BTK Burn Journal Review Early Excision
===

[00:00:00] You're on call at a level one trauma center. A 42-year-old previously healthy man is transferred to your burn center after a house fire. He has approximately 55% total body surface area burns involving the anterior and posterior to posterior torso, bilateral upper extremities, and portions of the neck.

The burns appear second and third degree. He arrives approximately six hours after injury. He was intubated in the field for concern for inhalation injury. Bronchoscopy shows moderate inhalation injury, but he's hemodynamically stable and resuscitation is underway. By the next morning, approximately 18 hours after injury, he has received appropriate fluid resuscitation.

His lactate is improving and his urine output is adequate. So the question becomes, when should we, should this patient go to the OR for excision? Dr. Johnson, when you see a patient like this, what are the factors you're thinking about in [00:01:00] terms of timing and excision?

So Dr. Romanowski, I think this is a very timely scenario 'cause it represents a clinical decision that comes up pretty often, but is a point of significant debate in the burn community.

When we talk about early excision in the modern era, it's important that we keep in mind that the definition varies somewhat in the literature among burn surgeons. We generally think of it as ultra early excision within the first 24 hours. Early excision happening somewhere between 24 hours and seven days, although there is some research that suggests that early should really be held to that 24 hour to 72 hour window.

And then delayed excision is anything beyond seven days. So if we go back to the underlying principle for burn surgery the key is that revitalized tissue acts as a major driver of inflammation, infection, and metabolic stress. So the earlier we remove it, the earlier the potential outcome, including hypertrophic scarring [00:02:00] and functional disability.

Another way to think about early excision is that burn escar acts as a massive infectious stimulus. Necrotic tissue promotes bacterial colonization, increases the cytokine release and contributes to the hypermetabolic response that large TBSA burn periods patients experience by removing that tissue early, we're essentially performing source control, similar to draining an abscess or debriding a necrotic soft tissue infection.

Getting back to your initial question, what factors am I thinking about in terms of timing for early excision in this patient? I'm generally balancing the patient's physiology, the anticipated burn depth progression, secondary infectious risk, and then burn center and hospital logistics.

Dr. Dav, it's interesting because the concept of early excision seems obvious to us now, but historically, burn surgeons didn't always operate this early.

Is that true?

Exactly. So prior to the [00:03:00] 1970s and early 1980s, and frankly still in austere environments where transfusion and other resources are limited, burn care was and still is, largely conservative. Surgeons waited for esgar separation and waited and waited and waited, which could. Take weeks or more before eventually grafting the wound if indeed the patient was still alive.

Meaning patients were suffering prolonged periods with open necrotic tissue, increasing their risk of sepsis, hypertrophic scarring, contracture, and death. So the idea of planned early excision and grafting really transformed burn care.

So how did this happen? What led to moving burn surgery towards this early excision?

So after Jankovich seminal work on tangential excision, suddenly the timing of excision became a relevant conversation. [00:04:00] To clarify, tangential excision involves sequentially removing thin layers of burned tissue using a blade until punk tape bleeding is encountered indicating viable dermis or subcutaneous tissue.

So this technique allows for maximal preservation of viable tissue while removing the necrotic escar. So let's start with one of the papers that helped push the field in that direction. Gray published a manuscript in the American Journal of Surgery in 1982 on early excision versus conventional therapy in burn patients.

This study examined patients with 20 to 40% total body surface area burns and compared to approaches, early surgical excision with grafting and conventional therapy involving delayed debridement and wound care. The investigators found that the patients treated with early excision demonstrated improved outcomes, specifically including faster wound closure, shorter hospital length of stay, [00:05:00] and generally fewer complications associated with prolonged open wounds.

Super interestingly, note that in this paper, early excision was considered sooner than 14 days.

Wow, that's a long lot longer than what we would consider early today. Dr. Miles, why was this study so influential?

Honestly, because it challenged the longstanding assumption that you should wait for burn wounds to separate before operating.

This study helped shift the field from weight and watch to a planned operative source control, and early wound closure. It suggested that actively removing necrotic tissue and closing the wound early, reduces systemic complications.

So obviously this work moved us forward some, but how did we move forward from Gray's work?

What came next?

In another classic paper, Thompson and colleagues out of Galveston published a manuscript entitled Effect of Early Excision on [00:06:00] patients with major thermal injury and the Journal of Trauma in 87. This study focused on patients with burns greater than 30% TBSA, which we we would consider major burns.

They compared early massive excision of full thickness burns. Which they now defined as being before seven days following injury with later on. Excision historically burn wound sepsis often developed around post burn day five to seven, which is one reason excision before that window became a major goal for everyone.

For those interested, this was one of the first randomized controlled trials published in Burn Surgical Management. Ultimately, and not surprisingly, their findings supported the concept that early excision improved outcomes in patients with large TBSA burns.

So, Dr. Johnson, you know, it seems like this kind of, uh, all these studies seem to have really laid the groundwork for early excision, but what were some of the early, [00:07:00] uh, some of these early studies limitations?

So, as my residents. Are used to hearing me say on a regular basis. Burn care in the 1980s looked very different than it does today because ICU Care in the 1980s looked very different than it does today. We didn't have a lot of the more modern ICU resuscitation protocols, advanced ventilator management and even in the operating room, nuanced anesthetic expo approaches, and many of the dermal substitutes that we now use.

Additionally, appreciation of the potential for early physical and occupational therapy to radically change functional outcomes had not yet developed because of course, as Dr. Nosov pointed out, these patients had just spent forever and ever and ever waiting to have their burn removed. One of the biggest technical challenges of early burn excision is blood loss, and while the first blood bank opened in the US in 1937 at Cook County.

Targeted blood product resuscitation strategies are still, were still and are still a relatively new concept. In the [00:08:00] 1980s, early excision often involved large single staged and single surgeon operations, which could lead to significant blood loss techniques such as epinephrine impregnated gauze, tourniquet use for extremity burns, rapid tangential excision, and coordinated multis surgeon teams can dramatically reduce operative time and transfusion requirements.

Today we often use stage excision strategies that are more physiologically tolerable, although institutions with the CA capability will perform multis, surgeon excisions whenever we're all around to operate with each other.

So it seems like these two papers, as well as several others from the same era really set the standard if a patient can tolerate it and the system can deliver it.

Early excision enclosure is the optimal trajectory. If we fast forward to the current environment, early excision is now widely accepted and almost all burn centers do it. However, the debate now over excision centers on how early is early enough, who [00:09:00] benefits and are there pitfalls to excision being performed too early?

Dr. Nosov, uh, what are some of the recent studies focused on the timing of wound care, uh, burn wound excision, now.

So one interesting study published in 2023 by Dilla Tera and colleagues out of UTMB used the large TriNetX multicenter database to compare patients who underwent excision within three days to those who underwent excision between four and 14 days.

And they found that earlier excision was associated with lower mortality and lower infection rates. But we have to keep in mind that database studies always do raise the question of selection bias, right? So patients who are stable enough to routinely undergo early surgery may be more physiologically normal to begin with.

So Dr. Miles, what about excision? Even earlier, within the first 48 [00:10:00] hours, has anyone looked at that yet?

Nationwide analysis of the American College of Surgeons, t Quip dataset published by Ramsey ET Owl, published in 2023 compared patients undergoing excision within 48 hours versus later, so 48 hours versus later.

They found that earlier surgery was associated with shorter hospital length of stay and overall fewer complications. This supports the concept that removing revitalized tissue early may reduce systemic inflammation and infection. Risk. However, it's really important that we remember. This was again, a large database study, which introduces selection bias, exact burn depth time from injury to admission.

Resuscitation variables and operative details were were not evaluated. Patients with inhalation injury and concomitant trauma were also excluded, which is a large portion of our patients, and a mortality benefit was not demonstrated.

There are also studies suggesting [00:11:00] that timing within the first week may not dramatically affect mortality.

For example, a Japanese nationwide database study by HII and colleagues in 2023 found that when excision occurred within the first seven days, the exact timing did not significantly change mortality. This suggested factors like burn size, inhalation injury, and patient physiology may be more important drivers of survival.

I don't mean to suggest that only mortality matters in the outcome of our burn patients, but the moment we just don't have the granularity of data to be able to state definitively if there is an outcome benefit in the range of two to seven days post-injury for excision.

Additionally, we have to keep in mind that things get a little murkier with deep partial thickness burns.

So like a 2024 review by Solomons and colleagues in the Netherlands points out that the timing of surgery in these injuries is still debated, partly because studies define early excision very differently as. We all do again, often [00:12:00] anywhere in the first week. And the real challenge is depth, uncertainty early after injury.

Operating early may reduce inflammation and shorten healing time, but weak size too soon we may actually end up grafting wounds that would've healed without surgery at all.

So it's been fun going back into the history of all this, but let's go back to our patient. We have our 55 percent total body surface area burn, and that's a 42-year-old man.

He's now resuscitated. He has some possible inhalation injury, but he's generally doing well. Dr. Johnson, what would your approach be?

So for clearly full thickness burns, I would typically aim for excision within the first 48 to 72 hours. Up to that point, I'm working to get the patient as physiologically appropriate for a major surgical excision as I can.

For areas where depth is uncertain, I will perform an initially more superficial excision and allow the wounds to fully declare it. My next operative [00:13:00] procedure here is where a temporizing skin substitute can be very helpful.

Another evolving option is also enzymatic debridement, which can sometimes succeed in removing escar early, actually without surgery in these intermediate depth burns.

But for large, full thickness burns or early surgical excision definitely remains standard of care. And I think I, I would agree with your approach, but can we actually take a moment and talk about a patient who maybe isn't as healthy as the one that we prescribed described at the beginning?

And I, I think that's a great point for any large burn.

It's definitely important to establish goals of care early with the patient if we are able and, and the family. In fact, once we know that the patient has an intact airway, we often take a few minutes in our massive burn patients to discuss goals of care really early on in their. Hospital course, we can frame prognostic discussions using the [00:14:00] modified B score, which incorporates the patient's age percent, TBSA burned and inhalation injury to estimate mortality risk.

Note, it doesn't include comorbidities. While it's not perfect, it helps provide a rough sense of expected outcomes and can guide early conversations with families. Patients with large burns undergo multiple operations over multiple weeks and months with extended intensive care case and, and lots of potential for complications, indefinite suffering.

It's important to explain this a part of the, as a part of the early informed consent process for burn surgical care.

So before we wrap up, let's just run through a few quick scenarios that might change how we think about the timing of excision. Dr. Johnson. Beyond physiologic instability, are there situations where you might intentionally delay excision?

Yes, absolutely. There are several situations where burn depth evolution can actually make early excision less straightforward, and these are the [00:15:00] situations that I would actually wait so. Given that certain mechanisms of burn injury can cause progressive tissue necrosis over the first several days, such as grease burns, electrical burns, and chemical burns, these are scenarios where I would actually wait because the true depth of injury may not be fully declared within that first 48 hours, and if I operate too soon, I might not excise enough tissue.

Patient factors also matter. Advanced age and comorbidities, particularly peripheral vascular disease, diabetes, or severe smoking related vascular disease can impair perfusion and lead to ongoing burn depth progression in these patients, allowing for a short period of time for the wound damage to fully declare itself can actually help guide a more accurate excision.

Those are some great example examples. Dr. Nosov suppose we're dealing with a mass casualty event, multiple burn patients [00:16:00] arriving simultaneously, you know, all chaos all around. How does that change your priorities?

So. As much as we like to think that we're used to functioning in chaos on a regular basis, mass casualty situations definitely are going to shift the focus from what we would consider optimal care, which is sort of everything we've been talking about so far, um, at least for an individual patient.

And now we really have to think about maximizing outcomes for the entire injured population. So in that environment, early excision may need to be prioritized for patients. At least those who are most likely to benefit, particularly those with moderate to large burns who we do think could survive with aggressive treatment.

Patients with extremely large burns and poorly predicted survival, despite best efforts, may be best to start with conservative management early on, while the operative resources are directed toward patients with the highest likelihood of meaningful recovery. [00:17:00] Operative staging also becomes important, so.

In this case, excising the largest sources of necrotic tissue first, such as the torso, while balancing again, ICU capacity, blood product availability, and operating room availability to say nothing of supplies and staff.

Another topic getting a lot of attention recently is enzymatic debridement, particularly with brolin based products like NexoBrid. Dr. Nosov, I know you mentioned this earlier in this podcast as being something that contributed to early excision. Dr. Miles does enzymatic debridement count as early excision.

It's a, that's a great question. That's a tough question. And I guess overall the answer is yes and no, depending on how you define it. So enzymatic, debridement can achieve early removal of escar, often within the first 24 to 48 hours. So in that sense, it [00:18:00] functions similarly to early surgical excision.

However, it has some important limitations. Large surface area, enzymatic, debridement, can and will trigger a significant sys systemic inflammatory response. So most protocols limit treatment to a relatively small. TBSA at a time. It's also very resource intensive. The procedure requires monitoring, wound preparation, aggressive pain control, because the debridement process can be extremely painful.

So while enzymatic debridement is a powerful tool for select burns, particularly intermediate or second degree injury, that is not at all replaced surgical excision for large, full thickness third degree burns.

Definitely agree. Alright, burn team. I think we've reached a consensus Overall, early excision remains one of the most important interventions we perform in burn surgery.

The landmark studies from the 1980s [00:19:00] established the concept and modern data suggests. That earlier surgery, often within the first 48 to 72 hours, but definitely within seven days, improves outcomes. Though the optimal timing remains dependent on patient physiology and clinical judgment. To be honest, half the fun in preparing this session was our own 20 minute debate on what constituted early excision before we even started discussing the papers.

Be on the lookout for more burn hot topics in our next podcast episode. And don't forget if you have any particularly burning questions, you can send them our way with that. Remember a chance to cut that esker off as a chance to dominate,

dominate the day.