of bums, there is no doubt that shortening of the
morbidity, together with reduction of infection, play an im 1 portant role in the
reduction of mortality.
B. Duration of Hospitalisation: This parameter is an exact indicator for the subjective evaluation of "improvement". As a rule, no one would hold a patient hospitalised for an unnecessary period, and the large number of patients in this series eliminates artifacts such as excessive stay due to social reasons, etc. The statistics are as follows:
It is clearly and significantly presented that patients in the Conservative phase stayed in hospital much longer periods than in the Surgical one. There is no doubt that the primary factor for this improvement can be no other than Early Surgical Treatment. C. Number of Secondary Operations Needed: Excellent results in treating severe, deep burns could be assessed on the basis of complete take of the grafts with no physical deficit and no need for secondary repairs. Thus the parameter of secondary repairs can play a role as an indicator for "improvement" in the treatment of burns. Going to the tables we can easily learn that the treatment of burns has been far better improved in the Surgical period compared with the previous Conservative one:
RESUME.
L'excision chirurgicale précoce avec autogreffe immédiate est depuis longtemps
devenue un traitement alternatif aux procédures plus conventionnelles de l'autogreffe
après la séparation spontanée et la chute de la croûte de la brûlure profonde. Dans
le Centre Médical de Soroka, l'année 1975 fut de grande importance car avant
cette date les brûlures étaient soignées selon une méthode de conservation tandis que,
à partir de cette année-là, on choisit de soigner les brûlés en pratiquant une rapide
excision tangentielle et la greffe immédiate de la peau. |
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