ANALELE UNIVERSITII DUNREA DE JOS GALAI MEDICIN FASCICULA XVII, no 2, 2012

REVIEW ARTICLE ARGUMENTS FOR PERFORMING EARLY EXCISION AND GRAFTING IN MAJOR BURNS
Carmen Chelmus1, Vald Mircea Enescu2
Plastic surgery department, Sf. Andrei Emergency County Hospital Galati, Romania Carol Davila University of Medicine a nd Pharmacy, Bucharest, Romania chelmuscarmen@yahoo.com

ABSTRACT
Major burns represent a public health problem worldwide. Early excision and grafting (EGP) of burns has largely replaced conservative approach in most of the burn centers in the world. Although conservative treatment is still practiced in certaines burn centers, there are enough arguments for using this technique for major burns. KEYWORDS: early excision and grafting, burn excision and grafting

treatment, morbidity.[10] Major burns must be considered rather systemic illness than simple skin lession, because they induce changes at the level of each organ of the burned body.[1] They represent an important problem of public health, worldwide, because of severity of the lession, long term, complexity and pluridiciplinarity of the treatment, necessity of specialized medical staff and equipment, complications, great number and gravity of This article try to explains, in short, the reasons for EGP have a key position in the treatment of great burns. Local injury[9-20] From an histopathological point of view, local wound was outlined, by David Jackson, in 1953, in three zones. Zone of necrosis or zone of coagulation is found in the centre of the injury. In this zone the tissue is dead and it is unsalvageable, in spite of the modern treatment methods. The zone of necrosis is a good environment for bacterial multiplication and it can become colonized and even infected and in this way it can be a source of bacterias for sepsis. Zone of stasis or ischaemia is found at the periphery and in the depth of the zone of necrosis.

reserved

prognosis,

possible

devastating and definitive functional, esthetic and psychical sequelae and great social costs which they can generate.[2-9] The precocity and the correctitude of the treatment have an important role in the evolution of burn and they reflect themselves in indices like mortality, lenght of hospital stay, costs of the

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Here, infected tissue is affected by the heat but still viable. This zone may evoluate either towards recovery if there is proper treatment or towards necrosis if local or systemic factors as infection, sepsis, local traumas, inflammation, oedema,

of retracted or hpertrophic scars or keloids. These scars can determine functional/esthetic/psychic

sequelae which prevent patient integration in social life as active member. Granulating is a manner of evolution of a large full thickness burn, when the contraction of the

inadequate treatment intervene. Zone of hiperemia or inflammation is found at the perphery and in the depth of the zone of stasis. At the level of this zone, tissue damage is minimum, there is vasodilatation produced by the released mediators and by local inflammatory process which will lead to extravasation of the fluids from blood vessel to interstitial space, leading to formation of the oedema in burn tissue. Local, the heat releasing as free induces toxic produces radicals, lipoproteic

wound and the migration of the marginal epithelium are not enough for the recovery of the wound. After burn occurrence, the zone of necrosis becomes shortly contamined (hours or days). The burn wound flora helps in eliminating the eschar, but this process is long and there is the risk of local or systemic infetion. Eschar elimination can be made surgicaly, too. After eschar elimination, spontaneously or surgicaly, the lack of the soft tissue is filled up with vascular and connective tissue, named granulation tissue. Experimental studies have shown that recovery by grafting a granulation tissue is exposed to the same risk as spontaneously recovery, that is later the graftig is made greater the risk of occurrence of keloids or hipertrofic scars at the borders of the graft. The deepening of burns occurs when there are local risk facctors (reduced blood flood, increased inflammation, infections, traumas) or sistemic risk factors (sepsis, hipovolemia, incresead catabolism, chronic diseases) All these findings plead for early surgical treatment for burns which are considered not to recovery spontaneously in less than three weeks. Thus, there are less pain for patient, shorter recovery period, shorter lenght of hospital stay and

oxign

complex(CLP) and activation of various cascades as complement cascade, coagulation cascade,

arachidonic acid cascade. All these phenomena induces productions of some mediators such as histamine, leukotrienes, prostaglandines, platelet aggregation factor, cytokines (TNF-, IL1, IL6, IL8) which have oedematous, trombozant/necrotisimg and proinflammatory action.These can lead to increasing of local phenomena induced by the heat and and thus partial superficial burns can be transformed in a full thickness one. Thus, EGP prevents local and sistemic infections. The burn wound evolution[8,9] Burn wound evolution can be towards recovery, granulation or deepening. Recovery. Depending on the depth of the burn, the recovery can be made by different mechanisms or a combination of these. Deeper the burn longer the recovery. Longer the healing time more deficient healing risks. If spontaneous wound healing occurs in more than three weeks, there is the risk of occurence

consequently lower costs. Systemic inflammatory response, generalized burn oedema and burn shock[24-30] If the burn area is large enough (about 25%) than the mediators released from local injury induce an systemic response that consist of increased microvascular permeability, hypermetabolism,

immunosuppression, impairment of gut function,

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alteration in the coagulation system.[24-26] Increased microvascular permeability allows proteins to pass from intravascular space to interstitial space. Thus, the interstitial colloid osmotic pressure will increase and consequently the intravascular fluids will pass into interstial space, leading to generalized burn oedema.[10-14,17] In adition to increase of microvascular permeability, inflammatory mediators released from burn tissue will induse vasodilatation, vascular stasis, decreased cardiac contractility and decresead cardiac output. All this phenomena, will result in tissue hypoperfusion, ischaemia and shock.27,28 Failure to adequately resuscitate the burn injured patient will lead to systemic inflammatory response syndrome (SIRS) and/or multiorgan and

All these purposes are acomplished by EGP.[31] In concluzion, the arguments for performing EGP in great burns are : -prevent local infection which can generate sepsis, MSOF and death -eliminate the source of toxins and burn mediators responsible for the systemic effects of burn, SIRS and MSOF -reduces suffering of burned patient -decreases mortality -improves metabolic status of the burned patient -decreases the lengt of hospital stay -reduces the cost of treatment -allows healing with scars of better quality and thus a better integration in social life of burned patient

dysfunction death.[1,22,24,29]

syndrome

(MODS)

References
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Experimental studies have shown there is an directly proportionality between the burned area and the intensity of systemic manifestations and EGP decreases mortality in burns. All these data

demonstrate that EGP is a good solution to drow out the burned body from under the devastating influence of burn wound and from under the mediators and phenomena generated by burn

wound.[8,10,17,22,29,30] Treatment of major burned patient is a complex and multidisciplinar one, local and systemic. The two forms of treatment, local and systemic, are interconditioned, failure of one of them could produces failure of the other and conversely.[10] Treatment of burned patients is intended not only to preserves the life and to enssures the recovery but also to prevent local and systemic infections,to reduce the costs, to enssures the recovery in a shorter period of time and without sequeles that is without functional, aesthetic and psychic deficits and to allow burned patients to be integrated in social

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