Pros and Cons of Early and Late Skin Grafting in Children with Burns—Evaluation of Common Concepts

Round 1

Reviewer 1 Report

Review of MDPI

This report demonstrated that early excision (within the first 14 days after first visit or admission) of <20% partial thickness / full thickness burn wounds in pediatric patients led to wound healing 7 days earlier than delayed procedures (after 14 days of admission or first visit)

 

Some issues need to be clarified.

1. Since the period from operation to healing did not show any difference between two groups, it simply implies that the observed difference in healing time was a matter of when the operation was done rather than other factors, such as increased inflammatory response or infection in the delayed group.
2. The authors stated “delayed surgery has risks in terms of infection, early surgery also risks the removal of potentially viable tissues…..”, but the authors did not present any data to support any of these statements. Did the delayed group showed higher CPR levels or move occurrence of wound infection?
3. What is the inclusion and exclusion criteria of patient (case) selection?
4. What is the unique reason and feature which motivated the present study in pediatric burn patients?
5. The merit of the report is to persuade clinician not to “wait” but to be more aggressive in performing excision and grafting in these patients with lower burn area within 14 days or earlier after burn.

Author Response

Review of MDPI

This report demonstrated that early excision (within the first 14 days after first visit or admission) of <20% partial thickness / full thickness burn wounds in pediatric patients led to wound healing 7 days earlier than delayed procedures (after 14 days of admission or first visit)

 

Some issues need to be clarified.

1. Since the period from operation to healing did not show any difference between two groups, it simply implies that the observed difference in healing time was a matter of when the operation was done rather than other factors, such as increased inflammatory response or infection in the delayed group.

Thank you for this comment. We agree with the reviewer comment.

 

The authors stated “delayed surgery has risks in terms of infection, early surgery also risks the removal of potentially viable tissues…..”, but the authors did not present any data to support any of these statements. Did the delayed group showed higher CPR levels or move occurrence of wound infection?

Thank you for the comment. No they did not show a higher incidence of infection. We used antibiotic administration as an indicator to infection and we did find significant difference between the groups. We still think that delayed surgery could have an increased risk of wound infection however our study was not able to show this. It is written in the results “Antibiotic administration before and after operation was observed in almost half of the children in both groups and there was no difference between the groups (Table 1)”.

 

What is the inclusion and exclusion criteria of patient (case) selection?

Thank you for the comment. We have clarified it in the method section and modified Figure 1.

What is the unique reason and feature which motivated the present study in pediatric burn patients?

Thank you for this comment. As we wrote in the discussion, introduction and in the abstract, there is no consensus or previous study on the issue of timing of operation specifically in the group of burns in children. We have an ongoing debate in our clinic regarding the optimal timing of surgery in this group, and we think it is an important issue to investigate. This debate has been noticed in other burn centers as well.

 

The merit of the report is to persuade clinician not to “wait” but to be more aggressive in performing excision and grafting in these patients with lower burn area within 14 days or earlier after burn.

Thank you for your comment. We agree with you but we wanted to present the results from a neutral point of view, as there are pros and cons with both strategies.

 

 

 

Reviewer 2 Report

The paper evaluates the outcome based on evidence in paediatric burn patients when treated with early vs late excision and skin grafting.  This a retrospective study in a single burns unit.

The study addresses a clinically important question. Although, there are convincing evidence that early debridement is beneficial in adults, not many studies have evaluated this in children.   The manuscript is well written.  My specific comments are:

Figure 1- Describe clearly what conservative treatment is and why the majority of patients, which are in this group, have been excluded from the study. 

Table 1- Authors should discuss that in early operation group,  although the time to heal is shorter in "days from the injury", time to heal is actually slightly increased when you consider "days from operation".

References- Some relevant references have not been cited. For example:

Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft

B. Griffin, A. Bairagi, L. Jones, Z. Dettrick, M. Holbert and R. Kimble

Sci Rep 2021 Vol. 11 Issue 1 Pages 23753

Accession Number: 34887486 PMCID: PMC8660833 DOI: 10.1038/s41598-021-03141-x

 

Author Response

The paper evaluates the outcome based on evidence in paediatric burn patients when treated with early vs late excision and skin grafting.  This a retrospective study in a single burns unit.

The study addresses a clinically important question. Although, there are convincing evidence that early debridement is beneficial in adults, not many studies have evaluated this in children.   The manuscript is well written.  My specific comments are:

Figure 1- Describe clearly what conservative treatment is and why the majority of patients, which are in this group, have been excluded from the study. 

Thank you for the comment. We changed the word conservative to “non-operative” in figure 1.

As the aim was to analyze the timing of surgical intervention, patients with no operations were excluded. The (included) group with delayed operation (n=41) were treated “conservatively “ until operation. Conservative treatment was in the form wound cleaning and dressing, we have clarified in the Methods.

Table 1- Authors should discuss that in early operation group,  although the time to heal is shorter in "days from the injury", time to heal is actually slightly increased when you consider "days from operation".

Thank you for this comment. We have added text in the discussion.

References- Some relevant references have not been cited. For example:

Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft

1. Griffin, A. Bairagi, L. Jones, Z. Dettrick, M. Holbert and R. Kimble

Sci Rep 2021 Vol. 11 Issue 1 Pages 23753

Accession Number: 34887486 PMCID: PMC8660833 DOI: 10.1038/s41598-021-03141-x

Thank you for this comment. We have added the reference in the manuscript.

Round 2

Reviewer 2 Report

I am happy with the changes.