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.

Department of Plastic Surgery and Burns
Soroka University Hospital, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel


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:

Years

N°. of burns N°. of deep burns
1964-1974
(Conservative)
1100 255
1975-1985 4734 934

"Conservative Treatment" consisted of bathing with various solutions and applying occlusive dressings with various antibiotic and bactericidal ointments or powders. After "Good Granulation Tissue" was obtained (at least 3 weeks post-bum) skin grafting was performed.
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.
The figures in our comparative study are:

Total Mortality Rate

Period N°. of deep burns N°. of deaths %
Conservative 255 49 19.21
Surgical 934 15 1.6

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:

Duration of Hospitalisation

Days Conservative period Surgical period
% %

A. Patients with 1-10% BSA

< 7 - - 203 27.9
8 - 21 3 2.8 487 66.8
22 - 43 64 40.4 39 5.3
44 - 65 29 27.4 - -
66 - 110 10 9.4 - -
111 < - - - -
B. Patients with 11-40% BSA
< 7 - - 5 3.1
8 - 21 2 2.6 89 55.3
22 - 43 30 39.5 43 26.7
44 - 65 15 19.7 19 11.8
66 - 110 15 19.7 2 1.2
111 < 14 18.4 3 1.9
C. Patients with over 40% BSA
< 7 - - - -
8 - 21 - - 16 36.4
22 - 43 2 13.3 14 31.8
44 - 65 4 26.7 3 6.9
66 - 110 1 6.7 6 13.6
111 < 8 53.3 5 11.4

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:

C-1: Number of patients needing secondary repair due
to contracted scars:

  N° of patients %
Conservative p. 85/255 33.3
Surgical p. 27/934 2.9

C-2: Number of operations needed as a later repair due
to contracted scars:
P 0/0001

N° of operation

Conservative p. Surgical p.
  % %
1 22 8.6 17 1.8
2 21 8.2 8 0.8
3 19 7.4 2 0.2
4 < 23 9.0 - -

In conclusion one can clearly see that Early Surgical Treatment of the Deep Burn offers major advantages over the Conservative: reducing the mortality rate, shortening hospital stay and minimizing the need for secondary operations.

 

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.
Entre 1964 et 1975, 1100 brûlés furent hospitalisés dans notre unité; 255 souffraient de brûlures graves, soignés selon le système traditionnel à base de solutions variées, de gazes, d'antibiotiques ou de pomades. Après la formation d'un bon tissu de granulation on effectuait la greffe de la peau. Entre 1975 et 1985, 4734 brûlés furent admis et soignés en pratiquant immédiatement l'excision tangentielle et la greffe précoce de la peau, suivies par le vêtement à pression Jobst, la thérapie professionelle et la physiothérapie. Ce traitement chirurgical immédiat par rapport au traitement traditionnel atténue la morbidité, réduit le séjour à l'hôpital, minimise la nécessité d'autres opérations, réduit le risque de mortalité de 33% à 2,71% et permet au brûlé de recouvrer le bon fonctionnement de ses moyens et de reprende rapidement la vie normale et ses activités.




 

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