EARLY EXCISION AND GRAFTING VERSUS CONSERVATIVE TREATMENT IN THE MANAGEMENT OF MAJOR BURNS: A COMPARATIVE STUDY.

Background :
1
Full thickness burns lose their eschar in 2-6 weeks through bacterial collagenase production and daily mechanical debridement .
The practice of leaving these dead tissues only serves as a nidus for infection that can lead to the patient's death. Hence the standard procedure is
surgical removal of eschar with grafting techniques.
Methods:Atotal of 50 patients divided in 25 patients in each group were included first group was managed conservatively and second underwent
th early excision and grafting within 5 day upto 10% TBSA.
Results: Early excision and grafting patients required significantly (p=0.04) more blood transfusions than conservatively managed patients. The
mean hospital stay was significantly (p=0.05) lower by 10 days in early excision and grafting than conservatively managed.
Conclusion : Early Excision and Grafting group was found to have significantly shorter hospital stay with decresed painful debridement but
required more blood transfusions than conservatively managed patients.


INTRODUCTION Early excision and grafting
The past 40 years have been witness to significant improvements in the 2 overall care and prognosis of those suffering burn trauma . General improvements in topical antimicrobials, systemic antibiotics, improvements of critical care, maintenance of the patients nutritional status and improved wound care are all critical factors in improving survival in burned patients . At the heart of this success is an aggressive approach to burn wounds. This approach involves early operative removal of 3 devitalised tissue and biological coverage of resultants wound .
Conservative treatment of burn wound by daily washing removal of loose dead tissue and topical application of antibiotics cause superficial dermal burns to heal in 2 weeks and deep dermal full 4 thickness burn to be ready for grafting in 3-8 weeks .
In 1970, Janekovic suggested a procedure which was designed to remove the devitalized part of the dermis till a plane of healthy bleeding dermis was reached and resurfaced this by immediate 5 autografting . For deep burns the standard procedure nowadays is to surgically remove the eschar and graft the defect. Reports have shown benefit over serial debridement in terms of survival, blood loss and 6,7,8 length of hospital stay . Availability of safer blood, better monitoring equipment and method, and a better understanding of the altered physiology and increased metabolic demands of patients and major 9 burns has made this possible . The ability to stabilize the patients within a few days of the injury has enabled the surgeon to excise deep burn wounds before invasive infection develops . The practice of leaving dead and devitalized tissue serves as a nidus for infection and is the principal source of complication in burn patient.
Dead tissue in the burn wounds act as a medium for bacterial growth. Antibiotics administered through the blood stream have difficulty in reaching the burn wounds due to poor blood supply of the dead and devitalized tissue . So dead skin must be removed as early as possible. 10 Early wound closure shortens hospital stay and duration of illness . Early in the twentieth century, primary burn wound closure was attempted in patients with major burns but systemic instability , massive hemmorrhage, graft loss, malnutrition and infection resulted in such high mortality rates that major burns excision were 11 abandoned . Until a useful artificial skin is available it is difficult to prove that early excision improves mortality in patients with extensive burns (>60%TBSA). Recently, a dermal substitute made of collagen matrix combined with a glycossaminoglycan ( chondroitin 6-sulphate ) that acts as a template for endogenous cells to reproduce a new dermis is a major step in the development of a permanent skin substitute .
More burn centres are practising early excision and grafting . The procedure is still limited due to difficulty in diagnosing depth of burns , limited donor sites and the difficulties involved in excision of threedimentional areas such as the perineum, ears and nose.
Evidence supports the following conclusions: 1) Full thickness burn <20%TBSAand burns of indeterminate depth(deep partial versus full thickness ) if treated by an experienced surgeon, can be safely excised and grafted with a decrease in hospital stay , cost and time away from work or school. 2) Early excision and grafting dramatically decreases the number of painful debridements. 3) Patients with burns between 20 and 40 percent TBSA will have fewer infectious complication if treated with early excision and grafting.

Review of Literature
In a study conducted by Herndon DN et al at the Shriners burn institute, 85 patients whose ages ranged from 17 to 55 years with >30% TBSA burns were randomly assigned to either early excision or topical antimicrobial therapy and skin grafting after spontaneous eschar seperation . Mortality from burns without inhalation injury was significantly decreased by early excision from 45 to 9% in patients who 12 were 17 to 30 years of age (P <0.025) . No differences in mortality could be demonstrated between therapies in adults older than 30 years of age or with a concomitant inhalation injury. The mean length of hospital stay of survivors was less than one day per percent of TBSA 12 burn in both children and adults . Employment of electrosurgery, with elimination of excessive blood loss immediate autografting has been advised. Immediate graft take was excellent on electrosurgical wounds after primary burn excision in 22 a study by RJ Lewis et.al . Poor graft take is another major problem which can be reduced by maintaining proper hemostasis.

TECHNICAL CONSIDERATIONS:
Excision of more than 10%TBSA should be done in well equipped setups only . Without tourniquets, blood loss may be alarming . Graft loss may result in devastating consequences . Excellent monitoring ,care ,physiotherapy, nutritional support , anaesthesia and 24 hours physician coverage are mandatory .

Timing:
It is advantageous to perform excisional procedures as early as possible after the patients is hemodynamically stable and prior to wound degeneration. This allows the wound to be closed before infection and softening of the wound occurs It also favours donor sites to be recropped as soon as possible.
This is generally between the second and fifth day post burn . It is rarely carried out after the eighth day . Any burn projected to take longer than 3 weeks to heal is a candidate for excision within the first 16 post burn week .

TYPES OF EXCISION:
There are several methods of performing burn wound excision, each applicable to a particular depth of burns.

Fascial Excision:
This involves excision of all burn skin down to muscle fascia (sometimes even including the muscle fascia).It is carried out for very deep burn (charred flame burn , prolonged contact burns, molten metal burns , electrical burns) or for patients with very large , life threatening full thickness burn . It is done either with a scalpel or an electrocautery.

Tangential (sequential) excision :
This involves shaving of very thin layers of burn eschar with a power or hand driven dermatome to reach viable tissue . A bed of viable dermis or subcutaneous tissue or fascia is obtained which is pinkish white , 17 shiny and bleeds briskly from punctate bleeders . Patients with recent burns admitted through ER will be taken into consideration for selecting the cases as study population.

Methods:
A total of 50 patients were included in the study. There were two study groups comprising of 25 patients each . The first group consisted of burn patients who were treated conservatively and the second group consisted of patients who were subjected to early excision and 0 0 grafting. Patients with 11-20% TBSA burns (2 or 3 ) involved hand, foot, perineum, mouth, joints etc.
(1) Detailed history to be taken for medicolegal purposes. Excision & Grafting will be done within 5 day of injury. In the 1 sitting only upto 10% of TBSA will be excised(priority will be given to burns of cosmetically and functionally important areas such as, face, neck, axilla, hand, foot, joints etc) and wound will be covered with meshed or sheet STSG immediately. Left over wound will be excised and grafted on another sitting 5-7days after st the 1 Excision and Grafting. (6) Conservatively managed group will be treated with alternate day or every 3rd day dressing with topical antibiotics till the eschar began to seperate. Their wounds will be mechanically debrided during dressing and under general anaesthesia whenever it is feasible and the raw areas will be left to granulate. When granulation will become free of debris and relatively uninfected, STSG will be applied to close wound. (7) All the informations about the patients will be meticulously recorded, including the investigation values, amount of blood transfusions, the day of surgery, the percentage of area excision, the % of area grafting, the number of sessions, the length of hospital stay and the outcome. (8) The age group and the percentage TBSA burnt were compared for homogeneity of the two groups. Fisher′s Exact Test by Epi Infoversion 6 was used to analyze the statistical significance between two groups regarding blood transfusion required or not to the patients. Two -way ANOVA test was used to analyze the statistical significance between two groups regarding hospital stay. A pvalue of <0.05 was taken as statistically significant. The results obtained are as follows:

1) Blood Transfusion:
All the patients of Early excision and Grafting group must required blood transfusion, where as in Conservative groupwith11-20% burnt area, only 4(40%) patients required blood transfusion ( p-value is 0.003) and inConservative group with 21-30 %TBSA burn 10 out of 15 (66.67%) patients required blood transfusion. These differences are statistically significant (p-value is 0.04).

2) Hospital stay: A) Patients sustained burns involving 11-20% TBSA
The mean hospital stay in the Early Excision & Grafting group of patient with 11-20% burnt area was 22.8 days (±5 days) and in the conservative group with same burnt area was 32.7 days (±7 days ). The difference in the length of stay was statistically significant (p-value of 0.02 ).
In the Early Excision & Grafting group, in majority of patients 9 (80% ) the hospital stay was < 29 days.
But in conservative group, only in 40% of patients the hospital stay was <29 days.  In the Early Excision & Grafting group, in majority of patients 10 (70% ) the hospital stay was < 29 days.
But in conservative group, only in 27% (4)of patients the hospital stay was <29 days. frequently leads to a multi-organ dysfunction syndrome with or without the presence of sepsis. If left in place , burn eschar maintains the inflammatory response of the patients and eventually develops 23 invasive infection that many times is lethal.
Survival after burn injury has been steadily increasing during the last two decades. Risk factors identified for death following thermal injury are age greater than 60 yrs, inhalation injury and burned body surface 24 area more than 80% Despite all the recent advances in burn care , massive burn still presents a high mortality and morbidity . Early excision and grafting is currently the standard of care for deep partial thickness and full thickness burn.
In this study 21 patients(42%) had sustained 11-20%TBSA burn and 29 patient had sustained21-30%TBSA burn Burns >30% TBSA were . not included in the study. The latter were excluded from the study as following excision of large surface area we are unable to graft the area with autologus skin .
The advantages of early excision and grafting in the treatment of 25 limited full thickness burns has been clearly established.
Primary excision has reduced mortality , morbidity, and later reconstructive measures by a factor of 50% when compared to results obtained by awaiting spontaneous separation of eschar with late 26 grafting .
All the patients of Early excision and Grafting group must required blood transfusion, where as in Conservative groupwith11-20% burnt area, only 4(40%) patients required blood transfusion and in Conservative group with 21-30 %TBSA burn 10 out of 15 (66.67%) patients required blood transfusion. These differences are statistically significant (p-value <0.05).
The mean hospital stay was also shortened by early excision and Patients with 11-20% TBSA burn, the mean hospital stay in the early excision and grafting group was 22.8 days (±5 days) and in conservative group the same was 32.7 (±7)days. (p-value is 0.02).
Patients with 21-30% TBSA burns, the mean hospital stay in the Early Excision & Grafting group was 25.5 days (± 6.4 days) and in the conservative group was 36.8days (± 10.5 days ). The difference in the length of stay was statistically significant (p-value of 0.005).
In Early Excision & Grafting group the minimum length of hospital stay was 16 days and the maximum was 41 days. The majority stayed for less than 24 days but there were 4 patients who had to be re-grafted nd due to 2 sitting grafting in three cases(as the deep burnt area were >10%TBSA in those patients) and graft loss in one case and stayed for a longer period resulting in a higher mean hospital stay. So it is important to ensure that proper graft take occurs in the excised areas in order to avoid repeated sessions of grafting so that hospital stay is shortened.  CONCLUSION This prospective study was carried out to compare the two modalities of treatment of burn injuries involving upto 30 % TBSA. The first group consisting of 25 patients was treated conservatively and other group comprising of 25 patients were subjected to Early Excision and Grafting . It was seen in the study that the patients in the group in whom early excision and grafting was done , had a shorter hospital stay than the patients treated conservatively .