Проблемы хирургического лечения глубоких ожогов

Актуальность. Пациенты с глубокими ожогами нуждаются в хирургическом лечении, однако сроки и объем оперативных вмешательств до настоящего времени не разработаны.

Цель. Проанализировать опыт хирургического лечения глубоких ожогов за рубежом.

Материал и методы. Поиск источников литературы проводили с использованием электронных баз PubMed, Scopus, CrossRef за период 1947–2023 гг. В работу включены некоторые ранние базовые публикации по хирургическому лечению глубоких ожогов, однако современное состояние проблемы отражают статьи за последние 20 лет.

Заключение. Данные зарубежных источников литературы показывают, что в странах с низким уровнем доходов эффективность ранней некрэктомии не подтверждена, что обусловлено отсутствием ожоговых отделений, донорской крови и раневых покрытий. В развитых странах Европы, США, Японии в настоящее время применяется активная хирургическая тактика и является правилом выполнение некрэктомии в первые сутки поступления пациента в стационар. В многочисленных работах авторы утверждают, что результаты ранней некрэктомии и аутодермопластики лучше, чем при отсроченных операциях, но приводимые данные по летальности неоднозначны. Авторы указывают, что на высокую летальность влияют пожилой возраст пациентов, большая площадь глубокого ожога и наличие ингаляционной травмы. При этом для планирования хирургического вмешательства не используют ни один из разработанных прогностических индексов, включающих указанные предикторы неблагоприятного исхода ожоговой травмы.

1. Nguyen TT, Gilpin DA, Meyer NA, Herndon DN. Current treatment of severely burned patients. Ann Surg. 1996;223(1):14–25. PMID: 8554414 https://doi.org/10.1097/00000658199601000-00004

2. Barret JP, Herndon DN. Effects of burn wound excision on bacterial colonization and invasion. Plast Reconstr Surg. 2003;111(2):744–750; discussion 751–752. PMID: 12560695 https://doi.org/10.1097/01.PRS.0000041445.76730.23

3. Wang Y, Beekman J, Hew J, Jackson S, Issler-Fisher AC, Parungao R, et al. Burn injury: challenges and advances in burn wound healing, infection, pain and scarring. Adv Drug Deliv Rev. 2018;123:3–17. PMID: 28941987 https://doi.org/10.1016/j.addr.2017.09.018

4. Ong YS, Samuel M, Song C. Metaanalysis of early excision of burns. Burns. 2006;32(2):145–150. PMID: 16414197 https://d oi.org/10.1016/j.burns.2005.09.005

5. Ashouri S. An introduction to burns. Phys Med Rehabil Clin N Am. 2022;33(4):871–883. PMID: 36243477 https://doi.org/10.1016/j.pmr.2022.07.001

6. Sheppard NN, Hemington-Gorse S, Shelley OP, Philp B, Dziewulski P. Prognostic scoring systems in burns: a review. Burns. 201;37(8):1288–1295. PMID: 21940104 https://doi.org/10.1016/j.burns.2011.07.017

7. Chua AWC, Khoo YC, Truong TTH, Woo E, Tan BK, Chong SJ. From skin allograft coverage to allograft-micrograft sandwich method: a retrospective review of severe burn patients who received conjunctive application of cultured epithelial autografts. Burns. 2018;44(5):1302– 1307. PMID: 29475746 https://doi.org/10.1016/j.burns.2018.01.021

8. Shen C, Deng H, Sun T, Cai J, Li D, Li L, et al. Use of fresh scalp allografts from living relatives for extensive deep burns in children: a clinical study over 7 years. J Burn Care Res. 2021;42(2):323330. PMID: 32960969 https://doi.org/10.1093/jbcr/iraa155

9. Butts CC, Holmes JH, Carter JE. Surgical Escharotomy and Decompressive Therapies in Burns. J Burn Care Res. 2020;41(2):263–269. PMID: 31504609 https://doi.org/10.1093/jbcr/irz152

10. Zhang L, Labib AM, Hughes PG. Escharotomy. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. PMID: 29489153

11. Ur R, Holmes JH 4th, Johnson JE, Molnar JA, Carter JE. Development of a burn escharotomy assessment tool: a pilot study. J Burn Care Res. 2016;37(2):e140– 144. PMID: 26594860 https://doi.org/10.1097/BCR.0000000000000322

12. Gibson JAG, Gorse SH, Pallister I, Cubitt JJ. Surgical simulation training for escharotomy: a novel course, improving candidate's confidence in a time critical procedure. Burns. 2023;49(4):783– 787. PMID: 35654704 https://doi.org/10.1016/j.burns.2022.05.017

13. Cope O, Langohr JL, Moore FD, Webster RC. Expeditious care of full-thickness burn wounds by surgical excision and grafting. Ann Surg. 1947;125(1):1–22. PMID: 17858906

14. Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma. 1970;10(12):1103–1108. PMID: 4921723

15. Brcić A, Zdravic F. Lessons learnt from 2,409 burn patients operated by early excision. Scand J Plast Reconstr Surg. 1979;13(1):107– 109. PMID: 377457 https://doi.org/10.3109/02844317909013034

16. Jouglard JP, Echinard C, Carlin G, Manelli JC, Palayret D. Severity and prognosis after early excisions from one to twenty percent of the body surface area. Scand J Plast Reconstr Surg. 1979;13(1):121– 125. PMID: 377460 https://doi.org/10.3109/02844317909013038

17. Gray DT, Pine RW, Harnar TJ, Marvin JA, Engrav LH, Heimbach DM. Early surgical excision versus conventional therapy in patients with 20 to 40 percent burns. A comparative study. Am J Surg. 1982;144(1):76–80. PMID: 7046487 https://doi.org/10.1016/0002-9610(82)90605-5

18. Demling RH. Improved survival after massive burns. J Trauma. 1983;23(3):179– 184. PMID: 6403712 https://doi.org/10.1097/00005373-198303000-00002

19. Kisslaogglu E, Yüksel F, Uccar C, Karacaogglu E. Rationale for early tangential excision and grafting in burn patients. Acta Chir Plast. 1997;39(1):9–12. PMID: 9212485

20. Still JM Jr, Law EJ. Primary excision of the burn wound. Clin Plast Surg. 2000;27(1):23–47, v-vi. PMID: 10665354

21. Herndon DN, Barrow RE, Rutan RL, Rutan TC, Desai MH, Abston S. A comparison of conservative versus early excision. Therapies in severely burned patients. Ann Surg. 1989;209(5):547– 552; discussion 552–553. PMID: 2650643 https://doi.org/10.1097/00000658198905000-00006

22. Kirn DS, Luce EA. Early excision and grafting versus conservative management of burns in the elderly. Plast Reconstr Surg. 1998;102(4):1013– 1017. PMID: 21596479 https://doi.org/10.1097/00006534-199809040-00013

23. Chamania S, Patidar GP, Dembani B, Baxi M. A retrospective analysis of early excision and skin grafting from 1993– 1995. Burns. 1998;24(2):177–180. PMID: 9625247 https://doi.org/10.1016/s03054179(97)00117-4

24. Mahar P, Wasiak J, Bailey M, Cleland H. Clinical factors affecting mortality in elderly burn patients admitted to a burns service. Burns. 2008;34(5):629– 636. PMID: 18207331 https://doi.org/10.1016/j.burns.2007.09.006

25. Goei H, van Baar ME, Dokter J, Vloemans J, Beerthuizen GIJM, Middelkoop E, et al.; Dutch Burn Repository group. Burns in the elderly: a nationwide study on management and clinical outcomes. Burns Trauma. 2020;8:tkaa027. PMID: 33123606 https://doi.org/10.1093/burnst/tkaa027eCollection2020

26. Goswami P, Sahu S, Singodia P, Kumar M, Tudu T, Kumar A, et al. Early excision and grafting in burns: an experience in a Tertiary Care Industrial Hospital of Eastern India. Indian J Plast Surg. 2019;52(3):337–342. PMID: 31908372 https://doi.org/10.1055/s-0039-3402707

27. Prasanna M, Mishra P, Thomas C. Delayed primary closure of the burn wounds. Burns. 2004;30(2):169– 175. PMID: 15019128 https://doi.org/10.1016/j.burns.2003.09.028

28. Vinita P, Khare NA, Chandramouli M, Nilesh S, Sumit B. Comparative analysis of early excision and grafting vs delayed grafting in burn patients in a developing country. J Burn Care Res. 2016;37(5):278– 282. PMID: 23816999 https://doi.org/10.1097/BCR.0b013e31827e4ed6

29. Gallaher JR, Mjuweni S, Shah M, Cairns BA, Charles AG. Timing of early excision and grafting following burn in sub-Saharan Africa. Burns. 2015;41(6):1353–1359. PMID: 26088149 https://doi.org/10.1016/j.burns.2015.02.011

30. Song G, Jia J, Ma Y, Shi W, Wang F, Li P, et al. Experience and efficacy of surgery for retaining viable subcutaneous tissue in extensive full-thickness burns. Burns. 2016;42(1):71–80. PMID: 26546384 https://doi.org/10.1016/j.burns.2015.06.012

31. Tang W, Li X, Deng Z, Zhang Z, Zhang X, Zhang T, et al. [Effects of unified surgical scheme for wounds on the treatment outcome of patients with extensive deep burn]. Zhonghua Shao Shang Za Zhi. 2015;31(4):254–258. (In Chinese). PMID:26715635

32. Atkins K, Schneider A, Rodriguez C, Gallaher J, Charles A. The predictive probability of mortality in the presence of full-thickness burns. Am J Surg. 2023;225(4):793–799. PMID: 36266136 https://doi.org/10.1016/j.amjsurg.2022.10.006

33. Keshavarzi A, Ayaz M, Dehghankhalili M. Ultra-early versus early excision and grafting for thermal burns up to 60% total body surface area; a historical cohort study. Bull Emerg Trauma. 2016;4(4):197–201. PMID: 27878124

34. Saaiq M, Zaib S, Ahmad S. Early excision and grafting versus delayed excision and grafting of deep thermal burns up to 40% total body surface area: a comparison of outcome. Ann Burns Fire Disasters. 2012;25(3):143–147. PMID: 23467391

35. Nakazawa H, Nozaki M. [Immediate burn wound excision and grafting decreases the mortality rate and hospital stay duration in extensive burn patients]. Nihon Geka Gakkai Zasshi. 1998;99(1):40–45. (In Japanese). PMID: 9547746

36. Nakazawa H, Nozaki M. [Experience of immediate burn wound excision and grafting for patients with extensive burns]. Nihon Geka Gakkai Zasshi. 2005;106(12):745–749. (In Japanese). PMID: 16869128

37. Muangman P, Sullivan SR, Honari S, Engrav LH, Heimbach DM, Gibran NS. The optimal time for early excision in major burn injury. J Med Assoc Thai. 2006;89(1):29–36. PMID: 16583578

38. Hayashi K, Sasabuchi Y, Matsui H, Nakajima M, Otawara M, Ohbe H, et al. Does early excision or skin grafting of severe burns improve prognosis? A retrospective cohort study. Burns. 2023;49(3):554–561. PMID: 36774244 https://doi.org/10.1016/j.burns.2023.01.013

39. Ramsey WA, O'Neil CF Jr, Corona AM, Cohen BL, Lyons NB, Meece MS, et al. Burn excision within 48 hours portends better outcomes than standard management: a nationwide analysis. J Trauma Acute Care Surg. 2023;95(1):111– 115. PMID: 37038260 https://doi.org/10.1097/TA.0000000000003951

40. De La Tejera G, Song J, Corona KK, Gotewal S, Wermine K, Efejuku TA, et al. 82 early skin excision decreased the risk of skin infection, sepsis and mortality among burn patients. J Burn Care Res. 2022;43(S1):S54–S55. https://doi.org/10.1093/jbcr/irac012.085

41. Butts CC, Bose K, Frotan MA, Hodge J, Gulati S. Controlling intraoperative hemorrhage during burn surgery: a prospective, randomized trial comparing NuStat® hemostatic dressing to the historic standard of care. Burns. 2017;43(2):374–378. PMID: 27658997 https://doi.org/10.1016/j.burns.2016.08.026

42. Murphy TJ, Paterson HM, Kriynovich S, Zang Y, Kurt-Jones EA, Mannick JA, et al. Linking the "twohit" response following injury to enhanced TLR4 reactivity. J Leukoc Biol. 2005;77(1):16–23. PMID: 15496450 https://doi.org/10.1189/jlb.0704382

43. Butt I, Shrestha BM. Two-hit hypothe sis and multiple organ dysfunction syndrome. JNMA J Nepal Med Assoc. 2008;47(170):82–85. PMID: 18709037

44. Rennekampff H-O, Tenenhaus M. Damage control surgery after burn injury: a narrative review. Eur Burn J. 2022;3(2):278–289. https://doi.org/10.3390/ebj3020024

45. Ayaz M, Bahadoran H, Arasteh P, Keshavarzi A. Early excision and graft ing versus delayed skin grafting in burns covering less than 15% of total body surface area; a non-randomized clinical trial. Bull Emerg Trauma. 2014;2(4):141–145. PMID: 27162886

46. Elmasry M, Steinvall I, Thorfinn J, Abdelrahman I, Olofsson P, Sjoberg F. Staged excisions of moderate-sized burns compared with total excision with immediate autograft: an evaluation of two strategies. Int J Burns Trauma. 2017;7(1):6–11. PMID:28123862 eCollection 2017.

47. Greenwood JE. A paradigm shift in practice – the benefits of early active wound temporisation rather than early skin grafting after burn eschar excision. Anaesth Intensive Care. 2020;48(2):93– 100. PMID: 32233644 https://doi.org/10.1177/0310057X19895788

48. Wong L, Rajandram R, Allorto N. Systematic review of excision and grafting in burns: comparing outcomes of early and late surgery in low and high-income countries. Burns. 2021;47(8):1705– 1713. PMID: 34303572 https://doi.org/10.1016/j.burns.2021.07.001

49. Rousseau AF, Massion PB, Laungani A, Nizet JL, Damas P, Ledoux D. Toward targeted early burn care: lessons from a European survey. J Burn Care Res. 2014;35(4):e234– 239. PMID: 24419142 https://doi.org/10.1097/BCR.0000000000000027

50. Israel JS, Greenhalgh DG, Gibson AL. Variations in burn excision and grafting: a survey of the American Burn Association. J Burn Care Res. 2017;38(1):e125– e132. PMID: 27893575 https://doi.org/10.1097/BCR.0000000000000475

51. Gibson C, Bessey PQ, Gallagher JJ. The global burn registry: a work in progress. J Burn Care Res. 2020;41(5):929– 934. PMID: 32483614 https://doi.org/10.1093/jbcr/iraa078

52. Жиркова Е.А., Спиридонова Т.Г., Сачков А.В., Синякова О.Г., Елисеенкова Е.И., Медведев А.О. и др. Стратификация пациентов с ожоговой травмой по риску летального исхода на основе пересмотренного индекса Франка. Анестезиология и реаниматология. 2024;(2):32–38. [Zhirkova EA, Spiridonova TG, Sachkov AV, Sinyakova OG, Eliseenkova EI, Medvedev AO, et al. Risk stratification of mortality in patients with thermal injury based on the Revised Frank Index. Russian Journal of Anesthesiology and Reanimatology. 2024;(2):32–38.] (In Russ.). https://doi.org/10.17116/anaesthesiology202402132