Delayed primary closure of the burn wounds

Abstract

'Early closure' of burn wounds by excising the burned tissues and promptly covering it with skin-grafts or its substitutes within first 'five' post-burns day is a standard technique of burn-wound-management in the burn-units of the "developed" world. But lack of education in general, and health-education in particular amongst the common people in the "developing" countries could hinder acceptance of this procedure. Lack of well-trained and motivated burns-surgeons could worsen the situation. The Sultanate of Oman is one of the developing gulf-countries in the middle-east, where at Khoula hospital, the National Burns-Center in the capital city of Muscat, 'early' surgery was introduced in November 1997 to soon become a routine protocol for burn-wound-management. But delay in getting consent for surgery from unwilling patients or in transferring them from the peripheral hospitals were often the reasons for delaying the burn-wound excision and closure 'beyond 6 days to 11th or 12th' day post-burn. Hence, instead of the term "early", the authors prefer to call it "delayed primary" burn-wound closure because, it still offers "primary intention healing" of the burn-wounds. The aim of this article is to analyze retrospectively the results of the "delayed primary" closure of the burn-wounds done in the Khoula Hospital Burns-Unit of the Sultanate of Oman. During a period of 50 months from November 1997 to December 2001, carefully selected 143 patients out of a total of 592 admissions in burns-unit were subjected to burn-wound excision and auto-skin-grafting (STSG), of whom about 87% patients had "delayed primary" and 13% had "early" surgery. There was no mortality or post-operative morbidity in these operated patients. However, due to the non-availability of skin substitutes the excision and auto-grafting could not be done in extensive burns with inadequate skin-donor-area. The maximum percentage of burns treated by delayed primary surgery (DPS) was 50% in children and 55% in adults. Follow-up results were good functionally as well as cosmetically. The authors conclude that "delayed primary" is the second best alternative to the "early" burn-wound excision and closure with similar advantages of reducing risk of septicemia, mortality, and morbidity, hospital stay and cost of treatment. It should be preferred over "secondary" skin-grafting of granulating wounds. Thus, in the developing countries, the indications of delayed primary burn surgery could be (1) patients unstable or unfit for surgery during the first post-burn week; (2) delay in transferring in the patients; (3) delay in getting patient's consent for surgery; (4) very major burns without availability of skin substitutes; and (5) lack of operating time in a busy burns-unit. The contraindications for delayed primary surgery are any sign of invasive sepsis or organ failure.