Timing of surgical excision for burn wounds: A systematic evaluation and meta-analysis comparing early and delayed excision

Abstract

Background

The optimal timing of burn wound excision remains controversial. We updated the evidence base by synthesizing data from comparative studies published from 1 January 2010 to 11 March 2024 that compared the outcomes of early and delayed excision in patients with thermal burns.

Methods

The PubMed, Embase, Cochrane Library, and Web of Science Core Collection databases were searched. Two reviewers independently screened studies, extracted data, and assessed the risk of bias. Random-effects meta-analysis was performed. Mortality was pooled as risk difference, and continuous outcomes were pooled as standardized mean differences with 95% confidence intervals. Prespecified subgroup analyses considered study design, country income group, and the operational definition of early excision. This systematic review and meta-analysis was formally registered in the International Prospective Register of Systematic Reviews (PROSPERO) on 3 December 2024 (CRD42024621585).

Results

Ten comparative studies (8 observational studies and two randomized controlled trials) involving 5070 patients fulfilled the eligibility criteria. Early excision was not associated with lower mortality than delayed excision (5 studies; risk difference: −0.01, 95% confidence interval: −0.06 to 0.03; p = 0.52; I² = 79%). Early excision was associated with a shorter duration of hospitalization (8 studies; standardized mean difference: −0.64, 95% confidence interval: −0.93 to −0.35; p < 0.001; I² = 94%). There were no statistically significant differences in the hospital cost (3 studies; standardized mean difference: −0.45, 95% confidence interval: −1.72 to 0.81; p = 0.48) or graft success rate (3 studies; standardized mean difference: 0.63, 95% confidence interval: −1.03 to 2.29; p = 0.46) between early and late excision. Sensitivity analyses did not materially change the direction of the main findings; however, there was substantial heterogeneity for several outcomes.

Conclusions

Early excision may shorten the duration of hospitalization for selected burn patients; however, no consistent mortality benefit was demonstrated. The available evidence for costs and graft success remains limited and highly heterogeneous; therefore, decisions pertaining to excision timing should be individualized within the broader perioperative burn-care pathway.

Keywords

Burn wound excision delayed excision timing of surgery burns meta-analysis

Introduction

Burn injury remains a major global public health problem. Although mortality rates have decreased over time in many settings, the absolute number of patients living with burns and burn-related disability remains substantial worldwide.¹ Since the original description of early excision and grafting by Janzekovic, the timing of operative debridement has been regarded as a potentially modifiable determinant of outcome.²

From a biological perspective, early removal of devitalized tissue may reduce bacterial colonization, inflammatory activation, ongoing tissue injury, and delays in wound closure.^3–5 Therefore, in major burn centers, early excision has become a core component of modern burn care for selected patients. However, universal implementation remains challenging, especially in low- and middle-income settings and in physiologically unstable patients. The need for adequate resuscitation, access to blood products, donor-site availability, nutritional support, anesthesia support, and perioperative temperature management can influence the feasibility and safety of early surgery.^3–5

The existing evidence base remains heterogeneous. Previous reviews have suggested shorter hospitalization durations and possible reductions in infection-related complications, whereas mortality benefits were reported to be less consistent.⁶ More recently, Miroshnychenko et al. focused on adult thermal burns and highlighted persistent uncertainty arising from divergent definitions of early intervention and limited randomized evidence.⁷

This study aimed to conduct an updated systematic review and meta-analysis of comparative studies published from 1 January 2010 to 11 March 2024 to examine whether early excision, compared with delayed excision, was associated with differences in mortality, duration of hospitalization, hospital costs, and graft success in patients with thermal burns.

Methods

Search strategy

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and Meta-analysis of Observational Studies in Epidemiology recommendations; the methodological quality of the review was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2).^8–10 The study was formally registered in the International Prospective Register of Systematic Reviews (PROSPERO) on 3 December 2024 (CRD42024621585). The initial database search was conducted on 11 March 2024; therefore, the formal PROSPERO registration was completed after initiation of the literature search rather than before the initial search. At the planning stage of this review, the research question, eligibility criteria, outcomes, and analytical framework were developed with reference to prior systematic reviews and the existing uncertainty regarding the timing of burn wound excision.

On 11 March 2024, two reviewers independently searched the PubMed, Embase, Cochrane Library, and Web of Science Core Collection databases, using combined search terms related to burn injury and excision (e.g. “burn*” AND “excision” OR “escharectomy” OR “tangential excision”). The review was restricted to English-language comparative studies published between 1 January 2010 and 11 March 2024. Eligibility was based on the publication date rather than the study period; therefore, studies published from 1 January 2010 to 11 March 2024 were considered eligible even when data collection began before 2010.

Eligibility criteria and study selection

The Population, Intervention, Comparison, and Outcome (PICO) framework was defined as follows:

patients with thermal burns constituted the study population;

early burn wound excision was the intervention;

delayed excision was the comparator; and

clinically relevant outcomes included mortality, duration of hospitalization, hospital costs, and graft success.

The primary outcome was mortality. Secondary outcomes included duration of hospitalization, hospital costs, and graft success.

Studies were eligible if they fulfilled the following criteria: (a) compared early versus delayed burn wound excision; (b) included patients with thermal burns; and (c) reported at least one clinically relevant comparative outcome. Letters, conference abstracts, reviews, duplicate publications, and studies without extractable comparative data were excluded. We retained the original study-specific definitions of early and delayed excision and then grouped early excision into three practical categories for subgroup analysis: (a) < 3 days after injury; (b) 3–7 days after injury; and (c) < 14 days after injury.

Data extraction and subgroup definitions

Two reviewers independently extracted data regarding study characteristics, sample sizes, burn severity, operational definition of early versus delayed excision, and available outcomes. For country-level subgroup analysis, studies were categorized as originating from high-income countries (HICs) or low-/middle-income countries (LMICs) according to the World Bank income grouping in use at the time of the review.

Risk of bias assessment

Risk of bias in randomized controlled trials (RCTs) was assessed using the risk of bias 2 tool (RoB 2),¹¹ while that in non-randomized studies was assessed using the Newcastle–Ottawa Scale (NOS).¹²

Statistical analyses

Meta-analysis was performed using a random-effects model because substantive clinical heterogeneity was expected across studies. Mortality was pooled as risk difference (RD) because event counts were available, and some studies had low event rates. Continuous outcomes, including duration of hospitalization, hospital costs, and graft success, were pooled as standardized mean difference (SMD) only when mean and SD values were available or extractable because outcome scales and variance structures differed across studies. Statistical heterogeneity was quantified using the I² statistic. Prespecified subgroup analyses considered country income group, study design, and definition of early excision. Formal meta-regression was not performed because the number of studies per covariate was too small to support stable estimates. Publication bias and sensitivity analyses were interpreted cautiously owing to the limited number of outcome-specific studies.

Results

Search results and study characteristics

The database search identified 7589 records. After removal of 3536 duplicates, 4053 records underwent title/abstract screening. In total, 225 full-text articles were reviewed, of which 10 comparative studies fulfilled the final eligibility criteria (Figure 1).

Figure 1.

The PRISMA flow diagram of study selection.

The included studies comprised two RCTs and eight observational studies published between 2011 and 2023, conducted across Iran, Germany, India, Japan, Australia, and the United States. Overall, 5070 patients were included, with 2510 managed with early excision and 2560 with delayed excision. Study characteristics are summarized in Table 1¹³^-22. RoB 2 judgments for the randomized trials are presented in Figure 2, and NOS assessments for the observational studies are summarized in Table 2.

Figure 2.

Risk of bias assessment of the randomized controlled trials using the RoB 2.

Table 1.

Characteristics of studies included in the meta-analysis.

Study	Country	Design	Study period	Early excision	Delayed excision	n (E/D)	Burn characteristics
Ayaz et al. 2014¹³	Iran	Cohort study	2012.09–2013.09	<14 days	>14 days	26/27	Second-/third-degree burns; <15% TBSA
Ayaz et al. 2019¹⁴	Iran	RCT	2013.01–2015.12	5–7 days	14 days	25/25	Deep hand burns; <50% TBSA
Glaser et al. 2021¹⁵	Germany	Cohort study	2016.10–2018.12	0–3 days	>3 days	670/824	Second-/third-degree burns; <30% TBSA
Goswami et al. 2019¹⁶	India	Cohort study	2016.04–2017.03	<7 days	>7 days	34/24	20%–40% TBSA
Hayashi et al. 2023¹⁷	Japan	Cohort study	2010.09–2019.03	0–2 days	3–7 days	389/389	Severe burns; burn index ≥10
Keshavarzi, Ayaz and Dehghankhalili, 2016¹⁸	Iran	Cohort study	2015.03–2016.03	2–3 days	7–10 days	56/51	Thermal burns up to 60% TBSA
Moussa, Lo and Cleland 2021¹⁹	Australia	Cohort study	2009.07–2018.06	<24 h	>24 h	120/30	Mixed burn severity; TBSA not consistently reported
Ramsey et al. 2023²⁰	United States	Cohort study	2017–2019	<48 h	48–120 h	1135/1135	≥10% TBSA; second-/third-degree burns
Salehi et al. 2016²¹	Iran	Cohort study	2012.04–2013.11	–	–	30/30	Dorsal hand burns; <20% TBSA
Mohammadi 2011²²	Iran	RCT	2006.09–2008.02	2–12 days	4–8 weeks	25/25	Deep hand burns; mean burn size <30% TBSA

E: early excision; D: delayed excision; TBSA: total body surface area; RCT: randomized controlled trial.

Table 2.

Newcastle–Ottawa Scale assessment of the observational studies.

Study	Selection				Comparability	Outcome			Total
Study	1	2	3	4	5	6	7	8	Total
Ayaz et al. 2014¹³	★	★	★	★	★★	★	★	★	9
Glaser et al. 2021¹⁵	★	★	★	—	★	★	★	—	6
Goswami et al. 2019¹⁶	★	—	★	★	★	★	★	★	7
Hayashi et al. 2023¹⁷	★	★	★	★	★	★	★	★	8
Keshavarzi, Ayaz and Dehghankhalili, 2016¹⁸	★	★	★	★	★	★	★	★	8
Moussa, Lo and Cleland 2021¹⁹	★	★	★	★	★	★	★	★	8
Ramsey et al. 2023²⁰	★	★	★	★	★	★	★	★	8
Salehi et al. 2016²¹	★	—	★	★	★	★	★	★	7

1: Representativeness of exposed cohort; 2: Selection of non-exposed cohort; 3: Ascertainment of exposure; 4: Outcome of interest was not present at the start of the study; 5: Comparability of cohorts on the basis of the design or analysis; 6: Assessment of outcomes; 7: Follow-up long enough for outcomes to occur; 8: Adequacy of follow-up cohorts.

Mortality

Five studies contributed to the mortality analysis. Early excision was not associated with a significant reduction in mortality compared with delayed excision (RD: −0.01, 95% CI: −0.06 to 0.03; p = 0.52), and heterogeneity was substantial (I² = 79%) (Figure 3). Subgroup analyses did not identify a subgroup with a statistically significant mortality benefit for early excision (Table 3). The LMIC subgroup and the 3–7-day subgroup each contained only one study;¹⁸ therefore, these findings should be interpreted as single-study observations rather than pooled subgroup effects.

Figure 3.

Forest plot of mortality comparing early versus delayed excision.

Table 3.

Subgroup analysis of mortality.

Subgroup	No. of studies	Pooled effect RD (95% CI)	p-value	I² (%)
Income group (HIC)	4	−0.005 (−0.051 to 0.041)	0.84	80
Income group (LMIC)	1	−0.061 (−0.142 to 0.021)	0.15	NA
Early excision <3 days	4	−0.005 (−0.051 to 0.041)	0.84	80
Early excision 3–7 days	1	−0.061 (−0.142 to 0.021)	0.15	NA

HIC: high-income country; LMIC: low- and middle-income country; RD: risk difference; CI: confidence interval; NA: not applicable.

Duration of hospitalization

Eight studies reported the duration of hospitalization. Early excision was associated with a significantly shorter hospitalization duration than delayed excision (SMD: −0.64, 95% CI: −0.93 to −0.35; p < 0.001), although heterogeneity was high (I² = 94%) (Figure 4).

Figure 4.

Forest plot of the duration of hospitalization comparing early versus delayed excision.

In subgroup analyses, the association with shorter hospitalization duration was observed in both HIC and LMIC settings; however, the pooled effect was larger and more heterogeneous in LMIC studies (Table 4). Timing-based subgroup analyses demonstrated a statistically significant association in studies defining early excision as <3 days, whereas the association did not reach conventional statistical significance in the 3–7-day and <14-day subgroups; the <14-day subgroup was based on a single study. Only one RCT reported the duration of hospitalization; therefore, no pooled RCT subgroup estimate was presented.

Table 4.

Subgroup analysis of the duration of hospitalization.

Subgroup	No. of studies	Pooled effect SMD (95% CI)	p-value	I² (%)
Income group (HIC)	4	−0.23 (−0.32 to −0.14)	<0.001	48
Income group (LMIC)	4	−1.91 (−3.28 to −0.54)	0.001	95
Early excision <3 days	5	−0.37 (−0.58 to −0.16)	0.001	89
Early excision 3–7 days	2	−0.51 (−1.11 to 0.09)	0.09	59
Early excision <14 days	1	−0.21 (−0.75 to 0.33)	0.450	NA

HIC: high-income country; LMIC: low- and middle-income country; SMD: standardized mean difference; CI: confidence interval; NA: not applicable.

Hospital costs

Three studies reported hospital costs. The pooled analysis showed no statistically significant difference between early and delayed excision (SMD: −0.45, 95% CI: −1.72 to 0.81; p = 0.48), with marked heterogeneity (I² = 93%) (Figure 5).

Figure 5.

Risk of bias assessment of the randomized controlled trials using the RoB 2.

Graft success

Three studies reported graft success. Early excision did not offer a statistically significant advantage over delayed excision (SMD: 0.63, 95% CI: −1.03 to 2.29; p = 0.46), and heterogeneity was very high (I² = 97%) (Figure 6).

Figure 6.

Forest plot of graft success comparing early versus delayed excision.

Publication bias and sensitivity analysis

Funnel plots for mortality and duration of hospitalization were visually acceptable; however, they should be interpreted cautiously because the number of studies was small (Figure 7).

Figure 7.

Funnel plots for (a) mortality and (b) duration of hospitalization.

Leave-one-out sensitivity analyses did not materially alter the direction of the pooled mortality or hospitalization results, suggesting that the main conclusions were not driven by a single study (Figure 8).

Figure 8.

Sensitivity analyses for (a) mortality and (b) duration of hospitalization.

Discussion

This updated review suggests that early excision shortens the duration of hospitalization in burn patients. However, it does not demonstrate a consistent reduction in mortality. However, the null mortality finding should not be interpreted as proof of equivalence. The mortality analysis was based on only five observational studies, with substantial between-study heterogeneity.

Several factors likely explain the observed heterogeneity. First, the definition of early excision varied considerably, ranging from surgery within 24 h to that within 14 days after injury. Second, the included populations were clinically diverse and included isolated deep hand burns, moderate burns, and larger burns with different total body surface area (TBSA) thresholds and severity profiles. Third, important perioperative covariates—such as inhalation injury, staged versus single-session excision, transfusion practice, hemodynamic status, donor-site availability, resuscitation quality, and anesthesia or temperature-management protocols—were inconsistently reported. Fourth, studies from HIC and LMIC settings likely reflected different resource constraints, rehabilitation pathways, discharge criteria, and thresholds for surgery. Together, these sources of variability probably contributed to the high I² values observed in the pooled analyses.

The association between early excision and shorter duration of hospitalization should also be interpreted cautiously. Although the direction of the point estimate generally favored early excision across most individual studies, the magnitude of benefit varied considerably. Shorter hospitalization duration may reflect faster wound closure and earlier mobilization; however, it could also have been influenced by selection bias in observational studies, center-specific discharge practices, bed availability, access to rehabilitation, and post-acute care infrastructure. Thus, although hospitalization duration is a clinically relevant factor, it is partially dependent on the healthcare system. Therefore, we have moderated the interpretation of this outcome and avoided framing it as an isolated marker for superiority.

Our findings are broadly aligned with previous syntheses. A previous meta-analysis by Ong et al. suggested advantages of early excision for selected outcome variables,⁶ whereas a more recent review by Miroshnychenko et al. reported that the overall evidence base remains limited by small randomized comparisons and inconsistent definitions of intervention timing.⁷ The present update differs from the previous review in that it includes more recent comparative cohorts and explicitly groups the timing of early excision into practical windows (<3 days, 3–7 days, and <14 days after injury). However, the central message remains similar: the effect of timing is likely context-dependent rather than uniform across all populations of burns patients.

The mechanistic rationale for early excision remains compelling. Experimental and clinical work suggests that prompt removal of devitalized tissue attenuates inflammatory signaling, reduces bacterial burden, and limits ongoing tissue damage.^23–25 Nevertheless, comparable data on inflammatory biomarkers, infection, transfusion requirements, blood loss, and organ dysfunction are too sparse and heterogeneous to be pooled in the present review. Therefore, we retained the inflammatory-response discussion as biological context rather than presenting it as a meta-analytic endpoint. Future burns trials should report these outcomes using more standardized definitions.

It is crucial to remember that early surgery is not risk free. Concerns about intraoperative bleeding, hypothermia, transfusion burden, and physiologic instability remain clinically important, particularly in patients with large burns or limited reserve.^26,27 In addition, the randomized and non-randomized literature on hand burns and moderate-sized burns indicates that the balance between wound closure, graft take, blood loss, and function may vary based on the burn site and extent.^{13,14,21,22,26} This supports an individualized, physiology-informed approach to surgical timing rather than a rigid universal threshold.

Therefore, in clinical practice, the timing of excision should be individualized according to both patient-level and system-level considerations. Early excision may be more appropriate for patients who have achieved hemodynamic stability after adequate resuscitation in whom burn size, depth, and anatomical location make timely wound closure clinically advantageous and in centers where adequate blood products, donor-site availability, anesthesia support, perioperative temperature control, and multidisciplinary burn-care resources are available. Conversely, delayed or staged excision may be more appropriate for patients with ongoing physiological instability, extensive TBSA involvement requiring further optimization, limited blood-product availability, or insufficient perioperative support.

Broader context and future directions

Contemporary optimization of burns management extends beyond the binary comparison of early versus delayed excision. Recent studies have highlighted tools and adjunctive therapies that may modify perioperative risk or recovery trajectories. For example, a validated nomogram for predicting intraoperative hypothermia during escharectomy may help individualize perioperative planning.²⁷ Updated meta-analyses have suggested that oxandrolone mitigates hypermetabolism and improves selected recovery outcomes.^28,29 Other evolving strategies—such as alginate-based dressings, acellular dermal matrix in pediatric burns, autologous epidermal cell suspensions, and negative-pressure wound therapy—may influence wound healing and complication profiles.^30–33 Patient-centered and supportive strategies, including virtual reality for pain and anxiety management and probiotics/synbiotics in critically ill patients, may also shape the broader recovery pathway around burns surgery.^34–36 These developments reinforce the idea that the optimal timing of excision should be integrated within a multimodal perioperative framework.

This study has certain limitations. Most included studies were observational, and outcome-specific analyses often relied on a small number of studies. Definitions of early excision, patient selection criteria, and perioperative management differed widely. Several potentially important outcomes were unavailable or insufficiently standardized for quantitative synthesis. Finally, the small number of studies limited the value of funnel plots and precluded robust meta-regression. Thus, the pooled estimates should be interpreted as hypothesis-informing rather than definitive. Another limitation is that the PROSPERO registration was completed after the initiation of literature search rather than before the initial search. Although the registered protocol was highly consistent with the final methodology, including the PICO framework, eligibility criteria, primary and secondary outcomes, and statistical synthesis methods, post-initiation PROSPERO registration may have introduced bias and represents a study limitation.

Conclusion

Early burn wound excision is associated with shorter hospitalization duration; however, the magnitude of this association should be interpreted cautiously because heterogeneity was substantial, and no clear mortality benefit was demonstrated in the currently available comparative literature. Evidence regarding hospital costs and graft success remains limited and is highly heterogeneous. Surgical timing should therefore be individualized according to burn severity, patient physiology, local resources, and the broader perioperative care strategy. Future well-designed comparative studies should include standardized reporting of infection-related, transfusion-related, inflammatory, functional, and economic outcomes.

Footnotes

Acknowledgments

The authors thank the Burns Clinical Medical Center of Gansu Provincial Hospital for providing methodological support during the study.

ORCID iD

Jun Liu

Ethical approval

Ethical approval was not required because this study synthesized data from published studies, and no new data were collected from human participants.

Informed consent

Since this is a systematic review and meta-analysis of previously published aggregate data, which did not entail direct contact with any human participants, there was no need to obtain informed consent.

Authors’ contributions

Conception and design: Jun Liu; statistical analyses: Da Wang and Hui Wang; supervision: Yue Wu, manuscript drafting: Da Wang and Hui Wang; and critical revision of the manuscript: all authors.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the 2021 Gansu Province Joint Scientific Research Fund (23JRRA1541) and the 2020 Lanzhou Science and Technology Development Project (2020-ZD-24).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

All data analyzed in this study are derived from published articles and are presented in the manuscript and figures.

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