The early excision of burns

This paper discusses the indications for the treatment of deep burns by early excision, describes the methods used at East Grinstead, and analyses the results obtained in 18 cases so treated. The importance of immediate and complete skin cover is stressed.     

Meta-analysis of early excision of burns

AIMS: This meta-analysis sought to establish if early excision and grafting is better or equivalent to the conservative treatment of burns in both children and adults with minor or major burns. The outcomes of interest are mortality, wound healing time, duration of sepsis, operating hours, complications of surgery, length of hospital stay, blood transfusion requirements and long term morbidity like joint contractures and hypertrophic scarring. METHODS: We searched MEDLINE (1966-July 2004), EMBASE (1980-August 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) with the keywords 'early excision' and 'burns'. This yielded 441 articles of which 15 were randomized controlled trials. Only six trials met the inclusion criteria. RESULTS: There was a significant reduction in mortality with early excision of burns when compared with traditional treatment only in patients without inhalational injury (RR 0.36, 95% CI 0.20 to 0.65). The blood transfusion requirement is significantly higher in the early excision group but the length of hospital stay was significantly shorter (WMD -8.89, 95% CI -14.28 to -3.50). There was no conclusive evidence on the difference between the two groups in terms of duration of sepsis, wound healing time and skin graft take. CONCLUSION: Early excision of burns is beneficial in reducing mortality (in patients without inhalational injury), length of hospital stay. The only drawback is the greater volume of blood loss.     

Deep foot burns: effects of early excision and grafting

Few on the problem of foot burns can be found in the available scientific literature. It is necessary to mention that often deep foot burns occur in Central Asia since many natives still use the ancient means of heating called ‘Sandal’ during the winter months. Eighty-four patients with severe foot burns were treated in the Burn department of RCSUMA and the Inter-regional Burn Center, Uzbekistan. The patients were subdivided into two groups, depending upon the terms of performing operative intervention. There was no special allocation of patients to groups. Criteria for selection were isolated deep burns of the foot. As for the character of the injury, area of deep burn and the severity of injury, patients of the control and basic groups were not different. The first group included 34 patients on whom early excision was done using skin graft 4–5 days after resuscitation, and the second group consisted of 50 patients who were treated in the traditional way. Methods used on the first group, described in this article, helped to improve the general condition of patients, contributed to the restoration of their foot function, lessened joint deformities and post-burn contracture deformities, shortened their stay in hospital and also reduced expenses.     

Results of early excision and grafting in hand burns

A total of 658 admissions to the Burns Unit at the Royal Brisbane Hospital were reviewed over a 4-year period. During this time, 73 hand burns were treated. The policies of the Burns Unit regarding hand burns are detailed; and, where possible, early excision and grafting is performed. The results of these hand burns are discussed and indicate minimal requirements for reconstructive surgery. The most common reconstructive surgery needed was for web space release in 10 patients and excision of hypertrophic scar in 2 patients. It is concluded that early excision and grafting of hand burns is safe and practical, and combined with adequate splinting, exercise and pressure garments, gives good results and lessens hospital stay in patients with relatively small injuries. The duration of stay in hospital in patients with large burns is not due to the treatment of their hand burns, but to their overall large body surface area burnt.     

Pediatric abdominal lymphangiomas: a plea for early recognition.

Abdominal lymphangiomas are usually classified together with mesenteric cysts. However, they differ by location, histology, and potential for recurrence, and should be considered a separate clinical entity. Thirteen children, aged 2 weeks to 11 years (mean, 5.8 years), with abdominal lymphangiomas were identified over the past 16 years at this institution. Of these, 12 were symptomatic. Abdominal pain (11), vomiting (8), increased abdominal girth (8), and nausea (6) predominated. Other presentations were less frequent. Symptoms were present for an average of 2 months (7 less than 1 week) before correct diagnosis. An abdominal mass was palpable in 10 cases. Intestinal gangrene secondary to volvulus was present in 2. Although multiple imaging modalities were used ultrasonography (8/8) and computed tomography (CT; 4/4) proved most expedient and reliable. In 2 cases, the lymphangioma could not be completely resected. There was 1 recurrence. Although intraabdominal cystic lesions are described in the literature as relatively symptom-free, our experience suggests otherwise. In this series, abdominal pain and an abdominal mass were common. Catastrophic complications can occur and excision is facilitated by earlier diagnosis and the benefit of smaller size. Ultrasound and CT can accurately diagnose the lesion and should be used liberally in children with intermittent or ill-defined abdominal pain, leading to prompt recognition and definitive treatment.     

A method of grafting hand burns following early excision.

Early excision and delayed primary grafting of burns of the hand is presented as a method of achieving rapid healing, thus allowing early full mobilization. The results of 19 consecutively treated patients are reported.     

Surgical reconstruction of the sequelae of penile and scrotal gangrene: a plea for simplicity

Gangrene of the scrotum with or without involvement of the penile skin and occasionally beyond these limits, is not an uncommon problem in some parts of the world. Various workers have used different techniques to provide skin cover including transplantation of testes, free skin grafts, axial groin flaps and myocutaneous flaps. This study brings out our experience with the treatment of 43 cases in the last 11 years. In three cases the gangrene had spread beyond the scrotum and penis and cover had to be supplemented with split-skin grafts. In all the other cases, cover was provided with scrotal skin remnants at the edge of the lesion and on the penis with the inner layer of the prepuce, which had remained intact.     

Primary tangential excision for hand burns

The article describes the correct technique of primary tangential excision in deep dermal and third-degree hand burns. The operation performed under tourniquet facilitates the preservation of viable tissue, which is of utmost importance in hand burns. The therapeutic results depend on the extent of destroyed tissue. Primary tangential excision prevents fibrosis due to prolonged infection and impaired circulation, thus creating much more favorable conditions for reconstruction and rehabilitation.     

Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation

OBJECTIVE: Postoperative chylothorax remains an uncommon but potentially life-threatening complication of esophagectomy for cancer, and the ideal management is still controversial. The aim of the study was to compare the outcomes of patients treated nonoperatively with those of patients promptly undergoing reoperation. METHODS: From 1980 to 1998, 1787 esophagectomies for esophageal or cardia cancer were performed, and 19 (1.1%) patients had postoperative chylothorax. We analyzed type of operation, surgical approach, delay of diagnosis of chylothorax, daily chest tube output, type of management, major complications, death, hospital stay, and final outcome. RESULTS: Of the 19 patients with chylothorax, 11 were initially managed nonoperatively (group A): 4 (36%) patients had spontaneous resolution of chylothorax, and the other 7 required reoperation for the persistence of a high-volume output. There were three infectious complications and one postoperative death in this group. No reliable predictive criteria of successful versus unsuccessful nonoperative management could be found. The 8 most recent patients underwent early reoperation (group B). All patients recovered, and no major complications possibly related to chylothorax or hospital deaths were observed. They were discharged after a median of 22 days (range, 12-85 days) compared with a median of 36 days (range, 21-64 days) for patients of group A. CONCLUSIONS: Early thoracic duct ligation is the treatment of choice for chylothorax occurring after esophagectomy. Reoperation should be performed immediately after the diagnosis is made to avoid the complications related to nutritional and immunologic depletion caused by prolonged nonoperative treatment.     

Conservative excision of penile melanoma

Penile melanoma is a rare disease, especially in younger men. Most authorities advocate aggressive surgical management by partial or radical phallectomy and in some cases inguinal lymph node dissection. A 27-year old man with a clinical stage I, Clark's level II, microinvasive (less than 0.76 mm) superficial spreading penile melanoma underwent conservative resection and skin grafting without inguinal node dissection. He has normal penile function and is disease free 5 years following surgery. We believe that in clinical stage I, microinvasive penile melanoma, local excision without inguinal node dissection should be the treatment of choice.     

Mild head injury: a plea for routine early CT scanning.

We reviewed the records of 1538 mild head injury patients admitted during a 4 1/2-year period to the Southern New Jersey Regional Trauma Center. All patients had experienced brief loss of consciousness or amnesia, but had a normal or near normal neurologic examination on admission, with Glasgow Coma Scale (GCS) scores of 13-15 and no focal neurologic deficit. Routine urgent cranial CT scans were obtained on all patients, and correlations between skull fractures and intracranial lesions investigated. Two hundred sixty-five patients (17.2%) harbored 340 lesions on CT scans, of which 131 were fractures and 209 were intracranial abnormalities. Fifty-eight patients needed surgery for their intracranial lesions; 23 of them had no skull fractures. None of the 1339 patients without CT evidence of intracranial lesions deteriorated under observation. We conclude that clinical observation with or without skull x-ray films is inadequate to rule out potentially dangerous intracranial lesions in apparently mild head injuries. If there is a history of loss of consciousness or amnesia, an immediate CT scan is indicated. If the results of the CT scan are normal and there are no other indications for admission, these patients may be safely discharged.     

Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management

BACKGROUND: Fulminant Clostridium difficile colitis is a common nosocomial infection that occurs with increasing frequency. METHODS: A total of 3,237 consecutive cases of C difficile cytotoxin-positive stool samples from 1998 to 2006 were reviewed. Commonly referenced indicators for surgical intervention were gathered on the day of surgery. The preoperative characteristics of patients surviving subtotal colectomy were compared with those who did not survive. RESULTS: Thirty-six patients underwent colectomy. Twenty-three patients (64%) were discharged from the hospital alive. Preoperative intubation and vasopressor requirement were risk factors for in-hospital mortality (odds ratio [OR], 7.15; 95% confidence interval [95% CI], 1.28-39.8 and OR, 6.0; CI, 1.08-33, respectively). Patients who had a recent surgical procedure had a lower in-hospital mortality rate (OR, .11; 95% CI, .02-.52). CONCLUSIONS: Fulminant C difficile colitis is associated with a high mortality rate. Development of a vasopressor requirement or need for intubation are ominous signs and should lead to rapid surgical intervention.