Front. Med. China 2008, 2(4): 332–336 DOI 10.1007/s11684-008-0063-5

REVIEW

Achievements in burn surgery over the past 50 years in China Shiliang WANG (*), MD Institute of Burn Research, Southwest Hospital, State Key Laboratory of Trauma, Burns and Combined Injury, the Third Military Medical University, Chongqing 400038, China

E

Higher Education Press and Springer-Verlag 2008

Abstract This paper reflects on the advancements of clinical and scientific research in the field of burn surgery in China. It includes emergency care of massive burns, resuscitation, anti-infection, prevention and cure of internal organ injuries, metabolic and nutritional support, wound repair and rehabilitation, and special types of burns; it also covers pathology, microbiology, immunology, cell biology, molecular biology, and tissue engineering. Keywords

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burn surgery; China

Introduction

The exact incidence of burns in China is not known, since the patients of minor burns especially in outlying villages are often not sent to medical stations. By rough estimates, the number of burn injuries annually is 5000 per million population, and about 10% of these injuries need hospitalization. According to a group of 113 298 cases, burns were caused by heating liquid or fire in 88.67%, chemical agents in 6.05%, electric injury in 5.20%, and combined radiation-burn injury in 0.08%. The ratio between domestic and industrial accidents was 3–4 to 1, and male to female burn patients was about 3 to 1. In burn accidents, 78.1% of patients were under 30 years of age, and the morbidity gradually decreased with age. Summer (June, July, August) incidence (32.24%) is the highest among the four seasons. Owing to different climates, geographies, economies, habits and customs in vast territories in China, there also exist regional incidence differences. The treatment of burn injuries was documented as early as the Eastern Jin Dynasty (A.D. 281–341), and burn surgery has developed rapidly since 1958 in China. In the past fifty years, with expeditious development of expertise, a nationwide network of burn units, including clinical Received September 8, 2008; accepted September 10, 2008 E-mail: [email protected]

treatment and relevant researches, has been established. According to incomplete statistics, there are 352 burn hospitals, institutes, centers and departments in China; at least 6 of above belong to the national level. Seven thousand one hundred and two burn beds have been set up according to the statistics of 16 provinces and municipalities directly under the Central Government. The data was collected from 59 main burn units in China, and patients admitted to the units varied from 400 to 1900 cases per year. The survival rate of burn patients is 90%–99.85%, and the LA50 (the lethal area of burned body surface which carries a 50% mortality) of burn victim has reached 90%–100%; the LA50 of 3rd degree burn is 71.80%–87.78% of the total body surface area (TBSA) [1–12].

2 Rescue and resuscitation We summarize here the experiences during rescues at the scenes of accidents, triage and transportation, and the scheme of emergency care for massive burns. Nowadays, transport of burn patients by airplane is being increasingly used [13]. The ‘‘Chinese rule of nines’’ and ‘‘1st, superficial 2nd, deep 2nd, 3rd, 4th-degree burns’’ were put forward to estimate the extent and depth of burns. Early and delayed fluid resuscitation formulas and the indices used for monitoring resuscitation have been established; the existence of gut covert shock was tested and verified, the combined treatment of burn shock was improved. It was determined that the amount of fluid for resuscitating burn shock combined with inhalation injury could not be decreased but increased. Initial burn wound excision could be performed during the shock stage [14]. Notice is given to preventing ‘‘abdominal compartment syndrome’’ induced by excessive fluid resuscitation when trying to normalize indices with an invasive hemodynamic monitor. The close internal relation between shock and infection and the overlapping stage of shock and infection were recognized [15].

Achievements in burn surgery over the past 50 years in China

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Control of infection

Hundreds of anti-infection topical agents were tested and verified. ‘‘Gut-origin infection’’ happens in severe burns, and fluorescein labeled microbes could translocate through the injured intestine, and these have been recovered in visceral organs; 125I labeled endotoxins begin to ascend in the portal vein 15 min after burn injury; radioautography of the liver section has demonstrated the labeled endotoxin granules [15–17]. The main factor influencing bacterial ecology on burn wounds is the selection of antibacterial agents and systemic antibiotics. So far, the detection rate of Staphylococcus aureus (SA) has been shown to have an increasing trend, and the detection rate of methicillin resistant Staphylococcus aureus (MRSA) has risen to 70%–80% of SA. In Gram negative bacteria, besides P. aeruginosa, Enterobacter species and Klebsiella pneumoniae, the detection rate of Acinetobacter baumani and Stenotrophomonas maltophilia has been rising since the 1990s. In order to optimize antibiotic therapy, the bacterial ecology pattern on burn wounds and the dominant invasive and currently prevailing pathogenic strains in burn units should be monitored continuously. It should be emphasized that the choice of the optimal time and duration when antibiotics should be administered, as well as administration during the peri-operative period should be recommended; patients have been treated with empirical therapy in the early stage of severe burns, persisted in ‘‘early use’’ and ‘‘early stop’’ [18–20]. It is of great significance to further elucidate pathogenetic mechanisms, such as the effects of TNFa and the high mobility group-1 protein on uncontrolled systemic inflammatory response. The management of severe sepsis should include rapid, suitable fluid resuscitation, early feeding, control of infection, early deep wound excision, and organ support, among which the most important procedure is prompt removal of the infected necrotic tissue and covering the clean wound immediately. It was inferred that the lethal endotoxin concentration in endotoxemia of a burn patient is about (325 ¡ 166) pg/mL blood. A study of anti-endotoxin preparation was initiated and continued for a long time [21].

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Wound closure

Intermingled transplantation (Chinese Method) for covering deep burn wound excisions is recommended. A large sheet of partial thickness alloskin, which is inserted using small pieces of skin auto grafts through the punched holes on the sheet, or a large sheet of allograft smeared with micrografts of auto skin, is transplanted on the extensive burn wound excision. An expansion rate of 100:1 can be made by a microskin graft; the orientation, dispersion and coverage of microskin grafting still needs to be improved.

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After intermingled transplantation of auto- with allo- or hetero- skin, local immune tolerance could be induced by inlaid auto epidermal horn cells [22–25]. It could prolong survival time of allo- or hetero- skin grafts if these grafts were pretreated with physical (ultraviolet or c ray), chemical (DMSO, cortisone) or biological (cyclosporine, cytokine) methods. A series of immune tolerance studies involving the thymus, Treg (regulatory T) cell, and the dendritic cell (DC) have been developed [26]. Studies on culturing sheets of epithelial cells, acellular dermis and various dermal substitutes constructing composite skin containing two layers of epidermis and dermis have been performed. Progress has been made on stem cell therapy in burn wound repair in terms of tissue engineering skin and promoting regeneration of sweat glands and hair follicles [27–30]. More than 70 axial flaps in burn areas have been used, thus further attention should be paid to studying fascia and fasciocutaneous flaps. The diameter of the perforator artery through the fascia should be >0.5 mm so as to anastomose vessels. If survival could be guaranteed, free skin flap transplantation should be chosen, which gives the advantage of shorter patient hospitalization and less suffering from the operation [31–33]. The effects of inflammatory cells, cell growth factors and extracellular matrix on the process of wound healing have been studied. Keeping degenerated dermal tissue followed by autoskin grafting is recommended to improve wound healing. The mechanism of cicatrix formation and intractable wounds such as burns complicated by diabetes has been probed into. Wound healing is the programmed process of interaction and is under the influence of various tissue cells, and studies on signal mechanism have already been carried out in concert using various tissue cells [34].

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Immune and metabolism nutrition

Abnormal immune responses following severe burns include hyper- and/or hypo- inflammatory/immune response, which are summarized as ‘‘postburn immune dysfunction’’. Immune dysfunction has been improved in terms of global or integral etiological factors, and at cellular and molecular levels of its mechanisms [35]. The theory of ‘‘Enterogenous Hypermetabolism’’ has been advanced. A formula has been developed to calculate the calorie requirements in Chinese burn adults. New ideas on glucose absorption, neoglycogenesis, insulin resistance, and the use of hypoglycemic agents after burn injury have been put forward. The variations in plasma level of free amino-acids have been observed; the changes and mechanisms of 26S proteasome and 19S regulator in the skeletal muscle after burn trauma have been investigated; the clinical application and the mechanisms of

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Shiliang WANG

glutamine and arginine have been studied. The approach using 13C NMR spectroscopy has been introduced to investigate the alterations of hepatic anabolism functions in severely burned rats. The suitable dosage of vitamin A, E, C and the trace elements zinc, copper, and iron for burn patients have been given. Serial studies on early enteral nutrition, parenteral nutrition and comparing enteral with parenteral nutrition have been carried out. Early enteral nutrition with symbiotics might be beneficial in controlling burn infections. Both Glucagon-like peptide-2 (GLP2) and Intestinal trefoil factor (ITF) exhibit protective effects on intestinal mucosa in terms of minimizing injury and protecting barrier functions. The choice of suitable opportunities for using recombinant human growth hormone (rhGH) has been investigated. In addition, the viewpoints on ischemia and anoxia in metabolism, anti-inflammatory immunity and nutrition have also been developed [36–41].

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Internal organs

The hypothesis of ‘‘volume replacement’’ plus ‘‘dynamic support’’ has been put forward. Ischemic/hypoxic myocardial structure and function may be damaged because activation of the heart rennin angiotensin system occurs immediately even before significant reduction in blood volume occurs. The cellular and molecular mechanisms of the structure and function variation of the heart in the stage of shock have been systemically investigated [42]. Models of steam and smoke inhalation injury had been created, chemical broncho-tracheitis, pulmonary edema and atelectasis were the basic pathological changes identified. The secondary inflammatory response could play an important role in the development of acute respiratory failure. The roles of some cytokines, inflammatory cells and pulmonary surfactant in its development have also been proved. The mortality of inhalation injury patients has been decreased significantly [43,44]. High frequency jet ventilation (HFJV) can decrease the water content, relocate interstitial fluid and accelerate the lymph stream in the lungs of smoke inhalation injured canines, and HFJV can improve breathing mechanics and gas exchange during steam inhalation injury [45,46]. Two striking phenomena in the pathogenesis of multiple organ dysfunction syndrome (MODS) in severe burn injury have been confirmed. Opportune resuscitation, early feeding, timely removal of necrotic tissue and wound closure, optimizing antibiotic therapy, and paying attention to modulation of immunity, metabolism, insulin, and growth hormones were the tactics and measures recommended for the prevention and cure of postburn MODS. The key role of postburn endothelial injury in early postburn internal organ injury has also been studied [47].

7 Special types of burns Electrical injury can be induced by high voltage electrical arcs of alternating current, though the body is not directly in contact with the current. The tissue in the parallel electric field suffers more severe injury than that in the vertical one. The necrotic tissue should be excised as soon as possible, and degenerated tendons, nerves and vessels should be preserved or/and necrotic tendons, nerves and vessels should be repaired immediately; auto- or artificial materials and varied skin flaps or tissue flaps should be used for primary closure of the wound [48–51]. The animal models of combined burn-blast injury have been established. Shock, infection, viscus injury and bone marrow depression become more serious in this type of injury. Using hypertonic saline during the shock stage is recommended, and doctors should pay attention to anticoagulation, administering insulin and cortisone in the treatment of injury. As lung injury is often the complication of blast trauma, the administration of a respirator should be carefully done [52,53]. Tissue damage due to combined radiation-burn injury is more serious and its treatment is difficult. Enhancing first aid and decreasing early death (induced by inhalation injury, cardio-pulmonary damage, severe shock), preserving hematopoietic function (using WR2721, E838, IL-3, rhGM-CSF, TNFa and bone marrow transplantation), immune modulation and anti-infection (GLP-2, sIgA, IL-4, HD-5), with timely extensive wound excision and covering with an alloskin graft (decreasing rejection by radiation, and ensuring a lasting survival time for the alloskin graft), blocking the cervical sympathetic nerve (stabilizing the internal environment), stem cell transfusion (promoting wound healing and reconstruction of hemopoietic function), show the progress of research and treatment in terms of this injury [54,55].

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