Systematic review of excision and grafting in burns: Comparing outcomes of early and late surgery in low and high-income countries

INTRODUCTION: While the benefits of early excision in burn surgery are clear, the advantages may be lost in low income countries with limited resources. It is important to identify the right timing of excision in different groups of patients, particularly those in low-income countries (LIC), as the burden of disease contributes to the highest global mortality and has the least resources. This systematic review and meta-analysis aims to determine the timing of excision in LICs and the outcomes associated with surgery: (1) mortality, (2) sepsis and (3) length of stay (LOS) compared to high income countries (HICs).

METHODOLOGY: The PRISMA guidelines and MOOSE checklist were followed for this review. Publications in English from year 1990 to 2017 that included data on the timing and type of burn surgery and outcomes were included. Searches were done using Web of Science, Cochrane collaboration and Pubmed using keywords "Burn and surgery", "Burn and excision", "Burn and excision and grafting" and "burn and skin grafting". Trial quality was evaluated using the Newcastle-Ottawa scale. Outcomes compared for early and late excisions were length of stay (LOS), sepsis and mortality between LICs and HICs.

RESULTS: From 278 citations, we selected 41 for full text evaluation, and identified 16 eligible trials. LOS is shorter in early excision compared to late excision in both LICs and HICs. Mortality is lower in late excision compared to early excision in both LICs and HICs. Further subgroup analysis of elderly patients in HICs confirmed that mortality is lower in late excision and unchanged if the elderly are excluded. Early excision reduces sepsis in both LIC and HIC.

DISCUSSION: The variable definitions of age, timing of excision, variable nature of % TBSA comparison, mixed inclusion of inhalation injury, co-morbidities and unquantified access to resources make the data difficult to interpret and it is not possible to draw accurate conclusions on the role of early excision for burns in low-middle income countries. A prospective study is needed in order to answer this question.