Is surgery with a high-pressure water jet (hydrosurgery) better than conventional surgery for early treatment of mid-depth burns?

Background

Burns are common injuries worldwide and can cause illness, lifelong disability and even death. Deep burns often require surgery because the skin is too damaged to heal on its own. The damaged, burnt skin must therefore be cut away (debridement) and replaced with healthy skin, which is typically a very thin layer of healthy skin (graft) taken from another part of the body. Debridement is normally done with a specific surgical knife.

Recently, a high-pressure, water-based jet system has been developed, known as hydrosurgery. This tool removes burnt skin only, leaving behind the unburned, healthy skin. Hydrosurgery may be more accurate than a knife in terms of removing burned skin, which may lead to better healing.

All open wounds, including burns, are at risk of infection so adequate debridement is important to reduce the risk of infection. If the wound is closed quickly, it will heal better, with less scarring and less risk of infection.

What did we want to find out?

In this Cochrane Review, we wanted to know whether burns treated with hydrosurgery heal more quickly and with fewer infections than burns treated with a knife. We also wanted to see whether there were any differences in overall quality of life, how well the wound healed in terms of scarring and the amount of medical resources used (using measures like the number of dressing changes and burn clinic appointments, length of hospital stay, and whether further surgery was needed).

Our methods

We searched medical databases for randomised controlled trials that compared burn treatment using hydrosurgery with conventional debridement. Randomised controlled trials are medical studies where the treatment people receive is chosen at random. This type of study provides the most reliable evidence about whether different approaches to health care make a difference. Participants in the studies could be any age. The studies could have taken place anywhere and be reported in any language.

What are the main results of the review?

We found only one Australian study that included 61 children with small burns. The children were randomly allocated to treatment with either hydrosurgery or conventional debridement. Hydrosurgery made little or no difference in the time burns took to heal completely, infection after the operation, or scarring compared to conventional debridement. There was little or no difference in the length of time debridement took using hydrosurgery compared with conventional surgery. The study did not give any information about quality of life or resource use.

Certainty of the evidence

Our certainty (confidence) in the evidence was very limited because we found only one study. It only included children, so the results may not apply to adults or people with more severe burns. It was a randomised study, but did not report the outcomes we expected it to, so we are not sure how reliable its results are.

Conclusions

We do not know if hydrosurgery is better than conventional surgery for early treatment of mid-depth burns. We need more studies to investigate this question.

Search date

This review includes evidence published up to December 2019.

Authors' conclusions: 

This review contains one randomised trial of hydrosurgery versus conventional debridement in a paediatric population with low percentage of total body surface area burn injuries. Based on the available trial data, there may be little or no difference between hydrosurgery and conventional debridement in terms of time to complete healing, postoperative infection, operative time, and scar outcomes at six months. These results are based on very low-certainty evidence. Further research evaluating these outcomes as well as health-related quality of life, resource use, and other adverse event outcomes is required.

Read the full abstract...
Background: 

Burn injuries are the fourth most common traumatic injury, causing an estimated 180,000 deaths annually worldwide. Superficial burns can be managed with dressings alone, but deeper burns or those that fail to heal promptly are usually treated surgically. Acute burns surgery aims to debride burnt skin until healthy tissue is reached, at which point skin grafts or temporising dressings are applied. Conventional debridement is performed with an angled blade, tangentially shaving burned tissue until healthy tissue is encountered. Hydrosurgery, an alternative to conventional blade debridement, simultaneously debrides, irrigates, and removes tissue with the aim of minimising damage to uninjured tissue. Despite the increasing use of hydrosurgery, its efficacy and the risk of adverse events following surgery for burns is unclear.

Objectives: 

To assess the effects of hydrosurgical debridement and skin grafting versus conventional surgical debridement and skin grafting for the treatment of acute partial-thickness burns.

Search strategy: 

In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

Selection criteria: 

We included randomised controlled trials (RCTs) that enrolled people of any age with acute partial-thickness burn injury and assessed the use of hydrosurgery.

Data collection and analysis: 

Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment, and GRADE assessment of the certainty of the evidence.

Main results: 

One RCT met the inclusion criteria of this review. The study sample size was 61 paediatric participants with acute partial-thickness burns of 3% to 4% total burn surface area. Participants were randomised to hydrosurgery or conventional debridement. There may be little or no difference in mean time to complete healing (mean difference (MD) 0.00 days, 95% confidence interval (CI) −6.25 to 6.25) or postoperative infection risk (risk ratio 1.33, 95% CI 0.57 to 3.11). These results are based on very low-certainty evidence, which was downgraded twice for risk of bias, once for indirectness, and once for imprecision.

There may be little or no difference in operative time between hydrosurgery and conventional debridement (MD 0.2 minutes, 95% CI −12.2 to 12.6); again, the certainty of the evidence is very low, downgraded once for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in scar outcomes at six months. Health-related quality of life, resource use, and other adverse outcomes were not reported.

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