The use of cultured epithelial autograft in the treatment of major burn injuries: A critical review of the literature

doi:10.1016/j.burns.2006.01.008

Burns

Volume 32, Issue 4, June 2006, Pages 395-401

https://doi.org/10.1016/j.burns.2006.01.008 Get rights and content

Abstract

Introduction

The need to achieve rapid wound closure in patients with massive burns and limited skin donor sites led to the investigation of in vitro cellular expansion of keratinocytes. The use of cultured epithelial autografts (CEA) was first reported in the treatment of major burns in 1981. Since that time, support for the use of CEA has varied, ranging from ‘a useful agent’ to having ‘no demonstrable effect on the outcome of extensively burned patients’.

Methods

This critical review of the literature examines issues associated with the use of CEA and the introduction of the technology into clinical practice. The factors potentially limiting the use of cultured CEA are the time necessary to culture CEA sheets, the reliability of ‘take’, vulnerability of grafts on the newly healed surface, long-term durability and the cost implications of such treatment. The available literature was located and critically evaluated using the Australian National Health and Medical Research Council Guidelines.

Findings

In the identified literature, the level of evidence to support the use of CEA in major burn injures is limited and often restricted to case studies and case series with no Level 1 evidence currently available.

Conclusion

The main question arising ‘Does CEA have a role in the treatment of major burns?’ has proven difficult to answer due to the wide variation in both the quality of study design and the findings. At best, the literature review has highlighted areas of concern that have hindered the successful use of CEA. Our review critically evaluates the use of CEA and explores the advances in techniques towards attempting to improve reliable clinical implementation of CEA. The need for higher level research into the use of CEA is emphasised by this review.

Introduction

The need to achieve rapid wound closure in patients with massive burns and limited skin donor sites led to the discovery that in vitro cellular expansion of keratinocytes could be achieved [1].

Reproduction and cell expansion techniques made it possible to explore the clinical potential of these techniques [2], [3], [4], [5]. O’Connor et al. first reported the use of cultured epithelial autografts in the treatment of major burns in 1981 [6]. Since that time, support for the use of CEA has varied, ranging from ‘a useful agent’ [7] to ‘no demonstrable effect on the outcome of extensively burned patients’ [8].

Evidence based medicine uses the best proof available to answer questions and develop optimal clinical practice. In answering the question, ‘Is there an evidence based practice for burns?’ Childs [9] clearly identified the difficulties in sourcing solid evidence for clinical practice. Cox [10] indicates that clinical practice is ‘too complex, ill defined, multi-faceted and situational to be handled by applying scientific method to its activities of diagnosis and management’, and further that, ‘value judgements pervade the balancing of trade-offs in every clinical decision but science has no calculus for handling meaning, purpose and choice of actions’.

The review aims to critically appraise the published literature on the use of CEA in major burns.

Section snippets

Methods

Electronic databases were searched using Medline and the key words ‘cultured epithelial autografts in burn wound care’. Publications were limited only by English language. Personal communications were included where appropriate.

In this critical review, the Australian National Health and Medical Research Council (NH&MRC) Guidelines on systematic identification and review of the scientific literature provided the framework to appraise the literature. Only the findings from rigorous studies with

Findings

The literature relating to the use of CEA in burn care was predominantly case studies and case series. The main issues consistently apparent included:

1.
time taken to culture cells for clinical use;
2.
preparation and provision of an appropriate wound bed;
3.
vulnerability to infection;
4.
difficulty in assessing ‘take’;
5.
long-term fragility;
6.
cost of treatment;
7.
quality of outcome (Table 2).

Discussion

The literature review presents benefits and limitations of using CEA in major burns. Despite these issues, there is a solid theoretical base for its use [3], [4], [5].

This critical review of the literature examines issues associated with the use of CEA and the introduction of the technology. The main limiting factors are the time necessary to culture CEA sheets, the reliability of ‘take’, vulnerability of grafts, long-term durability and the cost implications of such treatment.

The management of

Acknowledgments

We wish to thank Max Bulsara Director, Biostatistical Consulting Group School of Population Health, University of Western Australia; Susan Stanley Administrative Assistant Clinical Cell Culture; Mark Duncan-Smith Plastic and Reconstructive Surgeon; Burn Unit Royal Perth Hospital Multidisciplinary Burn Care Teams Royal Perth Hospital and Princess Margaret Hospital Perth, Western Australia Bess Fowler, Epidemiologist, Burns Unit Royal Perth Hospital.

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The use of cultured epithelial autograft in the treatment of major burn injuries: A critical review of the literature☆

Abstract

Introduction

Methods

Findings

Conclusion

Introduction

Section snippets

Methods

Findings

Discussion

Acknowledgments

Lancet

Lancet

Burns

Surgery

Biomaterials

J Paed Surg

Burns

Burns

Burns

Am J Surg

Burns

Burns

Burns

J Pediatr Surg

Burns

Burns

Burns

Burns

Burns

Burns

Growth of cultured human epidermal cells into multiple epithelia suitable for grafting

Proc Natl Acad Sci

Cultured cells for the treatment of disease

Sci Am

Skin replacements: the biotechnological quest for optimal wound closure

Arch Surg Vol

Wound healing potential of cultured epithelium

Wounds

Keratinocyte autografting, allografting and wound healing

The keratinocyte handbook

Wound closure and outcome in extensively burned patients treated with cultured autologous keratinocytes

J Trauma

Clinical practise is not applied scientific method

Aust N Z J Surg

Cultured autologous keratinocytes suspended in fibrin glue (KFGS) with allogenic overgraft for definitive burn wound coverage

Eur J Plast Surg

Grafting of cultured allogenic epidermis on second and third degree burn wounds on 26 patients

J Trauma

Cultured epithelial autografts: three years of clinical experience with eighteen patients

J Burn Care Rehabil

Randomized trial comparing cryopreserved cultured epidermal allografts with tulle-gras in the treatment of split-thickness skin graft donor sites

J Trauma

Multicenter experience with cultured epithelial autograft for treatment of burns

J Burn Care Rehabil

Tops and flops using cultured epithelial autografts in children

Pediatr Surg Int

Lack of long-term durability of cultured keratinocyte burn-wound coverage: a case report

J Burn Care Rehabil